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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: The International SCI Data Sets
CRF: International SCI Core Data Set v2.0
Item count: 23 (23 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.
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.
Adult;Pediatric
Supplemental
3.0
7/17/2013
SITE
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
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.
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.
Adult;Pediatric
Supplemental
1.0
6/5/2014
Aliases for variable name not defined
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
 
255
Free-Form Entry
       
C00007
Birth date
BirthDate
Date (and time, if applicable and known) the participant/subject was born
Date of Birth
  
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.).
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.
Adult;Pediatric
Supplemental
3.0
7/25/2013
caBIG: PER_BIR_DT; SCI CDEs: BIRTHDT
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
Birth date
 
Free-Form Entry
     
793
 
C05400
Injury date time
InjDateTime
Date (and time, if applicable and known) of injury
Date of Injury
  
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.).
For non-traumatic cases, the date of injury should be coded as the approximate date of first physician visit related to symptoms of spinal cord dysfunction.
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.
Adult;Pediatric
Supplemental
3.0
7/20/2013
SCI CDEs: INJURYDT
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
Injury date and time
 
Free-Form Entry
       
C05408
Hospital admission date and time
HospitlAdmissDateTime
Date (and time, if applicable and known) the participant/subject was admitted to the hospital
Date of Acute Care Hospital Admisson
  
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.).
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.
Adult;Pediatric
Supplemental
3.0
7/25/2013
SCI CDEs: ADMITDT
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
Hospital admission date and time
 
Free-Form Entry
       
C05134
Therapy rehabilitation start date time
TherpyRehabStrtDateTime
Date (and time, if applicable and known) on which the therapy or rehabilitation started
Rehabilitation admission date
  
Date or Date & Time
Record the year, month, and day for the inpatient rehabilitation facility admission. If the month or day is unknown, it should be coded “99”; if the year is unknown, it should be coded “9999.”
In centers where there is comprehensive management, i.e. acute and rehabilitation in the same department, there will often be a distinction between the acute care program and the rehabilitation program, and the date registered when the patient is considered to be transferred from the acute to the rehabilitation program. This variable will make it possible to calculate the length of stay for inpatient acute management and rehabilitation respectively.
No references available
Adult;Pediatric
Supplemental
3.0
7/20/2013
Aliases for variable name not defined
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
Therapy or rehabilitation start date and time
 
Free-Form Entry
       
C06411
Inpatient final discharge date and time
InpatFinalDischrgDateTime
Date (and time, if applicable and known) of discharge from the last inpatient hospital when all planned acute care and rehabilitation phases of treatment are completed.
Date of Final Inpatient Discharge
  
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.).
On this date, patients will typically be discharged home (with no further planned inpatient admissions) or discharged to a long-term care facility. Outpatient rehabilitation or a home rehabilitation program may continue after this date, or limited rehabilitation therapy may continue in the long-term care facility. If the patient dies during inpatient hospitalization, this will be the date of death.
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.
Adult;Pediatric
Supplemental
3.0
7/17/2013
DISCHGDT
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
Inpatient final discharge date and time
 
Free-Form Entry
       
C04802
Death date and time
DeathDateTime
Date (and time, if known) of participant's/subject's death
Date of Death:
  
Date or Date & Time
Record the year, month, and day of death. If the month or day is unknown, it should be coded “99”; if the year is unknown, it should be coded “9999”.
No references available
Adult;Pediatric
Supplemental
3.0
7/24/2013
Aliases for variable name not defined
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
Death date and time
 
