Author(s): Vera Staley, MD, Deanna Claus, MD, Emma Drenth, MD
Originally published: February 15, 2018 Last updated: April 30, 2025
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Overview and Description

The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), is the standardized examination which was originally validated for use in the classification of   traumatic spinal cord injuries (SCI).1 This examination and classification system is also commonly used in the clinical setting for non-traumatic SCI, and one recent Italian study verified the validity, inter-rater reliability and correlation to functional outcomes, but there is not currently data to support using the ISNCSCI for prognostication in this population.2 Knowing how to perform and interpret the ISNCSCI examination is essential for the care of individuals with SCI. The exam is used to describe the completeness of a SCI as well as the levels of the spinal cord that have sustained damage. This information helps guide rehabilitation strategies and management techniques, as the results can help predict functional outcomes. The ISNCSCI examination is also essential for research and will continue to evolve as SCI medicine advances.3

Classifying spinal cord injuries has evolved over time. An international standard of classifying SCI was first established in 1982 by the American Spinal Injury Association (ASIA) Standards utilizing the Frankel Scale. The goal was to provide precision in classification and to enhance communication between clinicians and researchers for the National SCI Statistical Center Database.4,5 After it was endorsed by the International Medical Society of Paraplegia, it was renamed the International Standards for Neurological and Functional Classification of Spinal Cord Injury. “Functional” was later deleted to become International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI).

The evaluation underwent revisions in 1990, 1992, 1996, 2000, 2003, 2011, and 2019.1,6-8 There have also been multiple updates to the format of the worksheet  In 2011, non-key muscles were introduced and the worksheet was revised.6-8 The 2013 worksheet revision grouped motor and sensory together according to the body side, along with having the myotomes and dermatomes graphically aligned by assigned levels. The 2013 revised worksheet improved overall classification accuracy, specifically in both the motor level and neurological level of injury compared to their use of the 2011 worksheet.9 The revision of the ISNCSCI worksheet from 2015 repositioned the dermatomal map of key sensory points C6-C8 in the middle of the page, added clarification about the use of “not determinable” for any classification variable, revised the term “motor incomplete”, and explained the use of non-key muscle function. The 2019 revision provided a new taxonomy for documenting non-SCI related conditions and an updated definition on when to apply the zone of partial preservation.3

Spinal cord injury (SCI) affects the conduction of motor, sensory, and autonomic signals across the site of the lesion. By systematically examining specific dermatomes and myotomes, the clinician can determine the spinal cord segments that have been injured.

Regarding terminology, tetraplegia is defined as the impairment or loss of motor and/or sensory function in the cervical segments of the spinal cord due to damage of the neural elements within the spinal cord. Tetraplegia results in impairment of function in the arms, as well as possibly the trunk, legs and pelvic organs. Tetraplegia is preferred to the term quadriplegia as it uses both Greek roots rather than mixing Latin and Greek roots. Paraplegia is defined as the impairment of motor and/or sensory function in the thoracic, lumbar, or sacral segments of the spinal cord secondary to damage of the neural elements within the sacral canal. This can also refer to cauda equina and conus medullaris injuries. Tetraparesis, Quadriparesis and Paraparesis are discouraged as they describe incomplete lesions imprecisely. Instead, the ISNCSCI examination helps define completeness of injury and motor and sensory involvement.

It is very common for patients with spinal cord injury to have other concurrent neurological injuries. In addition to the ISNCSCI examination, it is essential to perform a complete neurological exam, including but not limited to a mini mental status exam, cranial nerves, deep tendon reflexes, and an assessment of muscle tone.

Relevance to Clinical Practice

The ISNCSCI examination, previously known as the ASIA (American Spinal Injury Association) examination, is the gold standard for evaluation and classification of individuals with SCI. To begin the exam, have the patient lie supine in an anatomical position.

