SCI Flashcards
1
Q
5 risk factors that qualify a patient for 12 weeks (rather than normal 8 weeks) of DVT prophylaxis?
A
long bone fx, cancer, advanced age, obesity, heart failure
2
Q
About what percentage of SCI patients with complete injury are able to achive ejaculation?
A
15% (a little higher with LMN vs UMN)
3
Q
At what level does the spinal cord end?
A
L1
4
Q
common site for osteoporotic fracture in SCI patients?
A
distal femur
5
Q
describe posterior cord injury
A
injury to dorsal columns causing loss of light touch/proprioception and impaired ambulation
6
Q
Diameter of absolute stenosis in the spinal canal
A
less that 10mm
7
Q
Does likelihood of pregnancy after SCI change?
A
No, fertility is unimpaired
8
Q
Extradural spinal tumors are commonly metastases from what three areas of the body?
A
lung, breast, and prostate
9
Q
female fertility after SCI
A
normal menstruation returns in 6-12 months so long-term fertility is unaffected
10
Q
gold standard to dx pulmonary embolism
A
pulmonary arteriogram
11
Q
How can you tell the difference between autonomic dysreflexia and preeclampsia?
A
- AD symptoms occur with contraction of the uterus and normalize with relaxation of the uterus
- Preeclampsia is associated with protein in the urine, elevated uric acid, elevated LFTs, and decreased platelets
12
Q
How does Brown-Sequard syndrome present?
A
ipsilateral loss of motor function, light touch/proprioception and contralateral loss of pain and temperature
13
Q
How does cauda equina differ from conus medullaris syndrome?
A
Cauda equina is asymmetric, areflexia/hyporefleic, and can involve lumbar roots
14
Q
How does cauda equina present?
A
- Lower motor neuron lesions of lumbosacral nerve roots
- Asymmetric flacid paralysis and sensory loss in nerve root distributions
- Areflexic bowel, bladder, and sexual dysfunction
- Positive EMG findings
15
Q
How does conus medullaris syndrome present?
A
- UMN or mixed UMN/LMN lumbosacral lesions
- saddle distribution sensory loss
- possible bowel, bladder, and sexual dysfunction
- Normal EMG unless S1 or S2 involvement
16
Q
How does level of injury affect the ability of SCI patients to have an erection?
A
- T9 and above: reflexogenic intact, psychogenic lost
- T12 and below: psychogenic intact, reflexogenic lost
- S2-4: reflexogenic impossible, psychogenic greatly reduced
17
Q
How does subacute combined degeneration present?
A
insidious onset of sensory symptoms followed bilateral spastic paresis of lower limbs
18
Q
how does syringomyelia present in the setting of SCI?
A
insidious onset of ascending loss of reflexes, burning pain worse with sitting or valsalva
19
Q
How is baclofen cleared from the body?
A
renally (use lower doses in CKD)
20
Q
How is diazepam cleared from the body?
A
hepatically (use lower doses in liver disease)
21
Q
How long does it take for resolution of areflexic bladder seen in patients with spinal shock?
A
2 - 12 weeks
22
Q
In general, are prophylactical antibiotics to treat UTIs in SCI patients indicated?
A
No
23
Q
leading cause of death in acute SCI?
A
pulmonary embolism
24
Q
leading cause of death in chronic SCI?
A
pneumonia
25
leading cause of death in paraplegia?
heart disease
26
male fertility after SCI
decreased due to poor semen quality and impaired erections
27
mechanism of action of baclofen
GABA B agonist
28
mechanism of action of botulinum toxins
the toxin will cleave proteins needed for Ach vesicle fusion with the presynaptic membrane. Depending on the form of toxin, it will cleave syntax, synaptobrevin, or SNAP-25.
29
mechanism of action of dantrolene
binds to ryanodine receptor on sarcoplasmic reticulum (SR) to inhibit calcium influx from SR in to cell.
30
mechanism of action of diazepam
GABA A agonist (Cl channel activator)
31
Mechanism of action of mirabegron?
