Sacral examination in spinal cord injury: Is it really needed?

The Journal of Spinal Cord Medicine, 2018 · DOI: 10.1080/10790268.2017.1410307 · Published: September 1, 2018

Simple Explanation

The sacral exam, part of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), is crucial for determining 'sacral sparing' in spinal cord injuries. Sacral sparing is important because it determines whether a spinal cord injury (SCI) is classified as neurologically complete or incomplete. However, the rectal exam is an invasive and unpleasant portion of the exam with possible associated complications. This study investigates whether patient self-reporting of sacral motor and sensory function is accurate enough to potentially avoid the need for the invasive rectal exam. This study surveyed patients with chronic SCI, using a neutral-based comprehensive survey, to correlate self-report relative to the ‘gold standard’ of the neurological examination.

Study Duration

Not specified

Participants

116 patients aged 18+ with chronic SCI

Evidence Level

Prospective, single-blinded study

Key Findings

1
Patients with complete injuries (AIS A) who reported no sacral motor/sensory function via survey were correct in relation to the sacral exam, showing 100% Negative Predictive Value (NPV).
2
Patients with AIS D injuries who reported having light touch, pin prick, deep anal pressure and voluntary anal contraction were congruent with the sacral exam, demonstrating 100% Positive Predictive Value (PPV).
3
Survey results for AIS B and C were variable with PPV and NPV, likely due to varying sacral sparing present in these levels of injury.

Research Summary

This study aimed to determine if a self-report measure of sacral function in chronic SCI patients accurately predicts sacral examination results. The study compared self-report survey results with sacral exam findings, stratified by the patient’s American Spinal Cord Injury Association Impairment Scale (AIS) category. The results showed that patient report of sacral sparing can predict negative sensation in patients with AIS-A and predict positive sensation in persons with AIS-D. Overall, the self-report of sacral sparing of motor and sensory function is not predictive enough to rely on for accurate classification. The study concludes that the physical exam for sacral function should continue to be performed to determine the level of injury and overall prognosis. Self-report in persons with AIS A and D seems more reliable than in persons with AIS B and C if the exam is deferred.

Practical Implications

Clinical Practice

Physical exams for sacral function should continue in SCI patients, but self-reporting can be considered in specific AIS A and D cases.

Research

Further studies should refine self-report measures and investigate their use in longitudinal monitoring of sacral function.

Patient Education

Educating patients on the importance of accurate self-reporting can improve the reliability of this method in clinical settings.

Study Limitations

1
Use of anatomical terms may limit full understanding.
2
The study included only patients with chronic SCI (> 6 months post-injury) and is not generalisable to acute care.
3
Self-reported responses may have differed between different lengths of SCI chronicity.

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