title: International standards for neurological classification of spinal cord injury: classification skills of clinicians versus computational algorithms.
abstract: METHODS
  This is a retrospective analysis.
  
  
  OBJECTIVE
  The objective of this study was to describe and quantify the discrepancy in the classification of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) by clinicians versus a validated computational algorithm.
  
  
  METHODS
  European Multicenter Study on Human Spinal Cord Injury (EMSCI).
  
  
  METHODS
  Fully documented ISNCSCI data sets from EMSCI's first years (2003-2005) classified by clinicians (mostly spinal cord medicine residents, who received in-house ISNCSCI training by senior SCI physicians) were computationally reclassified. Any differences in the scoring of sensory and motor levels, American Spinal Injury Association Impairment Scale (AIS) or the zone of partial preservation (ZPP) were quantified.
  
  
  RESULTS
  Four hundred and twenty ISNCSCI data sets were evaluated. The lowest agreement was found in motor levels (right: 62.1%, P=0.002; left: 61.8%, P=0.003), followed by motor ZPP (right: 81.6%, P=0.74; left 80.0%, P=0.27) and then AIS (83.4%, P=0.001). Sensory levels and sensory ZPP showed the best concordance (right sensory level: 90.8%, P=0.66; left sensory level: 90.0%, P=0.30; right sensory ZPP: 91.0%, P=0.18; left sensory ZPP: 92.2%, P=0.03). AIS B was most often misinterpreted as AIS C and vice versa (AIS B as C: 29.4% and AIS C as B: 38.6%).
  
  
  CONCLUSIONS
  Most difficult classification tasks were the correct determination of motor levels and the differentiation between AIS B and AIS C/D. These issues should be addressed in upcoming ISNCSCI revisions. Training is strongly recommended to improve classification skills for clinical practice, as well as for clinical investigators conducting spinal cord studies.
  
  
  BACKGROUND
  This study is partially funded by the International Foundation for Research in Paraplegia, Zurich, Switzerland.
authors.affiliation: Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: C
authors.initials: C
authors.lastname: Schuld
authors.affiliation: Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: S
authors.initials: S
authors.lastname: Franz
authors.affiliation: 1] Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland [2] Rehabilitation Center for Children and Juveniles, University Children's Hospital Zurich, Affoltern am Albis, Switzerland.
authors.forename: H J A
authors.initials: HJ
authors.lastname: van Hedel
authors.affiliation: SRH Klinikum, Sektion Querschnittlähmung, Karlsbad-Langensteinbach, Germany.
authors.forename: J
authors.initials: J
authors.lastname: Moosburger
authors.affiliation: Department of Spinal Cord Injury, BG-Trauma Center, Murnau, Germany.
authors.forename: D
authors.initials: D
authors.lastname: Maier
authors.affiliation: Klinik Hohe Warte, Bayreuth, Germany.
authors.forename: R
authors.initials: R
authors.lastname: Abel
authors.affiliation: Department of Rehabilitation Medicine, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands.
authors.forename: H
authors.initials: H
authors.lastname: van de Meent
authors.affiliation: Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland.
authors.forename: A
authors.initials: A
authors.lastname: Curt
authors.affiliation: Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: N
authors.initials: N
authors.lastname: Weidner
authors.affiliation: Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: R
authors.initials: R
authors.lastname: Rupp
mesh_terms: D000465:Algorithms; D002983:Clinical Competence / Q000592:standards*; D066264:Datasets as Topic; D003936:Diagnosis, Computer-Assisted / Q000379:methods* / Q000592:standards*; D006801:Humans; D038622:Internationality; D012189:Retrospective Studies; D013119:Spinal Cord Injuries / Q000145:classification* / Q000503:physiopathology