Beta-3 agonist causing bladder relaxation
32
mechanism of action of mirabegron?
beta-3 agonist to cause bladder relaxation
33
mechanism of action of tamsulosin?
alpha-1 blocker causing internal sphincter relaxation
34
mechanism of action of tizanidine
alpha-2 agonist (inhibits spinal reflex arc)
35
Mneumonic for remembering Gaba receptor agonist and ion channels
* CLACK
* Gaba A: increase presynaptic Cl into neuron
* Gaba B1: increase presynaptic Ca2+ into neuron
* Gaba B2: increase postsynaptic K out of the neuron
36
most commmon cause of emergency abdominal surgery in chronic SCI patients?
cholecystitis
37
most common cause of death in acute SCI
pulmonary embolism
38
Most common cause of SCI?
MVC
39
most common level for central cord with hyperextension of the c-spine?
C4-C5
40
most common level for cervical compression fracture with flexion and axial load?
C5
41
most common level of injury of paraplegia?
T2
42
most common level of SCI
C5
43
most common presentation of myelopathy?
gait disturbance followed by UE paresthesias, decreased fine motor coordination, and hand weakness
44
most common presenting **sign** of syringomyelia in SCI patient?
ascending loss of deep tendon reflexes
45
Most common site for heterotopic ossification in SCI patients?
Hip
46
Most common site for pressure injuries in children?
occiput
47
Most common site for pressure injuries in SCI patients?
sacrum
48
most common presenting **symptom** of syringomyelia in SCI patient
aching/buring pain worse with coughing or straining
49
most common timing of DVT related to SCI
in the first two weeks
50
most common to least common type of SCI
incomplete tetra, incomplete para, complete para, complete tetra
51
most common type of multiple sclerosis
relapsing-remitting
52
Most common type of neurogenic bladder seen in SCI?
DSD (detrusor-sphincter-dyssynergia)
53
What are the key muscles and their root level for the ASIA exam?
54
What are key sensory points for the ASIA exam?
55
onset, peak, and duration of action of botox
3 days, 3 weeks, 3 months
56
Pressure injury staging
1. nonblanchable erythema 2. into dermis 3. through dermis 4. muscle, tendon, or bone exposed
57
Receptor type in bladder wall that allow for contraction?
ACh
58
Receptor type in bladder wall that allows for relaxation?
Beta-2
59
Sympathetic nerve that allows for bladder storage?
Hypogastic nerve (T11 - L2) "makes bladder as big as a Hippo"
60
Treatment for hypercalcemia in SCI patients?
IV fluids (increases urinary excretion) or Pamidronate (inhibits osteoclast-mediated bone resorption)
61
Treatment for neuromyelitis optica?
IV glucocorticoides, may follow with plasmapheresis
62
treatment for vertebral body compression fractures
Jewett or CASH brace to limit hyperflexion
63
Treatment options for adynamic ileus after SCI?
NGT, IVF, metoclopromide, erythromycin, neostigmine
64
two common tendon transfers for C5 SCI patient?
* brachioradialis to ECRB
* deltoid to triceps
65
type of lung pattern seen in SCI patients?
restrictive (all volumes decreased except residual volume)
66
What allows parasympathetic micturition action?
sacral micturition center
67
What are common vital sign findings in autonomic dysreflexia?
hypertension and bradycardia
68
What are four pharmacologic agents (and their associated mechansims) used to treat orthostatic hypotension in SCI patients?
* salt tabs
* midodrine (alpha-1-agonist)
* fludrocortisone (mineralocorticoid)
* droxidopa (norepinephrine pro-drug that can cross the blood-brain barrier)
69
What are the earliest changes seen in neurogenic bladder?
irregular thickend bladder wall with small diverticuli
70
What are the three phase of a triple phase bone scan?
* blood flow phase: check for vasoconstriction or dialation
* blood pool phase: check for edema
* delayed tracer uptake: indicates osteoblastic activity or bone turnover
71
What are three causes of incomplete spinal cord injuries?
* unilateral facet joint dislocation
* fall in the setting of cervical spondylosis
* gsw or stab wound that does not penetrate the spinal canal.
72
what are three reasons to treat an asymptomatic UTI in an SCI patient?
* pending bladder study,
* bladder pathology such as VUR
* growing urease-prodding bug
73
what are three risk factor for epidural abscess?
IVDA, diabetes, immunocompromised
74
What are three alpha-1 agonists that can be used to treat retrograde ejaculation?
midodrine, imipramine and pseudoephedrine
75
What are two areas to commonly see MS lesions
spinal cord, periventricular region
76
what are two uses for E-stim in SCI patients
* to move a extremity for functional activity
* to avoid complications of muscle inactivity
77
What bacteria is the most common cause of epidural abscess?
