American Spinal Injury Association (ASIA) Impairment Scale

Original Editor - Naomi O'Reilly.

Top Contributors - Naomi O'Reilly, Stacy Schiurring, Arnold Fredrick D'Souza, Kim Jackson, Jess Bell, Admin, Abbey Wright, Tarina van der Stockt, Rucha Gadgil and Olajumoke Ogunleye  

Disclaimer: digital rectal examination involving deep anal pressure and voluntary anal contraction is discussed on this page. This is an invasive and advanced assessment technique and should only be performed after demonstrating competency after in-person mentorship.

Introduction

Spinal cord injury (SCI) is a major cause of long-term disability worldwide. The Global Burden of Disease Study estimated that 20.6 million people were living with SCI in 2019, with 0.9 million new cases that year. Falls and road injuries were the two leading causes, and SCI at neck level was more common than SCI below the neck.

For a review of spinal cord injury, please read this article.

Spinal cord injury can severely impair or cease the conduction of sensory and motor signals, as well as functions of the autonomic nervous system. A systematic examination of dermatomes and myotomes allows clinicians to determine the affected segments of the spinal cord.

The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), often called the "ASIA exam," is the most widely used method of documenting the level and severity of SCI. The original Standards were introduced by the American Spinal Injury Association (ASIA) in 1982. They are now maintained jointly by the International Standards Committee of ASIA and the International Spinal Cord Society (ISCoS). The 8th edition was published in 2019, and the 9th edition was released in 2026. Because definitions change between editions, the version used should always be stated in clinical records and research.

The ISNCSCI examination has three components:

1. a dermatome-based sensory examination (light touch and pin prick at 28 key sensory points on each side)
2. a myotome-based motor examination (10 key muscle functions on each side)
3. an anorectal examination (deep anal pressure and voluntary anal contraction)

From these findings the examiner determines the right and left sensory and motor levels, the single neurological level of injury (NLI), the sensory and motor scores, the ASIA Impairment Scale (AIS) grade and, where applicable, the zones of partial preservation (ZPP).

ISNCSCI is a classification, not a comprehensive neurological examination. It does not include reflexes, tone or proprioception, and it does not capture autonomic function. The International Standards to document Autonomic Function after SCI (ISAFSCI) are recommended as an adjunct. The skeletal (radiological) level of injury is not part of ISNCSCI, because bony and neurological injury do not consistently correspond.

The Standards recommend the terms tetraplegia (rather than quadriplegia) and paraplegia. The terms tetraparesis and paraparesis are discouraged; severity is described with the AIS instead.

Timing of the examination

In the acute phase, findings may be affected by spinal shock, sedation, pain or other injuries, so serial examinations are needed to establish the true extent of injury. Early examinations still matter for prognosis. For example, the widely used clinical prediction rule for walking one year after traumatic SCI is based on age and ISNCSCI motor and light touch scores at L3 and S1, recorded within 15 days of injury.

International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)

ISNCSCI Scoring Outlines and ASIA Impairment Scale (AIS)

Sensory Examination

The required sensory examination tests one key point in each of the 28 dermatomes from C2 to S4–5, on the right and left sides. Each key point is tested for light touch (LT) and pin prick (PP; sharp/dull discrimination), and compared with sensation on the patient's cheek as the normal reference.

The examination is performed in supine, except for the anorectal examination, which can be performed side-lying. If the patient's spine is unstable and not stabilised with an orthosis, the patient should be log-rolled for the anorectal examination, or an abbreviated examination performed in supine.

Sensory Scoring

A three-point scale is used for sensory scoring:

Score	Meaning
0	Absent
1	Altered - Impaired or Partial Appreciation, including Hyperesthesia
2	Normal or Intact - Similar as on the cheek
NT	Not Testable
0*, 1*, NT*	Non-SCI condition present

Not testable is recorded when a key sensory point is not able to be assessed for any reason, such as a cast, burn, or amputation, or if the patient cannot perceive sensation on the face. The sensory scores for that side, and the total, then cannot be calculated. The levels should still be determined as accurately as possible; where a level or grade cannot be determined, it is recorded as ND (not determinable) and the reason given in the Comments box.

