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CDE Detailed Report
This report contains detailed information about the selected CDEs.
Note: If at least one CDE was selected from a copyright- or trademark-protected instrument/scale then all of the CDEs from that instrument/scale are included in this report.
Disease: Spinal Cord Injury
SubDisease: Spinal Cord Injury
Sub-Domain: Neurological Outcomes
CRF: International Standards for Neurological Classification of SCI Worksheet
Item count: 29 (29 distinct CDEs)
CDE ID
CDE Name
Variable Name
Definition / Description
Question Text
Permissible Value
Description
Data Type
Instructions
References
Population
Classification (e.g., Core)
Version #
Version Date
Aliases for Variable Name
CRF Module / Guideline
© or TM
Sub-Domain
Domain
Previous Title
Size
Input Restrictions
Min Value
Max Value
Measurement Type
LOINC ID
SNOMED
caDSR ID
CDISC ID
C06000
Site identifier number
SiteIDNum
Unique identification number given to the study site to distinguish the location where data is recorded.
Site
  
Alphanumeric
The site identifiers or IDs should be assigned by the study.
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015
Adult;Pediatric
Core
3.0
7/17/2013
SITE
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
Site identifier
255
Free-Form Entry
       
C19247
Subject ID
SubIDNam
Subject identification ID
Subject
  
Alphanumeric
The participant or subject identifiers or IDs should be assigned by the study.
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015
Adult;Pediatric
Core
1.0
6/5/2014
Aliases for variable name not defined
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
 
255
Free-Form Entry
       
C06005
Data collected date and time
DataCollDateTime
Date (and time, if applicable and known) the data were collected. This may be the date/time a particular examination or procedure was performed.
Date Time of Exam
  
Date or Date & Time
Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015.
Adult;Pediatric
Core
3.0
7/24/2013
Aliases for variable name not defined
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
Data collected date and time
 
Free-Form Entry
       
C06324
SCI Classification motor exam anatomic site
SCIClssMtrExamAntmicSite
Muscle (and associated spinal cord level) evaluated during the motor examination
Motor
Elbow flexor (C5);Wrist extensor (C6);Elbow extensor (C7);Finger flexor (C8);Finger abductor (T1);Hip flexor (L2);Knee extensor (L3);Ankle dorsiflexor (L4);Long toe extensor (L5);Ankle plantar flexor (S1);
Elbow flexor (C5);Wrist extensor (C6);Elbow extensor (C7);Finger flexor (C8);Finger abductor (T1);Hip flexor (L2);Knee extensor (L3);Ankle dorsiflexor (L4);Long toe extensor (L5);Ankle plantar flexor (S1);
Alphanumeric
This element and the 'SCI Classification motor or sensory exam laterality type' element should be used with the subsequent motor grades and scores to identify with which anatomic site and side (i.e., left or right) the motor grade/score is associated.
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015
Adult;Pediatric
Core
3.0
7/17/2013
Refer to SCI CDE Annotated Form
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification motor exam anatomic site
 
Single Pre-Defined Value Selected
       
C02411
Laterality type
LatTyp
Laterality type relative to the anatomic site of the body examined or affected
R L
  
Alphanumeric
This element, and the 'SCI Classification motor exam anatomic site' and 'SCI Classification sensory exam anatomic site' elements as applicable, should be used with the subsequent motor and sensory grades and scores to identify with which anatomic site and side (i.e., left or right) each motor and sensory grade/score is associated.
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015
Adult;Pediatric
Core
3.0
8/28/2013
Aliases for variable name not defined
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
Laterality type
 
Single Pre-Defined Value Selected
       
C06337
SCI Classification motor exam anatomic site grade
SCIClssMtrExamAntmicSiteGrd
Grade that documents the movement, range of motion, and resistance of the specific muscle on the right or left side.
Muscle Grading
0;1;2;3;4;5;5*;NT;
Total paralysis;Palpable or visible contraction;Active movement, full range of motion, gravity eliminated;Active movement, full range of motion, against gravity;Active movement, full range of motion, against gravity and provides some resistance;Active movement, full range of motion, against gravity and provides normal resistance;Muscle able to exert, in examiner’s judgment, sufficient resistance to be considered normal if identifiable inhibiting factors were not present;Not testable;
Alphanumeric
Choose best score and record for each muscle on each side
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015
Adult;Pediatric
Core
3.0
7/17/2013
Refer to SCI CDE Annotated Form
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification motor exam anatomic site grade
 
