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Thread: Frankel vs ASIA classification

  1. #1
    Senior Member cypresss's Avatar
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    Frankel vs ASIA classification

    Hi there

    I know that ASIA scale is more useful to use when is about the classification of a spinal cord injury, but I'm curios on this particular case.

    A person with sensory function preserved at the S4-S5 levels(no voluntary motor functions at S4-S5 levels only sensory functions) will be Frankel B and ASIA A?

    many thanks
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  2. #2
    Quote Originally Posted by cypresss View Post
    Hi there

    I know that ASIA scale is more useful to use when is about the classification of a spinal cord injury, but I'm curios on this particular case.

    A person with sensory function preserved at the S4-S5 levels(no voluntary motor functions at S4-S5 levels only sensory functions) will be Frankel B and ASIA A?

    many thanks
    Check this out might help you:



    Spinal Cord Injury Levels and Classification
    Wise Young, Ph.D., M.D.
    W. M. Keck Center for Collaborative Neuroscience
    Rutgers University, Piscataway, NJ


    http://www.mcpf.org/FacingSCI/SCICla...3/Default.aspx

  3. #3
    Senior Member cypresss's Avatar
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    Quote Originally Posted by manouli View Post
    Check this out might help you:
    Spinal Cord Injury Levels and Classification
    Wise Young, Ph.D., M.D.
    W. M. Keck Center for Collaborative Neuroscience
    Rutgers University, Piscataway, NJ
    http://www.mcpf.org/FacingSCI/SCICla...3/Default.aspx
    Many thanks Manouli. I know about that, and the source of the that paper is on this site. Dr Wise is gold for entire sci community.

    This is why i have doubts:
    "It should be noted that ASIA A and B classification depend entirely on a single observation, i.e. the preservation of motor and sensory function of S4-5."
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  4. #4
    Senior Member cypresss's Avatar
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    Quote Originally Posted by cypresss View Post
    A person with sensory function preserved at the S4-S5 levels(no voluntary motor functions at S4-S5 levels only sensory functions) will be Frankel B and ASIA A?
    I think the right answer is: A person with sensory functions only at S4-S5 is ASIA B.

    many thanks, sorry for this thread.
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  5. #5
    Quote Originally Posted by cypresss View Post
    Hi there

    I know that ASIA scale is more useful to use when is about the classification of a spinal cord injury, but I'm curios on this particular case.

    A person with sensory function preserved at the S4-S5 levels(no voluntary motor functions at S4-S5 levels only sensory functions) will be Frankel B and ASIA A?

    many thanks
    cypress,

    In your example, that person would be a ASIA B. I am not sure what that person would be on a Frankel scale because I don't think that the Frankel scale required an anal examination of the patient. The ASIA Impairment Scale is like the better defined version of the Frankel Scale. Let me explain.

    The American Spinal Injury Association (ASIA) and ISCOS (International Spinal Cord Society) adopted the ASIA Impairment Scale (AIS) in 1991 because it provided a more rational and consistent set of rules with which to apply the Frankel Scale.

    The Frankel scale classified patients into A, B, C, D, and E, using adjectives to describe the criteria for classification. So, for example, A is complete, B is sensory incomplete, C is motor incomplete without useful function, D is motor incomplete with useful function, and E is "normal". I am of course paraphrasing the Frankel scale because I don't have the original wording from the 1972 paper in front of me.

