PMR 7 - spinal cord Flashcards
Regarding epidemiology, which of the following is the most common cause of spinal cord injury (SCI)?
a. Falls
b. Violence
c. Motor vehicle accidents
d. Sports/recreation
C) Automobile accidents are the leading cause of SCI. However, there are differences among age groups. Falls are reported as the most common cause in the elderly, and violence is the leading cause in African Americans.
What is the leading cause of death in chronic spinal cord injury (SCI)?
a. Heart disease
b. Respiratory disease
c. Genitourinary disease
d. Suicide
B) The leading cause of death in spinal cord injury patients is respiratory diseases, with pneumonia as the most common cause.
According to the International Standards for the Neurologic Classification of Spinal Cord Injury (ISNCSCI), American Spinal
Injury Association (ASIA) impairment score of B is defined as?
a. Motor preservation greater than 3 levels below neurologic level and greater than half the key muscles below the single neurologic level are less than 3
b. No motor function more than 3 levels below the motor level with sensory preservation including sacral sparing
c. Motor preservation greater than 3 levels below the neurologic level and greater than half the key muscles below the single neurologic level are graded greater than or equal to 3
d. Complete injury with no sensory or voluntary anal sphincter contraction
B) * A = Complete. No sensory or motor preservation in sacral segments, S4-5. * B = Sensory incomplete. Sensory preservation below the neurological level with sacral sparing. No motor function more than 3 levels below the motor level.* C = Motor incomplete.
Motor preservation below the neurologic level (> 3 levels) and greater than half key muscles below the single neurologic level graded less than 3. * D = Motor incomplete. Motor preservation below the neurologic level > 3 levels) and greater than half muscles below the single neurologic level graded greater than or equal to 3. * E = Sensory and motor exams are normal.
A spinal cord injured patient was noted to have the following on physical examination: motor preservation greater than 3 levels below the neurologic level and greater than half the key muscles below the single neurologic level were less than 3. This would be classified as an
American Spinal Injury Association (ASIA)
level:
a. ASIA A
c. ASIA C
b. ASIA B
d. ASIA D
C) * A = Complete. No sensory or motor preservation in sacral segments, S4-5. * B = Sensory incomplete. Sensory preservation below the neurological level with sacral sparing. No motor function more than 3 levels below the motor level. * C = Motor incomplete.
Motor preservation below the neurologic level (> 3 levels) and greater than half key muscles below the single neurologic level graded less than 3. * D = Motor incomplete. Motor preservation below neurologic level (> 3 levels) and greater than half muscles below the single neurologic level graded greater than or equal to 3. * E = Sensory and motor exams are normal.
Which of the following are key muscles tested in the scoring of the American Spinal Injury Association (ASIA) exam?
A. C5-biceps, C7-triceps, T1-adductor digiti minimi, L5-quadriceps, S1-flexor hallucis longs
B. C5-biceps, C6-flexor carpi ulnaris, C8-flexor digitorum profundus, L3-quadriceps, L4-adductor magnus
C. C5-biceps, C8-flexor digitorum superficialis, L2-sartorius, L3-quadriceps, L5-biceps femoris
D. C5-biceps, C8-flexor digitorum profundus, T1-abductor digiti minimi, L4-tibialis anterior, S1-gastrocnemius
D) There are 10 key muscles tested, which include the following: * C5 = biceps brachialis; elbow flexors * C6 = extensor carpi radialis; wrist extensors * C7 = triceps; elbow extensors * C8 = flexor digitorum profundus; finger flexor of middle finger * T1 = abductor digiti minimi; small finger abductor * L2 = iliopsoas; hip flexors * L3 = quadriceps; knee extensors * L4 = tibialis anterior; ankle dorsiflexors * L5 = extensor hallucis longus; long toe extensors * S1 = gastrocnemius;
ankle plantar flexors
Which of the following is true regarding the zone of partial preservation (ZPP)?
a. Classified only in incomplete injuries
b. The most rostral segment below the assigned level that has sensory or motor function
c. The motor ZPP does not follow the sensory ZPP
d. All of the above
C) The ZPP is defined as the most caudal dermatomes and myotomes below the sensory and motor levels that remain partially innervated. It is classified only in complete injuries. The motor ZPP does not follow the sensory ZPP. In the scoring sheet, enter the motor or sensory level if there are no segments below and N/A for incomplete injuries. To calculate the length, count the number of levels from the sensory or motor level to the ZPP level.
