SCI Flashcards

Question

461) Which statement is true regarding marriage in SCI-injured women?

Answer 1

Rate of divorce is higher if married prior to SCI than post-SCI. | (Kreuter, SCI and Partner Relationships, Spinal Cord, Jan 2000)

Answer 2

C. In SCI, the incidence of HO is 20%, with most occurring in the hip region. The knee is also commonly affected. Garland DE. Clinical observations on fractures and heterotopic ossification in the spinal cord and traumatic brain injured populations. Clin Orthop. 1988 Aug;(233):86-101. In TBI patients, HO involves the upper and lower extremities equally. The incidence of HO ranges from 11-76%, most commonly involving the shoulder, elbow, and hip, occurring infrequently at the knee. PM&R Secrets, 1997, p. 240. Braddom includes the knees, although the incidence for each joint is not given in either reference.

Answer 3

B. I cannot find evidence on this one, so here goes my explanation. There is no need to tell the patient immediately. On the other hand, the patient is an adult and your primary responsibility is to the patient, not the family. There is no need to call Risk Management at this time, as the family has no grounds for a lawsuit even if you told the patient immediately (although if it happened on 8GN you would be ordered to call STAT). The obvious answer is to wait until a more appropriate time, after the family has time to calm down and accept the reality of their relative’s situation. Bill Kane, 2004.

Answer 4

D. Based on the ASIA classification revised in 2000, the highest intact level (normal muscle strength or \> 3/5 with the next level being normal) determines the level of injury. ASIA classification is based on completeness of injury. ASIA A indicates no motor or sensory preservation below the level of injury. ASIA B indicates sacral sparing. ASIA C is motor incomplete with more than half of the muscle groups below the level of injury with muscle grade \< 3/5. ASIA D is also motor incomplete, wit hat least half of the muscle groups \> 3/5. 2002 SAE-R Answer Key and Commentary on Preferred Choices, #115.

Answer 5

B. Persons with motor level C7 ASIA class A should be able to feed, dress, and bathe themselves using adaptive equipment and built-up utensils, independent with bed mobility, and level surface transfers, and should be able to propel a wheelchair outdoors. Independence in bowel and bladder function is generally seen with injury level at T1 and lower. 2003 SAE-R Answer Key and Commentary on Preferred Choices, #15.

Answer 6

B. I could not find evidence to support any of the choices given. Choosing a method of bladder management that minimizes the use of a foreign body, yet drains the bladder effectively, is the best available means to reduce the risk of UTI. The chief drawback to antimicrobial-coated catheters, topical or intravesicular antiseptic agents, and prophylactic oral antibiotics is that, over time, bacteria become resistant and overcome the obstacles to bladder invasion. Therefore, anti-infective catheter materials, antibiotics, and antiseptic agents are not beneficial for long-term prevention of UTI in persons with SCI. Novel approaches that avoid the use of antimicrobial agents offer hope for patients with recurrent UTI, but these techniques are still in the experimental stage. Trautner BW, Darouiche RO. Prevention of urinary tract infection in patients with spinal cord injury. J Spinal Cord Med. 2002 Winter; 25(4): 277-83.

Answer 7

A. For persons with motor level C5, activities of daily living include drinking from a cup and feeding with static spoons and set-up, some oral/facial hygiene, writing and typing with equipment, and possibly some upper body dressing. At the C6 injury level, individuals are able to feed and perform upper body dressing with set-up and can perform level surface transfers with assistance. 2003 SAE-R Answer Key and Commentary on Preferred Choices, #15

Answer 8

B. Initial experience with LMWH in SCI patients has demonstrated both an improved safety profile and superior thrombosis prevention when compared to earlier modes of treatment. LMWHs also exhibit better subcutaneous absorption, longer half-life (QD or BID dosing), and smoother anticoagulant response (do not reduce platelet activity or change vascular permeability). Braddom 2nd Ed, Ch. 55, p. 1252.

Answer 9

Ans. These are techniques to restore fertility by restoring ejaculation in SCI males. Vibroejaculatory stimulation of the glans penis is used to collect semen. It is only successful in 50% of SCI males as it requires an intact reflex arc. Pathway involves stimulation of the pudendal nerve which results in contraction of the bulbocavernosus muscle leading to ejaculation. Success is better with high amplitude stimulation. Main disadvantage/side-effect is risk of autonomic dysreflexia. Advantages are noninvasiveness, home use, possibility of natural fertilization, and lower chance of retrograde emission. Transrectal electrical stimulation or electroejaculation is the most common method of obtaining semen in the US. Can be obtained from 90% of patients. It involves stimulation of the myelinated preganglionic efferent sympathetic fibers of the hypogastric plexus to obtain seminal emission into the posterior urethra. Semen is then obtained by milking the urethral bulb and then catheterization. Disadvantage – decrease in sperm motility, more than in the case of vibratory stimulation. Also, it is an office/hospital based procedure. Braddom, Chapter 30, page 630.

