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International Standards for Neurological and Functional Classification of

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 Spinal Cord (1997) 35, 266 ± 274
 1997 International Medical Society of Paraplegia All rights reserved 1362 ± 4393/97 $12.00

International Standards for Neurological and Functional Classi®cation

of Spinal Cord Injury
Frederick M Maynard, Jr, Michael B Bracken, Graham Creasey, John F Ditunno, Jr, William H Donovan, Thomas
B Ducker, Susan L Garber, Ralph J Marino, Samuel L Stover, Charles H Tator, Robert L Waters, Jack E Wilberger
and Wise Young
American Spinal Injury Association, 2020 Peachtree Road, NW Atlanta Georgia 30309, USA

The ®rst edition of the International Standards for ASIA Board has established a standing committee
Neurological and Functional Classi®cation of Spinal to reevaluate regularly the need for further
Cord Injury, ie neural disturbances (`Spinal Cord modi®cations in the Standards booklet and in the
Injury') whether from trauma or disease, was Training Package, as well as to respond to
published in 19826 by the American Spinal Injury questions and criticisms of the Standards from
Association (ASIA). Reference was made to the 1992 the many users. This committee welcomes corre-
Revision of the International Standards and published spondence that raises questions, o€ers constructive
in Paraplegia (the former title of Spinal Cord) in 1994, criticism or provides new empirical data that is
Volume 32, pages 70 ± 80 by JF Ditunno Jr, W Young, relevant for further re®nements and improvements
WH Donovan and G Creasey7. Since then there have in the reliability and validity of the ISCSCI.
been three revisions, the most recent being in 1996. Dr Frederick M Maynard, Jr MD
Frederick M Maynard Jr in his Preface to this Fourth Chairperson
Revision said:- ASIA Neurological Standards Committee
August 1996
Since the earlier revision of the `ASIA
Standards' was completed in 1992, it has Permission has been very kindly given by Dr James
received endorsement by the International Med- Keene, President of the American Spinal Injury
ical Society of Paraplegia (IMSOP) and has been Association for publication of the 1996 Revision in
subsequently known as the International Stan- Spinal Cord. Copies of the booklet and training
dards for Neurological and Functional Classifica- package can be obtained by contacting: Lesley M
tion of Spinal Cord Injury (ISCSCI-92). As a Hudson MA, 2020 Peachtree Road NW, Atlanta,
result of the enthusiastic response from the Georgia 30309, USA.
international medical rehabilitation community
to these standards, there has been close scrutiny
Introduction
of their every word and concept. The changes in
the fourth revision are the 1992 Committee's The spinal cord is the major conduit through which
response to feedback from the wider community motor and sensory information travels between brain
of spinal cord injury clinicians and researchers for and body. The spinal cord contains longitudinally
greater precision in de®nition and clari®cation of oriented spinal tracts (white matter) surrounding central
points of ambiguity. areas (gray matter) where most spinal neuronal cell
Since 1994, a Training Package of four video bodies are located. The gray matter is organized into
tapes and a 143 page Reference Manual have segments comprising sensory and motor neurons. Axons
been completed by members of the 1992 from spinal sensory neurons enter and axons from motor
committee. This package is available from the neurons leave the spinal cord via segmental nerves or
ASIA Publications oce and is strongly recom- roots. The roots are numbered and named according to
mended to all clinicians and researchers who have the foramina through which they enter/exit the vertebral
a serious commitment to record neurological column. For example, the two C6 roots (left and right)
impairments in a standardized manner. The pass through foramina situated between the C5 and C6
Reference Manual is both a learning guide for vertebrae.
new users of the Standards and an authoritative Each root receives sensory information from skin
reference text for experienced users. The commit- areas called dermatomes. Similarly, each root inner-
tee also hopes that its content will promote vates a group of muscles called a myotome. While a
investigations that produce empirical data on dermatome usually represents a discrete and contig-
which to base further revisions. uous skin area, most roots innervate more than one
In consideration of the anticipated need for muscle, and most muscles are innervated by more than
further revisions based on new information, the one root.
 International Standards Classifications of SCI
FM Maynard et al
267

