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General

 

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

 

Eye Opening
Verbal Response
Motor Response
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
     1 Absent

 

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”

 

Eye Opening
Verbal Response
Motor Response
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

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.

 

Eye Response
Motor Response
Brainstem Reflexes
Respiration
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.

 


Steps:

1. Use AIS (Abbreviated Injury Scale) to define the entity of a lesion of six anatomical sites:

  • Head and Neck
  • Face
  • Chest
  • Abdomen
  • Extremity
  • External

 

Injury
AIS Score
1 Minor
2 Moderate
3 Serious
4 Severe
5 Critical
6 Unsurvivable

 

 

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.

 

Score
Grade
Description
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
5 Death Death

 

Spine

 

Anderson and D'Alonzo Classification

Anderson-D’Alonzo classification is about odontoid (C2) fractures.

 

Type Characteristics Notes
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.

 

Type Characteristics Mechanism
I Comminuted fracture Axial loading
II Linear fracture extending to skull base Extension
III Avulsion of condyle fragment Rotation and lateroflexion

ASIA Score

ASIA score assess both the severity and the extension of spinal lesions.

 

Grade
Description
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.
E Normal

 

Steps:

1. Determine sensory levels for both sides

 

Grade
Description
0 Absent
1 Altered (decreased or hypersensitivity)
2 Normal

 

2. Determine motor levels for both sides

 

Grade
Description
0 Total paralysis
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.

 

Grade
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

Frankel classification is used for the evaluation of motor and sensitive spinal functions in patients with spinal injuries.

 

Grade
Description
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.
E  Normal

Magerl Classification

Magerl classification is used to assess traumatic injuries of the vertebral column.

It is based on the theory of the three columns of Denis.

Type Sub-type   Description
A    COMPRESSION INJURIES
 

A1: Impaction fracture

    A1.1 Endplate fracture
    A1.2 Wedge fracture
    A1.3 Vertebral body collapse
  A2: Split fracture
    A2.1 Sagittal split
    A2.2 Frontal split
    A2.3 "Pincer" fracture
  A3: Burst fracture
    A3.1 Incomplete
    A3.2 Complete
    A3.3 Burst split fracture
B    DISTRACTION INJURIES
  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
C    TORSION INJURIES
  C1: Type A injuries with rotation
    C1.1 Impaction
    C1.2 Split
    C1.3 Burst
  C2: Type B injuries with rotation
    C2.1 With transligamentous flexion-distraction
    C2.2 With transosseous flexion-distraction
    C2.3 With hyperextension-distraction
  C3: Rotation-shear injuries

SLIC Score

SLIC score is used for the evaluation of subaxial cervical spine injuries.

It considers three features: morfology, integrity of ligament-disc complex, neurological signs.

 

Variable
Points
Morphology  
No abnormality 0
Compression 1
Burst
Distraction 3
Rotation/Translation 4
Disco-ligamentous Complex (DLC)  
Intact 0
Indeterminate 1
Disrupted 2
Neurological status  
Intact 0
Root injury 1
Complete cord injury 2
Incomplete cord injury 3
Continuos cord compression in setting of neurodeficit +1

TLICS Classification

TLICS classification is used for the evaluation of toracic and lumbar injuries and indicates a treatment.

 

Variable
Points
Morphology  
Compression fracture 1
Burst fracture 2
Rotation/Translation 3
Distraction 4
Neurologic involvement  
Intact 0
Root injury 2
Cord injury  
Incomplete 3
Complete 2
Cauda equina 3
Posterior ligamentous complex (PLC)  
Intact 0
Indeterminate 2
Injury 3

 

TLICS Score Management
≤3 not surgical candidates
4 may be considered fot opertive or conservative management
≥5 surgical candidates

 

Brain

 

Marshall Classification

Marshall classification is used for the evaluation of traumatic brain injuries (TBI) on the basis of CT and to correlate it with outcome.

 

Category
Definition
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

   

Skull

 

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

 

 

 

Peripheral Nerve

 

Seddon & Sunderland Classification

Seddon & Sunderland classification is used for the evaluation of peripheral nerves injuries.

Note that Sunderland classifies the axonotmesis in three types.

 

Seddon
Sunderland
Description
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

 

References

Fractures of the odontoid process of the axis. Lewis D. Anderson M.D and Richard T. D'alonzo M.D. The journal of bone and joint surgery. Vol. 56-A; 8; December 1974 Morphology and treatment of occipital condyle fractures. Anderson PA, Montesano PX. Spine. 1988 Jul;13(7):731–6. American Spinal Injury Association

Anderson LD, D'Alonso RT. Fractures of the Odonoid Process of the Axis. J Bone Joint Surg. 1974; 56A:1663-1674

Anderson PA, Montesano PX. Morphology and Treatment of Occipital condyle fractures. Spine. 1988; 13:731-736

Diffuse axonal injury in head injury: definition, diagnosis and grading. Adams JH et.al. Histopathology. 1989 Jul;15(1):49-59.

emedicine.medscape.com

The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care. Baker SP et al. J Trauma 14:187-196;1974

F. Magerl et.al. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J (1994) 3 : 184-201

Denis F (1983) The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 8:817–831

Ferguson RL, Allen BL Jr (1984) A mechanistic classification of thoracolumbar spine fractures. Clin Orthop 189:77–88

Prediction of outcome in traumatic brain injury with computed tomographic characteristics: a comparison between the computed tomographic classification and combinations of computed tomographic predictors. Andrew I.R. Maas, M.D, Ph.D. et.al. Neurosurgery Volume 57, Number 6, December 2005

The Subaxial Cervical Spine Injury Classification System. Alexander R. Vaccaro MD et.al. SPINE Volume 32, Number 21, pp 2365–2374

Thoracolumbar injury classification and severity score: a new paradigm for the treatment of thoracolumbar spine trauma. Joon Y. Lee et.al. J Orthop Sci (2005) 10:671–675

Vaccaro AR, Zieller SC, Hulbert RJ, et al. The toracolumbar injury severity score: a proposed treatment algorithm. Journal of Spinal Disorder Tech. 2005; 18:209-215

How to Simplify the CT Diagnosis of Le Fort Fractures. James T. Rhea et.al. AJR 2005;184:1700–1705

Assessment of coma and impaired consciousness. A practical Scale. Graham Teasdale and Bryan Jennet. The Lancet, July 13, 1974

Head injuries in infants and young children: the value of the Paediatric Coma Scale. D.A. Simpson et.al. Child's Nerv Syst (1991) 7:183-190 Validity of the FOUR Score Coma Scale in the Medical Intensive Care Unit. Vivek N. Iyer MD et.al. Mayo Clin Proc. August 2009;84(8):694-701

Greenberg M. Handbook of neurosurgery. 7th ed. New York: Thieme; 2010.

 

Authors

 

Antonio D'Ammando, MD

Neurosurgery Resident
University of Milan (Italy)
"Spedali Civili" Hospital Brescia (Italy)
Scientific Team UpSurgeOn

 

Giorgio Saraceno, MS

Medical Student
University of Brescia (Italy) 
Scientific Team UpSurgeOn

 

 


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