Answer 10

Ans. Increased sphincter spasm. I could not find a definitive answer to this. Complications with self cath in someone who is able to do it (C8 are independent in B/B care with setup, T1 completely independent) are sphincter spasm (managed with lubrication, local anesthetic gel, or coude catheter), urethral trauma, or stone formation. Best answer is most likely sphincter spasm. Tan, Practical Manual of PM&R, Chapter 5.7, page 545.

Answer 11

Ans. Central cord syndrome. Most common of the SCI clinical syndromes. Often associated with neck hyperextension injuries in elderly individuals with spondylosis. This is an incomplete injury, characterized by weakness more severe in arms than legs, with sparing of bladder and bowel function. Braddom, Chapter 55 (SCI Medicine), page 1233.

Answer 12

Ans. Removable arm rests. This is necessary so patient can transfer from chair to bed and vice versa. Braddom, Chapter 18 (prescription of WC’s), page 378

Answer 13

Ans. Conus medullaris. Bulbocavernosus reflex is a polysynaptic (S2-S4) sacral withdrawal reflex. Present in all normal individuals, and in SCI patients with lesions above the conus. Tested by squeezing glans and feeling contraction of anal sphincter muscle, or can be recorded objectively by stimulating dorsal nerve of penis and picking up EMG response in the anal sphincter muscle. Secrets, Chapter 77 (urologic disorders in rehab), Pg. 474.

Answer 14

Ans. Decreased gastric emptying. Note: N/V can also be presenting sign of immobilization hypercalcemia, but this develops several weeks to few months after injury. Delayed gastric emptying is common in these patients and is a common cause of N/V. Constipation can also lead to n/v. Braddom, Chapter 55, page 1257 (for general info, I could not fine a direct reference for which is MOST common)

Answer 15

Ans. Surgical management – colostomy. This offers independent bowel management, less incontinence, and decreased bowel care time. Secrets, chapter 76 (neurogenic bowel), page 469

Answer 16

Ans. Observational study. Randomized trial cannot be done with single subject, so observational study is best answer. (I could not find a specific reference, but this seems the obvious choice).

Answer 17

Ans. VC is increased when lying down in SCI. As opposed to other pulmonary conditions, patients with tetraplegia secondary to SCI exhibit higher vital capacities when lying down. This is related to improved diaphragmatic function as abdominal contents splint the lower rib cage. VC decreases when these patients sit upright, but can be countered to some extent by use of abdominal binder. Braddom, Chapter 55, page 1248

Answer 18

Ans. Cephalosporins. The rest are pregnancy category C and should be avoided in pregnant women. Pharmacopoeia

Answer 19

Ans. Distal femur. Bone loss following SCI occurs throughout the skeletal system, **with the exception of the skull.** These losses are regional; areas rich in trabecular bone are demineralized to the greatest degree. The distal femur and proximal tibia are the bones most affected, followed by the pelvis. Lumbar spine is usually preserved. Emedicine – Osteoporosis and spinal cord injury http://www.emedicine.com/pmr/topic96.htm

Answer 20

Ans. Muscle-muscle. HO is the development of para-articular ossification usually on the flexor surfaces of large joints, seen in individuals with SCI, TBI, burns, or after THA. The ectopic bone formation occurs in the connective tissue between muscles planes, and not within the muscle itself. Braddom, Chapter 55, page 1261

Answer 21

Ans. Should not be treated. It is not treated in patients with indwelling foleys or suprapubic tubes. Even patients on CIC may develop colonization, which is generally not treated. Treatment is reserved for those with fever, pyuria, foul smelling urine, or increased spasticity. Braddom, Chapter 55 (spinal cord injury medicine), page 1256

Answer 22

Braddom suggests nerve root blocks for pain relief. No oral or IV med is suggested , but there is a discussion of deafferentation central pain for SCI patients that states that the use of anticonvulsants is limited by the need for lab tests and side effects. Tricyclics have been used, however, for decades. Braddom 2nd ed p. 1258

Answer 23

TIBIALIS ANTERIOR. Action: ankle dorsiflexion. The ASIA (American Spinal Cord Injury Association) scoring system is the most commonly accepted impairment evaluation paradigm for SCI. Key muscles are examined for myotomes and graded 0-5. The system classifies the patient on the basis of the clinical exam. The Rehabilitation of People with Spinal Cord Injury: A House Officer’s Guide 1999 Shanker Nesathurai p. 26

Answer 24

Intermittent catheterization is usually inappropriate in the acute, ICU setting, when the patient is receiving IV fluids, and when dietary intake and urinary output are inconsistent. Intermittent catheterization is best reserved for a time when the patient’s urinary output and clinical status are stabilized. Braddom 2nd ed p. 1256

