Advantages and Limitations in the Evaluation of the Neurological and Functional Deficit in Patients with Spinal Cord Injuries

(1) Background: Vertebro-medullary trauma (VMT) causes osteo-articular injuries in a varied anatomical lesion associated with multiple clinical manifestations and therapeutic indications. The neurological evaluation of patients who have suffered a spinal cord injury (SCI) is costly in testing the motor and sensory function. To standardize the assessment, several scales are used that measure the neurological deficit in order to guide subsequent treatment according to complete or incomplete SCI. The aim of this study is to identify and present the relevant tools for assessing SCI. (2) Methods: Relevant SCI studies were used for a fact-finding investigation from a rational and critical perspective of this field of research. The relationship between clinical tools and those with a psychosocial component was assessed based on studies reported in the literature. (3) Results: SCI severity scales have been proposed throughout to be able to estimate the functional prognosis of victims of these traumatic events. These tools can be divided into scales for assessing the neurological deficit due to trauma, and functional scales that assess the ability to perform daily activities, self-care, etc. (4) Conclusions: The closest scale to the need for standardization and the most accurate assessment of neurological deficits secondary to SCI is ASIA/IMSOP.


Introduction
Vertebro-medullary trauma (VMT) causes osteo-articular injuries of the vertebrae and their contents (marrow, nerve roots, meninges and vessels) in a varied anatomical lesional association, with multiple clinical manifestations and therapeutic indications [1]. The occurrence of a spinal cord injury (SCI) causes a disability that can manifest itself in different levels of severity, the patient having difficulties in the family, social and economic context of functioning and integration [2,3]. SCI patients face poor financial situations and poor socio-economic achievements, and the life expectancy of the disabled person is much lower [4,5]. Worldwide, there has been an obvious concern for the development and implementation of policies and programs to improve the quality of life of people with disabilities [6,7]. The aim is to ensure people's access to specific medical services, education and viable employment opportunities [8][9][10]. It is important to add that SCI mainly affects the active population, the average age being 35 years, so the economic impact is great [11][12][13]. Another worrying aspect is the increasing incidence of patients with complete spinal cord section and quadriplegia, which implies increased care needs [14][15][16].
In order to determine the neurological and functional deficit in patients with vertebralmedullary injuries, different evaluation scales were developed. These scales have been validated and improved over the years to determine a predictive tool for the functional outcomes of patients with SCI [17,18].
Our objective is to analyze the advantages and limitations of the current scales for evaluating the neurological and functional deficit in patients with SCI.

Materials and Methods
We present the tools that have proven to be a reliable standard and have direct utility in the work of clinicians. Studies supporting the fidelity and validity of SCI research and assessment tools will be presented according to the instrument presented. Relevant SCI studies were used for a fact-finding investigation from a rational and critical perspective of this field of research. The relationship between clinical tools and those with a psychosocial component was assessed based on studies reported in the literature. To achieve this goal, SCI severity and functional prognosis scales were analyzed using Medline, PubMed, Scopus, Proquest, Science Direct, Springerlink, and WOS bases, including relevant keywords supported by internationally established sites in the field, or regionally (such as the International Spinal Cord Society). In order to select the articles, we utilized the following keywords: scales, spinal cord injury, vertebro-medullary trauma, neurologic recovery, functional recovery, neurologic deficit. Studies evaluating SCI in children were excluded due to the multitude of factors that would have distorted the presented information. The study will reveal the screening criteria for inclusion and the exclusion of studies. First of all, we selected from international journals the studies that validated these scales and which presented as relevant sources of empirical and meta-analytical data. Second, to avoid misinterpretation, the selected works included only articles published in English. Thirdly, in terms of chronology, a period of 20 years was selected. The selection of studies has been implemented to ensure sufficient time to observe the evolution of international research on SCI. We believe that we offer a sufficiently long time-frame to be able to identify the elements relevant to our SCI investigation. The eligibility of studies with relevant statistical data was the last step in which an additional and more in-depth examination of the literature was performed. Consequently, this step was aimed at reviewing the titles, abstracts, and main content of each type of study, research article, validation study, and quantitative meta-analysis to ensure that they meet the inclusion criteria. The selection process for this article is illustrated in Figure 1.

Results and Discussion
The need for standardization and accurate assessment of neurological deficits secondary to SCI has led to the development of various scales for their quantification, but

Results and Discussion
The need for standardization and accurate assessment of neurological deficits secondary to SCI has led to the development of various scales for their quantification, but none of them can be considered ideal, as each has its advantages and disadvantages. The choice of one or another of the scales also depends on the preferences of the doctor who uses them [19][20][21].
SCI severity scales have been proposed throughout to be able to estimate the functional prognosis of victims of these traumatic events. These tools can be divided into scales for assessing the neurological deficit due to trauma, and functional scales that assess the ability to perform daily activities, self-care, etc. Table 1 is the neurological deficit assessment scales.  Table 2 is scales for functional assessment of spinal cord injuries. These instruments are used specifically by specialists in the field of medical and neuromotor recovery, being    Table 3 is scales that evaluate both the neurological deficit and functional assessment of patients with SCI.

Conclusions
The closest scale to the need for standardization and the most accurate assessment of neurological deficits secondary to SCI is ASIA/IMSOP, adopted as the international standard for the neurological assessment of spinal cord trauma patients. The WISCI is a more accurate tool than the FIM for documenting changes in walking levels, but the FIM is more reliable in measuring patient self-care and independence.