The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most widely used classification in the field of spinal cord injury medicine. Since its first publication in 1982, multiple revisions refining the recommended examination, scaling, and classification have taken place to improve communication, consistency, and clarity. This article describes a brief historical perspective on the development and changes over the years leading to the current ISNCSCI, detailing the most recent updates of 2011 and the worksheet 2013 as well as issues facing the ISNCSCI for the future.
Key points
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The latest changes to the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) were made in 2011 and 2013.
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The purpose of the ISNCSCI remains to allow for accurate communication between clinicians and researchers working in the field of spinal cord injury (SCI).
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The ISNCSCI continues to evolve based on feedback from professionals in SCI.
Historical background and revisions
Accurate communication between clinicians and researchers working with SCI patients requires that standards be used in the classification of neurologic impairment. Such a standardized method is important to help document the course of recovery and the effect of interventions in the treatment of SCI, including regeneration. To this end, the American Spinal Injury Association (ASIA) first developed and published the Standards For Neurological Classification Of Spinal Injury Patients in 1982, which has since become the most widely used classification in the field.
Prior to this, in an attempt for consistency of definitions in 1969, a questionnaire was completed by leading physicians in the field of SCI to establish international agreement on neurologic terminology for SCI and to compare their opinions on the best time to accurately predict outcome after SCI. Their recommendations were published, but there was no agreement on the overall classification of SCI. Several classifications for SCI were subsequently proposed based on bony patterns of injury, mechanism of injury, neurologic function, and functional outcome. In 1969, Frankel and colleagues described a 5-grade system of classifying traumatic SCI, with a division into complete (A) and 4 incomplete (B–E) injury grades. The purpose of this article was to describe results of postural reduction in the treatment of SCI, and they described their classification as “crude.” ASIA’s first booklet of the Standards For Neurological Classification Of Spinal Injury Patients , published in 1982, incorporated the Frankel grades A–E along with an introduction of motor testing of key muscle groups and sensory testing in 29 dermatomes. These standards defined or described the following:
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Clarification of injury based on neurologic complete and incomplete injuries based on sparing below the level of injury
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Neurologic zone of injury (NLI)
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Quadriplegia, quadraperesis, paraplegia, and paraparesis
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Zone of injury up to 3 neurologic segments at the point of damage to the spinal cord where there is frequently some preservation of motor and/or sensory function
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Anatomic incomplete clinical syndromes (eg, central cord syndrome [CCS])
The standards from 1982 were refined by ASIA over the next 10 years, involving input from SCI clinicians and researchers. Changes included the use of specific key areas with anatomic landmarks to define the sensory level, combining the S4 and S5 dermatomes into a single S4-5 dermatome (perianal area), reducing the total number of dermatomes to 28, and redefining the zone of injury as the zone of partial preservation (ZPP) of sensory and/or motor function. Other changes included having only the elbow flexors examined to test the C5 myotome, clarification of muscle grading in the determination of motor levels, and clarification of the Frankel classification in terms of the degree of incompleteness (Frankel grade C vs D) as recommended by Tator and colleagues. Use of the terms, quadraparesis and paraparesis , was discouraged because they imprecisely described incomplete lesions.
In 1992, the fourth revision of the ISNCSCI was published. The key change of this major revision was the replacement of the Frankel classification with the ASIA Impairment Scale (AIS), with a major change in adopting the sacral sparing definition to determine the completeness of the injury. The sacral sparing definition of the completeness of the injury was considered a more stable definition, because fewer patients convert from incomplete to complete status over time postinjury. The AIS, similar to the Frankel scale, described 5 different severities of SCI. Other features of the 1992 revision included
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Incorporating the Functional Independence Measure (FIM)
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Printing of the key sensory points
- •
Testing pinprick and light touch separately on a 3-point scale
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Sensory index scoring
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Motor level changed such that a grade 4 on testing was no longer considered normal, unless it was examiner judgment that certain inhibiting factors, such as pain, positioning of the patient, hypertonicity, or disuse inhibited full effort
- •
Modification of the definition of the ZPP
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Optional tests (position sense, vibration, and additional muscles to better localize the level of the lesion) were added
- •
Tetraplegia introduced, as preferred to the term, quadriplegia.
These standards were endorsed by the International Medical Society of Paraplegia and, thereafter, became known as the “International Standards for Neurological and Functional Classification of Spinal Cord Injury.”
In 1994, ASIA published a written manual for the ISNCSCI and videos of the examination. To the 1996 version of the ISNCSCI booklet included clarification of how to score muscles whose strength may be affected by inhibiting factors and further clarification of how to differentiate between AIS C and D plus instructions on how to determine the motor level when the sensory level falls into a region where the key muscles cannot be clinically tested; for C1-C4, T2-L1, and S3-5, the motor level is designated as the same as the most rostral normal sensory level.