Answer 25

A: Sweating A patient may have one or more of the following findings on physical examination: • A sudden significant rise in both systolic and diastolic blood pressures, usually associated with bradycardia, can appear. Normal systolic blood pressure for SCI above T6 is 90-110 mm Hg. Blood pressure 20-40 mm Hg above the reference range for such patients may be a sign of AD. • Profuse sweating above the level of lesion, especially in the face, neck, and shoulders, may be noted, but it rarely occurs below the level of the lesion because of sympathetic cholinergic activity. • Goose bumps above, or possibly below, the level of the lesion may be observed. • Flushing of the skin above the level of the lesion, especially in the face, neck, and shoulders, frequently is noted. • The patient may report blurred vision. • Appearance of spots in the patient's visual fields may be noted. • Nasal congestion is common. • No symptoms may be observed, despite elevated blood pressure. www.emedicine.com, AD in SCI by Denise I Compagnolo, MD,MS

Answer 26

A: A lesion of the cauda equine produces LMN symptoms. It is often gradual and unilateral. Both ankle and knee jerks are affected. Severe radicular pain. Can have low back pain. Saddle anesthesia with decrease to pin/LT in a dermatomal distribution. Affected muscles will exhibit atrophy and atonia. Urinary retention can present late in the process.

Answer 27

Answer=A. The most common sexual concern for women with or without disabilities is low desire. Ability to bear children is usually not affected though may present challenges to SCI female. ## Footnote Ref: Braddom, Ch. 30 (Sexuality Issues in Persons with Disabilities) p. 624, 631

Answer 28

A: Baclofen acts as a GABA agonist by binding to the GABA B receptor. It inhibits calcium influx into presynaptic terminals and suppresses the release of excitatory neurotransmitters. Baclofen inhibits both mono- and polysynaptic reflexes and reduces activity at the gamma efferent. It readily crosses the BBB in contrast to GABA. Renally excreted. ## Footnote Ref: Braddom, Ch. 29 (Spasticity) p. 604

Answer 29

A: A number of interventions have been studied in the hope of preventing and treating disorders of calcium metabolism in spinal cord subjects. Physical activity, including wheelchair use, frame-assisted standing, and tilt table, might improve calcium balance in the acute phase, but no effect on bone density has been demonstrated. Functional electrical stimulation cycle ergometry can provide modest reductions in the rate of bone loss, sustained only during the period of application. ## Footnote Ref: Braddom, Chapter 55 (SCI Medicine) p. 1250

Answer 30

(decreased fertility, increased miscarriages, decreased libido, or early menarche?)

Answer 31

Braddom suggests nerve root blocks for pain relief. No oral or IV med is suggested , but there is a discussion of deafferentation central pain for SCI patients that states that the use of anticonvulsants is limited by the need for lab tests and side effects. Tricyclics have been used, however, for decades. Braddom 2nd ed p. 1258

Answer 32

A: A lesion of the cauda equine produces LMN symptoms. It is often gradual and unilateral. Both ankle and knee jerks are affected. Severe radicular pain. Can have low back pain. Saddle anesthesia with decrease to pin/LT in a dermatomal distribution. Affected muscles will exhibit atrophy and atonia. Urinary retention can present late in the process. ## Footnote Ref: http://www.emedicine.com/neuro/topic667.htm

Answer 33

Answer=A. The most common sexual concern for women with or without disabilities is low desire. Ability to bear children is usually not affected though may present challenges to SCI female. ## Footnote Ref: Braddom, Ch. 30 (Sexuality Issues in Persons with Disabilities) p. 624, 631

Answer 34

A: Baclofen acts as a GABA agonist by binding to the GABA B receptor. It inhibits calcium influx into presynaptic terminals and suppresses the release of excitatory neurotransmitters. Baclofen inhibits both mono- and polysynaptic reflexes and reduces activity at the gamma efferent. It readily crosses the BBB in contrast to GABA. Renally excreted. ## Footnote Ref: Braddom, Ch. 29 (Spasticity) p. 604

Answer 35

A: A number of interventions have been studied in the hope of preventing and treating disorders of calcium metabolism in spinal cord subjects. Physical activity, including wheelchair use, frame-assisted standing, and tilt table, might improve calcium balance in the acute phase, but no effect on bone density has been demonstrated. Functional electrical stimulation cycle ergometry can provide modest reductions in the rate of bone loss, sustained only during the period of application. ## Footnote Ref: Braddom, Chapter 55 (SCI Medicine) p. 1250

Answer 36

(decreased bacteriuria, decreased urosepsis, decreased pyelonephritis?

