Michael Keith MD
Ann Bryden OTRL
Cleveland Ohio USA
SCI Classification
 An
important component in
determining potential interventions is
the classification of the level of injury
 Classification
schemes provide a
common platform for understanding
the degree of function associated with
the level of SCI
SCI Classification

International Standards for Neurological
Classification of Spinal Cord Injury
(ISNCSCI)
 American Spinal Injury Association (ASIA)
 International Spinal Cord Society (ISCoS)
 Most commonly used

International Classification for Surgery of the
Hand in Tetraplegia (ICSHT)
 For cervical level SCI only
Both classifications include a motor and sensory
portion
 The ICSHT is focused on the upper extremity

Who are the Stakeholders,
and Why?

An increasing number of stakeholders
 International Tetraplegia Group – Therapists and
Surgeons
 International Campaign for Cures of Spinal Cord Injury
Paralysis (ICCP)
 American Spinal Injury Association (ASIA) / International
Spinal Cord Society (ISCoS) – UE Basic Data Set

Why?
 Detect changes from natural recovery
 Better define incomplete lesions
 Measure the impact of interventions
○ Aimed at cure
○ Activity based therapy
○ Surgical reconstruction
NEW
Version
2/2013
ASIA Update – Non Key Muscles
Movement
Shoulder: Flexion, extension, abduction,
internal and external rotation
Elbow: Supination
Elbow: Pronation
Wrist: Flexion
Root Level
C5
C6
Finger: Flexion at proximal joint, extension
Thumb: Flexion, extension and abduction
in plane of thumb
C7
Finger: Flexion at MP joint
Thumb: Opposition, adduction and
abduction perpendicular to palm
C8
Finger: Abduction of the index finger
T1
Congruence with ICSHT?
Movement
Root
Level
Shoulder: Flexion, extension, abduction,
C5
internal and external rotation
Elbow: Supination
ICSHT
No
Shoulder
Elbow: Pronation
Wrist: Flexion
C6
4
5
Finger: Flexion at proximal joint,
extension
Thumb: Flexion, extension and
abduction in plane of thumb
C7
8
6
7
Finger: Flexion at MP joint
Thumb: Opposition, adduction and
abduction perpendicular to palm
C8
8
Finger: Abduction of the index finger
T1
Current Classifications
A classification should tell you what to do.

ASIA, ISCOS, AIS, ISNCSCI
 Work well with complete lesions, complicated -
perhaps without predictive use for surgical
treatment. Does not classify results or permit
patient reported outcomes.
Current Classifications
A classification should tell you what to do.

International Surgical Classification
 Work well with complete motor paralysis,
voluntary (C5,C6), Group 0,1,2,3, 1/3 of
cases.
 Many Patient choices, surgical variations in
C7,C8
 Does not report anatomic change or PRO.
Can be used for equivalency of function.
Functional Enhancement for Cervical SCI - 1990
.
Electrical Stimulation
Tendon Transfers
Shoulder abduction
Elbow flexion
C4
OCu:8
C8 OCu:9
Br->EDC
OCu:7
Finger, thumb extension
PT->FPL
C7
OCu:4
OCu:5
OCu:6
Elbow extension
ECRL->FDP
C6 OCu:3
Br->FPL
OCu:2
Wrist extension
PD->Triceps
O:1
Br->ECRB
C5
FES
O:0
Finger, thumb flexion
Thumb abduction
Where do the Classifications Fail?
Specific Examples
Subject Characteristics (n=9, 18 Arms*)
ASIA (arms)
 C4 – 2
 C5 – 5
 C6 – 6
 C7 – 3
 NC - 2
ICSHT (arms)
 Group 0 – 4
 Group 1 – 3
 Group 2 – 5
 Group 5 – 3
 NC - 3
Where do the Classifications Fail?
Incomplete Injuries
 Spasticity
 Characterizing Paralysis
 Examples

 77VC R: C5, -C6, C7, C8 / 5, -6, -7, 8
 99VC R: C6 / 0, -1, 2, -3, 4, 5, 6, -7
 99 VC L: C6, -C7, C8 / 2, -3, -4, 5, 6, -7, 8
“IC Exceptions”
 Partial Tetraplegia
 Asymmetrical lesions
 Recovered Regenerated, Repaired
 Hyper-reflexive
 Contracted
 Bi-manual activities
Clinical Decision Support
Evidence Based Clinical Practice
Guidelines
 Appropriate Use Criteria
 Cumulative experience without evidence
 Informed Opinion

Clinical Practice Guidelines
Evidence based if outcome based.
 Solve problems of clinical decision
making.
 Make Recommendations based on
strong evidence.
 Find directions for outcomes research.
 Form the basis for national Performance
Measures and Appropriate Use Criteria.
 Search: www.guidelines.gov

Appropriate Use Criteria
RAND Methodology

Writing Group
 Classification
 Risk Adjustment
 Important Clinical Criteria
 Alternative Treatments
Appropriate Use Criteria
 Review
Group
 Refine credibility of application by
experts
 Voting
Group
 Shareholders Rate for Appropriate,
Maybe Appropriate, Rarely
Appropriate
Examples of AUC- AAOS App.

www.aaos.org/auc
Examples of AUC- AAOS App.

http://aaos.webauthor.com/go/auc
AAOS AUC App, Distal Radius Fx
Potential AUC writing table
Scenarios for AUC on Tetraplegia Management
Appropriate *, Maybe &, Not %
Muscle
ScoresVoluntary
IC
ASIA/AIS/ISN
CSCI/ISCOS Key Muscle
Key Muscle
O:0
O:1
Contracture release
Osteotomy, HO
resection
Hyper-reflexia
Botox, Chemo
Tendon, Nerve
neuromodulation Transfer,
A-C4
Deltoid
A-C5
Elbow Flexor
Bi to Tri*
Baclofen Pump&
Radial Osteotomypronation 40*
Ocu2
ECBL
ECRB
A-C6
Wrist Extensor
Ocu3
Biceps
BR
A-C7
Elbow Extensor
Ocu4
FDP
FDS
A-C8
Finger Flexor
APB
ADQ
A-T1
5th Abductor
etc
These combinations include both .AND. And .OR.
Fractional Lengthening*
Measuring Spasticity

Challenges in measuring spasticity
 Ashworth
 Tardieu
 Other

Distinguishing between measures of
spasticity and spasms
 Penn spasm scale, others>
Lets write a AUC about Surgical
Decision Making in Tetraplegia.
Review the literature for outcomes
summary. CPG unlikely.
 Writing group
 Review Group
 Voting Group
