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American Spinal Injury Association (ASIA) Impairment Scale

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    I am a C6 class D per Spinal cord unit Augusta Ga VA Hospital. You definately will need to go to someone who does spinal cord injury assessments not just any doctor. Sorry but the average doctors are good in their respective fields but not with spinal cord injuries. I can walk with a cane, but it did and does not come easy. If a mosquito lands on the hair on my leg I know something it there, however if it bites me it may not itch, depending on location. If it is on my left ankle it will itch on my thighs it will just make a whelp. My right leg is the best for movement but my left has the best feeling for hot cold etc. Its a crazy body we live in.



      Your injury level is the most difficult level to diagnose and classify. The following may be a little confusing so let me first define some of the terms. When I say T12 or L1 bony segmental level, I am referring to the T12 or L1 vertebrae and not the spinal cord. As you may know, most of the lumbosacral spinal spinal cord segments are located at T12-L1 bony segmental level. The conus or tip of the spinal cord (S4/5) is just below the L1 bony vertebrae. Below the conus, you have the cauda equina which includes many of the lumbar and sacral spinal roots heading downward and out the appropriate openings between the vertebral segments.

      An injury to the L1 and T12 vertebral level is likely to damage the sacral gray matter of the spinal cord. Depending on the extent of damage, the injury may have spared the lumbar spinal cord (located at T9-T11 vertebral levels) but may have damaged the S1-5 spinal cord which contains much of the circuitry that controls the bladder. The circuitry that controls the anal sphincter is at S4/5. Note that neurons that control the toes are situated at spinal cord level S1. Can you wiggle your toes? Also the S2 dermatomes are located on the back of your thighs, S3 around your buttocks, and S4/5 around the anus.

      So, based on your description, you may have a sacral neurological level, perhaps S1. You should have little or reduced sensation in the back of your leg and buttock. If you have no sensation around or voluntary contraction of your anal sphincter, you would be an ASIA A with a neurological level of perhaps S1. If you have sensation around your anus, you would be an ASIA B with a neurological level at S1. If you have any voluntary contraction of your sphincter, you would be considered an ASIA D (since there are no key muscles below S1 that can be used to distiguish between ASIA C or D).

      Actually, I would love to have some experienced physiatrist on board here to discuss and debate these issues because I suspect that there may be disagreements amongst clinicians concerning how to classify a patient with your symptoms.



        Dr. Young,

        Thank you for your response to my questions regarding the ASIA scale. I do have sensation on the back of my thigh and outer buttocks.
        My toes do move but I cannot control movement.
        It seems like the response is in slow motion, other times my toes curl - very difficult to describe.

        Is my neurological level then S-3?

        Thanks for all you do.

        Never, never, never quit. - Winston Churchill


          Dr. Young, do you have any explanation, in regard to axons, as to how I can have sensory function in half of a level? I printed off the classification test and we were testing with pinprick and light touch. My bicep on both arms are sensitive to both pinprick and light touch but only halfway down the bicep. Does this mean there are still some existing sensory connections at C5? And approximately how many axons are at each level? I believe I remember you saying there were on average approximately 12-15 million axons total? If only a certain percentage work, does that explain why some patches are more sensitive than others? If so, does your 10 percent rule apply to sensory function as to number of axons needed?


            Redford, according to the ASIA classification, the neurological level is the lowest level with normal motor and sensory function. As you describe, you can move but not control your toes, therefore your motor function at S1 is not normal. How is your ankle movement. Even though you can feel at S1, S2, and S3, this suggests that your neurological level is above S1. It may be L3, L4, or L5, depending on your motor function at those levels. Look in the classification booklet for the description of the key muscles for each of those levels.

            Carl, there may be dermatome expansion after spinal cord injury, i.e. a spinal root may receive information from an area larger than its original dermatome. Also, sensory testing at the edges of the dermatome may not be reliable. That is why the ASIA classification specifies a particular point where the pin sensation should be tested.

            Regarding the number of axons, I don't know what the minimum and necessary number of axons is required for normal sensation. However, I suspect that the number of axons varies depending on the dermatome. Some dermatomes may have more axonal innervation than others.



              wise, i believe i can feel the hemorrhoid but now that i think about it i suppose it could be neuropathic. i feel discomfort and a burning sensation. both of which are symptoms of neuropathic and hemorrhoids. when i apply cream i do feel relief however, which leads me to believe that it is, in fact, a hemorrhoid. i can't feel a pin or suppository but sometimes i can feel pressure. what do you think?




                  I am trying to get an opinion of a experienced practicing physiatrist to comment on the interpretation of the ASIA score. Let me frame the question a little more clearly. As I understand the classification, anybody who has anal sensation would not be classified an ASIA A. If the person does not have any motor function below the neurological level (this includes voluntary sphincter contraction) that person would be classified an ASIA B. If the person has any motor function below the neurological level, including voluntary sphincter contraction, the person would be classified an ASIA C. If the motor score exceeds 50% of the possible score below the neurological level, the person would be classified an ASIA D.