Free-Form Entry
     
2004152
 
C00035
Gender type
GenderTyp
Self-reported gender of the participant/subject. Gender is the socially constructed identity of sex. Gender is equated with phenotypic sex. Gender may differ from the sex of an individual determined genetically.
Gender
Female;Male;Unknown;Unspecified;Not reported;
Female;Male;Unknown;Undifferentiated/Indeterminant/Intersex;Not reported;
Alphanumeric
Choose one. Response is obtained by report of the participant/subject or caretaker.
Record the gender to which the patient identifies. In recognition of some people identifying as transgender, transsexual, intersex or other similar gender affiliation, this can be specified by ‘Transgender or other related category’ (New and Currie 2016; Reisner et al. 2016).
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. The NIH Guidelines on Inclusion of Women and Minorities as Subjects in Clinical Research: The Office of Management and Budget (OMB) Directive No. 15 - http://grants.nih.gov/grants/funding/women_min/women_min.htm
Reisner SL, Poteat T, Keatley J, Cabral M, Mothopeng T, Dunham E, Holland CE, Max R, Baral SD. Global health burden and needs of transgender populations: a
review. Lancet. 2016 Jul 23;388(10042):412-36.
Adult;Pediatric
Supplemental
3.0
8/28/2013
caBIG: PRSN_GENDER_TXT_TP; SCI CDEs: GENDER
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
Gender type
 
Single Pre-Defined Value Selected
     
2200604
 
C06414
Spinal cord injury etiology type
SpnalCrdInjEtlgyTyp
Etiology of the spinal cord injury. Traumatic spinal cord injury is impairment of the spinal cord or cauda equina function resulting from the application of an external force of any magnitude.
Spinal Cord Injury Etiology
1;2;3;4;Unspecified or Unknown;Congenital or genetic etiology (e.g. spina bifida);Tumor-benign;Vascular etiology;Other non-traumatic spinal cord dysfunction;Degenerative non-traumatic etiology;Tumor- malignant;Infection (e.g. bacterial, viral);Birth injury or other traumatic cause;
1 = Sports/leisure;2 = Assault;3 = Transport;4 = Fall;Unspecified or Unknown;Congenital or genetic etiology (e.g. spina bifida);Tumor-benign;Vascular etiology (e.g., ischemia, hemorrhagic, malformations);Other non-traumatic spinal cord dysfunction;Degenerative non-traumatic etiology;Tumor- malignant;Infection (e.g. bacterial, viral);Birth injury or other traumatic cause;
Alphanumeric
Because it is possible that an injury event may be classifiable into more than one of these categories, the following prioritization has been established for assigning codes: First coding priority is given to sports. If the injury event involved sports it should be coded as a 1 (Sports) regardless of whether it involved assault, transport or a fall. Code 1 would be appropriate whenever the ICECI Injury Activity Axis would be coded as "sports and exercise during leisure time" (ICECI Injury Activity code 4) regardless of coding on other ICECI Axes. Second priority is given to Assault. If the event did not involve sports but it did involve an assault, then the event should be coded as a 2 (Assault) regardless of whether it involved transport or a fall. Code 2 would be appropriate whenever the ICECI Intent of Injury Axis would be coded as "assault" (ICECI Intent of Injury code 3) and the ICECI Injury Activity Axis would not be coded as "sports and exercise during leisure time" (ICECI Injury Activity code 4) regardless of other ICECI Axes. Third priority is given to Transport. If the event was neither sports nor assault related but it involved transport, then the event should be coded as 3 (Transport) regardless of whether it involved a fall. Code 3 would be appropriate whenever the ICECI External Cause of Injury Axis would be coded as "transport injury event" (ICECI External Cause of Injury code 1.1) and ICECI Intent of Injury Axis would not be coded as "assault" (ICECI Intent of Injury code 3) and ICECI Injury Activity Axis would not be coded as "sports and exercise during leisure time" (ICECI Injury Activity code 4). Fourth priority is given to Fall. If the event was neither sports, assault nor transport related and it involved a fall then it should be coded as 4 (Fall). Code 4 would be appropriate whenever the ICECI External Cause of Injury Axis would be coded as "falling, stumbling, or jumping" (ICECI External Cause of Injury code 1.5) and ICECI Intent of Injury Axis would not be coded as "assault" (ICECI Intent of Injury code 3) and ICECI Injury Activity Axis would not be coded as "sports and exercise during leisure time" (ICECI Injury Activity code 4). Use code 5 (other traumatic cause) for all other known (specified) traumatic causes whenever codes 1 through 4 of this etiology variable do not apply. Paralysis secondary to surgical procedures when the patient does not have a neurological deficit prior to surgery would be coded in this category. Use code 6 (non-traumatic cause) if there is impairment of the spinal cord or cauda equina function that is not caused either directly or indirectly by an external event.
For traumatic spinal cord injuries, this variable has been adapted from the International Classification of External Causes of Injuries (ICECI). In its entirety, the ICECI provides a multi-axial description of the event that resulted in SCI. Four axes have been developed, including the External Cause of Injury Axis, the Intent of Injury Axis, the Place of Injury Axis, and the Injury Activity Axis. Use of the complete version of the ICECI (including all four axes and subcategories not included in the core data set) is recommended for injury surveillance activities or other research studies the goal of which would be to provide information useful for the development of interventions targeted at primary prevention of spinal cord injuries.
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.
Adult;Pediatric
Supplemental
3.1
7/27/2018
SCIETIOL
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
Spinal cord injury etiology type
 