Answer 37

A: Menstruation may not occur 3 or more months after CNS trauma. Vaginal lubrication occurs with reflex stimulation as long as the conus and autonomic connections remain intact. After complete spinal cord injury at level T6 and above, psychogenic subjective arousal does not produce vaginal lubrication; manual clitoral stimulation produces reflex lubrication and increased vaginal pulse amplitude. Fertility is generally not significantly affected by spinal cord injury. Pregnancy may be complicated by UTI’s, decubiti, constipation, and mobility limitations. Labor is initiated and driven hormonally. The delivery can be vaginally but should be anticipated and monitored, with autonomic hyperreflexia prevention and preparedness for forceps use or cesarean techniques. The most common sexual concern for women with or without disabilities is low desire. ## Footnote Ref: Braddom Ch. 30 (Sexuality Issues in Persons with Disabilities) p. 624, 631; 1997 Secrets Ch. 10 (Satisfying Sexuality Despite Disability) p. 63

Answer 38

A: On the ASIA Impairment Scale, an incomplete level D is motor function preserved below the neurological level, and at least half of the key muscles below the neurological level have a muscle grade of 3 or more. Level A is complete – no motor or sensory function preserved in sacral segments S4-S5. Level B is incomplete – sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5. Level C is incomplete – motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3. Level E is normal – motor and sensory function is normal. ## Footnote Ref: Braddom Ch. 55 (Spinal Cord Injury Medicine) p. 1235, Figure 55-1

Answer 39

A: It is a cause of progressive myelopathy. Often idiopathic in some cases, it is associated with developmental anomalies, spinal cord tumors, or late complication of trauma. Dissociated loss of pain and temperature usually in distal upper extremity secondary to spinothalamic involvement. Dorsal columns typically spared. ## Footnote Ref: http://www.emedicine.com/neuro/topic359.htm

Answer 40

A: Seven areas of consideration for pregnant spinal cord injured women: 1. Autonomic dysreflexia if the lesion is above T6 2. Bladder management is affected as uterus enlarges affecting the bladder’s ability to fill and at more risk for infections. Intermittent catheterizations may become more difficult. 3. Mobility (transfers, pressure relief, manual wheelchair propulsion) are variably affected depending on injury level and weight gain. 4. Spasticity can be problematic and affect positioning for vaginal delivery. Assess medicine treatment for fetal risk. 5. Skin breakdown. 6. Significant lower extremity edema and thrombophlebitis are greater concerns because of bilateral lower extremity paralysis. ## Footnote Ref: 1997 Secrets Ch. 80 (Women’s Issues in Rehab) p. 436

Answer 41

A: Normal values include a capacity of 300 to 600 mL, with an initial sensation of filling at approximately 50% of capacity.

Answer 42

A: Ureteral reflux or high bladder pressure in the absence of reflux can cause upper tract dilation. Dilation without reflux is said to be due to decreased compliance, but recent data from long-term monitoring suggest that baseline pressure elevations are minimal with natural rates of filling, and that increased phasic activity may be more important. With reflux, or ureteral dilation without reflux, the bladder pressure should be lowered with intermittent catheterization and anticholinergics. If reflux fails to improve but bladder pressure responds, a surgical procedure to repair the reflux can be considered. If bladder pressures do not improve, the options are to augment the bladder or, in men, to perform a sphincterotomy and rely on free drainage. ## Footnote Ref: Braddom Ch. 27 (Management of Bladder Dysfunction) p. 577

Answer 43

A: Syringomyelia is a recognized cause of progressive myelopathy. Posttraumatic syringomyelia has been termed progressive posttraumatic cystic myelopathy (PPCM). The classical clinical signs of PPCM include dissociated loss of pain and temperature sensation, usually in the distal upper extremities. The most common initial symptom is pain. PPCM has been noted as early as 2 months post injury and as late as 23 years. Symptoms commonly consist of segmental or radicular pain, late motor and sensory loss, increased spasticity, and hyperhydrosis. Horner’s syndrome and respiratory insufficiency can be seen with cysts that extend into the brainstem. ## Footnote Ref: Braddom, Ch. 55 (Spinal Cord Injury Medicine) p. 1259

Answer 44

Answer=A. Baclofen is probably the drug of choice in spinal forms of spasticity and may help to improve bladder control. The ideal patient has some preserved function below the level of the lesion. Higher dosages of baclofen can be placed near the spinal cord – the desired site for action of the drug while largely avoiding the CNS side effects associated with increased oral intake. Ref: Braddom Ch. 29 (Spasticity); p. 606 1997 Secrets Ch. 90 (Spasticity); p. 488,489

Answer 45

Answer=A. Triple-phase bone scans demonstrate abnormalities sooner than plain radiographs. The triple-phase bone scan, performed using radiolabeled diphosphates, is very helpful for early detection of HO. The first two phases, dynamic blood flow study and static scan for blood pool, are the most sensitive for early detection. ## Footnote Ref: Braddom Ch. 49 (Brain Injury Rehab); p. 1104 Braddom Ch. 55 (Spinal Cord Injury Medicine) p. 1262

