Michael Keith MD Ann Bryden OTRL Cleveland Ohio USA

REDEFINING TETRAPLEGIA

Michael Keith MD

Ann Bryden OTRL

Cleveland Ohio USA

SCI Classification

An important component in determining potential interventions is the classification of the level of injury

Classification schemes provide a common platform for understanding the degree of function associated with the level of SCI

SCI Classification International Standards for Neurological

Classification of Spinal Cord Injury (ISNCSCI)American Spinal Injury Association (ASIA)International Spinal Cord Society (ISCoS)Most commonly used

International Classification for Surgery of the Hand in Tetraplegia (ICSHT)For cervical level SCI only

Both classifications include a motor and sensory portion

The ICSHT is focused on the upper extremity

Who are the Stakeholders, and Why?

An increasing number of stakeholders International Tetraplegia Group – Therapists and Surgeons International Campaign for Cures of Spinal Cord Injury

Paralysis (ICCP) American Spinal Injury Association (ASIA) / International

Spinal Cord Society (ISCoS) – UE Basic Data Set Why?

Detect changes from natural recovery Better define incomplete lesions Measure the impact of interventions

○ Aimed at cure○ Activity based therapy○ Surgical reconstruction

NEW Version 2/2013

ASIA Update – Non Key Muscles

Movement Root Level

Shoulder: Flexion, extension, abduction, internal and external rotationElbow: Supination

C5

Elbow: PronationWrist: Flexion

C6

Finger: Flexion at proximal joint, extensionThumb: Flexion, extension and abduction in plane of thumb

C7

Finger: Flexion at MP jointThumb: Opposition, adduction and abduction perpendicular to palm

C8

Finger: Abduction of the index finger T1

Congruence with ICSHT?Movement Root

LevelICSHT

Shoulder: Flexion, extension, abduction, internal and external rotationElbow: Supination

C5 No Shoulder

Elbow: PronationWrist: Flexion

C6 45

Finger: Flexion at proximal joint, extensionThumb: Flexion, extension and abduction in plane of thumb

C7 867

Finger: Flexion at MP jointThumb: Opposition, adduction and abduction perpendicular to palm

C8 8

Finger: Abduction of the index finger T1

Current ClassificationsA classification should tell you what to do.

ASIA, ISCOS, AIS, ISNCSCIWork well with complete lesions, complicated -

perhaps without predictive use for surgical treatment. Does not classify results or permit patient reported outcomes.

Current ClassificationsA classification should tell you what to do.

International Surgical ClassificationWork well with complete motor paralysis,

voluntary (C5,C6), Group 0,1,2,3, 1/3 of cases.

Many Patient choices, surgical variations in C7,C8

Does not report anatomic change or PRO. Can be used for equivalency of function.

.Functional Enhancement for Cervical SCI - 1990Electrical Stimulation Tendon Transfers

Finger, thumb flexion

Finger, thumb extension

C4

C5

C6

C7

C8

O:0

O:1

OCu:2

OCu:3

OCu:4OCu:5

OCu:6

OCu:7

OCu:8

PD

->T

ricep

s

FE

S

EC

RL-

>F

DP

PT-

>F

PL

Br-

>E

CR

B

Br-

>F

PL

Br-

>E

DC

Thumb abduction

Elbow extension

Elbow flexion

Wrist extension

Shoulder abduction

OCu:9

Where do the Classifications Fail?

ASIA (arms) C4 – 2 C5 – 5 C6 – 6 C7 – 3 NC - 2

ICSHT (arms) Group 0 – 4 Group 1 – 3 Group 2 – 5 Group 5 – 3 NC - 3

Subject Characteristics (n=9, 18 Arms*)

Specific Examples

Where do the Classifications Fail?

Incomplete Injuries Spasticity Characterizing Paralysis Examples

77VC R: C5, -C6, C7, C8 / 5, -6, -7, 899VC R: C6 / 0, -1, 2, -3, 4, 5, 6, -799 VC L: C6, -C7, C8 / 2, -3, -4, 5, 6, -7, 8

“IC Exceptions”Partial TetraplegiaAsymmetrical lesionsRecovered- Regenerated, RepairedHyper-reflexiveContractedBi-manual activities

Clinical Decision Support

Evidence Based Clinical Practice Guidelines

Appropriate Use Criteria Cumulative experience without evidence Informed Opinion

Clinical Practice Guidelines Evidence based if outcome based. Solve problems of clinical decision

making. Make Recommendations based on

strong evidence. Find directions for outcomes research. Form the basis for national Performance

Measures and Appropriate Use Criteria. Search: www.guidelines.gov

Appropriate Use CriteriaRAND Methodology Writing Group

ClassificationRisk AdjustmentImportant Clinical CriteriaAlternative Treatments

Appropriate Use Criteria

Review GroupRefine credibility of application by

experts Voting Group

Shareholders Rate for Appropriate, Maybe Appropriate, Rarely Appropriate

Examples of AUC- AAOS App.

www.aaos.org/auc

Examples of AUC- AAOS App.

http://aaos.webauthor.com/go/auc

AAOS AUC App, Distal Radius Fx

Potential AUC writing table

Scenarios for AUC on Tetraplegia Management

Appropriate *, Maybe &, Not %

Muscle Scores- Voluntary

IC Key Muscle

ASIA/AIS/ISNCSCI/ISCOS Key Muscle Contracture release

Osteotomy, HO resection

Hyper-reflexia Botox, Chemo neuromodulation

Tendon, Nerve Transfer,

O:0 A-C4

O:1 Deltoid A-C5 Elbow Flexor Bi to Tri* Baclofen Pump&

Radial Osteotomy- pronation 40*

Ocu2 ECBL ECRB A-C6 Wrist Extensor

Ocu3 Biceps BR A-C7 Elbow Extensor

Ocu4 FDP FDS A-C8 Finger Flexor Fractional Lengthening*

APB ADQ A-T1 5th Abductor

etc

These combinations include both .AND. And .OR.

Measuring Spasticity

Challenges in measuring spasticityAshworthTardieuOther

Distinguishing between measures of spasticity and spasmsPenn spasm scale, others>

Lets write a AUC about Surgical Decision Making in Tetraplegia.

Review the literature for outcomes summary. CPG unlikely.

Writing group Review Group Voting Group