The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) or more commonly referred to as the ASIA Impairment Scale (AIS), was developed by the American Spinal Injury Association (ASIA) as a universal classification tool for Spinal Cord Injury based on a standardized sensory and motor assessment, with the most recent revised edition published in 2011. The impairment scale involves both a motor and sensory examination to determine the sensory and motor levels for the right and left side, the overall neurological level of the injury and completeness of the injury i.e. whether the injury is complete or incomplete.

1. INTERNATIONAL
STANDARDS FOR
NEUROLOGICAL
CLASSIFICATION OF SPINAL
CORD INJURY
Dr Joe Antony
JR 2,PMR

2. Contents
Sensory exam
01
Motor exam
02
Anorectal
Exam
03
Classification
04

3. Sensory
examination

4. Steps
◦ Sensory testing on Cheeks
◦ If normal sensation cannot be established , Mark NT in all dermatomes
◦ Start with sensation from C2 to S2
◦ Light Touch
◦ Pin Prick
◦ If any key sensory areas are not available,
◦ Due to burns,lacerations, casting etc
◦ Any other area in dermatome can be checked
◦ If alternate location used, should be mentioned in comment

5. Light touch
◦ Tool- Tapered wisp of cotton
◦ If alternative is used should be mentioned
◦ Method
◦ Start with establishing normal on cheeks
◦ Then test on dermatomes sequentioally
◦ Stroke with wisp of cotton over key sensory area
over a 1cm area
◦ Compare with cheek
◦ Repeat for 10 times- 8 correct out of 10 is normal
◦ Grading
◦ 0- not able to differentiate ‘touched’ and ‘not
toched’
◦ 1- able to feel the touch, but is different from
sensation on cheek (greater , lesser or otherwise
different)
◦ 2- Normal
◦ NT- Key sensory area and rest of dermatome not
available
◦ *- marked on abnormal score (0,1,NT) when score
is impacted by Non SCI condition
◦ For classification purposes * will be considered as
normal on levels above sensory level
◦ * at or below sensory level considered as
abnormal.

6. Sharp/dull discrimination exam
◦ Tool-Clean, unused safety pin
◦ Method- same as soft touch
◦ Grading
◦ 0- No feeling or cannot reliably differentiate
◦ 1- Can reliably differentiate but less intense than
on cheek
◦ 2- Can differentiate and of the same intensity as
face.
◦ NT same as light touch

15. Challenging areas in Sensory examination
◦ T3 dermatome
◦ Sensation absent in T1 and T2 , but T3 has some
sensation
◦ Supraclavicular nerves(C4) descent onto anterior
superior chest
◦ Hence, If T2 and T4 dermatome are 0, T3 can also
be scored 0
◦ Patient not able to identify dull side of pin (
feeling sharp on dull)
◦ If “dull end” is less sharp than “sharp end” score as
1
◦ If patient cant feel the difference, score as zero
◦ If patient feels dullness on sharp end, score zero

16. Common pitfalls
◦ Misinterpreting response
◦ “Yes” response for sharp pin testing is not enough to interpret as present.
◦ Age of the patient
◦ Children less than 5years doesn’t give consistent responses.
◦ Poor explanations
◦ Cognitive impairments
◦ Delayed sensory response
◦ May be due to abnormal pathways.

17. Motor
examination

18. ◦ Key muscles
◦ To be tested in all patients
◦ Non key muscles
◦ To be tested in “Sensory incomplete “ 3 levels below motor level on each side to confirm motor
incomplete status.

19. Differences from regular clinical testing
◦ Patient position- Always Supine in international standards examination
◦ Allows to comparison between acute to rehab phase
◦ does not allow true gravity-eliminated position in all muscle groups
◦ Patient’s body habitus and ROM also preclude a truly gravity-eliminated position
◦ Despite all this consistent positioning improves reliability
◦ No ‘+’ or “-” scoring
◦ NT designation option

20. Key muscles
◦ C5- Elbow flexors
◦ C6-Wrist extensors
◦ C7-Elbow extensors
◦ C8- Long finger flexors
◦ T1- Finger abductors
◦ L2- Hip flexors
◦ L3-Knee extensors
◦ L4- Ankle dorsiflexors
◦ L5-long toe extensors
◦ S1- Ankle PFs

21. How key muscles are selected

22. Non Key muscles
◦ When?
◦ To differentiate between Asia B and Asia
C
◦ Test non key muscles 3 levels below NLI
◦ Ask patient if any movement is possible
other than what is already done.
◦ No standardized testing. Even a powr of 1
in any group below 3 levels of NLI is
enough to qualify ASIA C

23. Motor Grading
NT grading and
interpretation like
sensory

24. Special Notes
◦ Contracture limits ROM ( More than 50% available)- Score like normal from 0-5
◦ Contracture limits ROM (less than 50% available)- Score as NT
◦ Spasticity limit ROM- Score as NT if isolated movement not possible
◦ Abnormal response due to non SCI- Mark * with score and examiner judges how to use it in classification

25. Common pitfalls

26. Anorectal examination
◦ Verbally prepare the patient

27. Contraindication for anorectal examination
◦ Perineal Lacerations
◦ Burns
◦ Premorbid anorectal pathology

28. Steps
◦ First test external sensory examination
◦ Then internal exam

29. GRADING AND
CLASSIFICATION

30. Grading

33. Steps

36. Thank you
◦ Refernce
◦ ASIA Instep training materials (ASIA e-Learning Center - American Spinal Injury Association (asia-spinalinjury.org)