Answer 46

Answer= A. I am assuming that this is not an acute spinal cord injury based on the scenario. If this were acute, then a further work up should be done. The inability of tetraplegic and high paraplegic patients to control their body temperature is most striking in the period immediately after injury. These patients retain the ability to mount a febrile response to infectious conditions. Patients without leukocytosis should be evaluated for venous thromboembolism and HO as a source of their fever. As a patient progresses into rehab and chronic phase of injury, sensitivity to ambient temp remains, although striking dysregulation typically resolves. Ref: Braddom Ch. 55 (SCI Medicine) p. 1249

Answer 47

Answer=A. The receptors active during bladder contraction are cholinergic (M2,M3) receptors and are widely distributed in the body of the bladder, trigone, bladder neck, and urethra. Adrenergic receptors are concentrated in the trigone, bladder neck, and urethra and are predominantly alpha-1. Alpha-2 adrenergic receptors are found in the bladder neck and also in the body of the bladder. These receptors are inhibitory when activated and can produce relaxation at the bladder neck on initiation of voiding and relax the bladder body to enhance storage. Ref: Braddom Ch. 27 (Management of Bladder Dysfunction) p. 561

Answer 48

A: Phenoxybenzamine is an alpha-adrenergic receptor antagonist and has been used for inhibiting smooth muscle activity at the bladder neck and in the prostate. It reduces irritative symptoms in men with obstruction from BPH and increases emptying in patients with neurogenic voiding dysfunction. ## Footnote Ref: Braddom Ch. 27 (Management of Bladder Dysfunction) p. 570

Answer 49

A: The detrusor is innervated by cholinergic muscarinic (M2 and M3) receptors. ## Footnote Ref: Braddom Ch. 27 (Management of Bladder Dysfunction) p. 570

Answer 50

Answer: C. Difficult bowel evacuation==more than 60 min/day for bowel care or more than 1 manual disimpaction/week. Colostomy has been performed with good success in the subgroup of these patients with the most severe disability. | (Delisa “Rehab medicine—Principles and Practice”, 2nd Ed, Ch. 36, page 756-757)

Answer 51

Answer: C. In PTS (post-traumatic syringomyelia), cavity formation is followed by enlargement and extension of the cystic cavity. Rostral or caudal cyst extension may occur due to turbulent CSF flow or a "one-way valve" phenomenon that allows CSF into, but not out of, the cyst cavity. | (eMedicine: “Post-traumatic syringomyelia”, Lance Goetz)

Answer 52

Answer: C. Post-traumatic syringomyelia (PTS) refers to the development and progression of a cyst filled with cerebrospinal fluid (CSF) within the spinal cord. PTS is a relatively infrequent, but potentially devastating, complication following traumatic spinal cord injury (SCI). PTS is characterized clinically by the often insidious progression of pain and loss of sensorimotor function that may manifest many years after traumatic SCI. If left untreated, PTS can result in loss of function, chronic pain, respiratory failure, or death. Approximately 3-4% of persons with traumatic SCI develop clinically symptomatic PTS. A larger percentage of persons have clinically silent syrinx cavities diagnosed by imaging techniques. Pain is the most commonly reported symptom. Pain may be localized or diffuse and commonly is reported as a dull ache or a burning or stabbing sensation. Other symptoms include increased weakness, numbness, increased spasticity, and hyperhidrosis (increased sweating). Symptoms often are aggravated by postural change or the effects of the Valsalva maneuver. Decreased reflex micturition, progressive orthostasis, autonomic dysreflexia, and relatively painless joint deformity or swelling (Charcot joint) also may be reported. | (eMedicine: “Post-traumatic syringomyelia”, Lance Goetz)