UPDATE: The asterisk (*) replaces the former 5* grade and applies to both sensory and motor scores. An abnormal score affected by a condition other than the SCI (for example a brachial plexus injury, amputation, burn, pain or limb swelling) is recorded as examined and tagged with *. The Comments box must explain the condition and how the score should be treated for classification. Tagged scores above the sensory level are usually treated as normal; those at or below it are usually treated as not normal. Any level or grade that depends on the examiner's assumption is also tagged with *. For more information, see Non-SCI conditions and steps in classification section below.

Sensory ExaminationTesting Techniques

• Light touch: a tapered wisp of cotton stroked once across no more than 1 cm of skin, with the patient's eyes closed or vision blocked.
• Pin prick: a disposable safety pin, stretched apart so both ends can be used; the pointed end tests sharp and the rounded end dull:
  • The patient must reliably distinguish sharp from dull. If in doubt, 8 out of 10 correct answers is the suggested standard, which reduces the probability of correct guessing to less than 5%
  • 0 = unable to distinguish sharp from dull, or no feeling
  • 1 = distinguishes sharp from dull reliably, but the intensity of sharpness differs from the face (greater or lesser)

International Standards for Neurological Classification of Spinal Cord Injury Key Sensory Testing Points

Please see the additional resources section at the end of this article for video examples of dermatome testing of all key sensory points.

Level	Description of Key Points for Sensory Testing
C2	At least 1 cm lateral to the occipital protuberance (or 3 cm behind the ear)
C3	Supraclavicular fossa (posterior to the clavicle) at the midclavicular line
C4	Over acromioclavicular joint
C5	Lateral (radial) side of the antecubital fossa, just proximal to the elbow crease
C6	Dorsal surface of proximal phalanx of the thumb
C7	Dorsal surface of proximal phalanx of the middle finger
C8	Dorsal surface of proximal phalanx of the little finger
T1	Medial (ulnar) side of the antecubital fossa, just proximal to the medial epicondyle of the humerus
T2	Apex of axilla
T3	Midclavicular line and 3rd intercostal space
T4	Midclavicular line and 4th intercostal space at nipple line
T5	Midclavicular line and 5th intercostal space midway between T4 and T6
T6	Midclavicular line and 6th intercostal space at the level of xiphisternum
T7	Midclavicular line, seventh intercostal space (midway between T6 and T8)
T8	Midclavicular line, eighth intercostal space (midway between T6 and T10)
T9	Midclavicular line, ninth intercostal space (midway between T8 and T10)
T10	Midclavicular line and 10th intercostal space at the level of the umbilicus
T11	Midclavicular line and 11th intercostal space midway between T10 and T12
T12	Midclavicular line over midpoint of the inguinal ligament
L1	Midway between sensory point at T12 and L2
L2	Anterior-medial thigh, midway on a line from the midpoint of the inguinal ligament (T12) to the medial femoral condyle
L3	Medial femoral condyle above the knee
L4	Medial malleolus
L5	Dorsal foot at the 3rd metatarsal phalangeal joint
S1	Lateral aspect of the calcaneus
S2	Midpoint of the popliteal fossa
S3	Over ischial tuberosity or infragluteal fold
S4 - 5	Perianal area less than 1 cm lateral to the mucocutaneous junction (taken as one level)

Adapted from Rupp et al. 2021.

Deep Anal Pressure (DAP)

DAP is tested by inserting a gloved, lubricated index finger and applying gentle pressure to the anorectal wall, which is innervated by the somatosensory components of the pudendal nerve (S4–5). UPDATE: Alternatively, the thumb can gently squeeze the anus against the inserted finger. Consistently perceived pressure is recorded as present or absent (Yes/No). Any reproducible pressure sensation means the injury is at least sensory incomplete.

If LT or PP is present at S4–5, DAP testing is not needed, because the injury is already sensory incomplete. The rectal examination is still required to test for voluntary anal contraction.

Disclaimer: the anorectal examination is an intimate, invasive procedure. It requires valid consent, a chaperone in line with local policy, and competence demonstrated under in-person supervision.

Optional sensory elements

UPDATE: Joint movement appreciation, position sense and deep pressure appreciation may be tested, but they are not used for classification and are recorded only in the Comments box.

