SCI 2 - ASIA Scale

when should you perform the ASIA exam?

after spinal shock resolves ~72 hours

when do you perform the ASIA exam again?

one month mark → more depending on progress

what is the neurological level of injury?

level the patient is diagnosed at means that is the most caudal/distal intact level bilaterally

how many muscles involved in the motor assessment?

10

how many sensory points?

28 → light touch, sharp/dull

how do you determine complete vs. incomplete?

Voluntary Anal Contraction

Deep Anal Pressure or Light touch or pin prick at S4-5

Sensory Exam:

At least one cm lateral to the occipital protuberance at the base of the skull. Alternately, it can be located at least 3 cm behind the ear

C2

Sensory Exam:

In the supraclavicular fossa, at the midclavicular line

C3

Sensory Exam:

Over the acromioclavicular joint

C4

Sensory Exam:

On the lateral (radial) side of the antecubital fossa just proximal to the elbow (see image below)

C5

Sensory Exam:

On the dorsal surface of the proximal phalanx of the thumb

C6

Sensory Exam:

On the dorsal surface of the proximal phalanx of the middle finger

C7

Sensory Exam:

On the dorsal surface of the proximal phalanx of the little finger

C8

Sensory Exam:

On the medial (ulnar) side of the antecubital fossa, just proximal to the medial epicondyle of the humerus

T1

Sensory Exam:

at the apex of the axilla

T2

Sensory Exam:

At the midclavicular line and the third intercostal space, found by palpating the anterior chest to locate the third rib and the corresponding third intercostal space below it

T3

Sensory Exam:

At the midclavicular line and the fourth intercostal space, located at the level of the nipples

T4

Sensory Exam:

At the midclavicular line and the fifth intercostal space, located midway between the level of the nipples and the level of the xiphisternum

T5

Sensory Exam:

At the midclavicular line, located at the level of the xiphisternum

T6

Sensory Exam:

At the midclavicular line, one quarter the distance between the level of the xiphisternum and the level of the umbilicus

T7

Sensory Exam:

At the midclavicular line, one half the distance between the level of the xiphisternum and the level of the umbilicus

T8

Sensory Exam:

At the midclavicular line, three quarters of the distance between the level of the xiphisternum and the level of the umbilicus

T9

Sensory Exam:

At the midclavicular line, located at the level of the umbilicus

T10

Sensory Exam:

At the midclavicular line, midway between the level of the umbilicus and the inguinal ligament

T11

Sensory Exam:

At the midclavicular line, over the midpoint of the inguinal ligament

T12

Sensory Exam:

Midway between the key sensory points for T12 and L2

L1

Sensory Exam:

On the anterior-medial thigh, at the midpoint drawn on an imaginary line connecting the midpoint of the inguinal ligament and the medial femoral condyle

L2

Sensory Exam:

At the medial femoral condyle above the knee

L3

Sensory Exam:

Over the medial malleolus

L4

Sensory Exam:

On the dorsum of the foot at the third metatarsal phalangeal joint

L5

Sensory Exam:

On the lateral aspect of the calcaneus

S1

Sensory Exam:

At the midpoint of the popliteal fossa

S2

Sensory Exam:

Over the ischial tuberosity or infragluteal fold (depending on the patient their skin can move up, down or laterally over the ischii)

S3

Sensory Exam:

In the perianal area, less than one cm. lateral to the mucocutaneous junction

S4/5

Motor Exam: C5

elbow flexors

Motor Exam: C6

wrist extensors

Motor Exam: C7

elbow extensors

Motor Exam: C8

finger flexors (DIP at middle finger)

Motor Exam: T1

finger abductor (little finger)

Motor Exam: L2

hip flexors

Motor Exam: L3

knee extensors

Motor Exam: L4

ankle dorsiflexors

Motor Exam: L5

long toe extensors

Motor Exam: S1

ankle plantarflexion

Motor Exam: elbow flexors

C5

Motor Exam: wrist extensors

C6

Motor Exam: elbow extensors

C7

Motor Exam: finger flexors (DIP of middle finger)

C8

Motor Exam: finger abductor (little finger)

T1

Motor Exam: hip flexors

L2

Motor Exam: knee extensors

L3

Motor Exam: ankle dorsiflexors

L4

Motor Exam: long toe extensors

L5

Motor Exam: ankle plantarflexion

S1

motor examination is tested in ____ in SPECIFIC modified positions

supine

what are the important factors to consider when performing the motor exam?

good stabilization, proper positioning, observe for substitution

what are the important clinical judgment factors to consider when performing the motor exam?

presence of pain, poor positioning, weakness secondary to disuse

Muscle Function Grading: 0

total paralysis

Muscle Function Grading: 1

palpable or visible contraction

Muscle Function Grading: 2

active movement, full ROM with gravity eliminated

Muscle Function Grading: 3

active movement, full ROM against gravity

Muscle Function Grading: 4

active movement, full ROM against gravity and moderate resistance in a muscle specific position

Muscle Function Grading: 5

(normal) active movement, full ROM against gravity and full resistance in a functional muscle position expected from an otherwise unimpaired person

Muscle Function Grading: NT

i.e due to immobilization, severe pain such that the patient cannot be graded, amputation of the limb, or contracture of 50% of the normal ROM

a 0*-4* is permitted on a motor exam if…?

testing is limited due to other factors

how do you determine motor level?

Lowest myotome with intact innervation

Muscle grade of at least 3/5 AND Rostral muscle function is (5/5)

if a myotome is not clinically testable, what do you use instead?

sensory level

what is the grading for sensory?

0 = absent

1 = impaired (cannot distinguish)

2 = normal (same as face)

how do you score the sensory exam?

Most caudal level on that side of body where both light touch and pin prick are “Intact” = 2

why do we use the face as the reference area?

trigeminal nerve → cranial nerve (not in the spinal cord!)

if a person says “yes” during the light touch/sharp/dull exam, what is the follow up question?

does it feel the same as your face?

how do you determine the single neurological level of injury?

most rostral of these 4 levels (used for classification)

what is complete injury?

no motor or sensory function is preserved in the sacral segments S4-S5

NO Voluntary Anal Contraction AND Deep Anal Pressure or Light Touch or Pin Prick

what is incomplete injury?

sensory and/or motor function is present at the most distal segments S4-S5

DAP may be absent, but they may have some LT or PP preserved at S4-5

if there is sensation at S4/5 but both VAC and DAP are no’s…is it complete or incomplete?

incomplete (B) → because there is still some sensation getting through the cord so its not complete

what is the rule of zone of partial preservation?

Can ONLY be present when a patient has absent motor or sensory function in S4-5; includes residual motor and/or sensory function below the ipsilateral motor or sensory level

if VAC = no…can you document ZPP?

yes, document motor ZPP bilaterally

if DAP = no, and LT and PP is 0 at S4-5…can you document ZPP?

yes, document sensory ZPP

Anytime VAC or DAP is preserved (including LT and PP) → meaning they have feeling or motor contraction (YES)…can you document ZPP?

no!