Answer 53

Answer: B. The extent of spinal cord injury is defined by the American Spinal Injury Association (ASIA) Impairment Scale (modified from the Frankel classification), using the following categories: • A - Complete: No sensory or motor function is preserved in sacral segments S4-S5. • B - Incomplete: Sensory, but not motor, function is preserved below the neurologic level and extends through sacral segments S4-S5. • C - Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have muscle grade less than 3. • D - Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have muscle grade greater than or equal to 3. • E - Normal: Sensory and motor functions are normal. Perform rectal examination to check motor function or sensation at the anal mucocutaneous junction. The presence of either is considered sacral-sparing. Definitions of complete and incomplete SCI are based on the above ASIA definition with sacral-sparing. • Complete - Absence of sensory and motor functions in the lowest sacral segments • Incomplete - Preservation of sensory or motor function below the level of injury, including the lowest sacral segments Sacral-sparing is evidence of the physiologic continuity of spinal cord long tract fibers with the sacral fibers located more at the periphery of the cord. Indication of the presence of sacral fibers is of significance in defining the completeness of the injury and the potential for some motor recovery. This finding tends to be repeated and better defined after the period of spinal shock. The following key muscles are tested in patients with SCI, and the corresponding level of injury is indicated: • C5 - Elbow flexors (biceps, brachialis) • C6 - Wrist extensors (extensor carpi radialis longus and brevis) • C7 - Elbow extensors (triceps) • C8 - Finger flexors (flexor digitorum profundus) to the middle finger • T1 - Small finger abductors (abductor digiti minimi) • L2 - Hip flexors (iliopsoas) • L3 - Knee extensors (quad\\\\\riceps) • L4 - Ankle dorsiflexors (tibialis anterior) • L5 - Long toe extensors (extensors hallucis longus) • S1 - Ankle plantar flexors (gastrocnemius, soleus) Motor level - Determined by the most caudal key muscles that have muscle strength of 3 or above while the segment above is normal (= 5) (eMedicine: “Spinal cord injury: Definition, Epidemiology, Pathophysiology”, Segun T)

Answer 54

Answer: A. Labor is initiated and driven hormonally. The delivery can be vaginal but should be anticipated and monitored, with autonomic dysreflexia prevention with anesthesia and preparedness fro forceps use or cesarean section. | (“Physical medicine and rehab secrets”, O’Young, 2nd ed, p.76)

Answer 55

Answer: B. The spinal cord tapers and ends at the level between the first and second lumbar vertebrae in an average adult. The most distal bulbous part of the spinal cord is called the conus medullaris, and its tapering end continues as the filum terminale. Conus medullaris constitutes part of the spinal cord (the distal part of the cord) and is in proximity to the nerve roots. Thus, injuries to this area often yield a combination of upper motor neuron (UMN) and lower motor neuron (LMN) symptoms and signs in the dermatomes and myotomes of the affected segments. On the other hand, a cauda equina lesion is a LMN lesion because the nerve roots are part of the PNS. Table 1. Symptoms and Signs of Conus Medullaris and Cauda Equina Syndromes Conus Medullaris Syndrome Cauda EquinaSyndroPresentation Sudden and bilateral Gradual and unilateral Reflexes Knee jerks preserved but ankle jerks affected Both ankle and knee jerks affected Radicular pain Less severe More severe Low back pain More Less Sensory symptoms and signs Numbness tends to be more localized to perianal area; symmetrical and bilateral; sensory dissociation occurs Numbness tends to be more localized to saddle area; asymmetrical, may be unilateral; no sensory dissociation; loss of sensation in specific dermatomes in lower extremities with numbness and paresthesia; possible numbness in pubic area, including glans penis or clitoris Motor strength Typically symmetric, hyperreflexic distal paresis of lower limbs that is less marked; fasciculations may be present Asymmetric areflexic paraplegia that is more marked; fasciculations rare; atrophy more common Impotence Frequent Less frequent; erectile dysfunction that includes inability to have erection, inability to maintain erection, lack of sensation in pubic area (including glans penis or clitoris), and inability to ejaculate Sphincter dysfunction Urinary retention and atonic anal sphincter cause overflow urinary incontinence and fecal incontinence; tend to present early in course of disease Urinary retention; tends to present late in course of disease (eMedicine: “Cauda equina and Conus medullaris syndromes”, Segun T Da)

Answer 56

The sympathetic innervation to the bladder is via the hypogastric nerve (with the afferent fibers coming from T10-L2 and the efferent from L1 to L3) (Chapter 27, P 563 Fig, Braddom, 2nd ed)

Answer 57

A T6 paraplegic will be constipated secondary to poor bowel motility and normal anal sphincter control. The above listed reflexes will be poor as well (Chapter 55, P 1257, Braddom, 2nd ed)

Answer 58

Of the listed, wedge compression fractures are generally the most stable. The others have a higher likelihood of neurological compromise (http://www.gpnotebook.com/cache/-1523253245.htm)

Answer 59

A C7 spinal cord lesion is an impairment. The inability or limitation in performing tasks and activities caused by C7 tetraplegia is a disability. The disadvantage from the above impairment or disability that prevents the fulfillment of a role is a handicap. (Chapter6, P 109, Braddom, 2nd ed.)