Sensory Level

Caudal/rostral anatomical positioning

The sensory level on each side is the most caudal dermatome with normal (grade 2) light touch and pin prick, with all dermatomes above it also normal. It is the intact dermatome immediately above the first dermatome with impaired or absent LT or PP.

• Determine a right and a left sensory level. Considering each modality on each side can give up to four levels (R-PP, R-LT, L-PP, L-LT); the sensory level for each side is the more rostral of its LT and PP levels.
• The single sensory level is the most rostral of these levels.
• If sensation is abnormal at C2 but normal on the face, the sensory level is C1. If LT and PP are intact in all dermatomes from C2 to S4–5 on a side, record "INT" (intact) rather than S5.

Sensory Score

LT (yellow on image above) and PP (green on the image above) scores are summed across all dermatomes and both sides to give two summary scores. With a maximum of 2 at each of 28 points per side, the maximum is 56 per side and 112 in total for each modality. Sensory scores cannot be calculated if any key point is NT. Scores tagged with * are summed as examined.

• 

Motor Examination

The required motor examination tests 10 key muscle functions on each side, representing the C5–T1 and L2–S1 myotomes. They are tested in a rostral-to-caudal sequence in supine, with standard positioning and stabilisation. Poor positioning or stabilisation allows substitution by other muscles and gives an inaccurate grade.

Special Topic: Spinal Precautions

• In a potentially unstable spine, take care with all manual muscle testing.
• With a suspected acute traumatic injury below T8, do not allow the hip to flex beyond 90° actively or passively, because of the kyphotic stress on the lumbar spine. Test hip flexion isometrically and unilaterally, keeping the opposite hip extended to stabilise the pelvis.
• Follow local spinal precautions until spinal instability has been excluded or managed.

Motor Grading

A six-point scale is used for motor scoring:

Grade	Meaning
0	Total paralysis
1	Palpable or visible contraction
2	Active movement, full range of motion with gravity eliminated
3	Active movement, full range of motion against gravity
4	Active movement, full range of movement against gravity and moderate resistance in a muscle specific position
5	Normal active movement, full range of motion against gravity and full resistance in a muscle specific position expected from an unimpaired person
NT	Not testable eg. due to immobilisation, severe pain such that the patient cannot be graded, amputation of limb, or contracture of >50% of the range of motion
0*, 1*, 2*, 3*, 4*, NT*	Non-SCI condition present

Adapted from Rupp et al. 2021.

• UPDATE: If a contracture limits ROM but more than 50% of normal range remains, grade through the available range. If less than 50% remains, record NT.
• UPDATE: 5* is no longer used. If pain, disuse or another non-SCI factor prevents full strength, record the grade actually achieved, tag it with *, and explain in the Comments box how it should be treated for classification (for example "treat as normal").
• If such factors prevent standardised testing altogether, record NT.

Key muscle functions

Please see the additional resources section at the end of this article for video examples of motor testing of all 10 myotomes.

Level	Key Muscle Function & Muscles	Description of Muscle Function Testing Position for Grade 4 or 5
C5	Elbow Flexion Biceps Brachii Brachialis	Elbow flexed at 90 degrees, forearm supinated
C6	Wrist Extension Extensor Carpi Radialis Longus Extensor Carpi Radialis Brevis	Full wrist extension
C7	Elbow Extension Triceps Brachii	Shoulder neutral rotation, adducted at 90 degrees of flexion with elbow at 45 degrees of flexion
C8	Flexion of Middle Finger Flexor Digitorum Profundus	Fully flexed distal phalanx with proximal finger joint stabilised in extension
T1	Abduction of Little Finger Abductor Digiti Minimi	Full abduction of fingers
L2	Hip Flexion Iliopsoas	Hip flexed at 90 degrees
L3	Knee Extension Quadriceps	Knee flexed at 15 degrees
L4	Ankle Dorsiflexion Tibialis Anterior	Full dorsiflexion
L5	Long Toe Extensors Extensor Hallucis Longus	Full extension 1st toe
S1	Ankle Plantarflexion Gastrocnemius Soleus	Hip neutral with full knee extension and full ankle plantarflexion

Adapted from Rupp et al. 2021. See the ASIA Motor Exam Guide and InSTeP ( fee required) for testing positions for grades 0–3.

