Basic Anatomy

1. Basic Anatomy International Autonomic Standards for the Classification of Spinal Cord Injury Part 2Autonomic Standards Form This part of the ASTeP course does NOT have an accompanying audio voiceover.

2. Part 2: Using the Autonomic Standards and Assessment Form Developed by the Autonomic Standards Committee • Comprised of members from the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCOS) including: • Co-Chairs: MarcaleeSipski (US) & Andrei Krassioukov (Canada) • General Functions sub-committee: Andrei Krassioukov (Canada) • Bladder sub-committee: Michael Kennelly (US) • Bowel sub-committee: Steven Stiens (US) • Sexual function sub-committee: MarcaleeSipski (US)

3. Autonomic Standards Download the PDF version here (subscription required) Or visit www.iscos.org.uk or www.asia-spinalinjury.org

4. Autonomic Standards ASIA & ISCoS support and encourage the use of the Autonomic Assessment and the Autonomic Assessment Form. After appropriate field testing, review, validity testing and if needed revision, the Autonomic Assessment will be included in the International Standards for the Neurological Classification of Spinal Cord Injuries (ISNCSCI). The Autonomic Standards were endorsed by both ASIA and ISCoS to document the remaining autonomic function after spinal cord injuries. It is recommended that the Autonomic Standards assessment form be completed, but it is not part of the ISNCSCI at this time.   

5. Differences between the ISNCSCI and the Autonomic Standards • The ISNCSCI : • Are based on an objective physical examination • Are designed to be completed all at once • The Autonomic Standards : • Are based on physical examination and history (general autonomic function), observation and patient report (lower urinary tract, bowel and sexual function) and urological procedures (urodynamic evaluation) • Have different sections that can be completed at different times  

6. Directions for Using the Autonomic Standards • Both the ISNCSCI and the Autonomic Standards can be done at any time. • A typical use might be acutely after injury, at admission, and at discharge from the initial rehabilitation. • Both assessments can be used clinically, for developing treatment plans and for research. 

7. Autonomic Standards Assessment/Form Sections General Autonomic Function Lower Urinary Tract, Bowel and Sexual Function Urodynamic Evaluation 1 2 3

9. Directions for the Autonomic Standards Assessment Form Each section has a different scoring method. A new and dated Assessment Form should be used when a section is scored or rescored. A section should be left blank if not assessed when other sections are scored. Subsequent Autonomic Assessment should include current observations/patient reports.    

10. General Autonomic Function

11. General Autonomic Function: Autonomic Control of the Heart Bradycardia:  if heart rate is less than 60 beats per minute Tachycardia:  if heart rate is greater than 100 beats per minute Other dysrhythmias: if any other clinically significant arrhythmias are present Unknown Unable to assess If none of the above is present: Normal

12. General Autonomic Function: Autonomic Control of Blood Pressure Resting Systolic:  if blood pressure below 90 mmHg Orthostatic hypotension:if there is a symptomatic or asymptomatic decrease in BP usually exceeding 20mmHg systolic or 10mmHg diastolic on moving from the supine to an upright position.

13. Control of Blood Pressure (continued) Autonomic dysreflexia:  if patients with injuries above T6 experience autonomic dysreflexia in response to noxious or non-noxious stimuli below the level of injury as manifested as an increase in systolic blood pressure greater than 20mmHg above baseline, and which may include any of the following symptoms: headache, flushing and sweating above the level of the lesion, vasoconstriction below the level of the lesion and dysrhythmias. Unknown Unable to assess If none of the above is present: Normal

14. General Autonomic Function: Autonomic Control of Sweating Hyperhydrosis above lesion: if non-physiological sweating occurs in response to noxious/non-noxious stimuli, positioning, etc. in the absence of fever, exercise or high environmental temperature Hyperhydrosis below lesion:  if non-physiological sweating occurs in response to noxious/non-noxious stimuli, positioning, etc. in the absence of fever, exercise or high environmental temperature Hypohydrosis below lesion: if no sweating present at any time Unknown Unable to assess If none of the above is present: Normal

15. General Autonomic Function: Temperature Regulation Hyperthermia:  if body temperature (rectal) is > 38.5° C (101.3° F), without signs of infection Hypothermia:  if body temperature < 35.0° C (95.0° F) Unknown Unable to assess If none of the above is present: Normal

16. General Autonomic Function: Control of Bronchopulmonary System Unable to voluntarily breathe requiring full ventilatory support:  if currently correct Impaired voluntary breathing requiring partial vent support: if currently correct Voluntary respiration impaired does not require vent support: if currently correct Unknown If none of the above is present: Normal In non-ventilated individuals with injury above T12, voluntary respiration could be impaired until excluded with additional evaluations.