Answer 60

The most common mechanism for quadriplegia in high school football players is axial compression, with associated neck flexion. This is most often caused by a spearing type tackle. (http://www.emedicine.com/orthoped/topic370.htm)

Answer 61

A: “ Hyperflexion injuries tend to apply compressive forces on the anterior column of the spine, and distractive forces on the posterior spine. Hyperflexion sprain involves varying degrees of disruption of the posterior ligaments of the spine, including the supraspinous, interspinous, ligamenta flava, facet joint capsules, posterior longitudinal, and posterior anulus fibrosis.”  SPINAL CORD MEDICINE, Kirshblum, pg. 54

Answer 62

A: “ In general, surgery should not be considered before 1 year post injury, and certainly not until the patient has been neurologically stable for at least 6 months. It is believed that the outcomes are less predictable if performed more than 5 years post injury. The patient should have a clear understanding of the surgery planned, the gains that can be realistically expected, and the potential complications such as increased dependency in the postoperative period. Because of the possibility that preoperative functional abilities can be temporarily lost, patient motivation is an important factor affecting the likelihood of a successful outcome.”  PHYSICAL MEDICINE & REHABILITATION, Bradom

Answer 63

* Average age of onset of SCI has been increasing * Most common cause of SCI is MVA (50%), but rate for falls has been progressively increasing, rate for sports is decreasing * Increasing percentage of cervical injuries

Answer 64

* Nontraumatic SCI more likely to be incomplete and less likely to have spasticity, DVT, autonomic dysreflexia * DDx: MS, degenerative CNS diseases, neoplasm, vascular disease, inflammatory disease, spinal stenosis, spinal cord tumors, epidural abscess, epidural hematoma * Transverse myelitis: can be primary or secondary to vasculitis or rheum d/o, more common in females * Radiation myelopathy can occur months after treatment

Answer 65

* Spina bifida has decreased due to folic acid * Most common is myelomeningocele: neural elements exposed, complete neurologic deficits à closure within 24 hours * Meningocele: dural sac exposed, neural elements may be intact * Occult spina bifida: closed spinal deficits including lipoma, tethered cord à should be investigated * Hydrocephalus seen in 90% of patients with myelomeningocele à most require VP shunt à underlying Chiari II malformation * Hydrosyringomyelia (syrinx) are common in myelomeningocele à presents with cervical pain, new weakness, spasticity, and scoliosis (can also be a sign of tethered cord) * Scoliosis affects people with myelomeningocele at thoracic levels à monitor curvature less than 25 degrees, greater may require TLSO or surgery

Answer 66

* Decompression within 24 hours may improve neurologic recovery, but data inadequate * High dose steroids called into question: may cause infection or bleeding * Avoid hypotension, can try abdominal binders, lower limb compression, oral vasopressors (midodrine) * Autonomic dysfunction is common: bradycardia, neurogenic shock, autonomic dysreflexia (after spinal shock over) * Spinal shock: loss of reflex neurologic activity in spinal cord (loss of reflexes) * Neurogenic shock: hypotension of neurogenic origin à need volume resuscitation and vasopressors * Bradycardia may occur due to unopposed vagal tone à usually self-limited but can use atropine * “quad fever” without identified source can occur in early weeks * Anticoagulation for DVT or IVC filter within 72 hours * High risk of stress ulcers à should start PPI for 4 weeks

Answer 67

* Early ROM, especially in shoulders * Splinting and orthosis to preserve joint ROM in hands and feet * Bowel program after starting enteral feeding * Can remove Foley when patient no longer requires IV fluid à avoid cath volumes greater than 500 cc * Pulmonary complications at all levels * Clearance of secretions: difficult with weak abdominal muscles, manual assisted cough better at clearing secretions than suctioning (hands placed over lower rib cage), mechanical insufflators-exsufflator is effective * Atelectasis present in 60% of SCI patients on admission, support of use of high tidal volumes * High rate of dysphagia, especially in patients with C-spine surgery, trachs, prolonged intubation, halo, TBI * Pressure ulcers: early most common in sacrum, heels, and occiput à minimize time on backboard, use pressure-relief beds, routine turning q2hrs

Answer 68

* Exam at 72 hours better than at 24 hours for prediction * Most UE recover occurs in first 6 months, mostly in first 3 months * Most patients recover 1 root level of function with cervical lesions * UE motor recovery twice as great in incomplete tetraplegia à more favorable if pinprick spared * 80% of patients with incomplete paraplegia regain antigravity hip flexors and knee extensors * 6% of ASIA A convert to ASIA B and none developed volitional motor below injury * Spinal shock: worse prognosis * Crossed adductor response to patellar tendon taps is highly predictive of functional motor recovery * Normal cord on MRI is positive predictor for recovery

Answer 69

* DDx: Myelopathy, motoneuron disease, MS * MRI for MS very sensitive but nonspecific * Spinal angio for diagnosis of spinal cord AV malformations * CT for bone mets * CSF: diagnosis of inflammatory disorders * Labs: test for Lyme, syphilis, HIV, DM, APA