Staph aureus
78
What can cause abdomina pain, nausea, and vomiting after rapid weight loss and prolonged supine position?
Superior mesenteric artery syndrome: duodenum is intermittently compressed between the SMA and aorta
79
What coordinates bladder contraction with internal urethral sphincter relaxation?
pontine micturition center
80
what direction does syringomyelia progress in the spinal cord?
cephalad and caudal
81
what finding is associated with a good prognosis in multiple sclerosis?
optic neuritis
82
What is a Chance fracture?
transverse fracture of the thoracic or lumbar spine from posterior to anterior
83
what is a common level in the cervical region for facet dislocation?
C5-C6
84
What is a Hangman fracture?
C2 burst fracture due to rapid decelerations injury of the head
85
What is a Jefferson fracture?
C1 burst fracture due to high impact axial load
86
What is a key difference between sildenafil (Viagra) and tadalafil (Cialis)?
Duration of action is longer with tadalafil (up to 36hrs) vs about 5 hours with sildenafil
87
What is a quick way to tell if a patient is ASIA A?
"NOON" sign on ASIA sheet
88
What is an ASIA B?
* "Sensory Incomplete"
* Intact sensory at S4-S5 or deep anal pressure
* No motor function more than three levels below motor level.
89
What is an ASIA C?
* "Motor Incomplete"
* Less than half of key muscles have a grade of at least 3/5
* Either voluntary anal contraction **OR** patient meets criteria for ASIA B with exception of motor function preserved more than 3 levels below the motor level (includes non-key muscles)
90
What is an ASIA D?
* Motor incomplete
* Meets criteria of ASIA C with exception of at least half (half or more) of key muscles are at least 3/5.
91
What is detrusor sphincter dyssynergia?
lack of coordination between pontine and sacral (S2-4) micturation centers due to neurological injury causing high bladder pressures and increased risk for reflux
92
What is first and last to recover in central cord syndrome?
* first to recover - lower extremity function
* last to recover - intrisic hand function
93
What is Lhermitte sign?
passive neck flexion causes shooting electrical pain in the neck and shoulders. classically seen in MS
94
What is LMN bladder?
flacid bladder causing overflow incontinence. Cannot urinate due to blocking of sacral micturition center
95
What is neuromyelitis optica?
An immune mediated combination of optic neuritis and transverse myelitis
96
What is recommended during delivery of the baby in a pregnant SCI patient?
spinal anesthesia if injury is at T6 or above
97
What is seen on CSF studies in MS?
oligoclonal IgG bands (markers of CNS inflammation)
98
What is seen on radiographs with vertebral body compression fractures?
anterior wedging, sometimes retropulsed bony fragments into spinal canal
99
What is spinal shock?
absence of all spinal reflex activity below level of injury for 24 hours
100
What is the "3-2-1" bowel program?
* colace 100mg 3 x a day
* senna 2 x a day
* suppository (dulcolax or magic bullet) 1 x a day after meal
101
What is the bulbocavernosus reflex and its significance?
* squeezing tip of penis/clitoris causes anal sphincter contraction
* absense after 24hrs indicates lower motor neuron injury (unlikley to get reflexogenic erection)
102
What is the cause of detrusor overactivity in upper motor neuron bladder (lesion above S2)?
lack of descending inhibition of sacral micturition center
103
What is the cause of retrograde ejaculation in SCI patients?
lack of coordination between urinary sphincters ie abnormally open internal and closed external sphincter
104
What is the etiology of autonomic dysreflexia?
noxious stimulus below level of injury causes sympathetic output, baroreceptors sense increased BP however signal from the brainstem to decrease sympathethic outflow and allow vasodilation is blocked in the spinal cord
105
What is the fasciculus gracilis?
medial dorsal column providing light touch and vibration sensation to the leg
106
What are the steps in treatment of autonomic dysreflexia?
1. sit the patient up and loosen clothing
2. flush indwelling catheter, look for other noxious stimulus
3. monitor BP every 5 minutes
4. treat with nitropaste (1/2" to start) or clonidine (0.3mg) before checking for fecal impaction
5. monitor for recurrent symptoms for at least 2 hours after resolution
107
What is the highest ASIA A level for being modified independent with driving?
