SCI Flashcards
You are examining a 45 year-old female SCI patient’s skin and notice a broken down area most notable for a lack of epithelium and the presence of visible dermis. This patient’s pressure injury can be classified as NPUAP stage:
A 4
B 3
C 2
D 1
Answer: C
Explanation:
• The National Pressure Ulcer Advisory Panel (NPUAP) pressure injury staging system is as follows:
• 1 = nonblanchable erythema (red skin that stays red when you press on it)
• 2 = skin breakdown extends into the dermis
• 3 = through the dermis with subQ fat exposed
• 4 = muscle, tendon, or bone is exposed
• Deep tissue injury = purple, intact skin, but the wound bed CANNOT be visualized
• Unstageable = really a stage 3 or 4, but you can’t tell because there is so much slough/debris
You are the medical director of an inpatient spinal cord injury (SCI) rehabilitation unit. Your therapy staff approach you regarding one of your patients. They are concerned that the patient frequently experiences sudden-onset lightheadedness and tachycardia when performing physical therapy exercises, and that this is limiting the patient’s ability to achieve functional progress in therapies. The symptoms are resolved with lying flat and applying compression garments. What is the most appropriate initial intervention for this problem?
A Increase oral fluid intake
B Start amantadine
C Start fludrocortisone
D Start midodrine
Answer: A
Explanation:
• This patient experiencing orthostatic hypotension is most likely to benefit from conservative measures such as increasing fluid intake +/- salt tablets.
• Failing this and compression garments/abdominal binder, consider adding Midodrine +/- Fludrocortisone for chemically induced blood pressure support.
64 year-old male sustains a fall resulting in weakness and bowel/bladder dysfunction. Upon presentation to your inpatient rehabilitation unit, you note bilaterally intact shoulder abduction, elbow flexion, and wrist extension strength with antigravity elbow extension strength and, and no intrinsic hand function. Sensory examination reveals intact pinprick and light touch sensation in the neck, lateral elbow, thumb, and middle finger, but absent sensation in the 5th digit, medial elbow, axilla, and down the trunk. Rectal examination reveals absent voluntary sphincter control and rectal sensation. This patient’s ASIA classification is:
A C8 ASIA A
B C7 ASIA A
C C6 ASIA A
D C5 ASIA A
Answer: B
Explanation:
• This patient demonstrates a C7 ASIA A injury. The motor and sensory levels bilaterally are C7.
• The motor level is defined as the most distal myotome that is at least 3/5 strength and all myotomes above it are normal 5/5 strength.
• The sensory level is defined as the most distal dermatome that is 2/2 (intact) and all dermatomes above it are also 2/2 (intact).
• Refer to the ASIA grading sheet and SCI lecture video for full myotome and dermatome map discussion.
• The neurologic level of injury is essentially the worst level (the highest up the cord) out of the 4 motor and sensory levels obtained.
• ASIA A is a complete injury (NOON sign), whereas ASIA B-E are all incomplete injuries.
• Sensory-only sparing (ASIA B)
• Weak motor and sensory sparing (ASIA C)
• Strong motor and sensory sparing (ASIA D)
• Normal exam in a patient with a previously documented ASIA injury (ASIA E)
You are examining a 29 year-old male SCI patient’s skin and notice a broken down area of skin most notable for green slough with visible muscle. This patient’s pressure injury can be classified as NPUAP stage: A. 4 B. 3 C. 2 D. 1
Answer: A
• The National Pressure Ulcer Advisory Panel (NPUAP) pressure injury staging system is as follows:
• 1 = nonblanchable erythema (red skin that stays red when you press on it)
• 2 = skin breakdown extends into the dermis
• 3 = through the dermis with subQ fat exposed
• 4 = muscle, tendon, or bone is exposed
• Deep tissue injury = purple, intact skin, but the wound bed cannot be visualized
• Unstageable = really a stage 3 or 4, but you can’t tell because there is so much slough/debris.