A hyperextension injury that occurs in low-velocity trauma that affects the upper (greater 7. than the lower) extremities is called?
a. Central cord syndrome
b. Brown-Séguard syndrome
c. Anterior cord syndrome
d. Cauda equina syndrome
A) Central cord syndrome is an incomplete injury that results in lower motor neuron weakness at the level of injury and upper motor neuron spasticity below the injury. It typically occurs in the elderly who have a preexisting spondylosis. Brown-Séquard is a hemisection of the cord that results in ipsilateral motor and proprioceptive loss with contralateral loss of pain and temperature.
Anterior cord svndrome occurs with a vascular injury that results in loss of motor and pain/temperature sensation with preservation of light touch and position sense. Cauda equina occurs with burst fractures or central disc herniations resulting in lower motor neuron flaccid paralysis with loss of sensation in the lower lumbar and sacral segments.
What is the typical presentation of an individual with Brown-Séguard syndrome?
a. Ipsilateral motor loss at the level of the lesion and contralateral loss of position sense, pain and
temperature below the level of the lesion
b. Contralateral proprioceptive and motor loss at the level of the lesion with ipsilateral loss of pain and temperature below the level of the lesion
c. Ipsilateral motor and proprioceptive loss at and below the level of the lesion with contralateral loss of pain and temperature below the lesion
d. Contralateral motor loss at the level of the lesion, ipsilateral proprioceptive loss at the level of the lesion, and contralateral loss of pain and temperature below the lesion
C) The neurological findings seen in Brown-L Séquard are based on where various pathways travel and cross over in relation to the brainstem and spinal cord. Since it is a hemisection of the cord, the following is seen:
* Ipsilateral motor and proprioceptive loss at and below the level of lesion * Ipsilateral sensory loss at the level of the lesion * Contralateral loss of pain and temperature below the level of the lesion.
Which of the following is true of the recommendations regarding prevention of upper limb pain and injury in spinal cord injury (SCI) patients?
a. Minimize frequency of repetitive upper limb tasks
b. Minimize the force used to perform upper limb tasks
c. Minimize extreme positions of the joints
d. All of the above
D) Task frequency can be modified by limiting the number of transfers or switching to power mobility in high-risk patients.
Minimizing force can be achieved by using a lighter wheelchair, improving propulsion techniques, and maintaining an optimal weight. Individuals are encouraged to avoid extreme positions of the wrist, avoid positioning above the shoulder by implementing assistive devices/technology, and avoid extreme shoulder internal rotation and abduction to prevent mechanical impingement.
What is the recommended duration for anticoagulant prophylaxis for an uncomplicated complete spinal cord injury?
a. 6 weeks
b. 8 weeks
c. 12 weeks
d. Until discharge from rehabilitation
B) Anticoagulant with either low-molecular-weight heparin or adjusted dose unfractionated heparin should be initiated within 72 hours of injury if there is no contraindication. It should be continued for 8: weeks in an uncomplicated case and 12 weeks or until discharge from rehabilitation for those individuals with other risk factors such as lower limb fracture, history of cancer/thrombosis, age > 70, heart failure, or obesity even in those with inferior vena cava
filters.
Vena cava filter placement should be considered for spinal cord injured patients with which of the following?
a. High cervical cord injury with poor cardiopulmonary reserve
b. As a substitute for prophylaxis in a complete injury
c. Older than 70 years
d. All of the above
A) Vena cava placement is indicated in those who have failed prophylaxis, have a contradiction to anticoagulation, and high lesions with poor cardiopulmonary reserve. It is not a substitute for prophylaxis and may increase the risk of complications in the future such as cava thrombosis or filter migration.
Which of the following is a true statement regarding women with spinal cord injury
(SCI) and pregnancy?
a. The likelihood of pregnancy is reduced since amenorrhea is common
b. The risk of complications during pregnancy is equivalent to that in the able bodied population
c. A caesarian section is the preferred method of delivery
d. Autonomic dysreflexia may be the only presentation of labor in iniuries above the T6 level
D) Amenorrhea may occur after injury, but most often menstruation returns 6 months after injury. Reproductive function and fertility is unaffected once menstruation returns.
