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The latest revision of the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) was available in booklet format in June 2011, and is published in this issue of the Journal of Spinal Cord Medicine. The ISNCSCI were initially developed in 1982 to provide guidelines for the consistent classification of the neurological level and extent of the injury to achieve reliable data for clinical care and research studies. This revision was generated from the Standards Committee of the American Spinal Injury Association in collaboration with the International Spinal Cord Society's Education Committee. This article details and explains the updates and serves as a reference for these revisions and clarifications.

Background/objectives: To evaluate the relationship between the severity of cervical spinal cord injury (SCI) (American Spinal Injury Association [ASIA] grade), presence of neurogenic shock, and timing of surgical intervention. This is a post-hoc analysis from the Sygen multicenter randomized controlled trial., Methods: Blood pressure (BP) and heart rate (HR) data were collected when patients were first assessed in the emergency room (Time A) and at the time of randomization (Time B). Individuals were subdivided by ASIA grade and by the level of the systolic BP (SBP)., Results: Only individuals with cervical SCI from the Sygen trial (n = 577) were evaluated. Severe complete SCI (ASIA grade = A) was established in 57% of these patients. A total of 74 (13%) patients with neurogenic shock (SBP < 90 mmHg) at Time A were identified. The SBP increased significantly from Time A to Time B (P < 0.0001). The median time from SCI to surgical intervention, for ASIA A, was 80.9 hours for patients with initial SBP < 90 mmHg and 58 hours for patients with initial SBP > or = 90 mmHg (P = 0.025). Multivariable analysis after adjusting for confounders revealed a statistically significant difference in the time to surgical intervention based on SBP for ASIA A (P = 0.026), yet not for ASIA B or C/D., Conclusions: The presence of neurogenic shock was associated with a delay in the timing of surgical intervention in patients with cervical SCI. Detailed evaluation of autonomic dysfunctions following SCI including cardiovascular instability could improve our understanding of the complexities of clinical presentations and possible neurological outcomes.

Background/objective: Three patients with spinal cord injury (SCI) and 3 able-bodied (AB) patients were infused with naloxone during a study to examine their neuroendocrine function. An unanticipated side effect occurred during the naloxone infusion. All 3 patients with SCI, but none of the AB patients, experienced profoundly increased spasticity during the naloxone infusion. Our report describes this side effect, which has potential implications for the clinical treatment or scientific evaluation of individuals with SCI., Methods: All patients were in good general health and medication free for 11 days or longer before the study. Each patient was placed on a 30-hour protocol to analyze pulsatile release of gonadotropins. Physiologic saline was intravenously infused on day 1 to serve as a control period for naloxone infusion on day 2., Results: AB patients experienced no muscle spasm activity or any other side effects at any time during the study. In contrast, all 3 patients with SCI experienced a profoundly increased frequency and duration of spasticity in muscles innervated by the nerve roots caudal to their level of injury. In all 3 patients with SCI, spasticity increased only during the period of naloxone infusion. Within 1 hour of stopping naloxone, spasticity returned to baseline levels., Conclusions: Naloxone infusion produced a differential effect on the muscle activity of men with SCI compared to AB men with intact spinal circuits. Consistent with previous studies, the results of this study indicate a relationship between opioid neuromodulation and spasticity after SCI.

Background/objective: Cardiovascular abnormalities and arrhythmias are common in individuals with spinal cord injury (SCI) who are undergoing vibrostimulation for sperm retrieval. The study aimed to examine cardiovascular control in men with SCI undergoing this procedure., Methods: Individuals with chronic cervical (n=8; age: 33.1 +/- 1.9 years) and upper thoracic SCI (n=5; age: 35.2 +/- 2.9 years) volunteered for vibrostimulation, with continuous blood pressure (Finometer) and electrocardiographic monitoring. Patients were characterized further by sympathetic skin responses (SSR) to assess descending autonomic spinal pathways and American Spinal Injury Association (ASIA) scores to assess motor and sensory pathways., Results: All but one subject with cervical SCI were ASIA A or B and were negative for SSR in the hands and feet. All subjects with upper thoracic SCI were ASIA A or B and were positive for SSR in the hands. Systolic blood pressure was lower in men with cervical injury at rest. Vibrostimulation induced an increase in systolic blood pressure >20 mmHg in all patients with cervical SCI (range = 125/65 - 280/152; median = 167/143 mmHg) and in 2 thoracic subjects (151/104 and 170/121 mmHg). During ejaculation, 6 cervical and 3 thoracic subjects developed arrhythmias (5 with bradycardia, 6 with premature atrial contractions, 4 with ventricular excitation, 1 with junctional rhythm, and 1 with heart block)., Conclusion: The vibrostimulation procedure induced electrocardiographic abnormalities and autonomic dysreflexia in subjects with either cervical or high thoracic SCI.