false
Catalog
Virtual Didactic- ASIA Exam presented by Jesse Lie ...
Virtual Didactic- ASIA Exam Led by Jesse Lieberman ...
Virtual Didactic- ASIA Exam Led by Jesse Lieberman, MD
Back to course
[Please upgrade your browser to play this video content]
Video Transcription
Oh wow, COVID ward in the rehab hospital. I'm hearing that those are popping up. Okay, we are ready to go. All right. Thank you everybody for your patience. I apologize for the delay. Without further ado, let's see if I can pull this up. There we go. So without further ado, we're excited to have Dr. Lieberman here with us. Dr. Lieberman, thank you for joining us. I've got you unmuted. Do I need to hit slideshow mode on my, does this work? Can anybody see this? I can hear you, but I can't see you yet. Again, I'm sorry, I don't know what else I'm supposed to, I have my lecture pulled up, so what do I need to do? On the Zoom platform, you should be able to click the green share screen button. Okay. And then that'll give you an option of what you want to share. You guys see this now? Yes, sir. Perfect. The exam, what is it? It's consistent with sensor exam to 28 urban homes, about pinprick and light touch. Motor exam using zero to five grading system for five key also groups upper extremities. If I have key groups, the lower extremities to characterize a sensory motor level for each side of the body allows us to give a classification of a complete injury or circum incomplete injury. Is my pace okay? Yes, I think it's fine. So definitions, you have a neurological level. This is the most common motors, which are normal sensory level, as well as a motor level, a skeletal level, radiological fracture. We as medical physicians don't use this very much, but others, that's just what they primarily use. By the surgeons, a dermal dome is a segmental innervation of skin and a mild tone segmental innervation of muscles. Again, you start with a sensory exam. It has 28 German homes, bilaterally. He's a safety pin for the sharp and all sides to differentiate pain and I touch. It must be able to distinguish light touch from pinprick. So they're either not gonna feel it, which is a zero. Or they can not distinguish by touching in practically, or they're normal. Rectal exam is the key part as well. As rectal sensation and rectal tone, all tailgate traction, all contribute to diagnosis of a complete or incomplete injury. So again, they must be able to distinguish between light touch and pinprick. Some people skip and don't do the pinprick exam and they say, well, I have feeling everywhere. But if you, you should always do both. If you only do one, it's better to do the pinprick exam. Again, 28 German homes bilaterally. He's a cotton swab for the light touch. Gentle single stroke. Must be able to distinguish light touch from pinprick. The motor exam is a zero to five point scale. There aren't any pluses or minuses, you don't have to figure out what the difference is. Four plus or five minuses. It's pretty simple, zero is total paralysis. A one, there's some palpable contraction of muscle. A two, they're active. They went through full range of motion with gravity eliminated. So for example, C5 at the bicep. You would hold their elbow out, so their arms parallel to the floor. Let's see if they could bend their arm in, in that neutral plane. Grade three, active movement through full range of motion against gravity. So again, the C5 level, the arms hanging down, you can curl up. Grade four is, they're stronger than this, but they can't get all the way through full, against resistance. So they can bring the arm up in a curling motion. They can fight some resistance, but it's not normal. And five, grade five is active movement through full range of motion, full resistance. Any questions? Not yet, but as they come up, folks will send them to me in the chat box and I'll ask them as we go. Thank you. So the five muscle groups of upper extremities are C5, elbow flexors. C6 are wrist extensors. C7 are elbow extensors. C8 are the finger flexors. A T1 is a fifth digit abductor. The lower extremities, L2, hip flexors, L3, the extensors, L4, ankle dorsiflexion, L5, great toe extension, and S1, ankle plantar flexion. This exam then generates an HS score. So your sensory exam is going to give you a pinprick and a light touch from both right and left sides. And the most caudal level where a pinprick and a light touch are normal is their sensory level. Motor level is given for both right and left sides as well. Defined as the most caudal level is grade three or better, provided that all muscle groups above are normal. If no key muscle group is testable, you defer the motor score to grade three. If no key muscle group is testable, you defer the motor score to the sensory level. For example, in the thoracic region, we don't have a motor level to assess for T4 or T5. It's based on the sensory level. So Asia classifications, Asia A, complete injury. There's no motor or sensory function preserved at the lowest sacral segments, meaning no rectal pressure or involuntary interaction. Asia B signs motor incomplete injury. They have sensory but no motor function in the lowest sacral segments, so they have rectal sensation. There's some sensory stuff, low level injury with no movement or motor. Asia C indicates an incomplete injury, both motor and sensory. Preservation of motor function in more than half the key muscle groups below the neurological level of injury are less than three. So if half the key muscle groups below the level of injury are less