Light touch and pin prick sensation compose the sensory portion of the examination and 28 dermatomes from C2 to S4/5 are tested on each side in specific locations noted on the dermatome person (Figure 1) Light touch sensation is tested using the stroke of a tapered cotton tip swab across an area of skin <1cm, while pin prick sensation or sharp/dull discrimination is tested using a clean and disposable safety pin.

Figure 1.

Neurological-exam-of-SCI-Figure-1

The dermatome chart per the International Standards for Neurological Classification of Spinal Cord Injury worksheet.1 Permission to use received from the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2019; Richmond, VA. (https://asia-spinalinjury.org/international-standards-neurological-classification-sci-isncsci-worksheet/).

Each sensory dermatome is given a score of 0, 1 or 2, with comparison to the individual’s face as the reference for normal. The ISNCSCI examination cannot accurately be performed if the patient has abnormal facial sensation. A light touch sensory score of 0 means absent sensation in that dermatome. A score of 1 is given for altered sensation when compared with the face. A score of 2 is given if the sensation is normal.  

For pin prick sensation, if sensation is absent or a patient cannot reliably discriminate sharp versus dull, this dermatome is given a score of 0. If sharp/dull are accurately differentiated, but the sensation is altered compared to the face, a score of 1 is given. If both pin prick and dull sensation feel the same as the face, that dermatome receives a score of 2. Correctly distinguishing sharp versus dull sensation on eight out of ten trials is used as the threshold of accuracy, as it is unlikely this could be guessed correctly by a patient without reliable sensation.

Key myotomes (Figure 1) are tested for the motor component of the exam using the standard muscle strength grading scale of 0-5. A score of 0 is given if there is no palpable or visible contraction of muscle. A score of 1 is given for palpable or visible muscle contraction. A score of 2 is given for movement with gravity eliminated through the full range of motion. A score of 3 is given for movement against gravity through the full range of motion. A score of 4 is given for movement through the full range of motion against gravity and moderate resistance. A score of 5 is given for movement through the full range of motion against gravity and full resistance in a muscle-specific position. A key muscle that is immobilized, removed by amputation, limited by severe pain, or contracted (lacking more than 50% of the normal range of motion) should be deemed not testable or “NT”.10

For patients with abnormal sensory or motor function due to a pre-existing or concomitant non-SCI condition, scores should be tagged with an asterisk (“*”) and the condition should be further described in the comments box of the ISNCSCI worksheet. Examples of non-SCI conditions include previous trauma (amputations), prior neurological deficits from cerebrovascular accidents or peripheral nerve injuries, pain, or debility. The asterisk (“*”) may be applied in sensory scores ranked 0, 1, or NT, and motor scores ranked 0, 1, 2, 3, 4, or NT.  For “*” scores above the sensory/motor level, these are considered to be normal during classification in most circumstances. For “*” scores at or below the sensory/motor level, those scores are handled as abnormal given the superimposition of the non-SCI condition to the deficits produced by the SCI. Therefore, any motor or sensory level, neurological level of injury (NLI), or ASIA Impairment Scale (AIS) grade that is affected by a “*” score should additionally be labeled with a “*” to clearly indicate the classification(s) is/are based on clinical interpretations of the subjective and objective score(s).10

Finally, a sacral examination is performed. This is essential to determine the completeness of a SCI, as the most caudal aspect of the spinal cord, and its associated nerve roots, innervate the perineum and anus. First, the sensation in S3 and S4/5 are tested for light touch and pin prick sensation, as detailed above. Then, a gloved, lubricated finger is inserted into the anus and gentle pressure is applied to the anorectal wall to test Deep Anal Pressure (DAP). The response is graded as present or absent. To test voluntary anal contraction (VAC), the examiner asks the patient to squeeze around their finger, as if holding in a bowel movement. It is important to differentiate VAC from the anal reflex; after finger insertion, allow a few seconds to pass before asking the patient to contract their anal sphincter. The response is graded as present or absent. Of note, if the patient has intact light touch or pin prick sensation at the S4-5 dermatomes, DAP does not need to be assessed, but the rectal exam must still be performed to assess VAC. Though not formally part of the ISNCSCI exam, the anocutaneous reflex (“anal wink”) and bulbocavernosus reflex are frequently tested at this time to assess for ongoing spinal shock and presence of intact reflexic activity below the level of injury.