17. Lower Urinary Tract, Bowel and Sexual Function

18. Lower Urinary Tract, Bowel and Sexual Function Lower Urinary Tract: The first two items are scored on the following scale: 2 = Normal Function 1 = Reduced or Altered Neurological Function 0 = Complete loss of control NT = Not testable. Unable to assess a specific function Awareness of need to empty bladder: Score based on patient self report Ability to prevent leakage (continence): Score based on patient self report

19. Lower Urinary Continued • Suggested list from the International Data Set: • Normal voiding • Bladder reflex triggering, Voluntary (tapping, scratching, anal stretch, etc.) • Bladder reflex triggering, Involuntary bladder expression • Bladder expression, Straining (abdominal straining, Valsalva’s maneuver) • Bladder expression, External compression (Credé maneuver) • Intermittent catheterization, Self-catheterization • Intermittent catheterization, Catheterization by attendant • Indwelling catheter, Transurethral • Indwelling catheter, Suprapubic catheter • Sacral anterior root stimulation • Non-continent urinary diversion/ostomy • Other method (specify)_____ • Unknown Lower Urinary Tract: This last item is self reported. Bladder emptying method ______________ (specify)

20. Lower Urinary Tract, Bowel and Sexual Function Sensation of need for a bowel movement: Score based on patient self report Ability to prevent stool leakage (continence): Score based on patient self report Voluntary sphincter contraction: Score based on anorectal examination Bowel: Continue to use the 2, 1, 0, NT scale

21. Lower Urinary Tract, Bowel and Sexual Function Genital arousal psychogenic (erection or lubrication due to fantasy, mood, and or non-genital touching): Score based on patient self report Genital arousal reflex (erection or lubrication due to direct physical stimulation of the genitalia): Score based on patient self report Sexual function: Continue to use the 2, 1, 0, NT scale

22. Sexual Function (continued) Orgasm: Score based on patient self report Ejaculation (male only): Score based on patient self report Sensation of Menses (female only): Score based on patient self report Sexual function: Continue to use the 2, 1, 0, NT scale

23. Urodynamic Evaluation

24. Urodynamic Evaluation It is recognized that not all centers will have the capacity (or accessibility) to use urodynamic technology. In that case, this section will be left blank. This section is based on findings during Urodynamic Testing for 3 urological functions. • Sensation during bladder filling (check one finding): • Normal • Increased • Reduced • Absent • Non-specific

25. Urodynamic Evaluation (continued) • Detrusor activity (check one finding): • Normal • Overactive • Underactive • Acontractile • Non-specific • Sphincter(check one finding): • Normal urethral closure mechanism • Normal urethral function during voiding • Incompetent • Detrusor sphincter dyssynergia • Non-relaxing sphincter

26. Autonomic Anatomical Classification • While viewing the next section, please understand that: • Describing and teaching an Autonomic Anatomical Diagnosis was one of the more difficult tasks for the Autonomic Standards Committee and the developers of ASTeP. • However there is a consensus that an autonomic classification is strongly needed for clinical and research purposes. • The following instructions are but a starting point in the development of a valid and reliable classification system and further input, research and revision will be needed.

27. The Autonomic Classification is specific to bowel, bladder and sexual function and has three categories. A SUPRACONAL injury is one that occurs above the conusmedullaris and the spinal cord below the level of injury has intact conal nerve roots and reflex arcs. With a supraconal injury, typical autonomic function includes an overactive or upper motor neuron (UMN) pattern of damage affecting the lower urinary tract, bowel and sexual functions. CONAL injuries affect the conusmedullaris of the spinal cord. Conal injuries often cause a mixed lesion to the lower urinary tract, bowel and sexual functions. Thus there may be a resultant overactive or acontractile picture affecting the lower urinary tract, bowel and sexual functions. Injuries affecting the CAUDA EQUINA generally cause an acontractile or lower motor neuron (LMN) picture affecting the lower urinary tract, bowel and sexual functions.

28. Like the ISNCSCI the autonomic classification can change with time. • The autonomic classification may vary in an individual case in response to: • Resolution of spinal shock • Urodynamic testing timing, availability and complexity • Evolution of incomplete injuries.

29. Autonomic Anatomical Classification • The Autonomic Classification starts with the ISNCSCI exam data including: • Neurological level of injury (NLI) based on the somatic motor and sensory examination • American Spinal Injury Association Impairment Scale (AIS-a classification of incompleteness of injury) • Findings of the anorectal examination • The results of the anorectal examination is the key starting point in making the autonomic classification.

30. The ISNCSCI’s NLI is based on the most rostral spinal nerve level with both normal sensory and motor function. Cervical and higher thoracic NLI are typically associated with a supraconal or UMN pattern of bowel, bladder and sexual function. Lower thoracic NLI can be associated with a supraconal or conal autonomic function. However cord ischemia or a diffuse injury to the lower cord (for example, SCI due to aortic artery injury/repair or a gunshot wound) can also result in a LMN/caudaequina function. Lumbar and Sacral NLI are typically associated with a caudaequina or LMN autonomic function.