Spinal cord injury (SCI) a€ects conduction of Quadriparesis and paraparesis

sensory and motor signals across the site(s) of Use of these terms is discouraged, as they describe
lesion(s). By systematically examining the dermatomes incomplete lesions imprecisely. Instead, the ASIA
and myotomes, as described within this booklet, one Impairment Scale (vide intra) provides a more precise
can determine the cord segments a€ected by spinal approach.
cord injury. From such an examination, several
measures of neurological damage are generated, e.g.,
Neurological Level, Sensory Level and Motor Level Dermatome
(on right and left sides), Sensory Scores (Pin Prick and This term refers to the area of the skin innervated by
Light Touch), Motor Score and Zone of Partial the sensory axons within each segmental nerve (root).
Preservation.
Here we endorse the ASIA Impairment Scale
(replacing the modi®ed Frankel Classi®cation of Myotome
earlier versions of this booklet) and recommend the This term refers to the collection of muscle ®bers
Functional Independence Measure (the FIM ± an innervated by the motor axons within each segmental
approach for assessing the impact of spinal cord injury nerve (root).
on the individual's daily life activities and functions).
Thus, the FIM data describing disability complement
the more traditional neurological and impairment Neurological level, sensory level and motor level (see
measures. summary chart, Figure 4)
We begin with basic de®nitions of common terms The ®rst of these terms refers to the most caudal segment
used herein. The section that follows describes the of the spinal cord with normal sensory and motor
recommended neurological examination, both sen- function on both sides of the body. In fact, the segments
sory and motor components. The following sections at which normal function is found often di€er by side of
cover sensory and motor scores, the ASIA Impair- body and in terms of sensory vs. motor testing. Thus, up
ment Classi®cation, clinical syndromes associated to four di€erent segments may be identi®ed in
with spinal cord injury, and the FIM. Finally, for determining the neurological level, ie, R-sensory, L-
ease of reference, a summary chart of the sensory, R-motor, L-motor. In cases such as this, it is
recommended system is included (Figure 5). A full- strongly recommended that each of these segments be
size version for photocopying and use in the separately recorded and that a single `level' not be used,
patient's record may be obtained by contacting: as this can be misleading in such cases. When the term
Lesley M Hudson MA, 2020 Peachtree Road, NW Sensory Level is used, it refers to the most caudal
Atlanta, Georgia 30309, USA. segment of the spinal cord with normal sensory function
on both sides of the body; the Motor Level is similarly
de®ned with respect to motor function. These `levels' are
De®nitions determined by neurological examination of: (1) a key
sensory point within each of 28 dermatomes on the right
Tetraplegia (preferred to`quadriplegia') and 28 dermatomes on the left side of the body, and (2) a
This term refers to impairment or loss of motor and/or key muscle within each of 10 myotomes on the right and
sensory function in the cervical segments of the spinal 10 myotomes on the left side of the body.
cord due to damage of neural elements within the
spinal canal. Tetraplegia results in impairment of
function in the arms as well as in the trunk, legs and Skeletal level
pelvic organs. It does not include brachial plexus This term refers to the level at which, by radiographic
lesions or injury to peripheral nerves outside the neural examination, the greatest vertebral damage is found.
canal.