The next step is determining the classification of an individual’s SCI as follows:

1. Determine the sensory level for both the right and left sides. This is the most caudal, intact dermatome for both light touch and pin prick sensation (graded as 2).

2. Determine the motor level for both the right and left sides, which is the most caudal key muscle function with a grade of at least 3, where all key muscles above that level are intact (graded as 5). Note: In regions where there is no key myotome to test, the motor level is presumed to be the same as the sensory level, if testable motor function above that level is also normal.

3. Determine the neurological level of injury (NLI). This refers to the most caudal segment of the spinal cord with intact sensation (grade 2) and antigravity (3 or greater) muscle function strength, provided that there is normal (intact) sensory and motor function rostrally. The NLI is the most cephalad of the sensory and motor levels determined in steps 1 and 2.

4. Determine if the injury is complete or incomplete through the testing of sensation and motor innervation of the sacral segments S4-5, including DAP and VAC. If there is absent VAC, absent DAP, and all S4-5 sensory scores are 0, the injury is complete. This is commonly referred to as the “N0000N” sign, because, on the worksheet, the bottom row reads “N” for no DAP, zeros for bilateral S4-5 pin prick and light touch sensation, and “N” for no VAC. If any DAP, VAC, or sensation in any of the S4-5 dermatomes is present, the injury is incomplete.

5. Determine the ASIA Impairment Scale (AIS) Grade.

Is injury complete (no sacral motor or sensory sparing)? If YES, AIS = A (Complete)

                       NO  ↓

Is injury motor complete (any sensory sparing in S4/5 or present DAP but no VAC or motor function more than three levels below the motor level on a given side)? If YES, AIS = B (Sensory Incomplete)

                       NO  ↓

Are at least half (half or more) of the key muscles below the neurological level of injury graded 3 or better (Sensory and Motor Incomplete)?

                        NO  ↓          YES   ↓

                        AIS=C         AIS=D

If sensation and motor function is normal in all segments, AIS=E

6. Determine the zone of partial preservation (ZPP).

The ZPP is used only in injuries with absent sacral motor (no VAC) or sensory function (no DAP, no LT, and no PP sensation) in the lowest sacral segments S4-5. Note that in 2019 ISNCSCI revision, ZPP rules were modified and are no longer contingent on any AIS grade. A ZPP refers to those dermatomes and myotomes caudal to the sensory and motor levels that remain partially innervated.  The most caudal level with intact sensation or motor function is documented as the sensory or motor ZPP, respectively.  Motor ZPP are now defined and should be documented in all cases including patients with incomplete injuries with absent VAC. With sacral sparing of sensory function, the sensory ZPP is not applicable and therefore “NA” is recorded in the block of the worksheet. Accordingly, if VAC is present, the motor ZPP is not applicable and is noted as “NA.” ZPPs can be important functionally. In fact, patients with AIS A injuries but have a motor ZPP greater than 3 levels below the injury are more likely to convert to incomplete injuries over time.11

Further explanation of the AIS grade is detailed below:

A=Complete. No sensory or motor function is preserved in sacral segments S4-5.

B=Sensory Incomplete. Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-5 (light touch or pin prick at S4-5 or DAP) AND no motor function is preserved more than three levels below the motor level on either side of the body.

C=Motor Incomplete. Motor function is preserved at the most caudal sacral segments for VAC OR the patient meets the criteria for sensory incomplete status (sensory function preserved at the most caudal sacral segments S4-5 by LT, PP or DAP) AND has some sparing of motor function more than three levels below the ipsilateral motor level on either side of the body. (This includes key or non-key muscle functions to determine motor incomplete status.) For AIS C – less than half of key muscle functions below the single NLI have a muscle grade ≥ 3.

