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Comparative Study
. 2016 Sep;39(5):504-12.
doi: 10.1080/10790268.2016.1180831. Epub 2016 Jun 14.

International Standards for Neurological Classification of Spinal Cord Injury: Impact of the Revised Worksheet (Revision 02/13) on Classification Performance

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Free PMC article
Comparative Study

International Standards for Neurological Classification of Spinal Cord Injury: Impact of the Revised Worksheet (Revision 02/13) on Classification Performance

Christian Schuld et al. J Spinal Cord Med. .
Free PMC article

Abstract

Study design: Prospective cohort study.

Objectives: Comparison of the classification performance between the worksheet revisions of 2011 and 2013 of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI).

Settings: Ongoing ISNCSCI instructional courses of the European Multicenter Study on Human Spinal Cord Injury (EMSCI). For quality control all participants were requested to classify five ISNCSCI cases directly before (pre-test) and after (post-test) the workshop.

Participants: One hundred twenty-five clinicians working in 22 SCI centers attended the instructional course between November 2011 and March 2015. Seventy-two clinicians completed the post-test with the 2011 revision of the worksheet and 53 with the 2013 revision.

Interventions: Not applicable.

Outcome measures: The clinicians' classification performance assessed by the percentage of correctly determined motor levels (ML) and sensory levels, neurological levels of injury (NLI), ASIA Impairment Scales and zones of partial preservations.

Results: While no group differences were found in the pre-tests, the overall performance (rev2011: 92.2% ± 6.7%, rev2013: 94.3% ± 7.7%; P = 0.010), the percentage of correct MLs (83.2% ± 14.5% vs. 88.1% ± 15.3%; P = 0.046) and NLIs (86.1% ± 16.7% vs. 90.9% ± 18.6%; P = 0.043) improved significantly in the post-tests. Detailed ML analysis revealed the largest benefit of the 2013 revision (50.0% vs. 67.0%) in a case with a high cervical injury (NLI C2).

Conclusion: The results from the EMSCI ISNCSCI post-tests show a significantly better classification performance using the revised 2013 worksheet presumably due to the body-side based grouping of myotomes and dermatomes and their correct horizontal alignment. Even with these proven advantages of the new layout, the correct determination of MLs in the segments C2-C4 remains difficult.

Keywords: Classification performance; ISNCSCI; International standards for neurological classification of spinal cord injury; Motor levels; Worksheet.

Figures

Figure 1.
Figure 1.. ISNCSCI worksheet layouts
Layouts and alignments of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) worksheet layouts 2006/2011 (A), revision 2013 (B) and revision 2003 (C). Distances between myotomes and dermatomes and their horizontal alignment are visualized by the angled red lines for the spinal segments C5 and L2
Figure 2.
Figure 2.. Detailed motor level (ML) analysis
Detailed motor level analysis of all five post-testing cases (A). ML distributions are presented unilaterally for the cases 1 (B) and 2 (C) and bilaterally for the case 5 (D, E). The correct MLs are highlighted in green and additionally marked with arrows. Abbreviations: ISNCSCI, International Standards for Neurological Classification of Spinal Cord Injury.* Left side ISNCSCI scoring in the depicted segments is symmetrical besides left light touch in C5, which is graded as 1.** Left side ISNCSCI scoring in the depicted segments is symmetrical besides left pin prick in C7, which is graded as 0
Figure 3.
Figure 3.. Detailed neurological level of injury (NLI) analysis
Detailed neurological level of injury analysis of all five post-testing cases (A). NLI distributions are presented for the case 2 (B) and case 5 (C). The correct NLIs are highlighted in green and additionally marked with arrows. Abbreviations: ISNCSCI, International Standards for Neurological Classification of Spinal Cord Injury

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