DISCUSSION

DOI:10.17816/PTORS4267-72

NEUROLOGICAL CLASSIFICATION OF SPINAL CORD INJURIES

(ASIA/ISNCSCI SCALE, REVISED 2015)
S.V. Vissarionov 1,2, A.G. Baindurashvili 1,2, I.A. Kryukova 2
1 The Turner Scientific and Research Institute for Children’s Orthopedics, Saint Petersburg, Russia;
2 North-Western State Medical University named after I. I. Mechnikov, Saint Petersburg, Russia
For citation: Pediatric Traumatology, Orthopaedics and Reconstructive Surgery, 2016;4(2):67-72 Received: 10.03.2016
Accepted: 04.05.2016

Standardization of neurological examination and diagnosis in the case of spinal injury is currently an important challenge
in neurotraumatology. At present, most organizations, worldwide, that are involved with spinal injuries, apply the
International Standards for Neurological Classifications of Spinal Cord Injury (ISNCSCI), drafted by American Spinal
Injury Association (ASIA) and approved in 1992. The ASIA/ISNCSCI scale is a quantitative system for estimation of
the neurological status of spinal cord injury patients. The ASIA/ISNCSCI scale has been repeatedly updated and revised
since 1992. The 2015 version of the ISNCSCI on the American Spinal Injury Association website is demonstrated in
this study, and the form and testing instruction are translated into Russian.
Keywords: spinal cord injury, International Standards for Neurological Classification of Spinal Cord Injury, American
Spinal Injury Association, neurological level, ASIA scale.

In 1992, the ASIA classification was recognized
by the International Medical Society of Paraplegia
(IMSOP), acquiring the status of International
Standards for Neurological Classification of Spinal
Cord Injury (ISNCSCI-92) [10-12]. Since then,
the ASIA classification has undergone several
reviews and updates, the last of which was in 2015
[13-21]. At present, it is recognized by almost all
organizations worldwide involved in spinal cord
injuries [1, 20, 21].
Although the ASIA/ISNCSCI standards had
been established for traumatic impairments of
the spinal cord, they are also used for evaluating
the neurological status of patients with other
pathological spinal conditions, such as those with
tumors and infections.
The aim of this study is to introduce
practitioners to the 2015 version of ASIA/ISNCSCI.
General characteristics of the ASIA/ISNCSCI
classification.
With the ASIA/ISNCSCI classification,
neurological examination is strictly standardized
and is conducted with the patient lying on their
back. The level of spinal cord injury is determined
as with neurological testing. All the obtained
results are written in a standardized form. Figures
1 and 2 demonstrate the original form and testing
instructions presented on the website of the
American Spinal Injury Association [20, 21], and
Figures 3 and 4 show the translated Russian version.
The algorithm for spinal cord assessment
involves the consecutive determination of the
following injuries: sensory levels of injury on the
left and right, motor levels of injury on the left
and right, neurological level of injury, extent of the
injury (complete or partial), and level of spinal cord
injury.
The system of sensory testing is based on the
dermatome map. A dermatome is an area of skin
innervated by a particular segment of the spinal
cord. A total of 28 key sensory points correlate to
each of the spinal cord segments: C2-1 cm around
the occipital prominence, C3-supraclavicular fossa,
C4-top of the acromioclavicular joint, C5-lateral
side of the antecubital fossa, C6-thumb (dorsal
surface, proximal phalange), C7-middle finger
(dorsal surface, proximal phalange), C8-little finger
(dorsal surface, proximal phalange), T1-medial side
68
of the antecubital fossa, T2-top of the axilla, T3-
third intercostal space on the midclavicular line,
T4-fourth intercostal space on the midclavicular
line (nipple level), T5-fifth intercostal space on the
midclavicular line, midway between the nipple and
the xiphoid, T6-xiphoid level on the midclavicular
line, T7-upper-fourth of the space between the
xiphoid and the navel (on the midclavicular line),
T8-midway between the xiphoid and the navel
(on the midclavicular line), T9-lower-fourth of
the space between the xiphoid and the navel (on
the midclavicular line), T10-navel level on the
midclavicular line, T11-midway between the navel
and the inguinal ligament (on the midclavicular
line), T12-middle of the inguinal fold (on the
midclavicular line), L1-midway between T12 and
L2, L2-halfway between the middle of the inguinal
ligament and the medial condyle of the femur, L3-
Fig. 1. Original form of the ASIA/ISNCSCI scale (2015)
presented on the website of the American Spinal Injury
Association (http://www.asiaspinalinjury.org/elearning/
ISNCSCI.php)
Fig. 3. ASIA/ISNCSCI form (2015), Russian version
Pediatric Traumatology, Orthopaedics and Reconstructive Surgery.