than three, zero, ones, or twos, you have Asia C. As opposed to Asia D, preservation of motor and function in at least half the key muscle groups below the neurological level of injury are greater than or equal to three, so three, four, and five. Asia E, incomplete injury, no sensory or motor function. Incomplete classifications. In order to classify as incomplete, you must have sensory and motor function preserved in the lowest sacral segments. It doesn't matter what happens above, you have to have rectal sensation or voluntary contraction to be incomplete, so that's what's, you start with that if there's no feeling, no movement in the anus and rectum area, and there's incomplete injury. The minimum requirement to be Asia C or D, you must have motor or sensory function in the lowest sacral segments, and either voluntary or contraction, or sparing of motor function more than three levels below the motor level. Zone of partial preservation. These are typically just seen in people with complete injuries. Defined as the most carnal segment with some preservation of motor and or sensory function. Measure on both right and left sides for sensory and motor modalities. Sometimes somebody will have rectal sensation or voluntary contraction. They may have a small group of termitomes they have sensory in, or sometimes one or two motor groups. The spinal cord syndromes. There are several of those. The first is central cord syndrome. This usually occurs with a violent flexion or extension injury. We see these in all Asian populations, but just for an elderly population, for example, they fall forward as their head's going into this flexion position, and they'll hit the ground or hit something. It snaps their head back into extension, and they end up with a central cord syndrome. You can see this in reflexes. You can see it in anything. It's anywhere where the head's going forward and then rapidly being snapped back as it makes impact with something. Often there is no fracture. A lot of times these people don't need surgery. What's interesting is that their upper trivies are worse than their lower trivies. Sometimes they have a recovery ability to walk, but they can't open a door. Standing, walking is easy for them. Feeding themselves, brushing their teeth is challenging. These people typically get better and recover that upper trivial use, but acutely you can see some of them just about 0 out of 5 strength in uppers and 4 or 5 out of strength in their lowers. The next one is Brown-Saccard syndrome. This Brown-Saccard goes back to the French Revolution with stabbings. This is where one half of the spinal cord is damaged and the other half is maintained intact. It arises from a hemisection of the spinal cord. This is going to give you ipsilateral motor at proprioception and contralateral loss of pain and temperature because the spinal clinic tracks crossover and then ascend. This has the best prognosis as far as recovery. Of all the incompletes, these people recover better than other incompletes. Injured spinal cord syndrome. We typically see these in people with abdominal aortic aneurysm ruptures or during surgery for the abdominal aortic aneurysms because the aorta comes off of the aorta at T10 and the whole area is perfused from the aorta. It's branched and spared. This usually arises from loss of blood flow to the anterior spinal artery which supplies the anterior two-thirds of the spinal canal. It manifests itself as a loss of motor and pain and temperature but the dorsal columns are preserved by touch and proprioception. This doesn't help very much. Their recovery is more likely than a complete injury but people don't typically gain a lot of motor recovery from this. Cauda equina which is Latin for the horse's tail. The spinal cord ends at L2. Below that you have a bunch of nerves that hang and look like a horse's tail. These injuries result from a direct injury of the lower motor neuron. There are roots that are called equina which is L1 below. This usually presents as a reflexive bound binder. Sometimes flaccid paralysis to lower extremity muscle groups will also occur. Conus medullaris. The conus medullaris is the bottom of the spinal cord usually around L1 or L2. So there's an injury right at that level. Patients may have a mixed picture of upper and lower motor neuron signs in the lower extremities and bowel binder impairments. These are very rare in pure form. I have a couple case presentations I want to go through. Can you guys finish me with this? We can't, what you'll need to do is click your share screen button again and choose the other window. I'm sorry, I'm not seeing that button come up again. It's all right. You may have to click on the Zoom icon. I'm sorry, everyone. No, this is fine. I run into the same issue all the time. There we go, we can see that. So first case, starting up with C5, the motor score is a 5, light touch a bit breaker 2, which means intact. The C6 is a 4 at the motor, 2 and 2. Zeroes throughout that and zeroes in these lower sacral segments. I'd like to start down here. So they have a complete injury. If it was Asia B, there would be some light touch and break. As well, if it was Asia C, you would have this as well as below this C6 level. Since I can't quiz anybody or ask any questions, I'll have to tell you this is a C6 injury because you're intact at C5 and the next level below that you have at least 3 out of 5 strength. Motor level C6, sensory level C6, neurological level C6, Asia A, no zone of partial resuscitation. So we start here