UPDATE: Non-key muscle functions

Non-key muscle functions are not used to determine motor levels or motor scores. They are used only to decide whether an injury is motor incomplete. In a patient who appears to be AIS B, non-key muscle functions more than three levels below the motor level on each side should be tested. Any preserved function is recorded in the Comments box.

Root level	Movement
C5	Shoulder: flexion, extension, abduction, adduction, internal and external rotation. Elbow: supination
C6	Elbow: pronation. Wrist: flexion
C7	Finger: flexion at proximal joint, extension. Thumb: flexion, extension and abduction in plane of thumb
C8	Finger: flexion at MCP joint. Thumb: opposition, adduction and abduction perpendicular to palm
T1	Finger: abduction of the index finger
L2	Hip: adduction
L3	Hip: external rotation
L4	Hip: extension, abduction, internal rotation. Knee: flexion. Ankle: inversion and eversion. Toe: MP and IP extension
L5	Hallux and toe: DIP and PIP flexion and abduction
S1	Hallux: adduction

Adapted from the 2026 worksheet.

Voluntary Anal Contraction (VAC)

The external anal sphincter is innervated by the somatic motor components of the Pudendal Nerve (S2-4). The examiner introduces a gloved and lubricated finger into the external anal sphincter and instructs the patient to “squeeze as if to hold back a bowel movement". Reproducible voluntary contraction is recorded as present or absent (Yes/No). Present VAC means the injury is motor incomplete.

VAC must be distinguished from reflex contraction. A contraction produced only with a Valsalva manoeuvre may be reflex and should be scored as absent.

Motor Level

The motor level on each side is the lowest key muscle function graded at least 3 (on supine testing), provided all key muscle functions above it are graded 5. By convention, a muscle graded 3 or more is taken to have intact innervation from the more rostral of its two innervating segments, so the next most rostral key muscle must be 5.

Where there is no key muscle to test (C1–C4, T2–L1 and S2–S5), the motor level is presumed to equal the sensory level, provided testable motor function above that level is also normal. For example:

• Sensory level C4, C5 graded <3: motor level is C4
• Sensory level C4, C5 graded ≥3: motor level is C5
• Sensory level C3, C5 graded ≥3: motor level is C3, because C4 cannot be presumed normal
• All upper limb key muscles 5, sensation intact to T6: motor level T6
• As above, but T1 graded 3 or 4: motor level T1

L2 can be a motor level only if sensation at L1 and above is intact.

Advanced note: an unresolved question in non-testable regions. The Standards describe the motor level in non-testable myotomes (C2–C4, T2–L1, S2–S5) in two ways that usually agree:

• the motor level follows the sensory level; or
• motor function is derived from sensory function, so a non-testable myotome is presumed normal wherever its dermatome is normal

In an analysis of 2,660 motor levels from 665 people in the European Multicenter Study about Spinal Cord Injury (EMSCI), the two approaches gave different motor levels in 49 cases (3.6%). The differences arose in an unusual pattern: all key muscles of the upper limb (or of both limbs) graded normal, sensation impaired in the key muscle segments, and normal sensation resuming from T2 (or S2). In these cases the second approach placed the motor level on average about 10 segments below the sensory level.

None of the differences changed the AIS grade, and most cases were AIS D, several with near-normal Spinal Cord Independence Measure scores. The authors suggested that isolated damage to sensory (afferent) tracts or a non-SCI condition might explain the pattern. They concluded that further investigation is needed before the motor level definition is revised.

For practice: apply the rule as written on the worksheet, and use the asterisk and Comments box if a non-SCI condition may explain the sensory findings.

Motor Score

Key muscle grades are summed into an upper extremity motor score (UEMS, maximum 50) and a lower extremity motor score (LEMS, maximum 50), each made up of right and left subscores of 25. The two should be reported separately, not added into a total out of 100, because they behave as separate scales. Motor scores cannot be calculated if any key muscle function is NT.

