Classifying Spinal Cord Injuries Overview

Welcome to InStep, the online training for the International Standards for the Classification of Spinal Cord Injury. This course series is sponsored by the American Spinal Injury Association. This is Module 5, Scoring, Scaling, and Classification. Funding for this project has been provided by The International Spinal Cord Society Medtronic The Craig H. Nielsen Foundation and the Christopher and Dana Reeve Foundation. The goal of this course series is to promote spinal cord injury knowledge, care, and research by providing an internet tutorial on the international standards for the classification of spinal cord injury. There are five modules in the series. Basic Anatomy, the Sensory Examination, the Motor Examination, the Anorectal Examination, and this module scoring scaling and classification this course series should prepare you to conduct and score the exam for the international standards for the classification of spinal cord injury at the end of this module you will be able to understand the scoring section the worksheet for the international standards for neurological classification of spinal cord injury the worksheet will be used to Define the neurological, sensory, and motor levels of injury. Define the ASIA impairment scale classification. And define the zone of partial preservation. This course is based upon the 2019 revised version, or the 8th edition of the Standards and the Updated 2019 Worksheet. Performing an accurate examination is the necessary first step in accurate scoring, scaling, and classification, but the skills required for scoring differ from those required for examination. The neurological assessment, which includes the motor and sensory examinations described in Module 2 and 3, and the anorectal examination described in Module 4, requires a high degree of interpretation and forms the data. database for the determination of the motor and sensory scores, the motor, sensory, and neurological levels, the completeness of neurological injury, the AIS grade, and the zone of partial preservation. Motor and sensory scores are important endpoints for determining change, such as improvement, lack of improvement, or deterioration of neurological function over time. For clinical purposes, the motor score provides a rapid method of communicating change. For research purposes such as in multi-center clinical trials, motor and sensory scores can serve as endpoints to demonstrate effectiveness of interventions. This module provides an introduction to scoring methods using case studies to further illustrate key concepts. To calculate the sensory score, each of the key sensory points on both sides of the body must be tested using both light touch and sharp or dull discrimination testing modalities. A score of 0, 1 or 2 is assigned to each key sensory point, as previously discussed in Module 2, the sensory examination. In case of the presence of non-SCI inhibiting factors, abnormal scores should be tagged with an asterisk. Normal sensation for each modality is reflected in a score of 2. A score of 2 for each of the 28 key sensory points tested on both sides of the body would result in a maximum score of 56 for light touch on each side for a total of 112. The same is true for sharp or dull, also a total of 112. The sensory score cannot be calculated if any required key sensory point is not tested. Sensory scores should be calculated based on actual scores, even those identified with an asterisk. To calculate the motor score, each of the 10 key muscles on both sides of the body is given a grade of 0 through 5, using the scale described in Module 3, the Motor Examination. In case of the presence of non-SCI inhibiting factors, abnormal scores should be tagged with an asterisk. Normal strength is assigned a grade of 5 for each muscle. A score of 5 for each of the 5 key muscles of the upper extremity would result in a maximum score of 25 for each extremity left and right totaling 50 for the upper limbs the same is true for the five key muscles of the lower extremity left and right totaling 50 for the lower limbs Although in the past a total motor score of 100 for all extremities was calculated, it is no longer recommended to add the upper limb and lower limb scores. Examination of the metric properties of the motor score indicate that it should be separated into two scales, one composed of the 10 upper limb muscles and one of the 10 lower limb muscles. The motor score cannot be calculated if any required muscle is not tested. Motor scores should be calculated based on actual scores, even those identified with an asterisk. Once the sensory and motor scores have been determined, there are six steps for determining classification. First, the sensory and motor levels are determined for right and left sides, based upon the examination findings for the key sensory points and key muscles. Therefore, four separate levels are possible. A right sensory level, a left sensory level, a right motor level and a left motor level. The neurological level of injury is the most rostral of these four levels. We'll start with the sensory level. The sensory level is the most caudal, normally innervated dermatome for both light touch sensation and sharp dull discrimination. Normal is a grade of 2 in all dermatomes beginning with C2. and extending to the first segment that has a score less than two. Starting from the top of the worksheet, proceed down the column until you see a 1 or 0 for either light touch or sharp dull. Then go up one level. This is the sensory level. If sensation is abnormal at C2, the sensory level should be designated as C1. Since the right and left sides may differ, the sensory level should be determined