Spinal Cord Injury: Neurological Exam, Classification and Prognosis

William McKinley MD Director SCI Rehabilitation Medicine Associate Professor VCU Dept PM&R

Case Presentation
 31 yo wm s/p MVA  Tetraplegia  Questions
  

Neurological recovery? Functional Outcome? Ambulation?

Case Study

           C5 C6 C7 C8 T1 T2-L1 L2 L3 L4 L5 S1 M LT PP 5 3 2 1 0 0 0 0 0 0 2 2 1 1 0 0 0 0 0 0 0 2 1 1 1 0 0 0 0 0 0 0

    

Motor Level ? Sensory Level ? NLI ? ASIA ? Neuro/Functional prognosis ?

Importance of Comprehensive Neurological Exam

 Evidence-based


valid, reliable, consistent to patient, family, team Neurological Functional (Rehabilitation goals)

 Better communication


 Allows for prognosis

 

 Allows study of interventions(rehab, drugs)

International Standards for Neurological Classification of Spinal Cord Injury

 ASIA (American Spinal Injury Association)  Two main components (motor & sensory)  motor & sensory level, neurological level, ASIA impairment classification
1982 ASIA standards use Frankel Classification 1992 ASIA Impairment Scale replaces Frankel 1996 & 2000 ASIA revisions

 72 hour exam - reliable prognostic time

Sensory Exam
 28 sensory points (within derms)
 

Test light touch & pin/pain **Importance of sacral pin testing

 3 point scale (0,1,2)



optional: proprioception & deep pressure to index and great toe (present vs absent) deep anal sensation recorded present vs absent

Sensory Exam (cont)

 Sensory level (SLI) = most caudal segment with normal (2/2) LT & Pin sensation  Sensory index score (SIS) = addition of sensory points (total possible 112)

Motor Exam
 10 key muscles (5 upper & 5 lower ext)
C5-Elbow flexion C6-wrist extension C7-elbow extension C8-finger flexion T1-finger abduction L2-hip flexion L3-knee extension L4-ankle dorsiflexion L5-toe extension S1-ankle plantarflexion

Sacral exam: voluntary anal contraction (present/absent) optional ms: diaphragm (VC), abdominal (Beevors test) , hip adductors

Motor Grading Scale

 6 point scale (0-5) ..(avoid +/-s)
     

0 = no active movement 1 = muscle contraction 2 = movement thru ROM w/o gravity 3 = movement thru ROM against gravity 4 = movement against some resistance 5 = movement against full resistance

Motor exam (cont)

 Motor level (MLI) = lowest normal level with 3/5 (& level above 5/5)


 

Each M has 2 root innervations, if 3/5 = full innervation by more rostral root level (4/5 acceptable with pain, deconditioning) Motor Index Score (MIS) = total 100 pts

 **Superiority of Motor level vs Sensory

Neurological Level of Injury (NLOI)

 Lowest level with normal sensory & motor


can record as MLI & SLI and on each side:

(ie: Right C5 sensory & C6 motor, Left C6 sensory & C7 motor) motor level = sensory levels , 50% If no key muscle for MLI, than NLI = SLI

Zone of partial preservation (ZPP) - preserved segments below NLOI

used only in complete SCI

Zone of Injury (ZOI) - 2-3 levels below NLOI

recovery may be better or worse in ZOI

Case:

           C5 C6 C7 C8 T1 T2-L1 L2 L3 L4 L5 S1 M LT PP 5 3 2 0 0 0 0 0 0 0 2 2 1 0 0 0 0 0 0 0 0 2 1 1 0 0 0 0 0 0 0 0

 Motor Level = C6  Sensory Level = C5  Neurological Level of Injury (NLOI) = C5  Zone of Injury = C6-8  Zone of Partial Preservation = C6-7

ASIA Impairment Scale

 A = Complete - no S/M sacral function  B = Sensory incomplete -sacral sensory sparing  C = Motor incomplete -motor sparing below ZOI (strength < 3/5 in most ms)  D = Motor incomplete - (>3/5)  E = Normal - Normal S/M exam

Mechanisms for Neurological Recovery

 1. Remyelination- neuropraxia (0-3 months)  2. Hypertrophy of innervated muscles (3-6 months)  3. Peripheral sprouting from intact nerves to denervated muscle (3-6 months)  4. Axonal regeneration (12-18 months)

Central Cord Syndrome

 Upper extremities weaker than LEs  seen with older age (Spondylosis) asso with hyperextension injuries  favorable prognostic factors:
 

LE > UE (proximal > distal), Bladder/bowel age < 50yr (vs > 50 yr): ambulation 90% (vs 35%), bladder 80% (vs 30%), dressing 80% (vs 15%)

Brown-Sequard Syndrome
 Cord hemi-section


incidence 2-4 %

 ipsilateral motor & proprioceptive loss and contralateral pain/temperature loss



P/T tracts cross at spinal cord level

 favorable prognosis for ambulation (90%), ADL independence (70%), bladder (85%)

Anterior/Posterior Cord Syndrome

 ACS


 PCS


Anterior spinal art. to ventral 2/3 of SC loss of motor, pain (sparing of proprioception) poor prognosis for neuro recovery

Posterior spinal art.to posterior columns loss of proprioception (sparing of motor & pain) poor prognosis for ambulation

