Patient examination: Neurological evaluation

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 INSCI
 Motor function
 Sensory function
 Sacral sparing tests
INSCI
Thoracic and lumbar fractures: Patient examination - neurological evaluation

To assess the neurologic status of the patient the International Standards for neurological classification of Spinal Cord Injuries (INSCI; formerly referred to as the ASIA standards) are used systematically.


Motor function
Thoracic and lumbar fractures: Patient examination - neurological evaluation

The following key muscles in the upper and lower extremities have to be examined. A Manual Muscle Test (MMT) is performed.

There are six levels of muscle strength, as indicated on the assessment sheet.


Upper limbs

Check the strength of key muscles in the upper limb.  The key muscles are listed below along with the spinal cord level in brackets.


Thoracic and lumbar fractures: Patient examination - neurological evaluation

Check elbow flexors (C5)


Thoracic and lumbar fractures: Patient examination - neurological evaluation

Check wrist extensors (C6)


Thoracic and lumbar fractures: Patient examination - neurological evaluation

Check elbow extensors (C7)


Thoracic and lumbar fractures: Patient examination - neurological evaluation

Check finger flexors (C8)


Thoracic and lumbar fractures: Patient examination - neurological evaluation

Check finger abductors (T1)


Lower limbs

Check the strength of key muscles in the lower limb. 


Thoracic and lumbar fractures: Patient examination - neurological evaluation

Check hip flexors (L2)


Thoracic and lumbar fractures: Patient examination - neurological evaluation

Check knee extensors (L3)


Thoracic and lumbar fractures: Patient examination - neurological evaluation

Check ankle dorsiflexors (L4)


Thoracic and lumbar fractures: Patient examination - neurological evaluation

Check long toe extensors (L5)


Thoracic and lumbar fractures: Patient examination - neurological evaluation

Check ankle plantar flexors (S1)


Sensory function
Thoracic and lumbar fractures: Patient examination - neurological evaluation

Key sensory points
Pin prick sensation is assessed with a needle, light touch. Sensation is assessed with a piece of tissue paper.

Sensation is scored as absent (0), abnormal (1), or normal (2).


Thoracic and lumbar fractures: Patient examination - neurological evaluation

Pearl: C4/5 and T1/2

Be aware that C4 sensory level goes to just below the collar bone and the next dermatome below is T2. C5 through T1 are in the arms. The T2 dermatome includes the medial forearm the axilla and the upper chest.


Thoracic and lumbar fractures: Patient examination - neurological evaluation

Pearl: Left and right

The left and the right need to be examined separately and are not always the same.


Reflex examination

Upper and lower extremities should be examined for asymmetries and deep tendon reflexes.

In the setting of an acute spinal cord injury, the deep tendon reflexes are absent below the level of the injury.


Thoracic and lumbar fractures: Patient examination - neurological evaluation

In the upper extremities these are biceps tendon reflex (C5),


Thoracic and lumbar fractures: Patient examination - neurological evaluation

brachioradialis reflex (C6) …


Thoracic and lumbar fractures: Patient examination - neurological evaluation

…and the triceps tendon reflex (C7). 


Thoracic and lumbar fractures: Patient examination - neurological evaluation

In the lower extremities these are knee tendon (L4)


Thoracic and lumbar fractures: Patient examination - neurological evaluation

and Achilles tendon (S1)


Thoracic and lumbar fractures: Patient examination - neurological evaluation

Pathological reflex
Clonus and Babinski reflexes should be assessed as well. If clonus or Babinski reflexes are positive, this may be an indication for spinal cord injury.

 


Sacral sparing tests
Thoracic and lumbar fractures: Patient examination - neurological evaluation

Rectal examination
A rectal examination should be done to assess for anal tone. And the anal tone should be scored as absent or flaccid, reduced or normal.


Thoracic and lumbar fractures: Patient examination - neurological evaluation

The reason for this is that the anal sphincter muscle is the lower motor innervation.


Thoracic and lumbar fractures: Patient examination - neurological evaluation

The S2-5 dermatomes should be assessed for pin prick and light touch sensation (diagram, dermatome).