C5
108
What is the highest possible ASIA A level that can live independently?
C6 (extremely motivated)
109
What is the mechanism for a cervical compression fracture?
axial load with the neck flexed
110
What is the mechanism for orthostatic hypotension in SCI patients?
lack of vasoconstriction due to block in sympathetic outflow
111
what is the mechanism for spasticity in SCI?
loss of descending inhibition of spasticity arc
112
What is the mechanism of injury that will cause central cord syndrome?
excessive hyperextension (fall on outstretched chin)
113
What is the most common cause of autonomic dysreflexia?
bladder overdistention or infection
114
What is the most common cause of progressive myelopathy after SCI?
syringomyelia
115
What is the most common medical complication after SCI?
UTI
116
What is the most common type of dens (odontoid) fracture?
Type 2 (fracture through the base), often requires surgery
117
What is the most restrictive removable cervical brace?
Minerva brace
118
What is the **usual** ASIA A level for achieving independence?
C7
119
What is UMN bladder?
spastic bladder due overactive detrusor caused by loss of descending inhibition to sacral micturition center from the frontal lobe and pontine micturition center.
120
What vertebral level does cauda equina occur at?
below L1-L2
121
What level of SCI are at risk for impaired temperature regulation?
T8 and above
122
What level of SCI can ambulate with assistive devices?
T10
123
What level of SCI injury puts a patient at risk for autonomic dysreflexia?
T6 and above
124
What long tracts in the spinal cord have both lateral and anterior/ventral locations?
* corticospinal (lateral and anterior)
* spinothalamic (lateral and ventral)
* spinocerebellar (lateral and ventral)
125
What nerve fiber is critical for a psychogenic errection?
hypogastric nerve (T11-L2, sympathetic)
126
What nerve fiber is critical for a reflexogenic erection?
pelvic nerve (S2-4, parasympathetic)
127
What percentage of SCI patients develop detrusor sphinceter syssynergia?
85%
128
What percentage of SCI patients have returned to work at 5 years post injury
25%
129
What portion of SCI patients develop upper extremity compression neuropathies?
Nearly 2/3
130
What provides innervation to the external urethral sphincter?
pudendal nerve (S2- S4) - voluntary action
131
What provides parasympathetic innervation to the bladder and bowel?
pelvic nerve "parasympathetics pee pelvic"
132
What three nerves innervate the bladder and sphincter?
* pudendal (somatic)
* pelvic (parasympathetic, S2-4, cholinergic receptors)
* hypogastric (sympathetic, T11-L2, alpha-1, beta-2/3)
133
What two ADL areas can a ASIA C4 be modified independent?
weight shifts and wheelchair propulsion (both in a power WC)
134
What type of exercise is recommended for MS patients?
submaximal
135
When can you wean an SCI patient off a ventilator?
Vital capacity \> 15-20 ml/kg
136
When does hypercalcemia present in SCI patients?
usually 4 to 8 weeks post injury
137
When is a patient **not** a candidate for phrenic nerve pacing?
There is damage to the phrenic nerve nucleus or C3-C5 nerve roots
138
When is onset of heterotopic ossification most commonly after SCI injury?
2 months
139
When should you consider mechanical ventilation in an SCI patient?
* Vital capacity \< 1L
* PO2 \< 50 mmHg
* PCO2 \> 50 mmHg
140
where is the watershed region between the anterior spinal artery and artery of adamkiewicz?
lower thoracic region
141
Why are lumbar root unaffected in conus medullaris syndrome?
They have already come off the cord at this point
142
Why does bladder wall hypertrophy increase the risk of vesicoureteral reflux?
With hypertrophy, the distal ureter goes from traveling up into the bladder to more horizontal. This prevents normal closure of the one-way valve on the inner surface of the bladder wall.
143
Why is birth control problematic in women with SCI?
* OCPs raise risk of thromboembolism (avoided in first year after injury)
* IUDs can increase risk for pelvic inflammatory disease and related autonomic dysreflexia
144
Women with SCI injury above what level are at risk to not percieve uterine contractions and have AD be the only sign of labor?
T10
145
work-up for suspected syringomyelia
MRI with contrast