Single Pre-Defined Value Selected
       
C06419
SCI Classification motor strength upper limb single side score
SCIClssMtrStrgthUpLmbSnglSdScr
Score of motor strength for the upper limb on the specific side
Motor Upper Limb R/L
  
Numeric Values
Should be calculated/derived from the raw data. The maximum score for each side is 25.
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015
Adult;Pediatric
Core
3.0
7/17/2013
MTRULL; MTRULR
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification motor strength upper limb single side score
 
Free-Form Entry
       
C06320
SCI Classification motor strength upper limb total score
SCIClssMtrStrgthUpLmbTtlScore
Total score of motor strength for the upper right and left limbs.
Motor Upper Limb Total
  
Numeric Values
Should be calculated/derived from the raw data. The maximum total score is 50.
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015.
Adult;Pediatric
Core
3.0
7/17/2013
MTRULT
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification motor strength upper limb total score
 
Free-Form Entry
       
C06420
SCI Classification motor strength lower limb single side score
SCIClssMtrStrgthLwLmbSnglSdScr
Score of motor strength for the lower limb on the specific side.
Motor Lower Limb R/L
  
Numeric Values
Should be calculated/derived from the raw data. The maximum score for each side is 25.
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015.
Adult;Pediatric
Core
3.0
7/17/2013
MTRLLL; MTRLLR
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification motor strength lower limb single side score
 
Free-Form Entry
       
C06347
SCI Classification motor strength lower limb total score
SCIClssMtrStrgthLwLmbTtlScore
Total score of motor strength for the lower right and left limbs.
Motor Lower Limb Total
  
Numeric Values
Should be calculated/derived from the raw data. The maximum total score is 50.
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015
Adult;Pediatric
Core
3.0
7/17/2013
MTRLLT
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification motor strength lower limb total score
 
Free-Form Entry
       
C06326
SCI Classification sensory exam anatomic site
SCIClssSensExamAntmicSite
Spinal cord level evaluated during the sensory examination
Sensory
C2;C3;C4;C5;C6;C7;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;C8;
C2;C3;C4;C5;C6;C7;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;C8;
Alphanumeric
This element and the 'SCI Classification Sensory Exam Laterality Type' element should be used with the subsequent sensory grades and scores to identify with which anatomic site and side (i.e., left or right) the sensory grade/score is associated.
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015
Adult;Pediatric
Core
3.0
7/17/2013
Refer to SCI CDE Annotated Form
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification sensory exam anatomic site
 
Single Pre-Defined Value Selected
       
C06325
SCI Classification light touch anatomic site grade
SCIClssLteTchAntmicSteGrd
Grade that documents the ability to sense light touch on the specific spinal cord level and side
Ability, Impaired, Normal, Not Testable
0;1;2;NT;
Absent;Impaired;Normal;Not testable;
Alphanumeric
Choose the best score and record for each spinal cord level and side.
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015
Adult;Pediatric
Core
3.0
7/17/2013
Refer to SCI CDE Annotated Form
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification light touch anatomic site grade
 
Single Pre-Defined Value Selected
       
C06421
SCI Classification light touch single side score
SCIClssLghtTchSnglSdScore
Score of sensation of light touch for the specific side of the body.
Light Touch R/L
  
Numeric Values
Should be calculated/derived from the raw data. The maximum score for each side is 56.
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015
Adult;Pediatric
Core
3.0
7/17/2013
SENSLTL; SENSLTR
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification light touch single side score
 