Conus Medullaris/Cauda Equina Syndromes

 Conus


 CES
   

 

 

lies behind T-10-l-2 vertbrae S1-5 spinal cord bladder, bowel & sexuality dysfunction more often complete poor prognosis

L/S nerve root injury spinal cord ends ot L1-2 more often asso with pain more often incomplete (+/recovery 12-18 mo) better prognosis

Neurologic vs Functional Outcome

 Neurological Outcome - degree of motor & sensory recovery after SCI  Functional Outcome - degree of mobility and self-care performance  Key factors
  

patient motivation availability of services avoidance of complications (pain, spasticity, contractures)

Functional Outcomes by Level of Injury

    C1,2,3- power chair, ECU, ventilator C5 - feeding C6 - tenodesis grasp C7 ** independent w/ most ADLs/mobility


- manual W/C, transfers, dressing

 C8/T1 - bladder/bowel independence  L 2,3 - **Ambulation

Neuro-testing & Neurological Prognosis

 MRI


better than CT for cord & soft tissue visualization Cord transection (rare) and hemorrhage correlate with poor prognosis Edema (1-2 levels only) correlates with incomplete injury & better prognosis no more reliable than neuro exam

 SSEP (may assist when assoc LOC)



Etiology and prognosis

 Better
  

 Worse
  

spinal stenosis fall unilateral facet disloc.

GSW flexion/rotation bilateral facet disloc.

Medical Intervention & Prognosis

 Methylprednisilone - greater motor recovery noted if given < 8 hrs (for 24 hrs)  Gangliosides - no difference at 1 yr  Surgery (decompression/stabilization) - no neurological differences, but decreased LOS

Neurological Recovery
 Incomplete injuries have better prognosis


sparing of motor/sensory WITHIN or BELOW the zone of injury (ZOI).

 Key factors:
  

incomplete > complete **motor & PIN sparing are key early recovery is better

ASIA Classification & Outcome

Admit ASIA (at 72hr) ASIA D (at 1 year) A B-1 0-5% 20-25%

B-2 (sacral pin prick) 40-50% C 60-75%

Neurological Outcomes in ZOI

 Most pts with complete injury recover one motor level  Recovery to 3/5 at one yr:
 

25-50% of 0/5 ms 75-100% of 1-2/5 ms

 Most occurs during first 6 months with greatest rate of change in first 3 months

Ambulation
 Benefits: overcome barriers, self esteem, cardiopulmonary exercise  Prognostic Factors
 

Age & Energy expenditure (3-9 X in para) NLOI

Below T-11Para - good prognosis L 2-3 para (pelvic control, hip flexion & knee ext with hip/knee proprioception)
community ambulators

Community Ambulation and Lower extremity motor strength (LEMS at 1 month)

0 Tetra-C 0% Tatra-I Para-C Para-I 33% 1-9 NA 21% 45% 70% 100% 10-19 NA 63% 20-29 NA 100% 100% 100%

Case Study #1

           C5 C6 C7 C8 T1 T2-L1 L2 L3 L4 L5 S1 M LT PP 5 3 2 1 0 0 0 0 0 0 2 2 1 1 0 0 0 0 0 0 0 2 1 1 1 0 0 0 0 0 0 0

    

Motor Level = C6 Sensory Level = C5 NLI = C5 ASIA = A Neuro/Functional prognosis

  

ZOI = good below ZOI = none Ambulation = none

Case Study #2

           C5 C6 C7 C8 T1 T2-L1 L2 L3 L4 L5 S1 M LT PP 5 3 0 0 0 0 0 0 0 0 2 2 1 0 0 0 0 0 0 1 1 2 1 0 0 0 0 0 0 0 0 0

    

Motor Level = C6 Sensory Level = C5 NLI = C5 ASIA = B-1 (no pin) Neuro/Functional prognosis
  

ZOI = poor below ZOI = poor Ambulation = poor

Case Study #3

           M LT PP C5 5 C6 3 C7 0 C8 0 T1 0 T-L L2 0 L3 0 L4 0 L5 0 S1 0 2 2 2 1 0 0 0 0 0 1 1 2 1 1 1 0 0 0 0 0 1 1

    

Motor Level = C6 Sensory Level = C5 NLI = C5 ASIA = B-2 (pin*) Neuro/Functional prognosis
  

ZOI = good below ZOI = good Ambulation = good

Case Study #4

          C5 C6 C7 C8 T1 L2 L3 L4 L5 S1 M LT PP 5 3 0 0 0 1 0 0 0 1 2 2 0 0 0 0 0 0 1 1 2 1 0 0 0 0 0 0 1 1

    

Motor Level = C6 Sensory Level = C5 NLI = C5 ASIA = C Neuro/Functional prognosis

 

ZOI = Poor below ZOI = good Ambulation = good

Future Considerations for Enhance Recovery

 Basic science/clinical research
  

Neuropharmacologic agents (4-AP) Nerve transplantation, stem cells BWS (body weight support)
training of central pattern generator in inc SCI

FES - (UE grasp, ambulation, bladder)

Conclusions
 Accurate neuro exam is imperative  Incompleteness in key for prognosis  Earlier recovery (1-3 months) is better  ZOI & below ZOI may have different prognosis