INTERNATIONAL STANDARDS FOR NEUROLOGICAL Patient Name_____________________________________ Date/Time of Exam _____________________________

CLASSIFICATION OF SPINAL CORD INJURY

Examiner Name ___________________________________ Signature _____________________________________
(ISNCSCI)
SENSORY SENSORY
T MOTOR
KEY MUSCLES
KEY SENSORY POINTS
Light Touch (LTR) Pin Prick (PPR)
KEY SENSORY POINTS
Light Touch (LTL) Pin Prick (PPL)
MOTOR
KEY MUSCLES LEFT
INTERNATIONAL STANDARDS FOR NEUROLOGICAL Patient Name_____________________________________ Date/Time of Exam _____________________________
C2 C2
CLASSIFICATION OF SPINAL CORD INJURY
C3 C3
Examiner Name ___________________________________ Signature _____________________________________
(ISNCSCI)
C4 C2 C4
SENSORY SENSORY
C5 Elbow flexors
Elbow flexors C5
RIGHT MOTOR
LEFT
C3
KEY SENSORYC4POINTS
MOTOR
KEY SENSORY POINTS
Wrist extensors C6 KEY MUSCLES
INTERNATIONAL STANDARDS FOR NEUROLOGICAL T2 Light Touch (LTR) Pin Prick (PPR) Patient Name_____________________________________ C6 Wrist extensors Date/Time
Light Touch (LTL) Pin Prick (PPL)
KEY MUSCLES
of UEL
Exam _____________________________
Elbow extensors C7 T3 C7 Elbow extensors (Upper Extremity Left)
CLASSIFICATION OF SPINAL CORD C2 INJURY
C2 C8 Finger flexorsC2Signature _____________________________________
C5
Finger flexors C8 0 = absent T4
Examiner Name ___________________________________
(ISNCSCI)C3 T5 C3 (little finger)
bductors (little finger) T1 21 == normal
altered
T6 T1 Finger abductors C4
C4 SENSORY SENSORY
RIGHT LEFT
T7 C2
T2
NT = not testable
MOTOR T2 MOTOR
cle? Reason for NT? Pain?): Elbow flexors C5 KEY
C3
SENSORY T8
POINTS C3 KEY SENSORY POINTS MOTOR C5 Elbow flexors
T3 KEY MUSCLES 0 = absent T9 T1 T3 (SCORING KEY MUSCLES
ON REVERSE SIDE)
UER Wrist extensors C6 Light Touch (LTR)
1 = altered
C4
Pin Prick (PPR) C4 Light Touch (LTL) Pin Prick (PPL) C6 Wrist extensors UEL
(Upper Extremity Right) T4 2 = normal T10 C6
T2 T4 0 = total paralysis (Upper Extremity Left)
Elbow extensors C7 C2 NT = not testable T11 T3 C2 C7 Elbow extensors
T5 C2
T4 C5 T5 1 = palpable or visible contraction
Finger flexors C8 0 = absentC3 T12 C3 eliminated
2 = active movement, gravity C8 Finger flexors
T6 T5 T6 3 = active movement, against gravity
bsent Finger abductors (little finger) T1 21 == normal C4
altered L1
Palm T6
C2 4 = active movement, C4
against some T1 Finger abductors (little finger)
resistance
ltered
T7 T7 T7
ormal
Elbow flexors C5 NT = not T2 testable C3
T2pain/disuse
5 = active movement, against
C5 Elbow flexors
full resistance
not testable Comments (Non-key Muscle? Reason for NT? Pain?):
T8
C3 T8
T8 5* = normal corrected for MOTOR
UER Wrist extensors C6 T3 S3 0 = absent C4
T9 T1 NT = not testable T3 C6 (SCORING ON REVERSE SIDE) UEL
Wrist extensors
(Upper Extremity Right) T9
Elbow extensors C7 T4 L2 • 2 = normal
1Key Sensory
= altered
C4 T10
C2testable T3
T2 C6 T9 T4 C7 Elbow
0 = total extensors
paralysis (Upper Extremity Left)
T10 Finger flexors
S4-5 NT Points
= not T11 C5 T10 SENSORYT5
C8 0 = absentT5
T4 1 = palpable or visible contraction
T11 (SCORING ON REVERSE SIDE) C8
2 = Finger
active flexors
movement, gravity eliminated
FingerT11 T6
(little finger) T1 1 = altered
T12
T5
T6 2 = normal T1
0 abductors Finger abductors
T6 L1 3 = active movement, against(little
gravity
finger)
T12
= absent 2 = normal
NT = not T7
T7 Palm T12 0 = absent
T7 4 = active movement, against some resistance
1 = altered
T2 S2
testable L3
C3 C8 6 C8 T8 1= altered T2 NT = not5 = testable
active movement, against full resistance
2 = normal
L1= not testable
Comments (Non-key Muscle? Reason for NT? Pain?): C6 C L1 T8 MOTOR
NT
T8
T3 C7 C7 T9 T1 T3 5* = normal corrected
(SCORING
for pain/disuse
testable ON REVERSE SIDE)
0 = absent
1 S3 NT = not
Hip flexors L2 T9
T4 Dorsum =DorsumC4
altered
2 = normal T10 L2 • Key C6Sensory L2 Hip flexors T9
T4 0 = total paralysis
Knee extensors L3
T11
T10
T5
S4-5
NT = not testable Points L3 Knee extensors T10
T5 1 = palpable or SENSORY
visible contraction
L4 T12 LEL
2 = active movement,ONgravity eliminated
Ankle dorsiflexors L4 T11
T6 L1 L4 Ankle T11
T6
dorsiflexors (Lower
3 =
(SCORING
Extremity
active movement, Left)
REVERSE
against gravity
SIDE)
0 = absent L5
ong toe extensors L5 1 = altered T12
T7 L3
Palm
L5 Long toe extensors T12
T7 40== absent
active movement, against 2 = normal
some resistance
NT resistance
= not testable
2 = normal S2 C8 6 C8 51==altered
active movement, against full
nkle plantar flexors S1 NT = not testable L1 L5 S1
T8 C6
C 7
C 7
C S1 Ankle plantar L1
T8
flexors 5* = normal corrected for pain/disuse