for each side. If sensation is intact on one side for both light touch and sharp dull, and at all dermatomes C2 through S4-S5, the sensory level for that side should be recorded as INT, which indicates intact. Do not record the level as S5. Try this example. For the current worksheet scores, enter the sensory levels in the boxes, and submit when both values have been entered. The motor level is the most caudal normal or intact innervated spinal nerve or segment, below which a motor deficit exists. As stipulated in the international standards, the key muscle representing this segment must be a grade of 3 or better to be considered intact, provided all segments rostral to the key muscle segment test as grade 5 or normal. Just as each segmental nerve root innervates more than one muscle, Most muscles are innervated by more than one nerve segment. By convention, if a muscle has a grade of at least three, it is considered to have intact innervation by the more rostral of the innervating segments. In determining the motor level, the next most rostral key muscle must test as five, since it is assumed that the muscle will have both of its two innervating segments intact. Accurate motor level determination depends on accurate muscle grading. including the appropriate use of asterisk as an indicator of how to handle a respective motor score during classification. Motor levels may differ by side of the body, so they must be determined for both right and left sides. For those myotomes that are not clinically testable by a manual muscle exam, such as C2 to C4, T2 to L1, and S2 to S5, The motor level is presumed to be the same as the sensory level, if the testable motor function above that level is normal as well. If sensation in the non-motor testable zones is impaired, motor function is considered impaired. Special rules are needed when either C5 or L2 is the first weak key muscle, since there is not a next most rostral key muscle to test. In this case, sensation in the next rostral level, C4 or L1, is the first weak key muscle to test. is used as the substitute for muscle function the neurological level of injury or nli is the most caudal segment of the cord with intact sensation and anti-gravity muscle function strength three or greater provided that there is normal sensory and motor function rostrally in short the neurological level of injury is the most rostral of all the sensory and motor levels The neurological level of injury is used when determining the Asia Impairment Scale, or AIS, grade between an AIS-C and D. It is also useful for situations where designation of up to four separate levels would be cumbersome, such as in epidemiologic research. However, since the prediction of self-care and ambulation is usually based on the motor level, and when a difference exists between motor and sensory levels, The use of the neurological level may be misleading in predicting functional activities. What is the neurological level of injury for this worksheet? Injuries are also classified in terms of neurologically complete or incomplete. A complete injury is defined as the absence of sensory and motor function in the lowest sacral segment, S4-5. An incomplete injury is defined as partial preservation of sensory and or motor function at S4-5. This is determined by examination of the most caudal sacral segment, which is the key sensory point for the S4-5 dermatome. Sacral sensation includes light touch or pinprick sensation near the anal mucocutaneous junction or the presence of deep anal pressure upon digital rectal exam. The test of motor function is the presence of voluntary contraction of the external anal sphincter upon digital rectal examination. Sacral sparing refers to the presence of any sensory or motor function in the S4-5 segment that meets the criteria for an incomplete injury. The sacral sparing definition of a complete versus incomplete injury was adopted by the Standards Committee in 1992. Prior to 1992, an injury was considered to be incomplete if sensory or motor function extended more than three levels below the level of injury. If there is sacral sparing of only sensory function and there is not motor function more than three levels below the motor level on either side, The injury is said to be sensory incomplete or AIS-B. An injury is said to be motor incomplete, AIS-C or D, if either 1. there is sacral sparing of motor function determined by voluntary anal contraction or 2. there is sacral sparing of sensory function and motor function is present more than three levels below the motor level on either side. The standards do allow non-key muscles more than three levels below the motor level to be used in determining motor incomplete injuries in sensory incomplete patients. Specific levels for each of the non-key muscles have been developed to more consistently apply for this classification. For more information on these topics, please see Module 3, the Motor Examination, and Module 4, the Anorectal Examination. The Asia Impairment Scale, or AIS, uses the letters A through E to grade the various degrees of impairment. The following definitions are used in the grading. A equals complete injury. No sensory or motor function is preserved in the sacral segments S4, 5. B equals sensory incomplete. Sensory, but not motor function is preserved below the neurological level. and includes the sacral segments S4-5, either with light touch or pinprick 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 equals motor incomplete. Motor function is preserved below the neurological level, and more than half of the key muscles below the neurological level of injury have a muscle grade less than three. D equals motor incomplete. Motor function is preserved