DISCUSSION
medial condyle of the femur above the knee, L4-top
of the medial malleolus, L5-dorsal surface of the foot
down to the level of the third metatarsophalangeal
joint, S1-lateral surface of the heel, S2-middle of the
popliteal space, S3-ischial tuberosity, S4-S5-perianal
zone (<1 cm around the anal edge).
Tactile sensitivity is assessed by touch with a
piece of cotton or a brush (this tests the function of
the posterior columns of the spinal cord), and pain
sensitivity is assessed by pricking (to test the function
of the spinothalamic tract). Sensitivity is scored from
0 – no sensation, 1 – disordered/modified sensation
(reduced or hypersensitivity), to 2 – normal sensation.
The obtained scores are added together. The maximum
score for sensitivity on each side is 56. NT, which
stands for “not tested,” is used if it is impossible to
assess sensitivity (in cases of immobilization, acute
pain, limb amputation, and contraction affecting
Fig. 2. Original ASIA/ISNCSCI testing instructions (2015)
(http://www.asiaspinalinjury.org/elearning/ISNCSCI.php).
Fig. 4. ASIA/ISNCSCI testing instruction (2015), Russian
version
Volume 4. Issue 2. 2016
DISCUSSION 69

> 50% of the normal scope of mobility). If it is less than 3 points, provided that the muscles of the
impossible to differentiate a prick from a touch, it is segment above have normal strength (5 points).
assessed as absence of pain sensitivity. In the areas where there are no indications
The level of sensory injury is determined as the for myotome testing, the level of motor injury is
most caudal dermatome with intact pain and tactile estimated using the sensory scale, provided that the
sensitivity. tested motor function above this level complies with
In addition, sensory function of the most caudal the standard.
segments of the spinal cord (S4-S5) is determined by The neurological level of injury is determined
slight finger pressure on the anorectal wall (anorectal based on the assessment of sensory and motor
pressure). Testing of anorectal sensitivity is necessary function.
to define if there is complete or partial injury. The level of neurological injury is the most
The system of motor function testing is based on caudal spinal cord segment with intact sensory
the estimation of muscle strength in 10 key groups function and key muscle strength of 3 points and
of muscles correlated to spinal cord segments: C5- higher if there is normal (initial) sensory and motor
forearm flexors, C6-wrist extensors, C7-forearm function in the rostral segments. Neurological level
extensors, C8-finger flexors, T1-muscles retracting is the most cranial of sensory and motor levels.
fingers (little finger), L2-femur flexors, L3-knee After estimating the function of the most
extensors, L4-ankle flexors, L5-great toe extensors, caudal spinal cord segments (S4-S5), it is necessary
S1-plantar foot flexors. The T2-T12 myotomes are to determine if the impairment is complete or
not tested. Muscle strength is estimated on each partial. The impairment is considered complete if
side using a 6-point Medical Research Council there is no voluntary contraction of the anus and
(MRC) scale (Table 1). The obtained scores are no sensation of anorectal pressure. If contraction
combined. The maximum score for the 10 segments of the anal sphincter is possible, spinal cord injury
on each side is 50. If strength cannot be tested is deemed partial regardless of any other data. In
for some reason, then NT is used. Motor function complete injuries, partially undamaged areas are
of the most caudal spinal cord segments (S4-S5) fixed (the dermatome with the lowest location on
is tested by eliciting anal contraction on rectal each side or myotome with partial innervation).
touching. The final stage is estimation of the level of spinal
Motor level is defined as the most caudal spinal cord injury, according to the ASIA Impairment
cord segment, with the strength of key muscles not Scale (AIS) (Table 2).
Table 1
Muscle strength assessment based on the MRC scale (Medical Research Council Scale, 1981)
Score Muscle strength characteristic
0 Complete palsy
1 Palpable or visible muscle contraction
2 Complete active movements without overcoming gravity
3 Complete active movements overcoming gravity
4 Complete active movements overcoming gravity and small external resistance
5 (Normal) complete active movements overcoming gravity and maximum external resistance

Level of impairment
A Complete
B Partial with retained
sensitivity
C Partial with retained
movements
Table 2
Scale of Spinal Cord Impairment Severity (AIS)
Criteria
no sensory or motor functions in segments S4–S5
sensation under the neurological level is retained, including segments S4–S5 (touch or
prick or anorectal pressure);
no motor function more than three levels below motor level on both sides.
motor (voluntary anal contraction) or sensory (touch or prick, or anorectal pressure)
function of segments S4–S5 is retained;
partial motor function at more than three levels below the ipsilateral motor level on
both sides;
less than half of the key muscles below the neurological level have strength ≥ 3 points.

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70 DISCUSSION

Level of impairment Criteria

motor (voluntary anus traction) or sensory (touch or prick, or anorectal pressure)
function of segments S4–S5 is retained;
D Partial with retained there is motor function at more than three levels below the ipsilateral motor level on
movements both sides;
half or more of key muscles bellow neurological level have strength of ≥3 points.
E Norm sensitive and motor function of all spinal cord segments comply with the norm.

Note: In patients with injury class determined as B: for more accurate classification (differentiation between B and C),
secondary muscles more than three levels below the motor level on the both sides are tested. Persons who have no spinal
cord injury are not tested using this scale.