Sensory scores and motor scores (see summary chart,

Paraplegia Figure 4)
This term refers to impairment or loss of motor Numerical summary scores that re¯ect the degree of
and/or sensory function in the thoracic, lumbar or neurological impairment associated with the SCI.
sacral (but not cervical) segments of the spinal cord,
secondary to damage of neural elements within the
spinal canal. With paraplegia, arm functioning is Incomplete injury
spared, but, depending on the level of injury, the If partial preservation of sensory and/or motor
trunk, legs and pelvic organs may be involved. The functions is found below the neurological level and
term is used in referring to cauda equina and conus includes the lowest sacral segment, the injury is de®ned
medullaris injuries, but not to lumbosacral plexus as incomplete. Sacral sensation includes sensation at
lesions or injury to peripheral nerves outside the the anal mucocutaneous junction as well as deep anal
neural canal. sensation. The test of motor function is the presence of
 International Standards Classifications of SCI
FM Maynard et al
268

voluntary contraction of the external anal sphincter touch at each of the key points is separately scored on
upon digital examination. a three-point scale:
0 = absent
1 = impaired
Complete injury (partial or altered appreciation, including
This term is used when there is an absence of sensory hyperaesthesia)
and motor function in the lowest sacral segment.15 2 = normal
NT = not testable
The testing for pin sensation is usually performed
Zone of partial preservation (ZPP) with a disposable safety pin; light touch is tested with
This term refers to those dermatomes and myotomes cotton. In testing for pin appreciation, the inability to
caudal to the neurological level that remain partially distinguish between dull and sharp sensation is graded
innervated. When some impaired sensory and/or motor as 0.
function is found below the lowest normal segment, the The following key points are to be tested bilaterally
exact number of segments so a€ected should be for sensitivity (see Figures 1 and 4). Asterisks indicate
recorded for both sides as the ZPP. The term is used that the point is at the mid-clavicular line:
only with complete injuries. C2±Occipital protuberance
C3±Supraclavicular fossa
C4±Top of the acromioclavicular joint
Neurological examination C5±Lateral side of the antecubital fossa
C6±Thumb
Introduction C7±Middle ®nger
The neurological examination has two components C8±Little ®nger
(sensory and motor), which are separately described T1±Medial (ulnar) side of the antecubital fossa
below. Further, the neurological examination has T2±Apex of the axilla
both required as well as optional, though recom- T3±Third intercostal space (IS)*
mended, elements. The required elements are used in T4±Fourth IS (nipple line)*
determining the sensory/motor/neurological levels, in T5±Fifth IS (midway between T4 and T6)*
generating scores to characterize sensory/motor T6±Sixth IS (level of xiphisternum)*
functioning and in determining completeness of the T7±Seventh IS (midway between T6 and T8)*
injury. The optional measures, though not used in T8±Eighth IS (midway between T6 and T10)*
scoring, may add to a speci®c patient's clinical T9±Ninth IS (midway between T8 and T10)*
description. T10±Tenth IS (umbilicus)*
T11±Eleventh IS (Midway between T10 and T12)*
T12±Inguinal ligament at mid-point
When the patient is not fully testable L1±Half the distance between T12 and L2
When a key sensory point or key muscle is not L2±Mid-anterior thigh
testable for any reason, the examiner should record L3±Medial femoral condyle
`NT' instead of a numeric score. In such cases, L4±Medial malleolus
sensory and motor scores for the a€ected side of the L5±Dorsum of the foot at the third metatarsal
body, as well as total sensory and motor scores, phalangeal joint
cannot be generated with respect to the injury at that S1±Lateral heel
point in treatment. Further, when associated injuries, S2±Popliteal fossa in the mid-line
e.g., traumatic brain injury, brachial plexus injury, S3±Ischial tuberosity
limb fracture, etc, interfere with completion of the S4±5 Perianal area (taken as one level)
nuerological examination, the neurological level In addition to bilateral testing of these key points,
should still be determined as accurately as possible. the external anal sphincter should be tested through
However, obtaining the sensory/motor scores and insertion of the examiner's ®nger; perceived sensation
impairment grades should be deferred to later should be graded as being present or absent (ie, enter
examinations. Yes or No on the patient's summary chart). This
information is needed in determining completeness/
incompleteness of injury.
Sensory examination: required elements
The required portion of the sensory examination is
completed through the testing of a key point in each of Sensory examination: optional elements
the 28 dermatomes on the right and on the left sides of For purposes of SCI evaluation, the following
the body.2 aspects of sensory function are de®ned as optional
At each of these key points, two aspects of (though they are strongly recommended): position
sensation are examined: sensitivity to pin prick and sense and awareness of deep pressure/deep pain. If
to light touch.3 Appreciation of pin prick and of light these are examined, it is recommended that they be
 International Standards Classifications of SCI
FM Maynard et al
269