Neurological level of injury (NLI)

The NLI is the most caudal segment of the cord with normal sensation and antigravity (grade 3 or more) muscle function on both sides, provided that sensory and motor function above it is normal.

Four levels are determined: right sensory, left sensory, right motor and left motor. The single NLI is the most rostral of these four. It is good practice to record all four as well, because a single NLI can be misleading functionally, for example when the sensory level lies rostral to the motor level.

If any of the four levels depends on an examiner's assumption (an *-tagged score), the NLI is also tagged with *.

ASIA Impairment Scale (AIS)

The AIS, modified from the Frankel scale, classifies the severity (completeness) of the injury. Completeness depends only on sacral sparing: any preserved sensory or motor function in the lowest sacral segments, S4–5.

• Sensory sacral sparing: LT or PP preserved (intact or impaired) at S4–5 on either side, or DAP present
• Motor sacral sparing: VAC present
• Complete injury: VAC absent, all S4–5 sensory scores 0 and DAP absent
• Incomplete injury: any sacral sparing

A person can therefore be classified as complete (AIS A) even when some function is preserved several segments below the NLI. That preserved function is documented with the ZPP.

ASIA Impairment Scale (AIS)

Grade	Type of Injury	Description of Injury
A	Complete	No sensory or motor function is preserved in sacral segments S4-S5, no sacral sparing
B	Sensory Incomplete	Sensory but not motor function is preserved below the NLI and includes S4–5 (LT or PP at S4–5, or DAP) AND no motor function is preserved more than three levels below the motor level on either side of the body.
C	Motor Incomplete	Motor function is preserved at the most caudal sacral segments (VAC) OR the patient is sensory incomplete and has some motor function more than three levels below the ipsilateral motor level on either side. Key or non-key muscle functions may be used to establish motor incomplete status. For AIS C, less than half of the key muscle functions below the single NLI have a grade ≥3.
D	Motor Incomplete	Motor incomplete status as defined above, with at least half (half or more) of the key muscle functions below the single NLI graded ≥3.
E	Normal	Sensation and motor function, as tested with ISNCSCI, are normal in all segments AND the patient had prior deficits. Someone without an SCI does not receive an AIS grade

Adapted from Rupp et al. 2021 and the 2026 worksheet.

UPDATE:

• Two different reference levels are used. To distinguish AIS B from C, motor sparing is judged against the motor level on each side. To distinguish AIS C from D, the proportion of key muscles graded ≥3 is judged against the single NLI.
• AIS E is used only at follow-up, when someone with a documented SCI has recovered normal ISNCSCI findings. If no deficit is found at the first examination, the person is neurologically intact and the AIS does not apply. Normal ISNCSCI findings do not rule out impairments the examination does not test, such as autonomic dysfunction. In a large European cohort, first conversion to AIS E occurred at a median of 171 days after injury.
• If the grade depends on an examiner's assumption about -tagged scores, it is tagged with * (for example AIS C). If it cannot be determined, record ND.

Zone of Partial Preservation (ZPP)

The ZPP records how far partially preserved function extends below the sensory and motor levels. Before 2019 it was used only in complete (AIS A) injuries. Since the 2019 revision, the motor and sensory ZPPs are decided separately, based on the sacral findings rather than the AIS grade.

1. The motor ZPP is recorded whenever voluntary anal contraction is absent.
2. The sensory ZPP is recorded whenever there is no sacral sensation (no DAP, LT or PP at S4–5).

As a result, a ZPP can now be recorded in some AIS B, C and D injuries. It does not apply when the relevant sacral function is present; for example, most AIS D injuries have both VAC and sacral sensation, so neither ZPP applies.

Worked examples: does a ZPP apply?

