Glasgow Coma Scale (GCS)
GCS is used both to assess the state of consciousness and coma.
Note that the GCS considers three variables: motor, verbal, ocular response.
It’s impossible to assess GCS in case of: immobilization of a limb, tracheostomy, III nerve palsy or eyelid edema
|4 Spontaneous||5 Oriented, Alert||6 Obey to command|
|3 To Speech||4 Disoriented||5 To localized pain|
|2 To Pain||3 Incoherent||4 Withdraws from pain|
|1 Absent||2 Incomprehensive||3 Flexion to pain|
|1 Absent||2 Extension to pain|
Pediatric Glasgow Come Scale (PGCS)
PGCS is used to assess the state of consciousness and coma in children.
Note that the PGCS is similar to GCS but it is different as far as verbal and motor response are concerned.
PGCS is between 1 and 14 (GCS between 1 and 15) because there is no difference between “normal” and “abnormal flexion”
|4 Spontaneous||5 Oriented, Alert||5 Obey to command|
|3 To Speech||4 Words||4 To localized pain|
|2 To Pain||3 Vocal Sounds||3 Flexion to pain|
|1 Absent||2 Cries||2 Extension to pain|
|1 Absent||1 Extension to pain|
FOUR score is used to assess the prognosis in intubated ICU patients.
Note that the FOUR score is similar to GCS but it provides more informations: assessment of brainstem reflexes (B), ocular movement (E), different motor responses (M), respiratory disorders (R).
FOUR score lacks of evaluation of verbal response.
|4 Opened, Track/Blink to command||4 Make signs ("thumbs up")||4 Corneal and Pupil||4 Not intubated, Regular|
|3 Opened, Not tracking||3 Localizing to pain||3 One pupil fixed, wide||3 Not intubated, Cheyne-Stokes|
|2 Closed, Open to loud voice||2 Flexion to pain||2 Corneal or pupil reflex absent||2 Not intubated, Irregular|
|1 Closed, Open to pain||1 Extension to pain||1 Both reflexes absent||1 Above ventilator rate|
|0 Closed||0 Absent / Myoclonus||0 No Corneal, Pupil, Cough reflexes||0 At ventilator rate, Apnea|
Injury Severity Score (ISS)
ISS scale is used to assess the severity of multiple lesions in multiple body regions.
Note that the ISS scale is an anatomy-based classification that must be integrated with AIS classification who assess the severity of a lesion.
1. Use AIS (Abbreviated Injury Scale) to define the entity of a lesion of six anatomical sites:
- Head and Neck
2. Square the three higher scores and add each result to obtain the ISS Score.
Note that AIS Score is from 0 to 75. If an injury is classified as AIS 6, the ISS Score is automatically 75.
Glasgow Outcome Coma Scale (GOS)
GOS scale is used to assess the degree of functional recovery in patients suffering for cerebral lesions.
|1||Good recovery||Returned to the original functional level and employment with no deficit.|
|2||Moderate disability||Minor neurological deficits that does not interfere with daily functioning or work|
|3||Severe disability||Significant neurological deficits that interfere with dali functioning or prevent return to employment|
|4||Vegetative||Coma or severe deficit rendering the patient totally dependant|
Anderson and D'Alonzo Classification
Anderson-D’Alonzo classification is about odontoid (C2) fractures.
|I||Fracture of the tip of the odontoid process||i.e. above transverse ligament. Rare|
|II||Fracture of the base of odontoid process||i.e. below transverse ligament. Usually unstable.|
|III||Fracture of the base of odontoid process extending into the body of the axis.||Usually stable.|
Anderson and Montesano Classification
Anderson-Montesano classification is about occipital condyle fractures.
|I||Comminuted fracture||Axial loading|
|II||Linear fracture extending to skull base||Extension|
|III||Avulsion of condyle fragment||Rotation and lateroflexion|
ASIA score assess both the severity and the extension of spinal lesions.
|A||Complete. No motor or sensory function in S4-S5|
|B||Sensory Incomplete. Only sensory function is preserved below the neurological level|
|C||Motor Incomplete. Motor function is preserved below the neurological level. More than half of key muscle function below the neurological level have a grade <3.|
|D||Motor Function is preserved below the neurological level. At least half of key muscle function below the neurological level have a grade >3.|
1. Determine sensory levels for both sides
|1||Altered (decreased or hypersensitivity)|
2. Determine motor levels for both sides
|1||Palpable or visible contraction|
|2||Active movement. Full range of motion (ROM) with gravity eliminated|
|3||Active movement. Full ROM against gravity|
|4||Active movement. Full ROM against gravity and moderate resistance in a muscle specific position.|
|5||Active movement. Full ROM against gravity and full resistance in a muscle specific position.|
3. Determine the Neurological Level of Injury (NLI): the most caudal segment of the spine with intact sensory and antigravity muscle functions (more than score 3)
4. Determine if the injury is Complete or Incomplete:
- Complete: NO voluntary anal contraction, NO deep anal pressure, S4-S5 sensory score=0
5. Determine ASIA Score
DAI (Diffuse Axonal Injuries) Classification
DAI classification is about the site of severe diffuse axonal injury that correlates with outcome.