Free-Form Entry
       
C06329
SCI Classification light touch total score
SCIClssLteTchTtlScore
Total score of sensation of light touch on the right and left sides of the body.
Light Touch Score
  
Numeric Values
Should be calculated/derived from the raw data. The maximum total score is 112.
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015
Adult;Pediatric
Core
3.0
7/17/2013
SENSLTT
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification light touch total score
 
Free-Form Entry
       
C06331
SCI Classification pin prick anatomic site grade
SCIClssPnPrckAntmicSiteGrd
Grade of the ability to sense a pin prick on the specific spinal cord level and side
Ability, Impaired, Normal, Not Testable
0;1;2;NT;
Absent;Impaired;Normal;Not testable;
Alphanumeric
Choose the best score and record for each spinal cord level and side.
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015
Adult;Pediatric
Core
3.0
7/17/2013
Refer to SCI CDE Annotated Form
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification pin prick anatomic site grade
 
Single Pre-Defined Value Selected
       
C06422
SCI Classification pin prick single side score
SCIClssPnPrckSnglSdeScore
Score of sensation of a pin prick for the specific side of the body.
Pin Prick R/L
  
Numeric Values
Should be calculated/derived from the raw data. The maximum score for each side is 56.
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015
Adult;Pediatric
Core
3.0
7/17/2013
SENSPPL; SENSPPR
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification pin prick single side score
 
Free-Form Entry
       
C06335
SCI Classification pin prick total score
SCIClssPnPrckTtlScore
Total score of a pin prick on the right and left sides of the body.
Pin Prick Score
  
Numeric Values
Should be calculated/derived from the raw data. The maximum total score is 112.
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015
Adult;Pediatric
Core
3.0
7/17/2013
SENSPPT
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification pin prick total score
 
Free-Form Entry
       
C06387
SCI Classification anal contraction voluntary indicator
SCIClssAnalContVolunInd
Indicator of whether or not the patient can have a voluntary anal contraction.
Voluntary anal contraction
Yes;No;Unknown;
Yes;No;Unknown;
Alphanumeric
Choose one
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015
Adult;Pediatric
Core
3.0
7/17/2013
ANALCONT
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification anal contraction voluntary indicator
 
Single Pre-Defined Value Selected
       
C06348
SCI Classification anal sensation indicator
SCIClssAnalSensInd
Indicator of whether or not the person has any anal sensation.
Any anal sensation
Yes;No;Unknown;
Yes;No;Unknown;
Alphanumeric
Choose one
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015
Adult;Pediatric
Core
3.0
7/17/2013
ANALSENS
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification anal sensation indicator
 
Single Pre-Defined Value Selected
       
C06006
SCI Classification sensory neurological level left result
SCIClssSensNeuroLvlLftReslt
Result of the most caudal segment of the spinal cord on the left side of the body with normal sensory function for pinprick and light touch.
Neurological Level Sensory L
C1;C2;C3;C4;C5;C6;C7;C8;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;X00;X99;
C1;C2;C3;C4;C5;C6;C7;C8;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;X00;X99;
Alphanumeric
If only the alphabetic part of the level is known, it is permissible to use code C, L, T, or S followed by numeric code "99". Use code X99 if the level is completely unknown, the exam was not done, or there was no corresponding admission or discharge.
Core for ages 6 and older.
DeVivo M, Biering-Sørensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Refer to the latest published version of The International Standards for Neurological Classification of Spinal Cord Injury for complete information on the sensory examination and a listing of all key points.
Adult;Pediatric
Core
3.0
7/17/2013
SENSLVLL
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification sensory neurological level left result
 