    In 1990-1991, John Ditunno and I co-chaired the American Spinal Injury Association Committee to revamp the spinal cord injury classification system. This effort took two years and we came out with a revised ASIA Impairment Scale that resolved several ambiguities in the Frankel Classification. This scale was accepted by the International Spinal Cord Society, including Hans Frankel himself. The scale resolved the following ambiguities:
    1. Complete versus incomplete. Many people with spinal cord injury recovered several segments of motor and sensory function below the injury level. This was particularly true in patients that had received methylprednisolone. By the Frankel and the old ASIA scale, these would be incomplete but we knew that many of them did not recover all that much. Are they incomplete or complete? We argued about this a long time and we agreed to use the definition of having having some level of the spinal cord below which there is no voluntary movement or sensory perception. As it turned out, voluntary anal sphincter contraction and peri-anal sensation is the lowest level of the spinal cord. If somebody did not have anal function or sensation, they were classified as ASIA A. ASIA B is if the person some level below which there is only sensation and no motor function.
    2. Useful versus non-useful. It is hard to measure "useful" and so we arbitrary chose <50% of the motor score in the legs as the dividing line. ASIA C is if somebody has a level below which motor or sensory function was abnormal and the motor score was less than 50% of the normal motor score. ASIA D is if there the motor score was 50% or greater than normal.
    3. Neurological level. This turned out to be the most difficult problem. Surgeons tended to refer to the injury level, usually defined by where the bony fracture is located. Neurologists tended to refer to the injury level as the first neurological segment that is abnormal. Rehabilitation doctors tended to refer to the neurological level as the lowest spinal cord injury that has "intact" neurological function. After much debate, we decided to accept the rehabilitation doctor's approach to neurological level, i.e. the lowest contiguous segment of the spinal cord that showed intact neurological funciton. Because many muscles receive motor innervation from two or more segments, "intact" motor function does not necessarily mean normal strength of the muscle innervated by the segment. So, we said that "intact" muscle strength would be a grade of 3 of 5. However, both pinprick and touch sensation in the dermatome must be normal, i.e. 2 of 2.


    The ASIA Impairment Scale requires an anal examination. Without an anal examination, you cannot tell whether the person is an ASIA A. The person also must be conscious and cooperative during the examination, to tell you that he or she cannot feel or to contract the anal sphincter voluntarily. Many groups have validated the scale now on thousands of patients with spinal cord injury. ASIA A turns out to be highly predictive of poor prognosis of substantial recovery such as locomotor function. Less than 10% of people who have ASIA A during the first week after injury recover unassisted walking. About 30% of ASIA B recover walking. Over 90% of ASIA C and 100% of ASIA D recover unassisted walking.

    The motor score requires careful examination of ten muscle groups on each side of the body. Each muscle must be tested in a specific position with the body lying supine, using the 0-5 scale. Pinprick (sharp) and touch (dull) sensation must be tested and scored in each dermatome at a specific place (in front and along a longitudinal line midway between the midline and nipples). The scores are added up and there is a specific form that must be used for filling out the scores. Doctors who have not been specifically trained to carry out the examination usually don't know how the do the examination and their scores cannot be relied upon. Yes, I know, doctors always think that they know but I have been involved in the training of hundreds of doctors who thought that they know how to do the exams and they did not. They must receive training, particularly for clinical trials.

    Wise.

  6. #6
    The major weakness of the ASIA classification system is the imprecision in classifying ASIA C vs. ASIA D pts. If a pt has voluntary movement below the LOI with the majority of key muscles graded at least 3/5, he/she is classified as ASIA D. If he/she has voluntary movement below the LOI with the majority of key muscles graded <3/5, he/she is classified as ASIA C. However, this does not assess function as the old Frankel system did. Hence, a pt like Christopher Reeve was classified as ASIA C because he was able to twitch a couple of fingers and his quadriceps although he did not have any real functional use. By contrast, a pt could be ambulatory without having the majority of key muscles graded at least 3/5, but would still be classified as ASIA C. The same patient would be classified as D by the Frankel system.
    Last edited by PaidMyDues; 10-15-2009 at 05:23 PM.

  7. #7
    Quote Originally Posted by PaidMyDues View Post
    The major weakness of the ASIA classification system is the imprecision in classifying ASIA C vs. ASIA D pts. If a pt has voluntary movement below the LOI with the majority of key muscles graded at least 3/5, he/she is classified as ASIA D. If he/she has voluntary movement below the LOI with the majority of key muscles graded <3/5, he/she is classified as ASIA C. However, this does not assess function as the old Frankel system did. Hence, a pt like Christopher Reeve was classified as ASIA C because he was able to twitch a couple of fingers and his quadriceps although he did not have any real functional use. By contrast, a pt could be ambulatory without having the majority of key muscles graded at least 3/5, but would still be classified as ASIA C. The same patient would be classified as D by the Frankel system.
    PaidMyDues,

    I agree with you that the ASIA Classification may not necessarily reflect the functional capabilities of the patient. However, in my opinion, the ASIA Impairment Scale is more reliable and consistent than the Frankel scale because it is precisely defined. Moreover, AIS classification is highly predictive of future locomotor recovery. A person who was ASIA C during the first week after injury is very likely (95%) to recover unassisted walking. A person who was ASIA B only has a 30-40% probability of recovering unassisted locomotion.

    To classify actual walking and other functions, we use WISCI and SCIM.

    Wise.

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