Description of axonal injury
Duration of coma
|1||Widespread injury that involves grey-white matter interfaces. Most commonly are involved parasagittal area of frontal lobes.||Transient loss of consiousness|
|2||Grade 1 pattern in addiction to corpus callous involvement. More anterior is the lesion, more severe is the consequence.||Coma with recovery processes unclear|
|3||Grade 1 and 2 patterns in addiction to tissue tear hemorrhages in the brainstem||Immediate coma and incomplete recovery|
Frankel classification is used for the evaluation of motor and sensitive spinal functions in patients with spinal injuries.
|A||Complete neurological injury. Absence of motor/sensory function below the site of the lesion.|
|B||Preserved sensitivity only. No motor function below the site of the lesion.|
|C||Preserved motor, non functional. Some voluntary motor function preserved below the site of the lesion but too weak. Sensitivity could be or couldn't be preserved.|
|D||Preserved motor, functional. Motor function preserved and useful below the site of the lesion.|
Magerl classification is used to assess traumatic injuries of the vertebral column.
It is based on the theory of the three columns of Denis.
A1: Impaction fracture
|A1.3||Vertebral body collapse|
|A2: Split fracture|
|A3: Burst fracture|
|A3.3||Burst split fracture|
|B1: Posterior disruption predominantly ligamentous|
|B1.1||With transverse disc disruption|
|B1.2||With type A vertebral body fracture|
|B2: Posterior disruption predominantly osseous|
|B2.1||Transverse bicolumn fracture|
|B2.2||Posterior osseous disruption with transverse disc disruption|
|B2.3||With type A vertebral body fracture|
|B3: Anterior disruption through disc|
|B3.1||through the pedicles|
|B3.2||through the isthmus|
|C1: Type A injuries with rotation|
|C2: Type B injuries with rotation|
|C2.1||With transligamentous flexion-distraction|
|C2.2||With transosseous flexion-distraction|
|C3: Rotation-shear injuries|
SLIC score is used for the evaluation of subaxial cervical spine injuries.
It considers three features: morfology, integrity of ligament-disc complex, neurological signs.
|Disco-ligamentous Complex (DLC)|
|Complete cord injury||2|
|Incomplete cord injury||3|
|Continuos cord compression in setting of neurodeficit||+1|
TLICS classification is used for the evaluation of toracic and lumbar injuries and indicates a treatment.
|Posterior ligamentous complex (PLC)|
|≤3||not surgical candidates|
|4||may be considered fot opertive or conservative management|
Marshall classification is used for the evaluation of traumatic brain injuries (TBI) on the basis of CT and to correlate it with outcome.
|Diffuse Injury I||No intracranial visible pathology|
|Diffuse Injury II||
Cisternal midline shift <5mm and/or
Lesion densities present;
No high or mixed density lesions >25cm3 may include bone fragments and foreign bodies
|Diffuse Injury III||
Cisterns compressed or absent with midline shift <5mm;
No high or mixed density lesions >25cm3
|Diffuse Injury IV||
Midline shift >5mm;
No high or mixed density lesions >25cm3
|Evacuated mass lesion||Any lesion surgically evacuated|
|Non-evacuated mass lesion||High or mixed density lesions >25cm3 not surgically evacuated|
Le Fort Classification
Le Fort fractures of maxillary bones.
|LeFort I||Transverse||Fracture line crosses pterygoid plate and maxillary bone just above the apices of the upper teeth|
|LeFort II||Pyramidal||Fracture extends upward across inferior orbital rim floor to medial orbital wall, then across nasofrontal suture|
|LeFort III||Caniofacial Dislocation||Involves zygomatic arches, zygomaticofrontal suture, nasofrontal suture, pterygoid plates and orbital floors|
Seddon & Sunderland Classification
Seddon & Sunderland classification is used for the evaluation of peripheral nerves injuries.
Note that Sunderland classifies the axonotmesis in three types.
|Neurapraxia||First degree||Segmental demyelination|
|Axonotmesis||Second degree||Axon injury with endonevrium intact|
|Axonotmesis||Third degree||Axon discontinuity, endonevrium discontinuity, perineurium and fascicular arrangement intact|
|Axonotmesis||Fourth degree||Only epinevrium intact|
|Neurotmesis||Fifth degree||Loss of continuity of the entire nerve|
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Giorgio Saraceno, MS
University of Brescia (Italy)
Antonio D'Ammando, MD
University of Milan (Italy)