Example	Sacral findings	Motor ZPP	Sensory ZPP
AIS A	No VAC, no sacral sensation	Recorded	Recorded
AIS B	No VAC, sacral sensation present	Recorded	NA
AIS C or D, motor incomplete because of muscle function more than 3 levels below the motor level	No VAC, sacral sensation present	Recorded	NA
AIS C or D with VAC but no sacral sensation (uncommon)	VAC present, no sacral sensation	NA	Recorded
AIS C or D with VAC and sacral sensation (common)	Both present

Recording the ZPP

• Four ZPPs are recorded: right sensory, left sensory, right motor and left motor
• Each is a single segment (not a range): the most caudal segment on that side with any sensory or motor function. For example, if the right sensory level is C5 and some sensation extends to C8, record "C8"
• If there is no partially preserved function below a level, record the level itself as the ZPP
• Motor ZPP does not follow sensory function. It is based only on voluntary muscle contraction below the motor level. For example, if the sensory and motor levels are T4 with some sensation at left T6, the left sensory ZPP is T6 but the motor ZPP remains T4
• Non-key muscle functions are generally not included in the motor ZPP. However, if a non-key muscle function is used to classify an injury as AIS C, its root level is recorded as the motor ZPP
• ZPPs that depend on an examiner's assumption are tagged with *

When ZPP is "not applicable" (NA)

Finding at S4–5	Sensory ZPP	Motor ZPP
VAC present	Depends on sensory findings	NA on both sides
VAC absent	Depends on sensory findings	Recorded on both sides
DAP present	NA on both sides	Depends on VAC
DAP absent, LT or PP present on one side only	NA on that side; recorded on the other side	Depends on VAC
DAP absent, LT and PP absent on both sides	Recorded on both sides	Depends on VAC

Adapted from Rupp et al. 2021 and Schuld et al. 2024. The worksheets summarise this as "with sacral sparing of sensory function, the sensory ZPP is not applicable"; the booklet gives the side-by-side rule shown here.[5]

Steps in classification

The recommended order is:

1. Sensory levels (right and left): the most caudal intact dermatome for both PP and LT.
2. Motor levels (right and left): the lowest key muscle graded ≥3, with all key muscles above graded 5. Where there is no myotome to test, the motor level is presumed to equal the sensory level if testable motor function above is normal.
3. Neurological level of injury: the most rostral of the four levels from steps 1 and 2.
4. Complete or incomplete? If VAC is absent, all S4–5 sensory scores are 0 and DAP is absent, the injury is complete. Otherwise it is incomplete.
5. AIS grade:
   • Complete? If yes, AIS A.
   • Motor complete? If yes, AIS B. (It is motor incomplete if VAC is present, or if a sensory incomplete patient has motor function more than three levels below the motor level on either side; test non-key muscles before assigning B.)
   • Are at least half of the key muscles below the NLI graded ≥3? No: AIS C. Yes: AIS D.
   • All segments normal in someone with a documented SCI: AIS E.
6. Zones of partial preservation: only where VAC or all S4–5 sensory function (including DAP) is absent.

Use ND wherever a level, grade or ZPP cannot be determined.

Expedited ISNCSCI (E-ISNCSCI). In some situations, such as initial screening or follow-up in the chronic phase, a full examination may not be practical. For these, the International Standards Committee developed the expedited ISNCSCI, which determines the NLI and AIS grade with the fewest possible steps, using standard ISNCSCI testing procedures. It is published separately as guidance and is not part of the Standards booklet; the full examination remains the reference standard for documenting SCI. Because items are omitted, the E-ISNCSCI may not generate the full motor and sensory scores used to track change over time. Shortcuts also carry a risk of misclassification; in one validation study, substituting S1 findings for the anorectal examination misclassified 45% of true AIS B injuries.

Computerised classification

Classification errors are common, even among experienced clinicians. Validated online algorithms can check hand classification and are recommended as a learning and quality tool. They do not replace the examination itself.

• EMSCI ISNCSCI Calculator (free access)

Non-SCI conditions and steps in classification

Documenting non-SCI conditions

Pre-existing or coexisting conditions often affect ISNCSCI scores. Examples include peripheral nerve injury, previous stroke, amputation, fracture, burns, pain, limb swelling and age-related weakness. The 2019 revision introduced a single approach for these:

1. Record the score as examined. Do not upgrade it.
2. Tag any affected abnormal score with * (sensory 0*, 1*, NT*; motor 0*–4*, NT*).
3. In the Comments box, name the condition and state how the score should be treated for classification (for example "treat as normal" or "treat as not normal").
4. Above the sensory or motor level, tagged scores are usually treated as normal.
5. At or below the level, the non-SCI condition is superimposed on the SCI. Classification then considers the examined score and every higher score except normal.
6. Tag every level, AIS grade or ZPP that depends on these assumptions with *.