Your long-time chronic cervical spinal cord injury patient, a 50 year-old female, presents to your clinic with new complaints of progressively worsening, burning neuropathic pain in all four limbs. Her pain as been well controlled for many years on gabapentin. Urinalysis is normal. She denies any new trauma or psychosocial stressors. What is the next best step? AEMG BCervical spine MRI with contrast CReassurance DIncrease gabapentin
Answer: B
• This patient is developing syringomyelia. This often presents as progressively worsening neuropathic pain, loss of reflexes, and potentially new myelopathy symptoms due to cystic cavitation of the spinal cord that compresses the cord itself.
• Essentially a large cyst within the central cord enlarges and compresses the spinal cord, causing the above symptoms.
• Maintain a low threshold for this condition in chronic SCI patients who previously have been very stable.
• MRI with contrast is the best first test to assess if a syrinx is developing.
• Treatment may involve neurosurgery for shunting; if syrinx is discovered, neurosurgery should be consulted.
• Increasing the gabapentin can be helpful, but doing this alone would miss the diagnosis. Reassurance is not appropriate, as she is at risk of further cord injury.
• EMG is not appropriate in this central nervous system problem, as EMG only assesses the peripheral nervous system.
A 25 y/o F presents to your inpatient rehab unit following a motor vehicle accident. On exam, you document the following intact upper limb strength, intact sensation including the nipple line (impaired below that level), and spared voluntary anal contraction. The lower extremity strength exam is 2/5 hip flexion with 3/5 knee extension and distal strength. What is this patient's ASIA classification? A. T4 AISA D B. T4 ASIA C C. T1 ASIA D D. T1 ASIA C
Answer: A
• The motor levels are T1 bilaterally, and the sensory levels are T4 bilaterally. In cases where there is no representative muscle group to test and the sensory level extends more distally than the motor level, the motor level is assumed identical to the sensory level on that side.
• The motor level is defined as the most distal myotome that is at least 3/5 strength and all myotomes above it are normal 5/5 strength.
• The sensory level is defined as the most distal dermatome that is 2/2 (intact) and all dermatomes above it are also 2/2 (intact).
• The neurologic level of injury is essentially the worse level (the highest up the cord) out of the 4 motor and sensory levels obtained.
• ASIA A is a complete injury (NOON sign)
• ASIA B - E are all incomplete injuries
• Sensory only sparing (ASIA B)
• Weak motor and sensory sparing (ASIA C)
• Strong motor and sensory sparing (ASIA D), at least 3/5 strength in over half of muscle groups distally to the neurologic level of injury
• Normal exam in a patient with a previously documented ASIA injury (ASIA E)
A 26 year-old female is involved in a skydiving accident and suffers a C8 ASIA D spinal cord injury. As you make your morning rounds, she becomes tearful and asks, “Will it ever be possible for me to have children?” What is the most appropriate response?
A. None of these answers is correct
B. It is not currently known, and more research is required
C. No, because the spinal cord injury prevents the necessary neural regulation of gestation
D. Yes, as female fertility is unaffected in the long term in SCI patients
Answer: D
• After several months following an SCI, normal menstrual cycles return in premenopausal female patients; thus, pregnancy is possible following an SCI.
Which peripheral nerve stimulates the bladder to facilitate urine storage?
Hypogastric nerve (“Hippogastric” nerve)
What is the most common site for pressure injuries in adults?
A Heel
B Sacrum
C Greater trochanter
D Occiput
Answer: B
Explanation:
• In adults the sacrum is the most common location for developing pressure injuries (pressure ulcers).
• In children, the occiput is the most common site.
A 23 year-old male is involved in an MVA and sustains a T10 ASIA A injury. He has impaired coordination of bladder contraction and sphincter contraction/relaxation. This is known as:
A Upper motor neuron bladder
B Lower motor neuron bladder
C Detrusor-sphincter-dyssynergia
D None of these answers is true
Answer: C
Explanation:
• A lesion somewhere between the brain and the bladder (e.g. in the spinal cord) causes the most common bladder pathology in SCI patients, known as detrusor-sphincter-dyssynergia (DSD).
• This is essentially a spastic bladder (upper motor neuron bladder) in combination with impaired coordination of bladder contraction with sphincter action.
• DSD causes high bladder pressures (vesicular pressures), which can lead to vesico-ureteral reflux, or urine refluxing backwards into the ureters, which can damage the kidneys over time if DSD is not controlled properly.