These women should be educated about the issues related to pregnancy in SCI, including complications such as increased risk of urinary tract infections, changes in respiratory function, and biomechanical effects of being in a wheelchair. Since uterine innervations arise from T10 to T12, these individuals may not present with the typical symptoms of labor and must be aware of autonomic dysreflexia. Although caesarian sections may be more common in this population, it is not the preferred plan for delivery.
In the treatment of erectile dysfunction in spinal cord injured males, the physiatrist should discuss which of the following options?
a. Phosphodiesterase type 5 inhibitors
b. Intracavernosal injections
c. Vacuum devices
d. All of the above
D) The physiatrist should begin the discussion of sexual function early and be respectful of this sensitive subject. PDE-5 inhibitors have been successful and well tolerated. Its use is contraindicated with the concurrent use of nitrates. When oral medications are ineffective, an injection of alprostadil can be given, but priapism can occur. A vacuum device requires manual dexterity and is contradicted in those on blood thinners or with a history of sickle cell.
Other options include intraurethral medications (which are not as widely available) and implantable penile prostheses (which are not preferred because they can lead to corporal tissue destruction).
What level spinal cord injury leads one to be concerned about the risk of developing autonomic dy sreflexia?
a. T4 and above
b. T6 and above
c. T8 and above
d. T10 and above
B) Autonomic dysreflexia occurs as a result of unopposed sympathetic discharge above the major splanchnic outflow (which occurs at T6 through L2). It occurs after spinal shock, when refl exes return. The patient may present with flushing and diaphoresis above the level of the lesion, hypertension, bradycardia, piloerection, skin pallor, and/ or headache.
What is the most common cause of autonomic dy sreflexia?
a. Pressure ulcers
b. Fractures or other trauma
c. Restrictive clothing
d. Bladder distention
D) The most common causes of autonomic dysreflexia involve the bladder and bowel. There are a number of causes, all of which involve noxious stimuli below the level of the spinal cord injury. All of the above are potential causes, as well as infection, pregnancy, sexual intercourse, diagnostic medical procedures, deep venous thrombosis, and ingrown toenails.
A T4 American Spinal Injury Association
(ASIA) C individual in your office begins to get flushed. You check the individual’s blood pressure and find that it is elevated with a decreased pulse. What should you do next?
a. Sit the person up and loosen any clothing
b. Catheterize the individual
c. Perform fecal disimpaction
d. Administer nifedipine
A) There are several causes for autonomic dysreflexia, but the first action should be to sit the person up and loosen any restrictive clothing, which will lower blood pressure by pooling blood in the lower extremities. Then, it is important to determine the stimulus causing the autonomic dy sreflexia. For instance, the most common cause is bladder distention–check for kinks or flush the catheter. Pharmacologic management may be necessary if symptoms persist.
Which of the following statements is true regarding prognosis and spinal cord injury
(SCI)?
a. Preserved sacral sensation has a better prognosis for lower extremity recovery
b. Individuals older than 50 years have a better prognosis for recovery
c. A sensory incomplete injury has a less than 10% chance for ambulation
d. Muscles with antigravity strength can recover two grades in the first vear
A) The recovery is faster and more favorable in incomplete injuries and in younger patients. To achieve antigravity strength, it can take an average of 2 months in a complete injury compared with 2 weeks in an incomplete injury. Muscles with a grade of 1 or 2 have a greater probability of improving one grade by 1 year compared with muscles with no activity. ASIA D has the best prognosis for ambulation. Of those persons with ASIA C, 75% will regain the ability to ambulate and 50% in ASIA B. The most significant predictor is the preservation of sacral sensation.
Which of the following individuals with spinal cord injury (SCI) can transfer on level surface without the use of a board?
a. C4
b. C5
c. C6
d. C7
D) Expected functional outcomes are important to discuss with an acutely inured patient and his or her family. For transfers, patients with a lesion at C4/C5 usually require total assist with a board or a mechanical lift.
C6 patients require minimal assist to independent with the use of a board or lift, and C7 patients are usually independent with or without the board on level surfaces (and some assist to independence on uneven terrain). An individual should gain complete independence in transfers at C8-T1, which was not listed as a choice.