below the neurological level and at least half of the key muscles below the neurological level of injury have a muscle grade greater than or equal to 3. For an individual to receive a grade of C or D and be graded as motor incomplete, they must have either voluntary anal sphincter contraction or sacral sensory sparing. with sparing of motor function more than three levels below the motor level for that side of the body the international standards currently allows non-key muscle function more than three levels below the motor level to be used in determining motor incomplete status AIS B versus C When distinguishing between AIS B and C, the motor level on each side is used to assess the extent of motor sparing below that level, whereas when distinguishing between AIS C and D, based on key muscle functions grade 3 or better, the neurological level of injury is used. E equals normal. If sensation and motor function are graded as normal in all segments and the patient had prior deficits, then the AIS grade is E. Someone without an initial spinal cord injury does not receive an AIS grade. For determining the AIS grade, start by determining if the injury is complete. Here's a tip to remember. If the injury is complete, the worksheet will read N0000N. The letter N indicates there is no anal sensation or voluntary anal contraction at the S4-5 levels. The zeros refer to absent sensation to light touch and pinprick at the S4 and S5 level. If the injury is complete, then the AIS grade is A. Next, if the injury is sensory incomplete, we determine the motor incompleteness using the motor level. That is, Is there any voluntary anal sphincter contraction or motor function more than three levels below the motor level on either side? This motor function does not have to be in a key muscle. Any voluntarily activated muscle whose innervation is at least three levels below the motor level counts. If not, then the injury is considered sensory incomplete. The AIS grade is B. If there is voluntary anal contraction or motor function more than three levels below the motor level on either side, the injury is considered motor incomplete. Next, we need to discern between AIS grades C and D, so we use the levels below the neurological level of injury. If more than half of the key muscles below the neurological level of injury are graded less than three, then the AIS grade is C. Likewise, if half or more of those key muscles are graded 3 or better, then the AIS grade is D. If sensation and motor function are scored on the worksheet as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Remember that someone without a spinal cord injury does not receive an AIS grade. The zone of partial preservation, or ZPP, refers to those dermatomes and myotomes caudal to the sensory and motor levels with partially preserved functions. The most caudal segment with some sensory or motor function defines the extent of the sensory or motor zone of partial preservation respectively and should be recorded for the right and left sides. The single lowest preserved segment is designated on the worksheet for each zone of partial preservation. rather than the entire range of segments with partially preserved functions. The ZPP is used only in injuries with absent motor, which means no voluntary anal contraction, or sensory function, no deep anal pressure, and no light touch and no pinprick sensation in S4-5 on a given side in the lowest sacral segments. With an injury without motor or sensory function in the segments S4-5, but no partially innervated segments below a motor or sensory level the motor or sensory level should be entered in the box for the zone of partial preservation note that motor function does not follow sensory function in recording motor ZPPs but rather the caudal extent of the motor ZPP must be based on the presence of voluntary muscle contraction below the motor level for instance in a case where the motor sensory and therefore NLI is T4, with sparing of some sensation at the left T6 dermatome. T6 should be entered for the left sensory ZPP, but the box for motor ZPP should remain T4. The sensory TPP on a given side is defined in the absence of light touch and pinprick sensation in S4-5. LTPP on this side, as long as deep anal pressure is not present. This means that in cases with present DAP sensory ZPPs on both sides are not defined and should be noted as not applicable or NA. In cases with absent DAP a sensory ZPP can be defined on one side assuming also absent light touch and pinprick sensation in S4-5 on this side while it may not necessarily be applicable and should be noted as NA on the other side if there is present light touch or pinprick sensation at S45. Accordingly, if voluntary anal contraction is present, the motor zones of partial preservation on both sides are not applicable and are noted as NA. Motor ZPPs are defined in all cases with absent VAC, including patients with sensory incomplete injuries. Non-key muscles are generally not included in the ZPP. However, when the most caudal non-key muscle function is used for AISC classification, the associated root level should be recorded as motor ZPP. The length of the zone of partial preservation is found by counting the number of levels from the designated sensory or motor level to the designated ZPP. For example, if the sensory level is T4 and the caudal extent of the sensory zone is T9, then the sensory ZPP is 5 spinal segments long. If the motor level is C6, and the caudal extent of the motor ZPP is C6, then the motor ZPP is zero spinal segments long. Determine the ZPP for this worksheet. Now try this one. And one more. And another case. Let's do a final case of ZPP before we move to a series of other case examples.

