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International Standards for Neurological Classification of Spinal Cord Injury

The Miami Project and The Buoniconti Fund・2 minutes read

The lecture discusses the INS test for spinal cord injuries, covering sensory and motor testing, ASIA Impairment Scale assignment, and pitfalls to avoid. It emphasizes precise assessment techniques from shoulder to wrist extension and includes detailed instructions for testing muscle strength in various areas.

Insights

  • The INS exam focuses on sensory and motor testing to determine spinal cord injury severity and classification using the ASIA scoring system, including specific instructions for assessing sensation and muscle strength.
  • Sensory testing involves comparing sensation to the face and testing 28 dermatomes on both sides, with scoring ranging from 0 to 2 for normal sensation and guidelines for handling unavailable points or non-spinal cord injury conditions.
  • Motor testing assesses muscle strength from 0 to 5, with detailed instructions for evaluating specific muscle groups in the upper and lower extremities, emphasizing the importance of accurate testing and distinguishing between different grades of muscle contraction.

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Recent questions

  • What is the purpose of the INS exam?

    The INS exam assesses spinal cord injury severity.

  • How is sensory testing conducted in the INS exam?

    Sensory testing involves assessing 28 dermatomes.

  • How are motor levels determined in the INS exam?

    Motor levels are assessed for muscle strength.

  • What are the key considerations during sensory testing?

    Sensory testing requires attention to detail.

  • How are ASIA Impairment Scale classifications determined?

    ASIA Impairment Scale classifies injury severity.

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Summary

00:00

"INSKI Test: Sensory and Motor Assessment"

  • The lecture focuses on the International Standards for the Neurological Classification of Spinal Cord Injury (INSKI) test, also known as the ASIA scoring system.
  • Objectives include reviewing the 2019 version of the INS exam, optimal testing for sensory and motor scores, determining the level and completeness of injury, assigning an ASIA Impairment Scale, and discussing revisions and expectations for reporting.
  • Sensory testing involves comparing sensation to the face, testing light touch and pinprick sensation at all 28 dermatomes on both sides of the body, and noting any unavailable points due to conditions like splints or scarring.
  • Sensory scoring ranges from 0 (absent) to 2 (normal), with "not testable" used for conditions hindering testing, and asterisks for non-spinal cord injury conditions affecting sensation.
  • Tools for sensory testing include a tapered whisk of cotton or a safety pin for sharp and dull sensation comparison, with specific instructions for scoring each sensation level.
  • Detailed sensory dermatomes are outlined from C2 to S5, emphasizing the importance of accurately assessing all 28 dermatomes during an INS exam.
  • Pitfalls in sensory testing include patient misinterpretation, cognitive impairments, and delayed responses, with guidelines for handling such situations.
  • Motor testing involves assessing muscle strength from 0 (no contraction) to 5 (full resistance), focusing on finding a level with at least a grade 3 muscle test and intact sensory levels above.
  • Motor levels are determined for upper and lower extremities on both sides, with voluntary anal contraction also assessed after several seconds of finger placement.
  • Specific myotomes are evaluated for each muscle group, with instructions for observing anti-gravity strength and distinguishing between different grades of muscle contraction.

18:05

"Muscle Strength Testing Protocols for Rehabilitation"

  • To assess the forearm, start with the shoulder internally rotated and adducted, elbows at 30 degrees flexion, and a neutral hand wrist on the abdomen.
  • Grade two involves bending the elbow to bring the hand to the nose through the full range of motion with gravity eliminated.
  • Grade three requires flexing the elbow with the shoulder in a neutral abducted position, the elbow extended, and the forearm supinated.
  • Grade four entails providing resistance with the shoulder in a neutral abducted position, the elbow flexed at 90 degrees, and the forearm supinated.
  • Grade five is age and gender matched wrist extension against gravity.
  • For wrist extension grade three, the shoulder is neutral, the elbow extended, the forearm pronated, and the wrist flexed, lifting the fingers towards the ceiling against gravity.
  • Grade four involves providing resistance by stabilizing the forearm and pressing the metacarpals down.
  • Grade five is age and gender matched normal strength for wrist extension.
  • To test the elbow extensors, ensure the shoulder is internally rotated, abducted, the elbow is 30 degrees flexed, and the forearm is over the abdomen.
  • Grade zero, one, and two for finger flexors involve eliminating gravity with the elbow extended, neutral wrist, and stabilizing the MCP and PIP joints in extension.
  • Grade three for finger flexors requires bending the tip of the middle finger against gravity through the full range of motion.
  • Grade four involves applying resistance to the distal phalanx, and grade five is age and gender matched normal strength.
  • For finger abductors, eliminate gravity and ask them to move the finger away from the ring finger.
  • Grade three entails moving the little finger away from the ring finger against anti-gravity.
  • Grade four or five involves stabilizing the wrist and MCP joints and applying distal pressure to the abducted little fingers.
  • For the L2 hip flexors, rotate the hip outwards and ask them to move the knee out to the side.
  • Grade two involves moving the knee out to the side with the hip externally rotated and the knee flexed at 90 degrees.
  • Grade three requires moving the knee through the full range of motion, and grade four involves providing resistance.
  • Grade five is age and gender matched normal strength for the L2 hip flexors.
  • The L3 knee extensors are tested by straightening the knee with gravity eliminated.
  • Grade two involves straightening the knee through the full range of motion.
  • Grade three requires straightening the knee completely from a 30-degree flexed position.
  • Grade four and five involve resisting knee flexion, with grade five being age and gender matched normal strength.
  • Ankle dorsiflexors are tested by lifting the toes towards the head with gravity eliminated.
  • Grade three involves bending the ankle so the foot and toes go up towards the head through the full range of motion.
  • Grade four is resistance against expected strength, and grade five is age and gender matched normal strength.
  • EHL is tested by moving the big toe upwards towards the knee with gravity eliminated.
  • Grade three involves lifting the big toe against gravity, and grade four is resistance against expected strength.
  • Plantar flexors are assessed by pointing the toes downward with gravity eliminated.
  • Grade three requires pushing the foot down into the hand and lifting the heel off the bed.
  • Grade four involves providing resistance against dorsiflexion, with grade five being age and gender matched normal strength.

34:17

Assessing Spinal Cord Injury: Key Examination Points

  • Ensure muscle movement is palpated or visibly seen
  • Know the passive range of motion
  • Avoid using pluses and minuses for spinal cord injuries
  • Test specific myotomes for muscle strength
  • Look for the "noon sign" at S4 and S5 for complete injury
  • Be cautious of reflex contractions during exams
  • Determine sensory levels for right and left sides
  • Maximal score for light touch and pinprick is 56 each
  • Calculate total scores for light touch and pinprick separately
  • Determine motor levels for upper and lower extremities on both sides

53:20

Neurological Level T12: Incomplete Injury Status

  • The patient's neurological level of injury is determined to be T12, with incomplete injury status.
  • The Asian Impairment Scale classification for the patient is determined to be A, indicating a complete injury.
  • Sensory levels are identified as T12 bilaterally, with motor levels at T12 on the right side and L4 on the left side.
  • Optional testing for proprioception and motor function in various muscle groups is mentioned, with encouragement for further practice and collaboration among colleagues.
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