Figure 1

graded using the sensory scale provided herein 4=active movement, full ROM against moderate
(absent, impaired, normal). It is also suggested that resistance
only one joint be tested for each extremity; the 5=(normal) active movement, full ROM against
index ®nger and the great toe of the right and left full resistance
sides are recommended. NT=not testable
The following muscles are to be examined
(bilaterally) and graded using the scale de®ned
Motor examination: required elements above. The muscles were chosen because of their
The required portion of the motor examination is consistency for being innervated by the segments
completed through the testing of a key muscle (one on indicated and their ease of testing in the clinical
the right and one of the left side of the body) in the 10 situation, where testing in any position other than the
paired myotomes (see below). Each key muscle should supine position may be contraindicated.
be examined in a rostral-caudal sequence. C5 ± Elbow ¯exors (biceps, brachialis)
The strength of each muscle is graded on a six-point C6 ± Wrist extensors (extensor carpi radialis longus
scale:1,4,5,11 and brevis)
0=total paralysis C7 ± Elbow extensors (triceps)
1=palpable or visible contraction C8 ± Finger ¯exors (¯exor digitorum profundus) to
2=active movement, full range of motion (ROM) the middle ®nger
with gravity eliminated T1 ± Small ®nger abductors (abductor digiti minimi)
3=active movement, full ROM against gravity L2 ± Hip ¯exors (iliopsoas)
 International Standards Classifications of SCI
FM Maynard et al
270

L3 ± Knee extensors (quadriceps) than one nerve segment (usually two segments; see
L4 ± Ankle dorsi¯exors (tibialis anterior) Figure 2). Therefore, the assigning of one muscle or
L5 ± Long toe extensors (extensor hallucis longus) one muscle group (ie, the key muscle) to represent a
S1 ± Ankle plantar¯exors (gastrocnemius, soleus) single spinal nerve segment is a simpli®cation, used
For those myotomes that are not clinically testable with the understanding that in any muscle the presence
by a manual muscle exam, i.e., C1 to C4, T2 to L1 and of innervation by one segment and the absence of
S2 to S5, the motor level is presumed to be the same innervation by the other segment will result in a
as the sensory level. weakened muscle.
In addition to bilateral testing of these muscles, the By convention, if a muscle has at least a grade of 3,
external anal sphincter should be tested on the basis of it is considered to have intact innervation by the more
contractions around the examiner's ®nger and graded rostral of the innervating segments. In determining the
as being present or absent (i.e., enter Yes or No on the motor level, the next most rostral key muscle must test
patient's summary sheet). This latter information is as 5, since it is assumed that the muscle will have both
used solely for determining the completeness of injury. of its two innervating segments intact. For example, if
no activity is found in the C7 key muscle and the C6
muscle is graded as 3, then the motor level for the
Motor examination: optional elements tested side of the body is C6, providing the C5 muscle
For purposes of SCI evaluation, it is recommended is graded 5.
that other muscles be evaluated, but their grades are The examiner's judgement is relied upon to
not used in determining the motor score or motor level. determine whether a muscle that tests as less than
It is particularly suggested that the following muscles normal (5) may in fact be fully innervated. This may
be tested: (1) diaphragm (via ¯uoroscopy), (2) deltoids, occur when full e€ort from the patient is inhibited by
(3) abdominals (via Beevor's Sign), (4) media ham- factors such as pain, positioning and hypertonicity or
strings, (5) hip adductors. Their strength is to be when weakness is judged to be due to disuse. If any of
described as absent, weak or normal. these or other factors impede standardized muscle
testing the muscle should be graded as not testable

Sensory and motor scores/levels

Sensory scores and sensory level

Required testing generates four sensory modalities per
dermatome: R-pin prick, R-light touch, L-pin prick, L-
light touch. As is indicated on the summary chart
enclosed, these scores are then summed across
dermatomes and sides of body to generate two
summary sensory scores: Pin Prick and Light Touch
Score. The sensory scores provide a means of
numerically documenting changes in sensory function.
Further, through the required sensory examination
the sensory components for determining neurological
level (i.e. the sensory level), zone of partial preserva-
tion and impairment grade are obtained.