S2 Hip flexors L2 T9
S3
L2 • Key
Dorsum Sensory
Dorsum S2 T9
NT = not testable
L2 Hip flexors
Points
S3 Knee extensors L3 T10 S4-5
S3 T10 L3 SENSORY
raction LER L4 (DAP) Deep anal(SCORING
Knee extensors
pressureON REVERSE SIDE) LEL
Yes/No) (Lower Extremity Right) S4-5 Ankle dorsiflexors L4 T11 S4-5 T11 L4 Ankle dorsiflexors (Lower Extremity Left)
L5 (Yes/No) 0 = absent
Long toe extensors L5 T12 S2 L3 T12 L5
2 = normal
Long toe extensors NT = not testable
1= altered
8 C8 LEFT TOTALS
RIGHT TOTALS Ankle plantar flexors S1 L1 S1
C6
C
C6 L1
L5 C7 C7 S1 Ankle plantar flexors
(MAXIMUM) (MAXIMUM)
Hip flexors L2 S2 Dorsum Dorsum S2 L2 Hip flexors
S SENSORY SUBSCORES
Knee extensors L3 S3 S3 L3 Knee extensors LEL
= UEMS TOTAL LER
(VAC) Voluntary anal contraction
LER + LEL = LEMS TOTAL
S4-5 + LTL L4 + PPL S4-5 = PP TOTAL
(DAP) Deep anal pressure
(Lower Extremity Right) (Yes/No)Ankle dorsiflexors L4 LTR = LT TOTAL PPR
L4 Ankle dorsiflexors
(Yes/No) (Lower Extremity Left)
(50) (25) (25) (50) L5
MAX
Long toe extensors L5 MAX (56) (56) (112) MAX (56) (56)
L5LEFT Long (112)
toe extensors
TOTALS
RIGHT TOTALS S1
R L Ankle plantar flexors S1 L5
4. COMPLETE OR INCOMPLETE? (In complete injuries only) S1(MAXIMUM)
Ankle
R plantar L flexors
(MAXIMUM)
3. NEUROLOGICAL
1. SENSORY
MOTOR SUBSCORES S2 Incomplete = Any sensory or motor function in S4-5 ZONE OF PARTIAL S2
SENSORY
LEVEL OF INJURY SENSORY SUBSCORES
2. MOTOR (NLI) S3 5. ASIA IMPAIRMENT SCALE (AIS) PRESERVATION S3MOTOR
(VAC)
UER Voluntary Anal Contraction
+ UEL = UEMS TOTAL S4-5 LER + LEL = LEMS TOTAL LTR Most caudal level with any innervation
+ LTL = LT TOTAL S4-5 PPR + PPL (DAP) Deep= Anal PP TOTALPressure
MAX (25) (25)
This (Yes/No) (50)but should
form may be copied freely MAXnot(25) (25) permission from the (50)
be altered without American Spinal
MAXInjury
(56) Association.
(56) (112) MAX (56) REV (Yes/No)
02/13(56) (112)
RIGHT TOTALS LEFT TOTALS
NEUROLOGICAL R L 3. NEUROLOGICAL 4. COMPLETE OR INCOMPLETE? (In complete injuries only) R L
LEVELS (MAXIMUM) (MAXIMUM)
ZONE OF PARTIAL
1. SENSORY LEVEL OF INJURY Incomplete = Any sensory or motor function in S4-5 SENSORY
MOTOR
Steps 1-5SUBSCORES
for classification PRESERVATION
as on reverse 2. MOTOR (NLI) 5. ASIA SENSORY
IMPAIRMENTSUBSCORES
SCALE (AIS) Most caudal level with any innervation
MOTOR
UER + UEL = UEMS TOTAL LER + LEL = LEMS TOTAL LTR + LTL = LT TOTAL PPR + PPL = PP TOTAL REV 02/13
This form may be copied freely but should not be altered without permission from the American Spinal Injury Association.
MAX (25) (25) (50) MAX (25) (25) (50) MAX (56) (56) (112) MAX (56) (56) (112)