D=Motor Incomplete. Motor incomplete status as defined above, with at least half (half or more) of key muscle functions below the single NLI having a muscle grade ≥ 3.

E=Normal. If sensation and motor function as tested with the ISNCSCI are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Someone without an initial SCI does not receive an AIS grade.

Note: Not Determinable or “ND” is used to document the sensory, motor and NLI levels, the AIS grade, and/or the ZPP when they are unable to be determined based on the examination results.

Additional clinical pearls to consider when using the ISNCSCI are as follows:

  • Key or non-key muscle functions can be used to determine motor incomplete status (differentiation between AIS B from C). Non-key muscle function should be documented in the comments box. See the ISNCSCI worksheet for root levels that correspond to specific non-key muscles.
  • When distinguishing between a sensory incomplete versus a motor incomplete (AIS B from C) injury, the MOTOR LEVEL on each side is used. When distinguishing between motor incomplete injuries (AIS C from D), the NEUROLOGICAL LEVEL OF INJURY is used.
  • Motor ZPP does not follow sensory function (applicable in regions where there is no key muscle to test).
  • When non-key muscles are used to determine AIS C classification, motor ZPP in the most distal non-key muscles is recorded.

A patient’s neurological classification of SCI provides clinicians with useful information about the patient’s current level of function and can help prognosticate functional outcomes. For example, it can help determine whether a patient will be at risk for respiratory dysfunction, their expected level of independence for transfers, daily activities, or bowel and bladder cares, and the types of assistive devices they may require to improve their independence with these tasks. Further, it can help guide which mobility devices may be most appropriate for traversing their home and community, as well as prognosis for future ambulation.12 Finally, this information is helpful for education as the patient and their support systems learn about their injury.

Cutting Edge/Unique Concepts/Emerging Issues

Studies have demonstrated that accurate and reliable classification of a SCI by use of the ISNCSCI requires comprehensive examiner training, but the ideal training process and experience level for optimal accuracy and reliability are yet to be determined by the literature.13 Examples of formal training include the International Standards Training E-Program (InSTeP) or training per European Multicenter Study on Human Spinal Cord Injury (EMSCI).14 Working through challenging practice cases can also help provide clinician’s experience and help to clarify differences between worksheet revisions.15 The ASIA website has an ISNCSCI classification workbook that provides excellent practice cases.

Apart from further training, there are other ways to enhance accuracy, including use of a computer algorithm. One study demonstrated that 75% of ISNCSCI worksheets had at least one error when completed manually, with most errors occurring on the motor portion of the exam.16 A more recent study reports accuracy is highest for classifying injury completeness and sensory levels, but lowest for motor ZPP and AIS grade.17 The Rick Hansen Institute-ISNCSCI Algorithm (RHI-ISNCSCI Algorithm) is a computerized tool that aims to eliminate potential for human error in some aspects of SCI classification by providing a more accurate and reliable interpretation of the ISNCSCI exam. Upon capturing exam information, it correctly derives the AIS grade, total motor score, and NLI. It can reduce the time to classify large numbers of cases and also provides education to clinicians.16 The European Multicenter Study about Spinal Cord Injury (EMSCI) ISNCSCI calculator is another tool that has been validated in multiple languages and has similar advantages to the RHI-ISNCSCI Algorithm.14,18

