SENSORY
C3
SENSORY
C5 Elbow flexors
C5
MOTOR
MOTOR
KEY SENSORYC4POINTS
KEY
SENSORY POINTS
KEY
MUSCLES
KEY MUSCLES
Wrist extensors Date/Time
C6
C6
Patient
Name_____________________________________
of UEL
Exam _____________________________
Light
Touch
(LTR)
Pin Prick (PPR)
Light Touch (LTL) Pin Prick (PPL)
INTERNATIONAL STANDARDS FOR NEUROLOGICAL
T2
(Upper
Extremity Left)
T3
Elbow
extensors
C7
C7
C2
CLASSIFICATION OF SPINAL
C5
T4
C2 CORD INJURY
Examiner Name ___________________________________
C8 Finger flexorsC2Signature _____________________________________
C8 0 = absent
(ISNCSCI)
T5
C3 (little finger)
C3
altered
T6
T1 Finger abductors
T1 21 == normal
C4
C4
C2
T7
SENSORY
NT = not testable
SENSORY
T2
T2
MOTOR
C3
MOTOR
T8
C3
cle? Reason for NT? Pain?):
MOTOR
C5 Elbow flexors
KEY SENSORY POINTS
KEY SENSORY POINTS
C5
KEY MUSCLES
T1
KEY MUSCLES
T9
0 = absent
T3 Elbow flexors
T3
(SCORING
ON REVERSE
SIDE)
Pin
Prick
(PPL)
Light
Touch
(LTL)
Light
Touch
(LTR)
Pin
Prick
(PPR)
C4
Wrist extensors
1 = altered
UER
Wrist extensors C6
UEL
C6
C4
C6
T10
T4
2 = normal
0 = total paralysis
T2
(Upper Extremity Right) T4
(Upper Extremity Left)
T3
Elbow
extensors
T11
NT
=
not
testable
Elbow extensors C7
C7
C2
C2
C2
1 = palpable or visible contraction
C5
T5
T5
T4
2 = active movement, gravity
Finger flexors C8 0 = absentC3
T12
C8 Finger flexors
C3 eliminated
T5
T6
3 = active movement, against gravity
T6
altered
L1
bsent
Finger abductors (little finger) T1 21 == normal
C4 some resistance
C2
T6
T1 Finger abductors (little finger)
Palm
C4
4 = active movement, against
ltered
T7
T7
T7
NT = not testable
ormal
5
=
active
movement,
against
full
resistance
C3
T2
T2
Elbow flexors C5
C5 Elbow flexors
C3
T8
not testable Comments (Non-key Muscle? Reason for NT? Pain?):
MOTOR
5* = normal corrected for pain/disuse
T8
T8
C4
T1
T9
0
=
absent
T3
T3
S3
Wrist extensors
Wrist
extensors
NT
=
not
testable
UER
(SCORING
ON REVERSE SIDE) UEL
C6
C6
= altered
T9
Sensory
T2
C4
• 21Key
C6
L2
(Upper Extremity Left)
(Upper Extremity Right) T9 Elbow extensors
T10
T4
= normal
T4
T3
0 = total
paralysis
Elbow
extensors
C7
C7
C2
S4-5
T11
NT Points
= not testable T4
C5
T10
SENSORY
T10 Finger flexors
1
=
palpable
or
visible
contraction
T5
Finger
flexorsgravity eliminated
C8 0 = absentT5
2SIDE)
= active
movement,
(SCORING ON REVERSEC8
T5
T12
T11
T11
1 = altered
T6
3
=
active
movement,
against(little
gravity
T6
T6
finger)
(little
finger)
Finger
abductors
Finger
abductors
T1
T1 2 = normal
L1
0 = absent
2 = normal
0 = absent
Palm
4 = active movement, against some resistance
T12
T7
T12
1 = altered
L3
NT = not T7
testable
T7
NT
=
not
testable
1=
altered
8
S2
8
T2
C3 C 6 C
T2
2 = normal
5 = active movement, against full resistance
T8
Comments (Non-key Muscle?