NEUROLOGICAL R L 3. NEUROLOGICAL 4. COMPLETE OR INCOMPLETE? (In complete injuries only) R L

LEVELS 1. SENSORY Incomplete = Any sensory or motor function in S4-5 ZONE OF PARTIAL SENSORY
LEVEL OF INJURY
Steps 1-5 for classification
2. MOTOR (NLI) 5. ASIA IMPAIRMENT SCALE (AIS) PRESERVATION MOTOR
as on reverse Most caudal level with any innervation

This form may be copied freely but should not be altered without permission from the American Spinal Injury Association. REV 11/15
Muscle Function Grading
0 = total paralysis
1 = palpable or visible contraction
2 = active movement, full range of motion (ROM) with gravity eliminated
3 = a ctive movement, full ROM against gravity
4 = active movement, full ROM against gravity and moderate resistance in a muscle
specific position
5 = (normal) active movement, full ROM against gravity and full resistance in a
functional muscle position expected from an otherwise unimpaired person
5* = (normal) active movement, full ROM against gravity and sufficient resistance to
be considered normal if identified inhibiting factors (i.e. pain, disuse) were not present
NT = not testable (i.e. due to immobilization, severe pain such that the patient
cannot be graded, amputation of limb, or contracture of > 50% of the normal ROM)
Sensory Grading
0 = Absent
1 = Altered, either decreased/impaired sensation or hypersensitivity
2 = Normal
NT = Not testable
When to Test Non-Key Muscles:
In a patient with an apparent AIS B classification, non-key muscle functions
more than 3 levels below the motor level on each side should be tested to
most accurately classify the injury (differentiate between AIS B and C).
Movement Root level
Shoulder: Flexion, extension, abduction, adduction, internal C5
and external rotation
Elbow: Supination the ISNCSCI are graded as normal in all segments, and the
Elbow: Pronation C6
Wrist: Flexion without an initial SCI does not receive an AIS grade.
Finger: Flexion at proximal joint, extension. C7
Thumb: Flexion, extension and abduction in plane of thumb the ASIA Impairment Scale grade, and/or the zone of partial
Finger: Flexion at MCP joint C8
Thumb: Opposition, adduction and abduction perpendicular
to palm
Finger: Abduction of the index finger T1
Hip: Adduction L2
Hip: External rotation L3
Hip: Extension, abduction, internal rotation L4
Knee: Flexion
Ankle: Inversion and eversion
Toe: MP and IP extension
Hallux and Toe: DIP and PIP flexion and abduction L5 Note: AIS E is used in follow-up testing when an individual with a documented
Hallux: Adduction S1
ASIA Impairment Scale (AIS)
A = Complete. No sensory or motor function is preserved in
the 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 deep anal
pressure) 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 voluntary anal contraction (VAC)
OR the patient meets the criteria for sensory incomplete status
(sensory function preserved at the most caudal sacral segments
(S4-S5) 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
patient had prior deficits, then the AIS grade is E. Someone
Using ND: To document the sensory, motor and NLI levels,
preservation (ZPP) when they are unable to be determined
based on the examination results.
INTERNATIONAL STANDARDS FOR NEUROLOGICAL
CLASSIFICATION OF SPINAL CORD INJURY
Steps in Classification
The following order is recommended for determining the classification of
individuals with SCI.
1. Determine sensory levels for right and left sides.
The sensory level is the most caudal, intact dermatome for both pin prick and
light touch sensation.
2. Determine motor levels for right and left sides.
Defined by the lowest key muscle function that has a grade of at least 3 (on
supine testing), providing the key muscle functions represented by segments
above that level are judged to be intact (graded as a 5).
Note: in regions where there is no 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 cord with intact sensation and
antigravity (3 or more) muscle function strength, provided that there is normal
(intact) sensory and motor function rostrally respectively.
The NLI is the most cephalad of the sensory and motor levels determined in
steps 1 and 2.
4. Determine whether the injury is Complete or Incomplete.
(i.e. absence or presence of sacral sparing)
If voluntary anal contraction = No AND all S4-5 sensory scores = 0
AND deep anal pressure = No, then injury is Complete.
Otherwise, injury is Incomplete.
5. Determine ASIA Impairment Scale (AIS) Grade:
Is injury Complete? If YES, AIS=A and can record
ZPP (lowest dermatome or myotome
NO on each side with some preservation)
Is injury Motor Complete? If YES, AIS=B
NO (No=voluntary anal contraction OR motor function
more than three levels below the motor level on a
given side, if the patient has sensory incomplete
classification)
Are at least half (half or more) of the key muscles below the
neurological level of injury graded 3 or better?
NO YES
AIS=C AIS=D
If sensation and motor function is normal in all segments, AIS=E
SCI has recovered normal function. If at initial testing no deficits are found, the
individual is neurologically intact; the ASIA Impairment Scale does not apply.