Because the exam can be long and classification is complex, the first version of the expedited ISNCSCI (E-ISNCSCI) protocol was published by ASIA in 2020, with a revision expected in 2025.19 It aims to define the NLI and AIS grade using the fewest exam items, which is achieved by omitting aspects of the ISNCSCI and/or substituting S1 sensory and motor findings for the anorectal exam and S4-5 dermatomes. It is recommended that only experienced evaluators utilize this protocol and additional training is recommended for use. The standard ISNCSCI and E-ISNCSCI protocols can produce conflicting AIS classifications, but NLI is likely comparable. Caution is required to avoid replacing the standard ISNCSCI protocol with the E-ISNCSCI for the acute inpatient hospital setting, admission and discharge from rehabilitation, or when neurologic changes are suspected in patients with a chronic SCI. Despite attempts at simplifying the exam, it can be difficult for some patients to participate in the ISNCSCI exam. Patients who are under sedation, intoxicated, on centrally acting medications, in acute pain, or with cognitive impairments may not be able to follow or understand instructions essential for accurate classification. This can result in significant classification and prognostication challenges, particularly in the acute care setting.

Performing the ISNCSCI examination in the pediatric population can be both challenging and time consuming. In practice, many children are anxious during the pin prick examination, have difficulty remaining focused, and may lack the ability to provide appropriate responses. However, it was recently found that using only the preselected dermatomes C4, C6, T4, T6, T10, L2, L4, S1, and S3 provided an excellent estimate of the full exam.20 Studies have shown the ISNCSCI examination to be reliable in children older than six years old on repeated motor and sensory scores, however, there remains disagreement on the reliability of the anorectal portion of the examination.21

Finally, though not characterized by the ISNCSCI, it is important to consider the degree of autonomic dysfunction an individual experiences after their SCI. The International Standards to document Autonomic Function following SCI (ISAFSCI), formally known as International Autonomic Standards (IAS) was conceived in 2009 as an adjunct to the ISNCSCI. It is used to characterize general autonomic function (cardiovascular, thermal and sudomotor, bronchopulmonary function) and sacral autonomic function (lower urinary and gastrointestinal tracts, genitalia and reproductive organs).22 One study found that, even though most patients with SCI are affected by some degree of autonomic dysfunction, this evaluation was only partially or fully completed in 63% and 39% of individuals with SCI at time of admission and discharge, respectively. This was in contrast to the 93% and 78% of those who completed the ISNCSCI. This variation could be due to the relative newness of the autonomic standard.23

Gaps in Knowledge/Evidence Base

The ISNCSCI may not reflect the evolution of complex spinal cord function, as it is a clinical exam dependent on the experience of the examiner and subjective reports from the patient. For example, the exam classifies clinically complete and incomplete injuries but is not sensitive enough to detect “discomplete” injuries. This concept reflects that there are some patients with some residual, preserved neural continuity but clinically appear complete.24-26 The functional significance of this is yet to be determined, though it may explain differences in functional outcomes among patients that have a similar ISNCSCI exam. Additionally, some studies report using electromyography (EMG) to confirm clinical exam findings for muscle strength (especially for grades 0 or 1)27 or even fMRI for confirmation of the anorectal exam, particularly in children.28  There is some debate about whether or not the motor function at levels without key muscles should be deferred to sensory function at that level as here can be testable motor function in non-key muscles.29 For example, one article has indicated that deferring to sensory function in the high cervical region of C2–C4 is counterintuitive whenever the C5 myotomes are intact.30 Furthermore, decline in AIS classification can occur amid improved neurologic function in certain cases.31 A research subcommittee of international clinicians and researchers was formed to review and revise the ISNCSCI, under the input from the Education Committees of ASIA and ISCoS and approval from the ASIA’s Board of Directors.8

