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Hi all, im review my case base exam and am a little stumped on number 13. This question revolves an SCI with hip flexor (L2) MMT for 4/5 and knee ext (L3) MMT of 3+/5. No sensation at knee or ankle. My understanding is that the level of SCI is the most caudal between motor and sensory. For motor, the level has to be at least a 3 with the scores above being at least a 5 so this puts me at L2 since it was a 4, L3 does not have a 5/5 above it. Sensory as well has no sensation at L3 and below meaning it would be L2 as well. This does not align with the answer. Any clarifications on where i went wrong? Thanks in advance!
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The motor level is the most caudal key muscle with at least 3/5 strength, provided the muscles above are functionally intact. In this case, knee extension (L3) is 3+/5, which meets the ≥3 requirement, and hip flexion (L2) is 4/5, indicating preserved function above. The rule does not require the muscle above to be 5/5, just that it is not absent. Since ankle musculature (L4–S1) is absent, L3 is the lowest functioning level and therefore the suspected neurological level. If this were truly an L2 injury, we would expect knee extension to be less than 3/5 or absent. For sensory, he has not sensation behind the knee (S2) and at the ankle (L3-S1), and nothing in the stem say L3 dermatome is absent, so you cannot assume L3 sensory loss. So, based on this, L3 is the likely neurological level.
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Hi Maggie,
I am jumping in to help as Jessica is taking a vacation break!Neurologic Level of Injury (NLI): The lowest spinal segment where sensory AND motor function are intact bilaterally.
This requires three components: Sensory exam (dermatomes), Motor exam (myotomes), Sacral exam (S4–5)****So, yes your hypothetical would indicate a L2 NLI because that is the level where both sensory AND motor function are intact bilaterally.
Neurological level of injury (NLI):
The NLI refers to the most caudal segment of the spinal cord with normal sensory and antigravity motor function on both sides of the body, provided that there is normal (intact) sensory and motor function rostrally. The segments at which normal function is found often differ by side of the body and in terms of sensory and motor testing. Thus, up to four different segments may be identified in determining the neurological level, i.e., R(ight)-sensory, L(eft)-sensory, R-motor, L-motor. The single NLI is the most rostral of these levels.
Motor level (per side): Lowest key muscle with ≥3/5 strength; Provided muscles above are 5/5(Rupp R, Biering-Sørensen F, Burns SP, et al. International Standards for Neurological Classification of Spinal Cord Injury: Revised 2019. Top Spinal Cord Inj Rehabil. 2021;27(2):1-22. doi:10.46292/sci2702-1)
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Not sure if it’s my computer glitching but my response just disappeared, if it shows up double sorry in advance.
I note the L3 sensory indeed was not mentioned, only the back of the knee. I’m now getting a little twisted with the rule as the replies seem to contradict each other. Is there a time when the 5/5 rule is needed vs is not?
1. The motor level is the most caudal key muscle with at least 3/5 strength, provided the muscles above are functionally intact…..The rule does not require the muscle above to be 5/5, just that it is not absent.
2. Motor level (per side): Lowest key muscle with ≥3/5 strength; Provided muscles above are 5/5-
Hi Arti! I’m Chrissy – I’m the instructor for the NCS Advantage and am going to jump in on this one because Jessica is on a much-deserved vacation this weekend and I want to make sure you have an answer in the home stretch of your studies!
The motor level is the lowest level with at least 3/5 strength provided all testable segments above are scored 5/5. The NLI is the most cephalad of the motor and sensory levels. Therefore, the NLI for this patient should be L2. We’ll work on getting the key adjusted soon – but you were spot on with your initial question! Thanks for keeping this discussion going and let us know if you need anything else! 🙂
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Jennifer,
Yes, we need to correct the practice test. The NLI for this patient should be L2. As we were developing that question, we came across some conflicting information and went with what seemed to be best practice at the time. Chrissy is the NCS expert for Rehab Knowledge, so we asked her to weigh in since SCI is more common in the adult world. So sorry for the error and inconvenience!Good luck!
Helen -
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