International standards for neurological classification of spinal cord injury: impact of the revised worksheet (revision 02/13) on classification performance

Study Design: Prospective cohort study. Objectives: Comparison of the classification performance between the worksheet revisions of 2011 and 2013 of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Settings: Ongoing ISNCSCI instructional courses of the European Multicenter Study on Human Spinal Cord Injury (EMSCI). For quality control all participants were requested to classify five ISNCSCI cases directly before (pre-test) and after (post-test) the workshop. Participants: One hundred twenty-five clinicians working in 22 SCI centers attended the instructional course between November 2011 and March 2015. Seventy-two clinicians completed the post-test with the 2011 revision of the worksheet and 53 with the 2013 revision. Interventions: Not applicable. Outcome Measures: The clinicians' classification performance assessed by the percentage of correctly determined motor levels (ML) and sensory levels, neurological levels of injury (NLI), ASIA Impairment Scales and zones of partial preservations. Results: While no group differences were found in the pre-tests, the overall performance (rev2011: 92.2% +/- 6.7%, rev2013: 94.3% +/- 7.7%; P = 0.010), the percentage of correct MLs (83.2% +/- 14.5% vs. 88.1% +/- 15.3%; P = 0.046) and NLIs (86.1% +/- 16.7% vs. 90.9% +/- 18.6%; P = 0.043) improved significantly in the post-tests. Detailed ML analysis revealed the largest benefit of the 2013 revision (50.0% vs. 67.0%) in a case with a high cervical injury (NLI C2). Conclusion: The results from the EMSCI ISNCSCI post-tests show a significantly better classification performance using the revised 2013 worksheet presumably due to the body-side based grouping of myotomes and dermatomes and their correct horizontal alignment. Even with these proven advantages of the new layout, the correct determination of MLs in the segments C2-C4 remains difficult.