The revisions to the ISNCSCI in 2000 further clarified motor incomplete injuries and how to document the ZPP and eliminated the FIM from the standards. This revision developed the now current title, The International Standards for the Neurological Classification of Spinal Cord Injury . In 2003, ASIA published a revised version of the written manual for the ISNCSCI. Additional minor revisions and reprintings of the booklet were published in 2002, 2006, and 2008. In 2006, ASIA started developing an Internet-based learning course for the ISNCSCI, called the International Standards Training eLearning Program (InSTeP) that is available and continues to be updated along with the ISNCSCI. InSTeP offers modules on anatomy as well as how to perform an examination and classify an injury based on the AIS. In 2009 an update was published to explain some of the updates and processes of the International Standards Committee.
Historical background and revisions
Accurate communication between clinicians and researchers working with SCI patients requires that standards be used in the classification of neurologic impairment. Such a standardized method is important to help document the course of recovery and the effect of interventions in the treatment of SCI, including regeneration. To this end, the American Spinal Injury Association (ASIA) first developed and published the Standards For Neurological Classification Of Spinal Injury Patients in 1982, which has since become the most widely used classification in the field.
Prior to this, in an attempt for consistency of definitions in 1969, a questionnaire was completed by leading physicians in the field of SCI to establish international agreement on neurologic terminology for SCI and to compare their opinions on the best time to accurately predict outcome after SCI. Their recommendations were published, but there was no agreement on the overall classification of SCI. Several classifications for SCI were subsequently proposed based on bony patterns of injury, mechanism of injury, neurologic function, and functional outcome. In 1969, Frankel and colleagues described a 5-grade system of classifying traumatic SCI, with a division into complete (A) and 4 incomplete (B–E) injury grades. The purpose of this article was to describe results of postural reduction in the treatment of SCI, and they described their classification as “crude.” ASIA’s first booklet of the Standards For Neurological Classification Of Spinal Injury Patients , published in 1982, incorporated the Frankel grades A–E along with an introduction of motor testing of key muscle groups and sensory testing in 29 dermatomes. These standards defined or described the following:
- •
Clarification of injury based on neurologic complete and incomplete injuries based on sparing below the level of injury
- •
Neurologic zone of injury (NLI)
- •
Quadriplegia, quadraperesis, paraplegia, and paraparesis
- •
Zone of injury up to 3 neurologic segments at the point of damage to the spinal cord where there is frequently some preservation of motor and/or sensory function
- •
Anatomic incomplete clinical syndromes (eg, central cord syndrome [CCS])
The standards from 1982 were refined by ASIA over the next 10 years, involving input from SCI clinicians and researchers. Changes included the use of specific key areas with anatomic landmarks to define the sensory level, combining the S4 and S5 dermatomes into a single S4-5 dermatome (perianal area), reducing the total number of dermatomes to 28, and redefining the zone of injury as the zone of partial preservation (ZPP) of sensory and/or motor function. Other changes included having only the elbow flexors examined to test the C5 myotome, clarification of muscle grading in the determination of motor levels, and clarification of the Frankel classification in terms of the degree of incompleteness (Frankel grade C vs D) as recommended by Tator and colleagues. Use of the terms, quadraparesis and paraparesis , was discouraged because they imprecisely described incomplete lesions.
In 1992, the fourth revision of the ISNCSCI was published. The key change of this major revision was the replacement of the Frankel classification with the ASIA Impairment Scale (AIS), with a major change in adopting the sacral sparing definition to determine the completeness of the injury. The sacral sparing definition of the completeness of the injury was considered a more stable definition, because fewer patients convert from incomplete to complete status over time postinjury. The AIS, similar to the Frankel scale, described 5 different severities of SCI. Other features of the 1992 revision included
- •
Incorporating the Functional Independence Measure (FIM)
- •
Printing of the key sensory points
- •
Testing pinprick and light touch separately on a 3-point scale
- •
Sensory index scoring
- •
Motor level changed such that a grade 4 on testing was no longer considered normal, unless it was examiner judgment that certain inhibiting factors, such as pain, positioning of the patient, hypertonicity, or disuse inhibited full effort
- •
Modification of the definition of the ZPP
- •
Optional tests (position sense, vibration, and additional muscles to better localize the level of the lesion) were added
- •
Tetraplegia introduced, as preferred to the term, quadriplegia.
These standards were endorsed by the International Medical Society of Paraplegia and, thereafter, became known as the “International Standards for Neurological and Functional Classification of Spinal Cord Injury.”