Example: a patient with T10 paraplegia also has an old right ulnar nerve injury, and right T1 (little finger abduction) is graded 2. The score is recorded as 2*, and the Comments box notes "right ulnar neuropathy; treat as normal for classification". Because the condition lies above the motor level, the right motor level can still be T10, but it is tagged T10* because it depends on the examiner's judgement.

Psychometrics

Reliability and Validity

• Trained examiners: the motor and sensory examinations show high inter-rater and intra-rater reliability when performed by trained examiners.
• Non-traumatic SCI: in people with non-traumatic spinal cord lesions, ISNCSCI showed substantial internal consistency and substantial inter-rater agreement for AIS grade, motor and sensory scores, and the motor score correlated with the Spinal Cord Independence Measure (SCIM).
• Children: SNCSCI is recommended for young people aged 6 years and over. Examiners should complete the InSTeP and WeeSTeP training first. More research is needed for children under 6.

Training and classification accuracy

Classification is complex, and errors are common. Formal training in scoring and classification improves accuracy, and the International Standards Committee has published case series (one/two) on common classification challenges. Discrepancies between clinicians' classifications and computerised reclassification have been documented, so algorithm checks are a useful safeguard.

Prognostic value

ISNCSCI findings are the main basis for predicting neurological recovery after traumatic SCI:

• Most AIS conversion and motor recovery occurs in the first 6–9 months, with the fastest motor recovery in the first 3 months
• Conversion from complete to incomplete injury is more common in tetraplegia than paraplegia
• Total motor recovery is greater after initial AIS B than AIS A, and greater after initial AIS C than after motor complete injury
• Older age has a negative effect on neurological and functional recovery, although the threshold (over 50 or over 65 years) is unclear. Penetrating injury reduces the likelihood of conversion
• In injuries with an initial NLI between T6 and T12, a sensory ZPP of 3 or more segments has prognostic value for AIS conversion
• Results from very early examinations (within about 4 hours of injury) should be interpreted with caution
• Walking: a clinical prediction rule using age (under or over 65 years), L3 and S1 motor scores, and L3 and S1 light touch scores, recorded within 15 days of injury, predicted independent walking at one year with high accuracy (area under the curve 0.96). It added prognostic value within each AIS grade, particularly B and C

What ISNCSCI does not measure

ISNCSCI does not assess autonomic function, so it should not be used on its own to predict bladder, bowel, sexual, cardiovascular or thermoregulatory outcomes. The International Standards to document Autonomic Function following SCI (ISAFSCI), second edition (2021), cover cardiovascular, thermoregulatory and sudomotor, bronchopulmonary and sacral (bladder, bowel and sexual) function, and are recommended alongside ISNCSCI. ISNCSCI also does not measure function or participation; tools such as the Spinal Cord Independence Measure (SCIM) are needed for these.

Additional Resources

Worksheets and Standards

• ISNCSCI worksheet, 2026 (REV 04/26): free download; licensed CC BY-NC-ND 4.0
• ISNCSCI resources page (ASIA): booklets, papers, calculators and training links
• ISNCSCI: Revised 2019 (open access)
• Expedited ISNCSCI (E-ISNCSCI), version 2
• ISAFSCI, second edition

Testing guides

• ASIA Key Sensory Points guide
• ASIA Motor Exam Guide
• Dermatome Testing Videos
  • Sensory Exam technique video
  • Sensory Exam overview
• Myotome Testing Videos
  • C5
  • C6
  • C7
  • C8
  • T1
  • L2
  • L3
  • L4
  • L5
  • S1

Training and practice

• InSTeP: International Standards Training e-Learning Program: five modules covering anatomy, sensory, motor and anorectal examination, and classification. WeeSTeP (paediatric) and ASTeP (autonomic) are also available.
• ISNCSCI Classification Workbook: practice cases
• ISNCSCI Classification Workbook: cases and answers: 26 practice cases with explanations

Classification calculators

• EMSCI ISNCSCI Calculator

For patients and families

• What is the ISNCSCI exam? Adult brochure