again, going down to the bottom. This is a light touch sensation around the anus or Asia B. And I don't think I discussed this at length or we ever discussed it at all. They have C5, 5, 2, 2 as a pressure below a previous person. Then at C6, they have 4, 101. At C7, 3, 101. At C8, 111. The level for this, you might say it's C7 because she has 3 out of 5 there or she. But in order to do that, the level above that has to be completely intact. So it won't be a C7 with this 3, 101. This would have to be a 5 and the light touch, the pinprick will have to be a 2. So you could just go down one level with 3 out of 5. And a little above it has to be 5 out of 5. So this is a C6. And I said Asia B. More level at C6. Central level is intact at C5. Yes, so sparing the sacral segments to make Asia B. Okay, this is the next one. We go down here and we see that there's rectal sensation. So they're at least a B. We go up here. Again, 5 out of 5 at C5, 4 out of 5 at C6. So their level can't, will not be below that. Now we look, we see all this motor recovery down here. So we now, we're now dealing with at least Asia C. And since all these are less than 3 out of 5, it's going to stay at Asia C. Motor level C6, central level C6, chronological level C6, Asia scale C. Our next one starts out the same way the one did before. We go down. We know we have Asia B. We start up here. And 5 out of 5 there, 2 out of 2. The next one is 4, so our level cannot be lower than C6. And we look here, we have 3 out of 5 straight throughout the legs. Since it's 3 out of 5, that's going to give us our Asia D rated. C6 on the motor again, C7 on the sensory. Neurological level is the lowest level that both sensory and motor are intact. That's Asia D. Has there been any questions or anything? Not yet. They tend to come up closer to the end of the lecture. Okay. Here we go, another one. So we go down to the bottom. This is a person with Asia A. We go back up to the motor. We have intact at C5, 2 out of 2. At C6, that's 5. But the sensory is not all the way through the pinprick. And we have C7 at 2, C8 at 1, as far as motors. And we know we have a Asia A, we have a complete injury. We have a motor level of C6. It can't be C7 because a motor level of C6 was not normal. Neurological level, where both motor and sensory were fully intact. Both motor and sensory were fully intact was at C5. And we have Asia A with a zonal partial preservation at C8. I want to just go back to that slide, make sure we can see that again. Okay, we have the C5, C6 as the motor level. So C6, this here counts as zonal partial preservation with a C8. Next case starts out the same way as all of them. Look down, we have Asia A. We have 5 out of 5 at C5, 5 out of 5 at C6, 4 out of 5 at C7, and 3 out of 5 at C8. So the motor level is going to again be, it's going to be C7. Because we're referring to be C8, it has to be 5 out of 5 at C7. C7 is the motor level. Light touch, pinprick is impaired at C7. So our neurological level is going to be C6. C8 gives some finger flexors. This person's going to function at a modified independent level. As these will also improve over time period. Case 5, I'll answer again. C6, motor level. C6, sensor level. And Asia A, neurological level C6 on the left, C5 on the right. Zonal partial preservation at C8. C6, I hope the pace is okay. Start as we did all of them at the bottom. S2, S3 is 0, so we know we have Asia A. And C5 is 5 out of 5. C6 is 4, C7 is 3. Again, motor level is going to be C6. Here you have the light touch, pinprick. Our 2 is there though. Then we have C3, as well as some sensor level at C4, C2, C4, normally intact there. Motor level against C6, sensor level C6, neurological level injury C6, Asia A, C5, C6. Zonal partial preservation around T2, T4, as well as versus C8. Again, we'll start at the bottom. This person has light touch preserves at least in Asia B. We go up to the top. We're 5 out of 5 at C5. 3 out of 5 at C6, 3 out of 5 at C7. Again, this is going to be C6. I know I keep reading this, but it's just important that we're saying that C6 has to be a 5 in order for it to be a C7. Motor level C6, sensor level C5, neurological level of injury C5, because it's sensor level. Asia B. Again, we start at the bottom. This is at least in Asia B. We come back to the top, C5, C6, C7, C8. We understand it's going to be C6 again. We have all this work to be straight here. 3 out of 5 is going to end up with a D. I'm sorry. It's always embarrassing when that happens. Because not half the groups were, go back, because not half the groups were 3 out of 5, at least 3 out of 5 is Asia C, so at least half of these groups would have to be, I don't know, 3 out of 5. The next one, we start at the bottom, Asia B, the top is a C6, but down here at the bottom, these are more than half the muscles. We're going to break out of 5. We're going to break out of 5. This is C6, we're at level C6 sensory, C6 level of injury with Asia D. The next case, we start at the bottom. These are zeros, Asia A. C5 is a 3, C6 is a 3, C7 is a 2. So we can't be C6 because the C5 is not a 3, it's not a 5. So this is going to be Asia A, C5 motor level, C5 neurological level. Motor level is C5, C5, Asia A, zone of force for preservation, C5 through C7. Next one starts out against Asia A, we come up to the top here, same thing, we can't be C6, it's going to be a C5. Zone of force for preservation down here at L2, L3. Next one, we start at the bottom, C5, 5 out of 5, C6, 4 out of 2. Sorry, 4 and over 2 at the levels of light touch. So we know it's