In 1994, ASIA published a written manual for the ISNCSCI and videos of the examination. To the 1996 version of the ISNCSCI booklet included clarification of how to score muscles whose strength may be affected by inhibiting factors and further clarification of how to differentiate between AIS C and D plus instructions on how to determine the motor level when the sensory level falls into a region where the key muscles cannot be clinically tested; for C1-C4, T2-L1, and S3-5, the motor level is designated as the same as the most rostral normal sensory level.
The revisions to the ISNCSCI in 2000 further clarified motor incomplete injuries and how to document the ZPP and eliminated the FIM from the standards. This revision developed the now current title, The International Standards for the Neurological Classification of Spinal Cord Injury . In 2003, ASIA published a revised version of the written manual for the ISNCSCI. Additional minor revisions and reprintings of the booklet were published in 2002, 2006, and 2008. In 2006, ASIA started developing an Internet-based learning course for the ISNCSCI, called the International Standards Training eLearning Program (InSTeP) that is available and continues to be updated along with the ISNCSCI. InSTeP offers modules on anatomy as well as how to perform an examination and classify an injury based on the AIS. In 2009 an update was published to explain some of the updates and processes of the International Standards Committee.
2011 revisions of the ISNCSCI
In 2011, the seventh revision of the ISNCSCI was published, along with an accompanying explanatory article, and included some clarifications as well as changes that were substantial enough such that the 2003 reference manual was no longer to be used or distributed.
The clarifications of the 2011 revisions included
- 1.
Greater detail describing the motor and sensory examination, including positions for motor testing, reinforcing specific manual muscle techniques, using static positioning with a patient resisting the examiner’s force, to grade a muscle function as 4 or 5. It was thought that standardization in performing muscle testing would allow for consistency in grading among examiners. Details on execution of the examination are available as part of the InSTeP program and Box 1 lists the specific positions for testing key muscles for grades 4 and 5.
Box 1
C5: Elbow flexed at 90°, arm at patient’s side, and forearm supinated
C6: Wrist in full extension
C7: Shoulder in neutral rotation, adducted, and in 90° of flexion, with elbow in 45° of flexion
C8: Full flexed position of the distal phalanx with the proximal finger joints stabilized in extended position
T1: Full abducted position of fifth digit (of the hand)
L2: Hip flexed to 90°
L3: Knee flexed to 15°
L4: Full dorsiflexed position of ankle
L5: First toe fully extended
S1: Hip in neutral rotation, the knee is fully extended and the ankle in full plantarflexion.
Positions for testing key muscles for grade 4 or 5
From Kirshblum SC, Waring W, Biering-Sorensen F, et al. Reference for the 2011 revision of the International Standards for Neurological Classification of Spinal Cord Injury. J Spinal Cord Med 2011;34(6):548; with permission.
- 2.
When defining the motor level in a patient with no correlating key motor function to test (above C5, between T2 and L1, and between S2 and S5), the motor level is presumed the same as the sensory level, if testable motor function above (rostral) that level is intact (normal) as well. Based on sample testing, it was thought that this concept required clarification, and examples were used to illustrate this point ( Box 2 ).
Box 2
Example 1: If the sensory level is C4, and there is no C5 motor strength (or the strength is graded <3), the motor level is C4.
Example 2: If the sensory level is C4, with the C5 key muscle function strength graded as ≥3, the motor level is C5. This is because the strength at C5 is ≥3 with the muscle function above considered normal. Presumably, if there were a C4 key muscle function, it is graded as normal because the sensation at C4 is intact.
Example 3: If the sensory level is C3, with the C5 key muscle function strength graded as ≥3, the motor level is C3. This is because the motor level presumably at C4 is not considered normal (because the C4 dermatome is not normal), and the rule of all levels rostral needing to be intact is not met.
Example 4: If all upper limb key muscle functions are intact, with intact sensation through T6, the sensory level as well as the motor level is recorded as T6.
Example 5: In a case similar to Example 4, but the T1 muscle function grade 3 instead of 5, whereas T6 is still the sensory level, the motor level is T1, because all the muscles above the T6 level cannot be considered normal. It is important to recognize that the motor level follows the sensory level only if the rule, “all the key muscle functions above are graded as normal,” applies.
Example 6: If the sensory level is T12, the hip flexor motor function (L2 key muscle) is graded as 3 bilaterally and muscle strength of upper extremity key muscle groups are graded 5/5, the motor level is T12. Although L2 motor function is graded as a 3, the motor function above that level (L1) is not normal because the sensory level, and thereby the motor level, is T12.
Example 7: If the sensory level is L2 and the hip flexor muscle function is graded as a 2 with all upper extremity key motor function graded as 5, the sensory level is L2, and the motor level is L1. Although the rule of the motor level deferring to sensory level is used when there is no functional motor level to test (ie, above the L2 level), once there is a key motor functional level to test (in this case at L2), the motor level no longer defers to the sensory level.
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