Conclusion 2. Jochheim KA. Problems of classification in traumatic

At present, the ASIA classification is the
most relevant way of estimating the neurological
status of patients with spinal cord injury. Its
main advantages include strict standardization
of neurological examination in patients lying on
their back, having the minimum sufficient scope
of neurological examination for determining the
level of impairment, quantitative interpretation of
the obtained results, availability of a standardized
form for neurological examination, and the
possibility of conducting neurological testing not
only by a neurologist, but also by other specialists
(traumatologist and vertebrologist). These advantages
make the results of neurological examination more
authentic and comparable. The main disadvantage
of using the ASIA scale is the testing duration.
Therefore, in time-poor situations, clinicians often
prefer to use the less precise qualitative Frankel’s
scale.
Information on funding and conflict
of interests
This paper was prepared without any financial
support. The authors state that there are no
explicit or potential conflicts of interests related to
publication of this paper.
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php.

INTERNATIONAL STANDARDS FOR МЕЖДУНАРОДНЫЕ СТАНДАРТЫ

НЕВРОЛОГИЧЕСКОЙ КЛАССИФИКАЦИИ ТРАВМЫ
СПИННОГО МОЗГА (ШКАЛА ASIA/ISNCSCI, ПЕРЕСМОТР 2015 ГОДА)
© С.В. Виссарионов 1,2, А.Г. Баиндурашвили 1,2, И.А. Крюкова 2
1 ФГБУ «НИДОИ им. Г.И. Турнера» Минздрава России, Санкт-Петербург;
2 ФГБОУ ВО «СЗГМУ им. И.И. Мечникова» Минздрава России, Санкт-Петербург
Статья поступила в редакцию: 10.03.2016 Статья принята к печати: 04.05.2016

Стандартизация неврологического осмотра и формулирования неврологического заключения при спинальной

травме является актуальной проблемой нейротравматологии. В настоящее время практически все организации
в мире, занимающиеся проблемой спинальной травмы, используют международные стандарты неврологиче-
ской классификации травмы спинного мозга (International Standards for Neurological Classification of Spinal Cord
Injury, сокращенно ISNCSCI), разработанные Американской ассоциацией спинальной травмы (ASIA) и утверж-
денные в 1992 году. Стандарты ASIA/ISNCSCI представляют собой унифицированную количественную систему
оценки неврологического статуса у пациентов с травматическими повреждениями спинного мозга. С 1992 года
шкала ASIA/ISNCSCI неоднократно пересматривалась и обновлялась. Демонстрируется пересмотренная и об-
новленная в 2015 году версия международных стандартов неврологической классификации травмы спинного
мозга, представленная на сайте Американской ассоциации спинальной травмы, переведены на русский язык
бланк и инструкция тестирования.
Ключевые слова: травма спинного мозга, международные стандарты неврологической классификации травмы
спинного мозга, Американская ассоциация спинальной травмы, неврологический уровень, шкала ASIA.

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 Volume 4. Issue 2. 2016
72
Information about the authors
Sergei V. Vissarionov  — MD, PhD, professor, Deputy
Director for Research and Academic Affairs, head of the
department of spinal pathology and neurosurgery. The
Turner Scientific and Research Institute for Children’s
Orthopedics. Professor of the chair pediatric traumatology
and orthopedics of North-Western State Medical University
n.a. I.I. Mechnikov. E-mail: turner01@mail.ru.
Alexei G. Baindurashvili  — MD, PhD, professor,
corresponding member of RAS, honored doctor of the
Russian Federation, Director of The Turner Scientific and
Research Institute for Children’s Orthopedics; Head of the
chair pediatric traumatology and orthopedics of North-
Western State Medical University n.a. I.I. Mechnikov.
E-mail: turner01@mail.ru.
Irina A. Kryukova  — MD, PhD, neurologist, assistant
professor of the chair of pediatric traumatology and
orthopedics of North-Western State Medical University
n.a. I.I. Mechnikov. E-mail: i_krukova@mail.ru.
Pediatric Traumatology, Orthopaedics and Reconstructive Surgery.

DISCUSSION
Сергей Валентинович Виссарионов  — д-р мед. наук,
заместитель директора по научной и учебной рабо-
те, руководитель отделения патологии позвоночника и
нейрохирургии ФГБУ «НИДОИ им. Г.И. Турнера» Мин-
здрава России; профессор кафедры детской травматоло-
гии и ортопедии ФГБОУ ВО «СЗГМУ им. И.И. Мечни-
кова» Минздрава России. E-mail: turner01@mail.ru.
Алексей Георгиевич Баиндурашвили  — д-р мед. наук,
профессор, чл.-корр. РАН, заслуженный врач РФ, ди-
ректор ФГБУ «НИДОИ им. Г.И. Турнера» Минздрава
России, заведующий кафедрой детской травматологии
и ортопедии ФГБОУ ВО «СЗГМУ им. И.И. Мечникова»
Минздрава России. E-mail: turner01@mail.ru.
Ирина Александровна Крюкова  — канд. мед. наук,
невролог, доцент кафедры детской травматологии и
ортопедии ФГБОУ ВО «СЗГМУ им. И.И. Мечникова»
Минздрава России. E-mail: i_krukova@mail.ru.
Volume 4. Issue 2. 2016