Motor scores and motor level12

The required motor testing generates two motor grades
per paired myotome: Right and Left. As indicated in
Figure 4, these scores are then summed across myotomes
and sides of body to generate a single summary motor
score. The motor score provides a means of numerically
documenting changes in motor function.
Further, through the required motor examination,
the motor components for determining neurological
level (ie, the motor level), zone of partial preservation
and impairment grade are obtained.

Motor level determination: further considerations

Just as each segmental nerve (root) innervates more Figure 2 Schematic depiction of innervation of each of three
than one muscle, most muscles are innervated by more key muscles by two nerve segments
 International Standards Classifications of SCI
FM Maynard et al
271

(NT). However, if these factors do not prevent the

patient from performing a forceful contraction and the
examiner's best judgement is that the muscle would
test normally (5) were it not for these factors, it may
be graded as 5.
In summary, the motor level (the lowest normal
motor segment ± which may di€er by side of body) is
de®ned by the lowest key muscle that has a grade of at
least 3, providing the key muscles represented by
segments above that level are judged to be normal (5).

Asia impairment scale (modi®ed from

Frankel)8,14,15
The following scale is used in grading the degree of
impairment:

A=Complete. No sensory or motor function is

preserved in the sacral segments S4-S5

B=Incomplete. Sensory but not motor function is

preserved below the neurological level and includes the
sacral segments S4-S5.

C=Incomplete. Motor function is preserved below

the neurological level, and more than half of key
muscles below the neurological level have a muscle
grade less than 3.

D=Incomplete. Motor function is preserved below

the neurological level, and at least half of key muscles
below the neurological level have a muscle grade Figure 3
greater than or equal to 3.

E=Normal. Sensory and motor function is normal. an are¯exic bladder, bowel and lower limbs, with
lesions as at B in Figure 3. Sacral segments may
occasionally show preserved re¯exes, eg. bulbocaver-
Clinical syndromes nosus and micturition re¯exes, with lesions as at A in
Figure 3.
Central cord syndrome
A lesion, occurring almost exclusively in the cervical
region, that produces sacral sensory sparing and greater Cauda equina syndrome
weakness in the upper limbs than in the lower limbs. Injury to the lubosacral nerve roots within the neural
canal resulting in are¯exic bladder, bowel and lower
limbs, with lesions as at C in Figure 3.
Brown-Sequard syndrome
A lesion that produces relatively greater ipsilateral
Functional independence measure (FIM)
proprioceptive and motor loss and contralateral loss of
sensitivity to pain and temperature. To fully describe the impact of SCI on the individual
and to monitor/evaluate progress associated with
treatment, a standard measure of daily-life activities
Anterior cord syndrome is necessary. The Functional Independence Measure
A lesion that produces variable loss of motor function (FIM)9 is one approach to functional assessment that
and of sensitivity to pain and temperature, while has become widely utilized in the U.S. and is gaining
preserving proprioception. acceptance internationally.
The FIM focuses on six areas of functioning: self-
care, sphincter control, mobility, locomotion, commu-
Conus medullaris syndrome nication and social cognition. Within each area, two or
Injury of the sacral cord (conus) and lumbar nerve more speci®c activites/items are evaluated, with a total
roots within the spinal canal, which usually results in of 18 items. For example, six activity items (eating,
 International Standards Classifications of SCI
FM Maynard et al
272