Single Pre-Defined Value Selected
       
C06007
SCI Classification sensory neurological level right result
SCIClssSensNeuroLvlRtReslt
Result of the most caudal segment of the spinal cord on the right side of the body with normal sensory function for pinprick and light touch.
Neurological Level Sensory R
C1;C2;C3;C4;C5;C6;C7;C8;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;X00;X99;
C1;C2;C3;C4;C5;C6;C7;C8;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;X00;X99;
Alphanumeric
If only the alphabetic part of the level is known, it is permissible to use code C, L, T, or S followed by numeric code "99". Use code X99 if the level is completely unknown, the exam was not done, or there was no corresponding admission or discharge.
Core for ages 6 and older.
DeVivo M, Biering-Sørensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Refer to the latest published version of The International Standards for Neurological Classification of Spinal Cord Injury for complete information on the sensory examination and a listing of all key points.
Adult;Pediatric
Core
3.0
7/17/2013
SENSLVLR
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification sensory neurological level right result
 
Single Pre-Defined Value Selected
       
C06008
SCI Classification motor neurological level left result
SCIClssMtrNeuroLvlLftReslt
Result of the lowest key muscle on the left side of the body that has a grade of at least 3, provided the key muscles represented by segments above that level are judged to be normal (grade 5).
Neurological Level Motor L
C1;C2;C3;C4;C5;C6;C7;C8;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;X00;X99;
C1;C2;C3;C4;C5;C6;C7;C8;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;X00;X99;
Alphanumeric
If only the alphabetic part of the level is known, it is permissible to use code C, L, T, or S followed by numeric code "99". Use code X99 if the level is completely unknown, the exam was not done, or there was no corresponding admission or discharge.
Core for ages 6 and older.
DeVivo M, Biering-Sørensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Refer to the latest published version of The International Standards for Neurological Classification of Spinal Cord Injury for complete information on the sensory examination and a listing of all key points.
Adult;Pediatric
Core
3.0
7/17/2013
MTRLVLL
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification motor neurological level left result
 
Single Pre-Defined Value Selected
       
C06009
SCI Classification motor neurological level right result
SCIClssMtrNeuroLvlRteReslt
Result of the lowest key muscle on the right side of the body that has a grade of at least 3, provided the key muscles represented by segments above that level are judged to be normal (grade 5).
Neurological Level Motor R
C1;C2;C3;C4;C5;C6;C7;C8;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;X00;X99;
C1;C2;C3;C4;C5;C6;C7;C8;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;X00;X99;
Alphanumeric
If only the alphabetic part of the level is known, it is permissible to use code C, L, T, or S followed by numeric code "99". Use code X99 if the level is completely unknown, the exam was not done, or there was no corresponding admission or discharge.
Core for ages 6 and older.
DeVivo M, Biering-Sørensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Refer to the latest published version of The International Standards for Neurological Classification of Spinal Cord Injury for complete information on the sensory examination and a listing of all key points.
Adult;Pediatric
Core
3.0
7/17/2013
MTRLVLR
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification motor neurological level right result
 
Single Pre-Defined Value Selected
       
C06410
SCI Classification S4-S5 sensory function result
SCIClssS4S5SensFuncReslt
Result of the extent to which motor or sensory function is preserved in the sacral segments S4-S5.
Complete or Incomplete?
Complete;Incomplete;
No motor or sensory function is preserved in the sacral segments S4-S5;Some motor or sensory function is preserved in the sacral segments S4-S5.;
Alphanumeric
Choose one
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015
Adult;Pediatric
Core
3.0
7/17/2013
COMPLETE
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification S4-S5 sensory function result
 
Single Pre-Defined Value Selected
       
C06330
SCI Classification sensory zone of partial preservation left result
SCIClssSensZnePrtlPresrvLftRes
Result of the caudal extent of partially innervated segments, demonstrating partial preservation of sensory function on the left side of the body.
Zone of Partial Preservation Sensory L
C1;C2;C3;C4;C5;C6;C7;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;C8;X00;X99;
C1;C2;C3;C4;C5;C6;C7;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12;C8;X00;X99;
Alphanumeric
Choose one dermatome
Core for ages 6 and older.
Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015
Adult;Pediatric
Core
3.0
7/17/2013
SENSZPPL
International Standards for Neurological Classification of SCI Worksheet
Neurological Outcomes
Outcomes and End Points
SCI Classification sensory zone of partial preservation left result
 
Single Pre-Defined Value Selected
       
12-16-2018
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