Funding for this project has been provided by The International Spinal Cord Society Medtronic The Craig H. Nielsen Foundation and the Christopher and Dana Reeve Foundation. The goal of this course series is to promote spinal cord injury knowledge, care, and research by providing an internet tutorial on the international standards for the classification of spinal cord injury. There are five modules in the series.

Basic Anatomy, the Sensory Examination, the Motor Examination, the Anorectal Examination, and this module scoring scaling and classification this course series should prepare you to conduct and score the exam for the international standards for the classification of spinal cord injury at the end of this module you will be able to understand the scoring section the worksheet for the international standards for neurological classification of spinal cord injury the worksheet will be used to Define the neurological, sensory, and motor levels of injury. Define the ASIA impairment scale classification. And define the zone of partial preservation. This course is based upon the 2019 revised version, or the 8th edition of the Standards and the Updated 2019 Worksheet.

Performing an accurate examination is the necessary first step in accurate scoring, scaling, and classification, but the skills required for scoring differ from those required for examination. The neurological assessment, which includes the motor and sensory examinations described in Module 2 and 3, and the anorectal examination described in Module 4, requires a high degree of interpretation and forms the data. database for the determination of the motor and sensory scores, the motor, sensory, and neurological levels, the completeness of neurological injury, the AIS grade, and the zone of partial preservation.

Motor and sensory scores are important endpoints for determining change, such as improvement, lack of improvement, or deterioration of neurological function over time. For clinical purposes, the motor score provides a rapid method of communicating change. For research purposes such as in multi-center clinical trials, motor and sensory scores can serve as endpoints to demonstrate effectiveness of interventions. This module provides an introduction to scoring methods using case studies to further illustrate key concepts.

To calculate the sensory score, each of the key sensory points on both sides of the body must be tested using both light touch and sharp or dull discrimination testing modalities. A score of 0, 1 or 2 is assigned to each key sensory point, as previously discussed in Module 2, the sensory examination. In case of the presence of non-SCI inhibiting factors, abnormal scores should be tagged with an asterisk. Normal sensation for each modality is reflected in a score of 2. A score of 2 for each of the 28 key sensory points tested on both sides of the body would result in a maximum score of 56 for light touch on each side for a total of 112. The same is true for sharp or dull, also a total of 112. The sensory score cannot be calculated if any required key sensory point is not tested. Sensory scores should be calculated based on actual scores, even those identified with an asterisk.

To calculate the motor score, each of the 10 key muscles on both sides of the body is given a grade of 0 through 5, using the scale described in Module 3, the Motor Examination. In case of the presence of non-SCI inhibiting factors, abnormal scores should be tagged with an asterisk. Normal strength is assigned a grade of 5 for each muscle. A score of 5 for each of the 5 key muscles of the upper extremity would result in a maximum score of 25 for each extremity left and right totaling 50 for the upper limbs the same is true for the five key muscles of the lower extremity left and right totaling 50 for the lower limbs Although in the past a total motor score of 100 for all extremities was calculated, it is no longer recommended to add the upper limb and lower limb scores. Examination of the metric properties of the motor score indicate that it should be separated into two scales, one composed of the 10 upper limb muscles and one of the 10 lower limb muscles.

The motor score cannot be calculated if any required muscle is not tested. Motor scores should be calculated based on actual scores, even those identified with an asterisk. Once the sensory and motor scores have been determined, there are six steps for determining classification.

First, the sensory and motor levels are determined for right and left sides, based upon the examination findings for the key sensory points and key muscles. Therefore, four separate levels are possible. A right sensory level, a left sensory level, a right motor level and a left motor level. The neurological level of injury is the most rostral of these four levels. We'll start with the sensory level.

The sensory level is the most caudal, normally innervated dermatome for both light touch sensation and sharp dull discrimination. Normal is a grade of 2 in all dermatomes beginning with C2. and extending to the first segment that has a score less than two. Starting from the top of the worksheet, proceed down the column until you see a 1 or 0 for either light touch or sharp dull.

Then go up one level. This is the sensory level. If sensation is abnormal at C2, the sensory level should be designated as C1. Since the right and left sides may differ, the sensory level should be determined for each side.