grooming, bathing, dressing-upper body, dressing- 1=Total assistance: Subject expends 0 ± 25% of the
lower body, and toileting) comprise the self-care area e€ort required in the activity.
(see Figure 4). Thus, the FIM total score (summed across all items)
Each of the 18 items is evaluated in terms of estimates the cost of disability in terms of safety issues
independence of functioning, using a seven-point scale: and of dependence on others and on technological
devices. The pro®le of area scores and item scores
Independent (no human assistance is required): pinpoints the speci®c aspects of daily living that have
7=Complete independence: The activity is typically been most a€ected by SCI.
performed safely, without modi®cation, assistive In using the FIM with individuals who have
devices or aids, and within reasonable time. experienced SCI, it should be kept in mind that the
6=Modi®ed independence: The activity requires an FIM was developed for the disabled population in
assistive device and/or more than reasonable time and/ general. It samples those areas of activity that have
or is not performed safely. been found to be a€ected by impairment among
diverse disability groups. Although basic issues of
Dependent (human supervision or physical assistance reliability and validity of the FIM have been explored
is required): by the developers,10 its validity as an instrument for
5=Supervision or setup: No physical assistance is precisely gauging changed functioning with all SCI
needed, but cuing, coaxing or setup is required. subpopulations has yet to be demonstrated empiri-
4=Minimal contact assistance: Subject requires no cally. For example, it is not yet clear that the self-care
more than touching and expends 75% or more of the items sensitively gauge changes in self-care functioning
e€ort required in the activity. experienced by tetraplegics during the course of
3=Moderate assistance: Subject requires more than rehabilitation. Further, the reliability estimates for
touching and expends 50 ± 75% of the e€ort required in the communication and social cognition areas have
the activity. been found to be lower than for other areas assessed.
2=Maximal assistance: Subject expends 25 ± 50% of Despite these caveats, the use of the FIM is
the e€ort required in the activity. recommended, as it is relatively simple to use, reflects

Figure 4
 International Standards Classifications of SCI
FM Maynard et al
273

Figure 5

functional issues of importance to SCI, and guidelines any form or by any means, electronic, photo-
for its use have been carefully developed.6 copying, recording or otherwise, without prior
Speci®c instructions for use of the FIM can be written permission of both ASIA and UDSMR.
obtained directly from the developers of the FIM. All rights reserved.
Request the `Guide for Use of the Uniform Data Set
for Medical Rehabilitation (1990),' at the following
The only portion of this booklet to which this
address: Uniform Data System for Medical Rehabili-
prohibition of modi®cation, reproduction, storage
tation, State University of New York, 232 Parker Hall,
in a retrieval system or transmission in any form
3435 Main Street, Bu€alo, New York 14214-3009
does not apply is the front page of the tri-fold pull-
USA
out sheet, called the `Standard Neurological Classi-
The copyright of the International Standards
®cation of Spinal Cord Injury' worksheet. Notice is
Booklet and of this article on it in Spinal Cord by
found at the bottom of that page which attests to the
ASIA/IMSOP must be noted:
permission granted by ASIA for duplication, but
alteration of this form in any manner is prohibited
Copyright# 1996 American Spinal Injury
without permission from ASIA.
Association (ASIA) and Uniform Data System
for Medical Rehabilitation (UDSMRSM) a divi-
sion of UB Foundation Activities, Inc. The Editors note (Mr Phillip Harris): It will be noted
booklet and this article on standards are that in pages 275 to 281 of this issue of Spinal Cord
intended for the express use of training there is further reference to these International
professionals in the use of the International Standards. It is interesting and important that since
Standards for Neurological and Functional their ®rst publication increasing use is being made by
Classi®cation of Spinal Cord Injury. No part doctors of these International Standards for research
of the publications may be modi®ed, reproduced, studies and scienti®c articles on spinal cord disorders,
stored in a retrieval system, or transmitted in non-traumatic and also traumatic.
 International Standards Classifications of SCI
FM Maynard et al
274

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