References

  1. American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, Revised 2019; Richmond, VA.
  2. Lena E, Baroncini I, Pavese C, et al. Reliability and validity of the international standards for neurological classification of spinal cord injury in patients with non-traumatic spinal cord lesions. Spinal Cord. 2022;60(1):30-36. doi:10.1038/s41393-021-00675-9
  3. Kirshblum S, Snider B, Rupp R, et. al. Updates of the International Standards for Neurologic Classification of Spinal Cord Injury. Physical Medicine and Rehabilitation Clinics of North America. 2020 Aug;31(3):319-330
  4. American Spinal Injury Association Standards for neurological classification of spinal injured patients. Chicago, IL: ASIA; 1982.
  5. Frankel HL, Hancock DO, Hyslop G, Melzak J, Michaelis LS, Ungar GH, et al. The value of postural reduction in the initial management of closed injuries in the spine with paraplegia and tetraplegia. Paraplegia 1969;7:179–92.
  6. International Standards for Neurological Classification of Spinal Cord Injury 2011 Revision. J Spinal Cord Med 2011;34(6):535–46.
  7. International Standards for the Neurological Classification of Spinal Cord Injury Revised 2011. (Booklet). Atlanta, GA: American Spinal Injury Association.
  8. Kirshblum SC, Waring W, Biering-Sorensen F et. al. Reference for the 2011 revision of the International Standards for Neurological Classification of Spinal Cord Injury. J Spinal Cord Med. 2011 Nov;34(6):547-54.
  9. Schuld C, Franz S, Brüggemann K et al. behalf of the EMSCI study group (2016) International standards for neurological classification of spinal cord injury: impact of the revised worksheet (revision 02/13) on classification performance, The Journal of Spinal Cord Medicine, 39:5, 504-512.
  10. ASIA and ISCoS international standards committee.  The 2019 revision of the International Standards for Neurological Classification of Spinal Cord Injury – What’s new? Spinal Cord (2019, 57: 815-817).
  11. Kirshblum S, Snider B, Botticello A, Benedetto J, Engel-Haber E. The Role of Motor Zones of Partial Preservation in Conversion From Initially Complete to Motor Incomplete Spinal Cord Injury. Arch Phys Med Rehabil. Published online February 11, 2025. doi:10.1016/j.apmr.2025.01.473
  12. Thomas B, Ragnarsson K, Stein A, Biering-Sorensen F. Spinal Cord Injury. In: Braddom, R. Physical Medicine and Rehabilitation. Philadelphia, PA:Saunders;2011;1308
  13. Franz S, Heutehaus L, Weinand S, Weidner N, Rupp R, Schuld C. Theoretical and practical training improves knowledge of the examination guidelines of the International Standards for Neurological Classification of Spinal Cord Injury. Spinal Cord. 2022;60(1):1-10. doi:10.1038/s41393-020-00578-1
  14. Schuld C, Wiese J, Franz S et al. Effect of formal training in scaling, scoring and classification of the international Standards for Neurological Classification of Spinal Cord Injury. Spinal Cord 2013 Apr:51(4):282-8
  15. Kirshblum S, Read M.  Classification Challenges of the 2019 Revised International Standards for Neurological Classification of Spinal Cord Injury.  Spinal Cord (2022 60:11-17).
  16. Armstrong AJ, et al. Achieving assessor accuracy on the International Standards for Neurological Classification of Spinal Cord Injury. 2017. Int Spinal Cord Soc.
  17. Snider BA, Eren F, Reeves RK, Rupp R, Kirshblum SC. The International Standards for Neurological Classification of Spinal Cord Injury: Classification Accuracy and Challenges. Top Spinal Cord Inj Rehabil. 2023;29(1):1-15. doi:10.46292/sci22-00036
  18. Schuld C, Franz S, Schweidler J et. al. Implementation of multilingual support of the European Multicenter Study about Spinal Cord Injury (EMSCI) ISNCSCI calculator. Spinal Cord. 2022; 60:37-44.