31. Autonomic Anatomical Classification • Anorectal Examination during the ISNCSCI is now standardized including: • Evaluating S4/5 pinprick, light touch and deep anal pressure sensations • Testing voluntary anal sphincter contractions • Eliciting motor reflexes (bulbocavernosus and anal wink) • Other less described/studied reflex findings include: • Involuntary anorectal contractions with digital stimulation • Anorectal contractions with a gentle pull on an indwelling urinary catheter if present

32. Autonomic Anatomical Classification • The presence of anorectal reflexes are: • Generally a sign of supraconal (UMN) and some conalautonomic function • They are also normal reflexes and may be present without a spinal cord injury. • The absence of anorectal reflexes can be seen: • Early after a SCI and resultant spinal shock, • In conal or caudaequina autonomic function, and • Occasionally in people without a spinal cord injury.

33. Autonomic Anatomical Classification At this time there is no specific response(s) on General Autonomic Function and the Lower Urinary Tract, Bowel and Sexual Function sections of the Autonomic Standards Assessment Form that will “make” the Autonomic Anatomical Diagnosis. However, there is ongoing research using the autonomic assessment variables to define completeness of injury to spinal autonomic pathways.

34. Autonomic Anatomical Classification • Other information needed to make the Anatomical Classification may include: • Patient reports • Patient examinations • Serial Autonomic assessments • ISNCSCI examinations and/or Anorectal testing • Urodynamic Testing

35. Summary • Supraconal (upper motor neuron) and lower motor neuron classification can often made on the basis of physical examination combined with a NLI and AIS. • A conal injury is difficult to make on clinical exam. • Urodynamics could be the only method to make a conal classification and confirm a caudaequina classification. • Leave the classification blank if there is insufficient information to make the classification. • Like the ISNCSCI, if a patient has normal function the Autonomic Assessment should not be used.

36. Autonomic Anatomical Classification • Further revisions of the Autonomic Standards and their inclusion with the ISNCSCI will be reviewed on a yearly basis by the ASIA Standards and Education Committees and approved by ASIA and ISCoS.

37. Helpful readings and websites • Alexander MS, Biering-Sorensen F, Bodner D, Brackett NL, Cardenas D, Charlifue S, Creasey G, Dietz V, Ditunno J, Donovan W, Elliott SL, Estores I, Graves DE, Green B, Gousse A, Jackson AB, Kennelly M, Karlsson AK, Krassioukov A, Krogh K, Linsenmeyer T, Marino R, Mathias CJ, Perkash I, Sheel AW, Schilero G, Schurch B, Sonksen J, Stiens S, Wecht J, Wuermser LA, Wyndaele JJ.International standards to document remaining autonomic function after spinal cord injury.Spinal Cord. 2009 Jan;47(1):36-43. Epub 2008 Oct 28. Review. Erratum in: Spinal Cord. 2009 Jul;47(7):575. • Krassioukov AV, Karlsson AK, Wecht JM, Wuermser LA, Mathias CJ, Marino RJ; Joint Committee of American Spinal Injury Association and International Spinal Cord Society. Assessment of autonomic dysfunction following spinal cord injury: rationale for additions to International Standards for Neurological Assessment. J Rehabil Res Dev. 2007;44(1):103-12. • Sipski, M.A., Marino, R., Kennelly, M., Krassioukov, A.V., and Stiens, S. Autonomic Standards and SCI: Preliminary Considerations. Topics in Spinal Cord Injury Rehabilitation, 11(3); 2006; p:101-109 • Krassioukov A, Alexander MS, Karlsson AK, Donovan W, Mathias CJ, Biering-Sørensen F. International spinal cord injury cardiovascular function basic data set. Spinal Cord. 2010 Aug;48(8):586-90. Epub 2010 Jan 26.

38. Helpful readings and websites (continued) • Biering-Sørensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. . International lower urinary tract function basic spinal cord injury data set. Spinal Cord. 2008 May;46(5):325-30. Epub 2007 Nov 27. • Alexander MS, Biering-Sørensen F, Elliott S, Kreuter M, Sønksen J. International Spinal Cord Injury Male Sexual Function Basic Data Set. Spinal Cord. 2011 Feb 1. [Epub ahead of print] • Biering-Sørensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International urodynamic basic spinal cord injury data set. Spinal Cord. 2008 Jul;46(7):513-6. Epub 2008 Jan 29. • Biering-Sørensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International urinary tract imaging basic spinal cord injury data set. Spinal Cord. 2009 May;47(5):379-83. Epub 2008 Nov 25. • Krogh K, Perkash I, Stiens SA, Biering-Sørensen F. International bowel function extended spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):235-41. Epub 2008 Aug 26. • Krogh K, Perkash I, Stiens SA, Biering-Sørensen F. International bowel function basic spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):230-4. Epub 2008 Aug 26. • American Spinal Injury Association http://www.asia-spinalinjury.org/