CDE Detailed Report

Disease: Spinal Cord Injury
Sub-Domain: Neurological Outcomes
CRF: International Standards for Neurological Classification of SCI Worksheet

Displaying 1 - 29 of 29
CDE ID CDE Name Variable Name Definition Short Description Question Text Permissible Values Description Data Type Disease Specific Instructions Disease Specific Reference Population Classification (e.g., Core) Version Number Version Date CRF Name (CRF Module / Guideline) Sub Domain Name Domain Name Size Input Restrictions Min Value Max Value Measurement Type External Id Loinc External Id Snomed External Id caDSR External Id CDISC
C06387 SCI Classification anal contraction voluntary indicator SCIClssAnalContVolunInd Indicator of whether or not the patient can have a voluntary anal contraction. 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

C06000 Site identifier number SiteIDNum Unique identification number given to the study site to distinguish the location where data is recorded. 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points 255

Free-Form Entry

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 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

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. 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

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 (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 3.00 2013-07-24 21:00:23.88 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

Free-Form Entry

C06326 SCI Classification sensory exam anatomic site SCIClssSensExamAntmicSite Spinal cord level evaluated during the sensory examination 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

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 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

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. 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

C06329 SCI Classification light touch total score SCIClssLteTchTtlScore Total score of sensation of light touch on the right and left sides of the body. 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

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. 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

Free-Form Entry

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. 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

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. 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

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. 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

Free-Form Entry

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). 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

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 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

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. 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

Free-Form Entry

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). 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

C06335 SCI Classification pin prick total score SCIClssPnPrckTtlScore Total score of a pin prick on the right and left sides of the body. 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

Free-Form Entry

C19247 Subject ID SubIDNam Subject identification ID 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 1.00 2014-06-05 13:10:49.0 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points 255

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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 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

Refer to the instructions on the ASIA Standard Neurological Classification of SCI worksheet
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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

C06336 SCI Classification motor zone of partial preservation left result SCIClssMtrZnePrtlPresrvLftRslt Result of the caudal extent of partially innervated segments, demonstrating partial preservation of motor function on the left side of the body. Result of the caudal extent of partially innervated segments, demonstrating partial preservation of motor function on the left side of the body. Zone of Partial Preservation Motor 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

C06320 SCI Classification motor strength upper limb total score SCIClssMtrStrgthUpLmbTtlScore Total score of motor strength for the upper right and left limbs. 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

Free-Form Entry

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. 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

C06322 SCI Classification sensory zone of partial preservation right result SCIClssSensZnePrtlPresrvRteRes Result of the caudal extent of partially innervated segments, demonstrating partial preservation of sensory function on the right side of the body. Result of the caudal extent of partially innervated segments, demonstrating partial preservation of sensory function on the right side of the body. Zone of Partial Preservation Sensory R 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

C06347 SCI Classification motor strength lower limb total score SCIClssMtrStrgthLwLmbTtlScore Total score of motor strength for the lower right and left limbs. 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

Free-Form Entry

C06323 SCI Classification motor zone of partial preservation right result SCIClssMtrZnePrtlPresrvRteRslt Result of the caudal extent of partially innervated segments, demonstrating partial preservation of motor function on the right side of the body. Result of the caudal extent of partially innervated segments, demonstrating partial preservation of motor function on the right side of the body. Zone of Partial Preservation Motor R 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

C06348 SCI Classification anal sensation indicator SCIClssAnalSensInd Indicator of whether or not the person has any anal sensation. 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

C02411 Laterality type LatTyp Laterality type relative to the anatomic site of the body examined or affected Laterality type relative to the anatomic site of the body examined or affected R L Left;Right Left;Right 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 3.00 2013-08-28 16:08:00.453 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

C06324 SCI Classification motor exam anatomic site SCIClssMtrExamAntmicSite Muscle (and associated spinal cord level) evaluated during the motor examination 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 3.00 2013-07-17 09:26:36.973 International Standards for Neurological Classification of SCI Worksheet Neurological Outcomes Outcomes and End Points

Single Pre-Defined Value Selected

CSV