Single Pre-Defined Value Selected
       
C55476
Congenital genetic spinal cord injury etiology specify text
CongGenetSCIEtioSpTxt
The free text field to describe the congenital or genetic etiology of spinal cord injury
Congenital or genetic etiology (e.g., spina bifida), Specify:
  
Alphanumeric
No instructions available
No references available
Adult;Pediatric
Supplemental
1.0
3/4/2015
Aliases for variable name not defined
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
 
255
Free-Form Entry
       
C55478
Spinal cord dysfunction non traumatic other specify text
SpnlCordDysfNonTraumSpTxt
The free text field to describe the other type of non-traumatic spinal cord dysfunction
Other non-traumatic spinal cord dysfunction, Specify:
  
Alphanumeric
Use code 5 (other traumatic cause) for birth injuries or all other known (specified) or unknown traumatic causes whenever codes 1 through 4 of this etiology variable do not apply. Paralysis secondary to surgical procedures when the patient does not have a neurological deficit prior to surgery would be coded in this category. It is possible to specify the cause.
No references available
Adult;Pediatric
Supplemental
1.0
3/4/2015
Aliases for variable name not defined
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
 
255
Free-Form Entry
       
C06412
Injury vertebral indicator
InjVertbrlInd
Whether there was a spinal fracture and/or dislocation in addition to the spinal cord injury. Spinal fracture or dislocation is defined as any break, rupture, or crack through or between any part(s) of the vertebral column from the occiput to the coccyx.
Vertebral Injury
0;1;9;
0=No;1=Yes;9=Unknown;
Numeric values
Choose one
Spinal fracture or dislocation is defined as any break, rupture, or crack through or between any part(s) of the vertebral column from the occiput to the coccyx.
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.
Adult;Pediatric
Supplemental
3.0
7/17/2013
VRTBRINJ
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
Injury vertebral indicator
 
Single Pre-Defined Value Selected
       
C06003
Injury associate spinal cord injury indicator
InjAssocSCIInd
Whether any of the following pre-specified major injuries occurred at the same time as the spinal cord injury: moderate to severe traumatic brain injury (Glasgow Coma Scale 12 or below at discharge), non-vertebral fractures requiring surgery, severe facial injuries affecting sense organs, major chest injury requiring chest-tube or mechanical ventilation, traumatic amputations of an arm or leg (or injuries severe enough to require surgical amputation), severe hemorrhaging, or damage to any internal organ requiring surgery.
Associated Injury
0;1;9;
0=No;1=Yes;9=Unknown;
Numeric values
Choose one - Do not include other associated injuries not listed above, negative findings from exploratory surgery, and do not include injuries that pre-date the spinal cord injury.
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.
Adult;Pediatric
Supplemental
3.0
7/17/2013
ASSOCINJ
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
Injury associated with spinal cord injury indicator
 
