What is the protocol for completing a baseline sensory and motor assessment on a patient with a 2-week-old gunshot wound at the thoracic 8 (T8) level with complete spinal cord severance resulting in paraplegia?

From the Guidelines

To complete a baseline sensory and motor assessment on a patient with T8 complete paraplegia from a gunshot wound, a thorough neurological examination focusing on the level of injury is essential, incorporating light touch and pinprick testing for sensory function and evaluating muscle strength using the standard 0-5 scale for motor assessment. When assessing sensory function, it is crucial to work systematically from head to toe, paying particular attention to the transition zone around T8 where sensation changes from intact to absent, and document the exact level where sensation is lost 1. For motor assessment, evaluate muscle strength in all major muscle groups, noting that muscles innervated below T8 will show no voluntary movement (grade 0).

Key Components of the Assessment

• Assess sensory function using light touch and pinprick testing
• Evaluate muscle strength using the standard 0-5 scale in all major muscle groups
• Test deep tendon reflexes, including patellar and Achilles reflexes
• Assess for pathological reflexes such as Babinski sign
• Check for autonomic function by noting skin temperature, sweating patterns, and bowel/bladder control status
• Document any spasticity using the Modified Ashworth Scale

Given the patient's condition, with a 2-week-old gunshot wound and complete spinal cord severance resulting in paraplegia, it is also important to consider the potential for osteoporosis and related complications, as highlighted in the updated practice guideline for dual-energy x-ray absorptiometry (DXA) 1. However, the immediate priority is the comprehensive neurological assessment to establish a baseline for monitoring recovery or complications and guiding rehabilitation planning. This approach reflects the neuroanatomy of spinal cord injury, where complete transection at T8 interrupts both ascending sensory and descending motor pathways, resulting in loss of voluntary movement and sensation below the injury level.

From the Research

Baseline Sensory and Motor Assessment Protocol

The protocol for completing a baseline sensory and motor assessment on a patient with a 2-week-old gunshot wound at the thoracic 8 (T8) level with complete spinal cord severance resulting in paraplegia involves the use of standardized assessment tools.

• The American Spinal Injury Association (ASIA) Standards are widely used to assess motor function and pin-prick and light-touch sensory function 2, 3.
• The ASIA Standards include the assessment of upper and lower extremity motor scores, sum scores of pinprick and light touch sensation, and the classification of lesion severity according to the American Spinal Injury Association Impairment Scale (AIS) grade 4.
• A detailed neurological examination using the ASIA Standards should be obtained at 72 hours after injury for comparison with subsequent neurological assessments 3.

Assessment of Sensorimotor Functions

The assessment of sensorimotor functions in patients with spinal cord injury (SCI) can be done using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) 4.

• The ISNCSCI segmental motor and sensory assessments can be used to derive upper and lower extremity motor scores, sum scores of pinprick and light touch sensation, and the neurological level of injury (NLI) 4.
• An Integrated Neurological Change Score (INCS) can be used to evaluate overall neurological change in patients with SCI, based on the combination of normalized changes between two time points of upper and lower extremity motor scores and total pinprick and light touch scores 4.

Psychometric Properties of ASIA Standards

The psychometric properties of the ASIA Standards have been examined in several studies, including reliability, responsiveness, and construct validity 2, 3.

• The ASIA Standards have been shown to be reliable and responsive to changes in motor and sensory function over time 2, 3.
• However, further investigation of the minimal clinically important difference of the ASIA Standards is required, as well as the functionally meaningful ASIA score threshold to document the benefit of a novel therapeutic intervention 3.