Spinal Cord Injury, SCI, Traumatic — Characterizing the Injury — Clinical Pathway: Emergency and Inpatient

Spinal Cord Injury (SCI) Clinical Pathway — Emergency Department and ICU

Characterizing the Injury

International Standards for Neurological Classification of Spinal Cord Injury

ASIA, International Standards ISNCSCI (International Standards for Neurological Classification of Spinal Cord Injury) Exam

  • Used for neurological classification has two components (sensory and motor).
  • Exam should be completed approximately 48 hrs (at least before 72 hours) post-injury with the patient in supine position (except for the rectal examination that can be performed side-lying) to allow for a valid comparison of scores throughout the phases of care.
  • For children younger than age 5, the test will be completed in a way that the child can understand. The results may not be accurate until a child is at least age 10.
  • Some components of the exam or other neurological tests will be done to determine when a patient is out of spinal shock.
  • Exam is usually given again before discharge and one time per year after that if there are any changes in strength or sensation.

Interpreting the ISNCSCI

Type Results
Complete
(ASIA-A) SCI
  • Results in permanent lack of motor function distal to the level of the injury, including sacral segments (S4-S5)
  • In the acute stage, reflexes are absent, there is no response to plantar stimulation, and muscle tone is flaccid
Incomplete
(ASIA-B, C, or D) SCI
  • This term is used when there is preservation of any sensory and/or motor function below the neurological level that includes the lowest sacral segments S4-S5 (i.e., presence of “sacral sparing”).
  • Results in some residual motor function distal to the level of the injury. Sensation is also partially preserved and to a greater extent than motor function because the sensory tracts are located in more peripheral, less vulnerable areas of the cord. The sacral segments (S4-S5) are spared.

Suspected Upper Motor Neuron (C-T-L spine) vs. Suspected Lower Motor Neuron (Sacral and Below)

  • Children in acute spinal shock will present similarly to the patient with a lower motor neuron lesion, at least initially. The child in spinal shock has no reflexes below the level of spinal injury and recovers rostral to caudal pattern in variable time frames.
  • Not confirmed until urodynamic study. Usually is not done until at least 3 months post-injury as it will not be reliable due to variable recovery and resolution of spinal shock.

Interpreting the ISNCSCI

Lesion Type Characteristics
Upper Motor Neuron
  • Spastic paralysis, hyperreflexia below the lesion, sensory less, and neurogenic bowel and bladder.
  • Sacral reflexes to lower gastrointestinal tract, bladder, and genitals remain intact, although volitional control is impaired.
Lower Motor Neuron Flaccid paralysis, sensory loss, absent lower limb deep tendon reflexes, and loss of sacral reflexes. Rare in pediatrics.