Single Pre-Defined Value Selected
       
C06413
Spinal surgery indicator
SpnalSurgryInd
Whether any of the following spinal surgical procedures were performed during the inpatient hospitalization following spinal cord injury: laminectomy, neural canal restoration, reduction, spinal fusion, or internal fixation of the spine. Laminectomy is defined as removal of normal intact lamina or foreign body at the site of spinal cord damage. Neural canal restoration is defined as the removal of bone or disk fragments, blood clots, or foreign bodies (such as bullet fragments) from the spinal canal. Reduction is defined as replacement of one or more dislocated, subluxed or angulated vertebra into anatomic or near anatomic alignment. Spinal fusion is defined as the addition of a bone graft to the vertebrae for the purpose of achieving intervertebral fusion or stability. Internal fixation of the spine is defined as attaching rods, plates, wires, etc. to the spine (individually or in combination) to provide internal surgical stabilization of the vertebral column.
Spinal Surgery
0;1;9;
0=No;1=Yes;9=Unknown;
Numeric values
Choose one
This variable documents whether any of the following spinal surgical procedures were performed during the inpatient hospitalization following a traumatic SCI: laminectomy, neural canal restoration, reduction, spinal fusion, or internal fixation of the spine.
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.
Adult;Pediatric
Supplemental
3.0
7/17/2013
SPNLSURG
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
Spinal surgery indicator
 
Single Pre-Defined Value Selected
       
C06004
Ventilatory assistance utilization frequency indicator
VentltryAsstncUtilztnFreqInd
Documents any use of any type of ventilatory assistance used to sustain respiration on the date of final inpatient discharge (the date of discharge from the last inpatient rehabilitation hospital or discharge from the last acute care hospital if the patient is not admitted to a rehabilitation hospital).
Ventilatory Assistance
0;1;2;3;9;
0=No;1=Yes, less than 24 hours per day;2=Yes, 24 hours per day;3=Yes, unknown number of hours per day;9=Unknown;
Numeric values
Choose one - Ventilatory assistance includes but is not limited to mechanical ventilators, phrenic nerve stimulators, external negative pressure devices, and BiPAP. Do not include routine administration of oxygen; periodic IPPB administration; or CPAP.
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.
Adult;Pediatric
Supplemental
3.0
7/17/2013
VENTASSI
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
Ventilatory assistance utilization frequency
 
Single Pre-Defined Value Selected
       
C19160
Discharge facility type
DischargeFacilityTyp
The type of facility to which the participant was discharged
Place upon discharge/current residence:
Assisted living residence;Correctional institution;Deceased;Group living situation;Homeless;Hospital;Hotel or motel;Nursing home;Other unclassified;Private residence;Unknown;
Assisted living residence;Correctional institution;Deceased;Group living situation;Homeless;Hospital;Hotel or motel;Nursing home;Other unclassified;Private residence;Unknown;
Alphanumeric
Place of residence at time of discharge should indicate the intended final disposition. If the patient is discharged to a hospital or nursing home temporarily for custodial care only pending home renovations or for other reasons, then the intended final destination should be coded, rather than coding a temporary destination, such as a “hospital,” “rehabilitation facility,” or “nursing home.” For cross-sectional post-discharge studies, this variable documents current place of residence. When the person is currently hospitalized on a temporary basis, the usual place of residence should be coded rather than “hospital.”
No references available
Adult;Pediatric
Supplemental
1.0
5/29/2014
Aliases for variable name not defined
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
  
Single Pre-Defined Value Selected
       
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 of Examination
  
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.).
The International Standards for Neurological Classification of SCI (Kirshblum et al 2011) cannot be conducted in children five years of age and younger (Mulcahey and Biering-Sorensen 2014; Mulcahey et al. 2011), thus for these children, the date should be recorded as 8888-88-88.

When parts of the examination are done on different dates, the date of the examination should be the day on which most parts of the examination were done.
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.
Adult;Pediatric
Supplemental
3.0
7/24/2013
Aliases for variable name not defined
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
Data collected date and time
 
Free-Form Entry
       
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.
Sensory Level - Left
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.
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 examination was not done due to age, condition, or other reason, or there was no corresponding admission or discharge.