  19. Expedited ASIA ISNCSCI Exam (E-ISNCSCI) Version 1. February 2020. https://asia-spinalinjury.org/wp-content/uploads/2020/01/expedited-isncsciI-exam-feb-2020-version-1.pdf Accessed 8 Feb 2022.
  20. Krisa, L., Mulcahey, M.J., Gaughan, J.P., Smith, B. & Vogel, L.C. (2013). Using a limited number of dermatomes as a predictor of the 56-dermatome test of the international standards for neurological classification of spinal cord injury in the pediatric population. Topics in Spinal Cord Injury Rehabilitation, 19(2), 114-20
  21. Mulcahey MJ, Gaughan JP, Chafetz RS, Vogel LC, Samdani AF, Betz RR. Interrater reliability of the international standards for neurological classification of spinal cord injury in youths with chronic spinal cord injury. Arch Phys Med Rehabil. 2011;92(8):1264-1269. doi:10.1016/j.apmr.2011.03.003
  22. Kirshblum S, Anderson K, Krassioukov A, Donovan W. Assessment and Classification of Traumatic Spinal Cord Injury.  In:Spinal Cord Medicine.  Philadelphia, PA: Lippincott Williams&Wilkins. 2011;85-105
  23.  Squair JW, Nobel G, Noonan VK, Raina G, Krassioukov AV. Assessment of clinical adherence to the international autonomic standards following spinal cord injury. Spinal Cord. 2015. 53, 668-672
  24.  Sherwood AM, Dimitrijevic MR, McKay WB. Evidence of subclinical brain influence in clinically complete spinal cord injury: discomplete SCI. J Neurol Sci. 1992;110(1-2):90-98. doi:10.1016/0022-510x(92)90014-c
  25. Awad A, Levi R, Waller M, Westling G, Lindgren L, Eriksson J. Preserved somatosensory conduction in complete spinal cord injury: Discomplete SCI. Clin Neurophysiol. 2020;131(5):1059-1067. doi:10.1016/j.clinph.2020.01.017
  26. Wahlgren C, Levi R, Amezcua S, Thorell O, Thordstein M. Prevalence of discomplete sensorimotor spinal cord injury as evidenced by neurophysiological methods: A cross-sectional study. J Rehabil Med. 2021 Feb 23;53(2):jrm00156. doi: 10.2340/16501977-2774. PMID: 33284352; PMCID: PMC8814834.
  27. Lee SW, Lim KB, Kim J, Lee H, Kim HS, Yoo J. Concordance between the international standards for neurological classification of spinal cord injury motor examination and needle electromyography findings in muscles with a motor power grade of zero or trace. J Spinal Cord Med. 2023;46(3):433-440. doi:10.1080/10790268.2021.2021044
  28. Krisa Laura et al. Cerebral Activation During the Test of Spinal Cord Injury Severity in Children: an fMRI Methodological Study Top Spinal Cord Inj Rehabil. 2013 Spring; 19(2): 121–128. Published online 2013 Apr. doi:  10.1310/sci1902-121
  29. Bjerkefors A, Squair JW, Malik R et. al. Diagnostic accuracy of common clinical tests for assessing abdominal muscle function after motor-complete spinal cord injury above T6. Spinal Cord. 2015 Feb;53(2):114-9.
  30. Franz S, Kirshblum SC, Weidner N et. al. Motor levels in high cervical spinal cord injuries: Implications for the International Standards for Neurological Classification of Spinal Cord Injury. J Spinal Cord Med. 2016 Sep;39(5):513-7.
  31. Gündoğdu I, Akyüz M, Oztürk EA et. al. Can spinal cord injury patients show a worsening in ASIA impairment scale classification despite actually having neurological improvement? The limitation of ASIA Impairment Scale Classification. Spinal Cord. 2014 Sep;52(9):719.

Original Version of the Topic

Tommy Yu, MD, Morgan Pyne, DO. Neurological examination and classification of SCI. 2/15/2018

Previous Revision(s) of the Topic

Tommy Yu, MD, Morgan Pyne, DO, Samantha Mendelson, DO, Matthew Wilhelm, DO. Neurological Examination and Classification of SCI. 5/11/2022

Author Disclosure

Vera Staley, MD
Nothing to Disclose

Deanna Claus, MD
Nothing to Disclose

Emma Drenth, MD
Nothing to Disclose