A to A. Yeah, it's going to be a C5, C6, sorry, C6, A to A because we have 5 out of 5 in C5. We have at least 3 out of 5 in C6. Again, the same thing, some of these are over repeats, but there are minor, minor differences in each of them. So, AJA, C6 at Milner, so partial polarization of C7. Again, we start here, H of E, minus aggro C5, C6 is 4, so we can't be C7, plus a partial reservation. Here we go again, we go to the bottom, we're incomplete, C5 then C6, there's no motor below that, so we're just going to say, it should be Down at the bottom, we're incomplete, we're attacked at C5, not full at C6, so this C7 is going to be our partial reservation. I'm sorry, there's no partial reservation, it's only incomplete injuries, so it's just considered A should be at C6. Next one, we're at least A should be, C5 and C6, level one, then we have semi-complete C7 here, less than 305, C6, C6, A should be. Now we'll open up for questions. Yeah, thank you. I think especially the cases, the cases are, I think especially in this exam, cases are one of those things that you're not going to get it unless you practice doing it. A couple of questions, one is kind of going back to basic overview, are there standardized testing times? I mean, I've been told that you do it as soon as possible, but then how frequently are you doing an AJA exam after that? Great question. One thing I didn't note it here is an AJA exam is regular at 72 hours, so somebody may be complete for 24, 48 hours, but at 72 hours is when we can make a definitive, complete or incomplete. The completes of the 72 hours, you should stay like that. Some people will regain AJA B, but really nobody goes from AJA A at that point to AJA D with a functional recovery. There's not a standard as how often you should check them. The incompletes are going to improve, the completes are not, so it could be weekly. As far as doing the whole AJA, it really doesn't need to be done again. And then is it something that you would do to some extent at follow-ups or you just kind of play it by ear as people are reporting more, reporting changes? Just reporting changes. I think all systems may require them to do a follow-up, I think that's just for tracking data. Okay. Okay. Second, you mentioned that you're not going to see somebody go from an A to a D typically, but you might see some incompletes improve. To what extent do you see somebody go from like a B to a D or dramatic improvements like that? Not often. Not often. One thing with the Bs is because the anatomy, the spinal cord, which I could go back to, but the spinal cord, the pain tracts run close to the motor tracts. So if somebody has a light touch, incomplete, like the anterior cord syndromes, they typically don't get their recovery back, but if somebody's incomplete, especially if they're really incomplete to pinprick multiple levels below, then I don't have percentage of time, but probably 20 to 30% of them will recover to at least A to C. Okay. All right. That's more than I anticipated. One question over here is there's a thought that maybe in the 2019 version of the ASIA exam that partial preservation might be also included in incomplete lesions. I'm not familiar with the changes. I'm not either. I should be. I'm sorry. I don't know. That's, I think, something we can circle back to. That's all the questions I see for now. I think we have your contact information up here. Let's see. Yes. Does that look accurate? Yeah. All right. Great. So if anybody has any further questions that come up after this lecture, can they reach out to you directly? Of course. Excellent. Well, thank you very much for joining us. We appreciate it. Thank you. All right. And for anybody who missed this lecture or missed part of it, or if a colleague missed it, again, the physiatry.org slash webinars has the link to all the videos, and I believe Candice is going to go through and kind of edit things as necessary in terms of trimming off fronts and beginnings and ends. And then you can reach out to Dr. Lieberman directly at his email address there. You can track me down, or the AAP Twitter handle is there as well. I think we have a few more minutes before Dr. Aaron Yang joins us. So we can just, again, thank you, Dr. Lieberman, for joining us, and thank you everybody for joining us. And we will get started here in a few minutes. Thank you. Thanks, everybody, for your patience.
Video Summary
In this video, Dr. Lieberman discusses the ASIA (American Spinal Injury Association) exam, which is used to assess and classify spinal cord injuries. He begins by explaining the different levels of injury and the criteria for assigning a classification, such as complete or incomplete injury. Dr. Lieberman then goes through a series of case presentations to demonstrate how to determine the motor and sensory levels and classify the injury using the ASIA scale. He also discusses the concept of zone of partial preservation and different spinal cord syndromes. Throughout the video, Dr. Lieberman emphasizes the importance of regularly assessing and tracking changes in neurological function following a spinal cord injury. The video concludes with a Q&A session in which Dr. Lieberman answers questions about the timing and frequency of ASIA exams, as well as the potential for improvement in incomplete injuries. No credits or sources are mentioned in the video.
Keywords
ASIA exam
spinal cord injuries
classification
motor and sensory levels
ASIA scale
neurological function
incomplete injuries
×
Please select your language
1
English