The International Standards for Neurological Classification of SCI (Kirshblum et al 2011) cannot be conducted in children five years of age and younger (Mulcahey and Biering-Sorensen 2014; Mulcahey et al. 2011), thus for these children, the sensory level should be recorded as X99.

For cross-sectional post-discharge studies, this variable documents the sensory level from the most recent neurologic examination.
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
Supplemental
3.0
7/17/2013
SENSLVLL
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
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.
Sensory Level - Right
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.
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 examination was not done due to age, condition, or other reason, or there was no corresponding admission or discharge.

The International Standards for Neurological Classification of SCI (Kirshblum et al 2011) cannot be conducted in children five years of age and younger (Mulcahey and Biering-Sorensen 2014; Mulcahey et al. 2011), thus for these children, the sensory level should be recorded as X99.

For cross-sectional post-discharge studies, this variable documents the sensory level from the most recent neurologic examination.
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
Supplemental
3.0
7/17/2013
SENSLVLR
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
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).
Motor Level - Left
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.
The motor level (the lowest normal motor segment - which may differ by side of body) is defined by the lowest key muscle function that has a grade of at least 3 (on supine testing), providing the key muscle functions represented by segments above that level are judged to be intact (graded as a 5). Note: in regions where there is no myotome to test, the motor level is presumed to be the same as the sensory level, if testable motor function above that level is also normal. Right and left levels are documented separately
The International Standards for Neurological Classification of SCI (Kirshblum et al 2011) cannot be conducted in children five years of age and younger (Mulcahey and Biering-Sorensen 2014; Mulcahey et al. 2011), thus for these children, the motor level should be recorded as X99.
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
Supplemental
3.0
7/17/2013
MTRLVLL
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
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).
Motor Level - Right
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.
The motor level (the lowest normal motor segment - which may differ by side of body) is defined by the lowest key muscle function that has a grade of at least 3 (on supine testing), providing the key muscle functions represented by segments above that level are judged to be intact (graded as a 5). Note: in regions where there is no myotome to test, the motor level is presumed to be the same as the sensory level, if testable motor function above that level is also normal. Right and left levels are documented separately
The International Standards for Neurological Classification of SCI (Kirshblum et al 2011) cannot be conducted in children five years of age and younger (Mulcahey and Biering-Sorensen 2014; Mulcahey et al. 2011), thus for these children, the motor level should be recorded as X99.
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
Supplemental
3.0
7/17/2013
MTRLVLR
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
SCI Classification motor neurological level right result
 
Single Pre-Defined Value Selected
       
C06010
ASIA Impairment Scale
ASIAImprmntScale
Scale for the participant's/subject's impairment level on The American Spinal Injury Association (ASIA) Impairment Scale classification, which attempts to quantitate the degree of impairment
ASIA Impairment Scale
A;B;C;D;E;U;
Complete Injury. No motor or sensory function is preserved in the sacral segments S4-S5.;Incomplete. Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5.;Incomplete. Motor function is preserved below the neurological level, and more than half of the key muscles below the neurological level have a muscle grade less than 3.;Incomplete. Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more.;Normal. Motor and sensory function are normal.;Unknown or not applicable.;
Alphanumeric
When an associated injury (e.g., traumatic brain injury) or certain non-neurologic impairments interfere with the performance of a complete neurological examination, the ASIA Impairment Scale should be coded Unknown. For an individual to receive a grade of B, C, or D, he/she must be incomplete, that is, have sensory or motor function in the sacral segments S4-S5. Any sensation felt in the anal area during this part of the exam signifies that the patient is sensory incomplete (at least grade B). In addition, for an individual to receive a grade of C or D, the individual must have either (1) voluntary anal sphincter contraction or (2) sparing of motor function more than three levels below the motor level.
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
Supplemental
3.0
7/17/2013
AIS
International SCI Core Data Set v2.0
The International SCI Data Sets
The International SCI Data Sets
ASIA Impairment Scale
 
Single Pre-Defined Value Selected
       
12-16-2018
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