Reason for NT? Pain?):
MOTOR
C
C6
L1
L1= not testable
NT
5* = normal corrected
for pain/disuse
T8
T1
C7 C7
T8
T9
T3
0 = absent
T3
(SCORING
ON REVERSE SIDE)
NT
=
not
testable
1 S3
=Dorsum
altered
C4
C6
Dorsum
Hip flexors L2
T9
Hip
flexors
L2
T10
Key
Sensory
T9
•
L2
T4
T4
2 = normal
0 = total paralysis
T11
S4-5
NT = not testable
Points
1 = palpable or SENSORY
visible contraction
Knee extensors L3
T10
T10
L3 Knee extensors
T5
T5
LEL
2 = active
movement,
eliminated
T12
L4
(SCORING
ONgravity
REVERSE
SIDE)
T11 (Lower
Ankle dorsiflexors L4
T11
T6
Ankle dorsiflexors
3 = active
movement,
against gravity
Extremity
Left)
T6
L4
L1
0 = absent
L5
2
=
normal
Palm
0
=
absent
4
=
active
movement,
against
some
resistance
1 = altered
T12
T12
ong toe extensors L5
L3
T7
T7
L5 Long toe extensors
NT resistance
= not testable
S2
51==altered
active movement, against full
2 = normal
C8 6 C8
S1
6
C
C
NT = not testable
L1 L5
nkle plantar flexors S1
flexors 5* = normal corrected for pain/disuse
T8
S1 Ankle plantar L1
T8
C7 C7
S3
NT = not testable
Key
Sensory
• Dorsum S2
Dorsum
T9
Hip flexors L2
L2 Hip flexors
S2
L2
T9
Points
S4-5
T10
S3 Knee extensors L3
SENSORY
S3
T10
L3 Knee extensors
LER
raction
(DAP) Deep anal(SCORING
pressureON REVERSE SIDE) LEL
L4
T11
S4-5
L4
S4-5
T11
Ankle dorsiflexors
(Lower Extremity Left)
Yes/No) (Lower Extremity Right) Ankle dorsiflexors
(Yes/No) L4
L5
2 = normal
0 = absent
T12
Long toe extensors L5
L3
T12
Long
toe
extensors
L5
S2
NT = not testable
1= altered
S1
C8 6 C8
LEFT TOTALS L1
RIGHT TOTALS
C
C6
L1
Ankle plantar flexors S1
L5
S1 Ankle plantar flexors
C7 C7
(MAXIMUM)
(MAXIMUM)
S2
S2
Dorsum Dorsum
Hip flexors L2
L2 Hip flexors
S
SENSORY SUBSCORES
S3
S3
L3
Knee
extensors
L3 Knee extensors
(VAC) Voluntary
(DAP) Deep anal pressure
LEL
LER anal contraction
L4
LER
+ LEL L4
= LEMS TOTAL
= UEMS TOTAL
S4-5
LTR
+
LTL
S4-5
PPR
+
PPL
=
LT
TOTAL
=
PP TOTAL
(Yes/No)
(Lower Extremity Left)
Ankle
dorsiflexors
(Lower Extremity Right) Ankle dorsiflexors
L4
(Yes/No)
L5
(25)
(50)
(50)
MAX (25)
MAX (56)
MAX (56)
(56)
(56)
(112)
Long
toe (112)
extensors
Long toe extensors L5
L5LEFT
TOTALS
S1
RIGHT TOTALS
L5
Ankle
plantar
flexors
flexors S1
(In complete injuries only)
S1
R
L
R
L Ankle plantar
(MAXIMUM)