If sensation is intact on one side for both light touch and sharp dull, and at all dermatomes C2 through S4-S5, the sensory level for that side should be recorded as INT, which indicates intact. Do not record the level as S5. Try this example. For the current worksheet scores, enter the sensory levels in the boxes, and submit when both values have been entered. The motor level is the most caudal normal or intact innervated spinal nerve or segment, below which a motor deficit exists.

As stipulated in the international standards, the key muscle representing this segment must be a grade of 3 or better to be considered intact, provided all segments rostral to the key muscle segment test as grade 5 or normal. Just as each segmental nerve root innervates more than one muscle, Most muscles are innervated by more than one nerve segment. By convention, if a muscle has a grade of at least three, it is considered to have intact innervation by the more rostral of the innervating segments. In determining the motor level, the next most rostral key muscle must test as five, since it is assumed that the muscle will have both of its two innervating segments intact. Accurate motor level determination depends on accurate muscle grading.

including the appropriate use of asterisk as an indicator of how to handle a respective motor score during classification. Motor levels may differ by side of the body, so they must be determined for both right and left sides. For those myotomes that are not clinically testable by a manual muscle exam, such as C2 to C4, T2 to L1, and S2 to S5, The motor level is presumed to be the same as the sensory level, if the testable motor function above that level is normal as well.

If sensation in the non-motor testable zones is impaired, motor function is considered impaired. Special rules are needed when either C5 or L2 is the first weak key muscle, since there is not a next most rostral key muscle to test. In this case, sensation in the next rostral level, C4 or L1, is the first weak key muscle to test.

is used as the substitute for muscle function the neurological level of injury or nli is the most caudal segment of the cord with intact sensation and anti-gravity muscle function strength three or greater provided that there is normal sensory and motor function rostrally in short the neurological level of injury is the most rostral of all the sensory and motor levels The neurological level of injury is used when determining the Asia Impairment Scale, or AIS, grade between an AIS-C and D. It is also useful for situations where designation of up to four separate levels would be cumbersome, such as in epidemiologic research. However, since the prediction of self-care and ambulation is usually based on the motor level, and when a difference exists between motor and sensory levels, The use of the neurological level may be misleading in predicting functional activities.

What is the neurological level of injury for this worksheet? Injuries are also classified in terms of neurologically complete or incomplete. A complete injury is defined as the absence of sensory and motor function in the lowest sacral segment, S4-5. An incomplete injury is defined as partial preservation of sensory and or motor function at S4-5.

This is determined by examination of the most caudal sacral segment, which is the key sensory point for the S4-5 dermatome. Sacral sensation includes light touch or pinprick sensation near the anal mucocutaneous junction or the presence of deep anal pressure upon digital rectal exam. The test of motor function is the presence of voluntary contraction of the external anal sphincter upon digital rectal examination. Sacral sparing refers to the presence of any sensory or motor function in the S4-5 segment that meets the criteria for an incomplete injury. The sacral sparing definition of a complete versus incomplete injury was adopted by the Standards Committee in 1992. Prior to 1992, an injury was considered to be incomplete if sensory or motor function extended more than three levels below the level of injury.

If there is sacral sparing of only sensory function and there is not motor function more than three levels below the motor level on either side, The injury is said to be sensory incomplete or AIS-B. An injury is said to be motor incomplete, AIS-C or D, if either 1. there is sacral sparing of motor function determined by voluntary anal contraction or 2. there is sacral sparing of sensory function and motor function is present more than three levels below the motor level on either side. The standards do allow non-key muscles more than three levels below the motor level to be used in determining motor incomplete injuries in sensory incomplete patients.

Specific levels for each of the non-key muscles have been developed to more consistently apply for this classification. For more information on these topics, please see Module 3, the Motor Examination, and Module 4, the Anorectal Examination. The Asia Impairment Scale, or AIS, uses the letters A through E to grade the various degrees of impairment.

The following definitions are used in the grading. A equals complete injury. No sensory or motor function is preserved in the sacral segments S4, 5. B equals sensory incomplete. Sensory, but not motor function is preserved below the neurological level.

and includes the sacral segments S4-5, either with light touch or pinprick 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 equals motor incomplete. Motor function is preserved below the neurological level, and more than half of the key muscles below the neurological level of injury have a muscle grade less than three. D equals motor incomplete. Motor function is preserved below the neurological level and at least half of the key muscles below the neurological level of injury have a muscle grade greater than or equal to 3. For an individual to receive a grade of C or D and be graded as motor incomplete, they must have either voluntary anal sphincter contraction or sacral sensory sparing.

with sparing of motor function more than three levels below the motor level for that side of the body the international standards currently allows non-key muscle function more than three levels below the motor level to be used in determining motor incomplete status AIS B versus C When distinguishing between AIS B and C, the motor level on each side is used to assess the extent of motor sparing below that level, whereas when distinguishing between AIS C and D, based on key muscle functions grade 3 or better, the neurological level of injury is used. E equals normal. If sensation and motor function are graded as normal in all segments and the patient had prior deficits, then the AIS grade is E. Someone without an initial spinal cord injury does not receive an AIS grade.

