Authors of section

Authors

Alex Vaccaro, Frank Kandziora, Michael Fehlings, Rajasekaran Shanmughanathan

Executive Editor

Luiz Vialle

General Editor

German Ochoa (in memoriam)

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Patient examination: Neurological evaluation

1. INSCI

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.

Thoracic and lumbar fractures: Patient examination - neurological evaluation

2. Motor function

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.

Thoracic and lumbar fractures: Patient examination - neurological evaluation

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.

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)

Thoracic and lumbar fractures: Patient examination - neurological evaluation

Lower limbs

Check the strength of key muscles in the lower limb.

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)

Thoracic and lumbar fractures: Patient examination - neurological evaluation

3. Sensory function

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.

Thoracic and lumbar fractures: Patient examination - neurological evaluation

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.

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.

Thoracic and lumbar fractures: Patient examination - neurological evaluation

4. Sacral sparing tests

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).

Thoracic and lumbar fractures: Patient examination - neurological evaluation