4. COMPLETE OR INCOMPLETE?
(MAXIMUM)
3. NEUROLOGICAL
ZONE OF PARTIAL
S2
Incomplete = Any sensory or motor function in S4-5
S2
SENSORY
1. SENSORY
MOTOR SUBSCORES
LEVEL OF INJURY
SENSORY SUBSCORES
PRESERVATION
S3
S3MOTOR
2. MOTOR
5. ASIA IMPAIRMENT SCALE (AIS)
(NLI)
Most caudal level with any innervation
LER
+ LEL
(VAC)
Anal Contraction
UER Voluntary
+ UEL
(DAP) Deep= Anal
Pressure
= LEMS TOTAL
= UEMS TOTAL
LTR
+ LTL
+ PPL
= LT TOTAL
PP TOTAL
S4-5
S4-5 PPR
(Yes/No)
Elbow flexors
Wrist extensors
Elbow extensors
Finger flexors
bductors (little finger)
RIGHT
LEFT
RIGHT
LEFT
MAX (25)
(25) permission from the (50)
(25)
(50)but should
MAX
This
form may be copied freely
not(25)
be altered without
American Spinal
MAXInjury
(56) Association.
(56)
NEUROLOGICAL
LEVELS
RIGHT TOTALS
R
(MAXIMUM)
1. SENSORY
MOTOR
Steps 1-5SUBSCORES
for classification
2. MOTOR
as on reverse
UER
+ UEL
= UEMS TOTAL
MAX (25)
(25)
NEUROLOGICAL
LEVELS
Steps 1-5 for classification
as on reverse
L
LER
R
4. COMPLETE OR INCOMPLETE?
Incomplete = Any sensory or motor function in S4-5
5. ASIA SENSORY
IMPAIRMENTSUBSCORES
SCALE (AIS)
LTR
+ LTL
= LT TOTAL
MAX (25)
L
(25)
3. NEUROLOGICAL
LEVEL OF INJURY
(NLI)
(50)
MAX (56)
(56)
4. COMPLETE OR INCOMPLETE?
Incomplete = Any sensory or motor function in S4-5
5. ASIA IMPAIRMENT SCALE (AIS)
(112)
LEFT TOTALS
(In complete injuries only)
(MAXIMUM)
ZONE OF PARTIAL
PRESERVATION
Most caudal level with any innervation
This form may be copied freely but should not be altered without permission from the American Spinal Injury Association.
(50)
1. SENSORY
2. MOTOR
3. NEUROLOGICAL
LEVEL OF INJURY
(NLI)
+ LEL
= LEMS TOTAL
REV (Yes/No)
02/13(56)
MAX (56)
(112)
PPR
(112)
R
+ PPL
MAX (56)
(56)
= PP TOTAL REV 02/13
(In complete injuries only)
ZONE OF PARTIAL
PRESERVATION
Most caudal level with any innervation
This form may be copied freely but should not be altered without permission from the American Spinal Injury Association.
L
SENSORY
MOTOR
SENSORY
MOTOR
(112)
R
L
REV 11/15
Muscle Function Grading
0 = total paralysis
1 = palpable or visible contraction
2 = active movement, full range of motion (ROM) with gravity eliminated
3 = a ctive movement, full ROM against gravity
4 = active movement, full ROM against gravity and moderate resistance in a muscle
specific position
5 = (normal) active movement, full ROM against gravity and full resistance in a
functional muscle position expected from an otherwise unimpaired person
5* = (normal) active movement, full ROM against gravity and sufficient resistance to
be considered normal if identified inhibiting factors (i.e. pain, disuse) were not present
NT = not testable (i.e. due to immobilization, severe pain such that the patient
cannot be graded, amputation of limb, or contracture of > 50% of the normal ROM)
Sensory Grading
0 = Absent
1 = Altered, either decreased/impaired sensation or hypersensitivity
2 = Normal
NT = Not testable
When to Test Non-Key Muscles:
In a patient with an apparent AIS B classification, non-key muscle functions
more than 3 levels below the motor level on each side should be tested to
most accurately classify the injury (differentiate between AIS B and C).