For determining the AIS grade, start by determining if the injury is complete. Here's a tip to remember. If the injury is complete, the worksheet will read N0000N.

The letter N indicates there is no anal sensation or voluntary anal contraction at the S4-5 levels. The zeros refer to absent sensation to light touch and pinprick at the S4 and S5 level. If the injury is complete, then the AIS grade is A. Next, if the injury is sensory incomplete, we determine the motor incompleteness using the motor level. That is, Is there any voluntary anal sphincter contraction or motor function more than three levels below the motor level on either side?

This motor function does not have to be in a key muscle. Any voluntarily activated muscle whose innervation is at least three levels below the motor level counts. If not, then the injury is considered sensory incomplete.

The AIS grade is B. If there is voluntary anal contraction or motor function more than three levels below the motor level on either side, the injury is considered motor incomplete. Next, we need to discern between AIS grades C and D, so we use the levels below the neurological level of injury. If more than half of the key muscles below the neurological level of injury are graded less than three, then the AIS grade is C. Likewise, if half or more of those key muscles are graded 3 or better, then the AIS grade is D.

If sensation and motor function are scored on the worksheet as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Remember that someone without a spinal cord injury does not receive an AIS grade. The zone of partial preservation, or ZPP, refers to those dermatomes and myotomes caudal to the sensory and motor levels with partially preserved functions. The most caudal segment with some sensory or motor function defines the extent of the sensory or motor zone of partial preservation respectively and should be recorded for the right and left sides. The single lowest preserved segment is designated on the worksheet for each zone of partial preservation.

rather than the entire range of segments with partially preserved functions. The ZPP is used only in injuries with absent motor, which means no voluntary anal contraction, or sensory function, no deep anal pressure, and no light touch and no pinprick sensation in S4-5 on a given side in the lowest sacral segments. With an injury without motor or sensory function in the segments S4-5, but no partially innervated segments below a motor or sensory level the motor or sensory level should be entered in the box for the zone of partial preservation note that motor function does not follow sensory function in recording motor ZPPs but rather the caudal extent of the motor ZPP must be based on the presence of voluntary muscle contraction below the motor level for instance in a case where the motor sensory and therefore NLI is T4, with sparing of some sensation at the left T6 dermatome.

T6 should be entered for the left sensory ZPP, but the box for motor ZPP should remain T4. The sensory TPP on a given side is defined in the absence of light touch and pinprick sensation in S4-5. LTPP on this side, as long as deep anal pressure is not present.

This means that in cases with present DAP sensory ZPPs on both sides are not defined and should be noted as not applicable or NA. In cases with absent DAP a sensory ZPP can be defined on one side assuming also absent light touch and pinprick sensation in S4-5 on this side while it may not necessarily be applicable and should be noted as NA on the other side if there is present light touch or pinprick sensation at S45. Accordingly, if voluntary anal contraction is present, the motor zones of partial preservation on both sides are not applicable and are noted as NA.

Motor ZPPs are defined in all cases with absent VAC, including patients with sensory incomplete injuries. Non-key muscles are generally not included in the ZPP. However, when the most caudal non-key muscle function is used for AISC classification, the associated root level should be recorded as motor ZPP. The length of the zone of partial preservation is found by counting the number of levels from the designated sensory or motor level to the designated ZPP.

For example, if the sensory level is T4 and the caudal extent of the sensory zone is T9, then the sensory ZPP is 5 spinal segments long. If the motor level is C6, and the caudal extent of the motor ZPP is C6, then the motor ZPP is zero spinal segments long. Determine the ZPP for this worksheet. Now try this one. And one more.

And another case. Let's do a final case of ZPP before we move to a series of other case examples.

Transcript for:Classifying Spinal Cord Injuries Overview

Transcript for:
Classifying Spinal Cord Injuries Overview