International Standards for Neurological Classification of Spinal Cord Injury

Abstract

Classification of Spinal Cord Injury (ISNCSCI) that describes the examination (referred to as the International Standards examination) as well as the classification including the American Spinal Injury Association (ASIA) Impairment Scale (AIS).In this edition, substantial revisions have been made in addition to the 2015 update of the 7th edition.(The key changes made in 2015 are found below. 1,2) The revisions in this new edition are based not only upon comments, questions, and suggestions from the international community of spinal cord injury (SCI) clinicians and researchers, but also take into account recently available evidence and structured feedback from ISNCSCI training courses. 3,4Due to the space constraints in this booklet, more details and explanations about each of the revisions will be/are separately published as journal articles.The following is a summary of the revisions included in this booklet. Documentation of non-SCI-related impairments: Most of the questions received by the InternationalStandards Committee over the last few years were related to the correct documentation of non-SCIrelated, pre-existing musculoskeletal or neurological problems.Such problems include among others chronic peripheral nerve injuries, acute or chronic pain, or age-related muscle weakness.In particular, age-related impairments represent a growing problem due to the increasing age of acutely injured persons seen in industrial countries.In the 7th edition of ISNCSCI, the only method for documentation of non-SCI-related impairments is the use of the "5*" grade in the motor exam.However, no such concept exists for documentation of non-SCI-related sensory deficits function.Additionally, guidelines on how to indicate the presence of "5*"s in classification variables such as levels or the AIS are missing.To address this issue, a general "*" concept applicable to the motor as well as the sensory exam independent from the level of occurrence (above, at, or below the sensory/motor level) is introduced in this edition: In those cases with non-SCI-related impairments, abnormal sensory and/or motor scores should be scored as examined and tagged with an "'*" to indicate that a non-SCI condition is impacting the examination results.If an examiner tags a score with the "*", details on the reason for this and how this "*"-tagged score should be handled during the classification process need to be specified in the Comments box.While "*"-tagged scores above the sensory/motor level will in most cases be handled as normal during classification, "*"-tagged scores at or below the motor/sensory level indicating a non-SCI-related impairment superimposed to the deficit caused by the SCI will typically be handled as not normal.Each classification variable such as levels or AIS, which is affected by the "*"-tagged scores, should also be designated with an "*".By this method, it is clearly indicated that the classification results are based on clinical interpretation of the recorded scores.The use of the "5*" grade to indicate that the active movement would be considered normal, if an identified inhibiting factor were not present, is not recommended anymore.Instead, the actual result of the motor examination should be noted, tagged with an "*", and the inhibiting factor together with the information that this score should be treated as normal during classification should be provided in the Comments box. Zone of partial preservation:The definition of the zone of partial preservation (ZPP) has been revised and extended to incomplete lesions with either missing voluntary anal contraction (VAC) or missing sensory function (deep anal pressure [DAP], light touch and pin prick).Besides the added value for clinical communication purposes, new evidence has become available that the ZPP based on this new definition provides a better prognosis of neurological recovery.5The ZPP definition has been changed as follows