Movement
Root level
Shoulder: Flexion, extension, abduction, adduction, internal and external rotation
Elbow: Supination
C5
C6
Finger: Flexion at proximal joint, extension. Thumb: Flexion, extension and abduction in plane of thumb
C7
Finger: Flexion at MCP joint Thumb: Opposition, adduction and abduction perpendicular
to palm
C8
Elbow: Pronation
Wrist: Flexion
T1
Hip: Adduction
L2
Hip: External rotation L3
Hallux: Adduction
the sacral segments S4-5.
B = Sensory Incomplete. Sensory but not motor function
is preserved below the neurological level and includes the sacral
segments S4-5 (light touch or pin prick at S4-5 or deep anal
pressure) AND no motor function is preserved more than three
levels below the motor level on either side of the body.
C = Motor Incomplete. Motor function is preserved at the
most caudal sacral segments for voluntary anal contraction (VAC)
OR the patient meets the criteria for sensory incomplete status
(sensory function preserved at the most caudal sacral segments
(S4-S5) by LT, PP or DAP), and has some sparing of motor
function more than three levels below the ipsilateral motor level
on either side of the body.
(This includes key or non-key muscle functions to determine
motor incomplete status.) For AIS C – less than half of key
muscle functions below the single NLI have a muscle grade ≥ 3.
D = Motor Incomplete. Motor incomplete status as defined
above, with at least half (half or more) of key muscle functions
below the single NLI having a muscle grade ≥ 3.
the ISNCSCI are graded as normal in all segments, and the
patient had prior deficits, then the AIS grade is E. Someone
without an initial SCI does not receive an AIS grade.
Using ND: To document the sensory, motor and NLI levels,
the ASIA Impairment Scale grade, and/or the zone of partial
preservation (ZPP) when they are unable to be determined
based on the examination results.
L5
S1
The following order is recommended for determining the classification of
individuals with SCI.
1. Determine sensory levels for right and left sides.
The sensory level is the most caudal, intact dermatome for both pin prick and
light touch sensation.
2. Determine motor levels for right and left sides.
Defined by the lowest key muscle function that has a grade of at least 3 (on
supine testing), providing the key muscle functions represented by segments
above that level are judged to be intact (graded as a 5).
Note: in regions where there is no myotome to test, the motor level is
presumed to be the same as the sensory level, if testable motor function above
that level is also normal.
3. Determine the neurological level of injury (NLI)
This refers to the most caudal segment of the cord with intact sensation and
antigravity (3 or more) muscle function strength, provided that there is normal
(intact) sensory and motor function rostrally respectively.
The NLI is the most cephalad of the sensory and motor levels determined in
steps 1 and 2.
4. Determine whether the injury is Complete or Incomplete.
(i.e. absence or presence of sacral sparing)
If voluntary anal contraction = No AND all S4-5 sensory scores = 0
AND deep anal pressure = No, then injury is Complete.
Otherwise, injury is Incomplete.
5. Determine ASIA Impairment Scale (AIS) Grade:
Is injury Complete? If YES, AIS=A and can record
ZPP (lowest dermatome or myotome
NO
on each side with some preservation)
Is injury Motor Complete? If YES, AIS=B
NO
(No=voluntary anal contraction OR motor function
more than three levels below the motor level on a
given side, if the patient has sensory incomplete
classification)
Are at least half (half or more) of the key muscles below the
neurological level of injury graded 3 or better?
NO
L4
Hallux and Toe: DIP and PIP flexion and abduction
A = Complete. No sensory or motor function is preserved in
E = Normal. If sensation and motor function as tested with
Finger: Abduction of the index finger
Hip: Extension, abduction, internal rotation
Knee: Flexion
Ankle: Inversion and eversion
Toe: MP and IP extension
Steps in Classification
ASIA Impairment Scale (AIS)
INTERNATIONAL STANDARDS FOR NEUROLOGICAL
CLASSIFICATION OF SPINAL CORD INJURY
AIS=C
YES
AIS=D
If sensation and motor function is normal in all segments, AIS=E
Note: AIS E is used in follow-up testing when an individual with a documented
SCI has recovered normal function. If at initial testing no deficits are found, the
individual is neurologically intact; the ASIA Impairment Scale does not apply.