                  Therefore, based on the above, I believe the following statements to be true:

                  1. A person who has anal sensation and voluntary anal contraction would be classified an ASIA C or higher.

                  2. A person who has anal sensation and any motor score of muscles below the neurological level (defined as the lowest segment that has normal motor and sensory function) would be classified an ASIA C or higher.

                  3. A person who has substantial motor function below the neurological level but no anal sensation or voluntary contraction would be classified an ASIA A.

                  Is this how a practicing physiatrist view the ASIA scoring?



                  • #24

                    If you have time, could you give a detailed explanation of anal sensation? I met Tie Qian in Beijing and he mentioned something about "deep sensation." That was the first time I had heard of such a thing and was wondering if you could elaborate. Thanks.



                      Deep sensation, particularly in the bowel, anorectal region, and bladder, are not well understood. While we know that light touch sensation (usually tested with a cotton swab or just finger touch) is carried by the dorsal columns and pinprick sensation representing pain is carried by the spinothalamic tracts situated in the lateral column, the spinal tracts that carry deep sensation including pressure on the legs are not well understood. There is a likelihood that autonomic systems may play a role.

                      The phenomenon and question which spinal tracts carry visceral sensation is of particular interest because of recent findings suggest that orgasms may be carried by non-spinal pathways. We know, for example, that the vagus nerve (the tenth cranial nerve) goes to the heart, stomach, guts, bladder, and probably sexual organs. The recent findings by Barry Komisaruk that women and animals with "complete" cord transections are still able to show evidence of orgasmic sensations is thought-provoking.


                      • Komisaruk BR and Sansone G (2003). Neural pathways mediating vaginal function: the vagus nerves and spinal cord oxytocin. Scand J Psychol 44:241-50. Summary: The initial observations, made in our laboratory with Knut Larsson, of the ability of vaginocervical stimulation (VCS) to block withdrawal responses to foot pinch in rats has led to findings of multiple behavioral, autonomic, and neuroendocrine effects of this potent stimulus in rats and also in women. It has led to an understanding of: (1) the neuroanatomical and neurochemical basis of a novel and potent pain-blocking mechanism; (2) likely neuroanatomical pathways mediating both the Ferguson reflex and a specific autonomic response - the pupil-dilating effect of VCS; (3) a role for oxytocin as a putative central nervous system neurotransmitter that stimulates autonomic sympathetic preganglionic neurons within the spinal cord; and (4) a novel pathway that can convey sensory activity from the cervix, adequate to induce orgasm, via the vagus nerves. This latter pathway bypasses the spinal cord and projects directly to the medulla oblongata, and thus can convey genital afferent activity despite complete spinal cord injury at any level. Department of Psychology and Biological Sciences, Rutgers, The State University of New Jersey, Newark, New Jersey 07102, USA.


                      • #26

                        I was told that deep sensation in the rectal region would classify me as ASIA B. I had not heard this before and was wondering if there was any truth to this?



                          To my knowledge, the ASIA classification emphasizes pinprick and touch of S4/S5 (not deep rectal sensation) and voluntary sphincter contraction. At least this was what we had in mind when I was on the committee on ASIA classification back in 1990-1992. I don't think that they have expanded the definition of S4/5 sensation and motor function to include deep rectal sensation.





                              Dear Dr Young,

                              I was refer to this website by another member from the SCI forum and would like to seek your opinion of my dad injury.

                              My dad had an accident in August 2003. He had dislocate C6 & C7 (all ligament surrounding them torn), broken collar, fractured right hand and brachial plexus injury on the left hand.

                              My dad is now in a rehab centre trying his best to recover. He has pain due to his brachial plexus injury but still he is learning to walk everyday and is doing rather well now. Today, one of the nurse told me that although my dad has done a reconstruction of nerve ie nerve graft chances of his left hand recovery is slim. Do you have any advise for me on this?

                              At the same time, my other worry is that my dad seems to need some assistant (lactus) in passing bowel but according to my dad, he can control the discreting of bowel... not just flow out by itself. As for urine... the doctor tried taking out the catheter about 5 to 6 weeks ago... he can pass the urine by himself very well for one whole day but on the second day there was some urine retention so the doctor put the catheter on for him. My question is what is the chances of him recovering both his bowel and bladder.

                              The doctor told me that there is a kind of small like catheter for the patient to extract the urine by himself (caregiver also have to learn to help the patient) every 4 hourly but I was hoping that my dad would recover and have no need of such assistant.

                              So now I really need to know your professional opinion.

                              Anxiously waiting for your reply. For now, I just like to thank you in advance for whatever advise you can give me.

                              Have a nice day. Take-care & all the best.

                              Hwee Yong


                                Hwee, I answered you in a new topic placed in the Care Forum. Click onto this link to get to it. Wise.