A 24 year-old female is evaluated in your clinic. She has a history of SCI resulting in paraplegia and urinary dysfunction. She performs clean intermittent catheterization every 6 hours, and produces about 600 ml of urine with each catheterization. However, she notes small amounts of urine leakage in between catheterization attempts. What is the most appropriate next step?
A Increase catheterization frequency to every 4 hours
B Wear diaper in between catheterization attempts
C Start mirabegron
D Start oxybutynin
Answer: A
Explanation:
• While oxybutynin and mirabegron would both be effective anticholinergic medications to prevent bladder contraction and thus facilitate urine storage, the most important first step would be to catheterize more frequently and make sure that her urine volumes remain below 500 ml on average.
• In general, bladder volumes over 500 ml place the patient at risk for vesicoureteral reflux and renal disease over time. This approach of catheterizing every 4 hours instead of every 6 hours also has the benefit of avoiding potentially unnecessary medications.
• Wearing a diaper is not an appropriate solution to her problem
A 28 year-old male suffers a mountain biking accident, resulting in C7 ASIA A spinal cord injury. He asks you what you know about male fertility following an SCI. What is the most appropriate response?
A None of these answers is correct
B You should be more worried about other problems than whether or not you can have children
C There is no difference in long-term male fertility following an SCI
D Males experience decreased fertility following an SCI
Answer: D
Explanation:
• Males suffer from poor semen quality and poor ability to achieve an erection following an SCI, both of which contribute to decreased male fertility in the long term.
A 36 year old-female with a history of cervical spinal cord injury presents to the ED with worsened spasticity. She is an intrathecal baclofen pump that has been controlling her spasticity until several hours ago, prompting her to go to the ED. You are consulted as the on-call PM&R physician. What is the next best step in action?
A Reassurance
B Obtain urinalysis
C Interrogate the baclofen pump
D Prescribe oral baclofen to “weather the storm”
Answer: B
Explanation:
• This patient with worsened spasticity presents as if her pump ran out of medication, which may be true. But before interrogating the pump, a urinalysis should be obtained, as very commonly patients develop worsened spasticity NOT because of medication or pump error, but because of urinary tract infection (UTI).
• UTI must not be missed in these patients. Worsened spasticity can serve as a “sentinel” for detecting UTIs in SCI patients.
• It is certainly appropriate to ask the patient or ED physician if a pump alarm has been sounding, which would indicate low or absent baclofen in the pump reservoir.
• Treating her spasms with baclofen alone when she may have a UTI is not medically safe. Reassurance alone when she may have a UTI is also not medically safe.
A 62 year-old male complains of 5 months of low back pain radiating into the left lower extremity. MRI of the lumbar spine reveals an L4-L5 far lateral disc herniation. Which of the following nerves is most likely being compromised?
A S1
B L5
C L4
D L3
Answer: C
Explanation:
• In the lumbar spine a central or paracentral disc herniation will involve the descending nerve root at that level (e.g. at the L3-L4 level, the L3 nerve is exiting via the neuroforamen, and the L4 nerve is descending to exit via the neuroforamen at the L4-L5 level).
○ Thus, a central or paracentral disc herniation at the L3-L4 level will potentially impinge the descending L4 nerve roots.
• A far lateral disc herniation will affect the exiting nerve root at a given spinal level.
○ Thus, a far lateral disc herniation at the L4-L5 level will most likely impinge the L4 nerve root.
You obtain a urinalysis on a 32 year-old female on your spinal cord injury inpatient rehabilitation unit. She denies any fever/chills, new pain, dysuria, or worsened spasticity. The urinalysis reveals 10 WBC and 90,000 bacteria. What is the next best step?
A Ask the patient what she prefers to do
B Do not treat the bacteriuria
C Wait for the culture and sensitivities before prescribing antibiotics
D Start empiric antibiotics
Answer: B
Explanation:
• Patients with SCI are chronically colonized by bacteria in the urinary tract. Thus, it is common to see bacteria on urinalysis.
• However, unless the patient has signs/symptoms as described in the question stem AND a clear urinary tract infection on urinalysis (>10 WBC, >100,000 bacteria), do NOT treat the bacterial colonization.
• Asking the patient their preferences for medical interventions is appropriate in some cases, but not here, though informed consent for treatment is always important.