Answer 70

* C1-4: C4 may wean off vent, need rehab for caregiver training, equipment, and prevention of complications, intro to advanced technology * C5: Prevention of elbow flexion and supination contractures, power wheelchair * C6: Tenodesis, which may allow patient to do ICP * C7-C8: C7 is key level for independence at transfers, weight shifts, light meal prep, may do bowel program * T1-12: Household ambulation may be possible for lower levels of thoracic injury * L1-2: Ambulation for short distances, but WC for functional ambulation * L3-4: Usually lower motor neuron, so sacral reflexes are lost. Bowel management through contraction and manual disimpaction. Bladder through ICP. Ambulation with AFO. * Community ambulation requires b/l hip flexors to be \> 3/5, 1 knee extensor at least 3/5

Answer 71

* Autonomic dysreflexia: rise in BP of 20-40 mmHg above baseline, reflex bradycardia, HA. Can lead to stroke, hemorrhage, seizure, MI, death. Other signs are flushing, sweating, and nasal congestion above level of injury. Causes include: overdistended bladder, kidney or bladder stones, ingrown toenails, menstrual cramps, infection, bowel impaction, pressure ulcers, msk conditions, abdominal pathology. Treated by sitting patient upright and identifying underlying cause. * Neurogenic bowel: Bowel program daily to q3days. Use of digital stimulation, adequate fluid, high fiber, oral meds, rectal evacuants. If changes in bowel meds, give at least three cycles to see effects. Colostomy if bowel program too difficult. * Orthostatic hypotension: Compensation with gradual position changes, ace wraps, compression stockings, abdominal binders, midodrine (alpha agonist), fludrocortisones (mineralocorticoid). Usually resolves with spinal reflexes return. * Immobilization hypercalcemia: N/V, decr appetite, lethargy, polyuria, usually presents 1-2 months postinjury. Treat with IV fluids or bisphosphonates. * HO: Incidence between 16-53% in SCI. Presents in hips, followed by knees, elbows, shoulders. Swelling, decr ROM. Confirmed with bone scan, treat with etidronate at 20mg/kg orally for 3-6 months. Surgery if functional limitations, but wait until HO is mature. * Spasticity: Treat with ROM, look for noxious stimuli (UTI), baclofen, benzo, dantrolene, alpha-2 agonists. Botox or phenol for localized spasticity. * Depression 20-45%

Answer 72

* Equipment: lift for transfers, padded commode or shower chair, power wheelchair with head, chin, or breath control (and independent pressure relief), manual WC for back-up, mouth stick, computer, van * Housing evaluation and modifications

Answer 73

* FES: improve hand grasp, lower extremity use, bladder control, respiration, and cardiovascular health * Tendon transfers * Wheelchairs: pushrum-activated power assist, iBOT 4000 Mobility System for climbing stairs * Partial body weight support treadmill training * Brain-based command signals

Answer 74

* Pressure ulcers most common complication: risks include cigarettes, sleep meds * Pneumonia (more common in tetraplegics) leading cause of death from SCI * UTI: ppx antibiotics not supported * Urolithiasis: risks are recurrent UTI, indwelling catheters, vesicoureteral reflux, prior stones, hypercalciuria → can treat with shock wave lithotripsy * Bladder cancer: risk including indwelling catheters, smoking, kidney stones * OSA * Loss of bone mineral density → no strong evidence for use of bisphosphonates * Fractures

Answer 75

* Question about B/B, BP control, skin, pain, spasticity, sexual function, equipment needs, changes in strength or function * Counsel on smoking cessation * Annual renal US for upper urinary tract, video urodynamics for lower urinary tract * For a woman, there may be increased spasticity, dyautonomia during menstruation → hormone contraceptives may help; pregnancy at high risk for UTI, AD; no higher risk of cancers or osteoporosis

Answer 76

* 92% of men can get an erection, but only about half can have successful intercourse, and less than 5% can have unassisted ejaculation * Vacuum suction and constrictor ring, penile implants (metal rod or inflatable implant) * PDE-5 inhib (Viagra) used, side effects mimic AD (HA, facial flushing) * Penile vibratory stimulation is first line treatment for anejaculation → other treatments are electroejaculation, rectal probes * Sperm count may be normal, but quality and motility can be poor → intrauterine insemination, IVF

Answer 77

* Pain in 64-80% of SCI * 15% report visceral pain * 19-24% have neuropathic pain * 42% have msk pain: most common in shoulders, followed by wrists, hands, and elbows → treat with stretching and strengthening, local injections, NSAIDs, occasional opiates

Answer 78

• Costs include: hospital charges, rehab, home and vehicle modifications, assistance with ADLs, loss of wages

Answer 79

* Comprehensive interdisciplinary document of future medical and rehab needs * Should be undertaken after patient has stabilized medically and functionally * Components: medical problems, psychological, vocational, recreational, social, rehab, prognosis, equipment needs, preventive medicine, aging complications

Answer 80

* 14% RTW at year one, 40% at 20 years * Educational level, functional status, driving, pre-employment in white collar job, computer experience, fewer medical complications

Answer 81

* Rehabilitation Act: guaranteed civil rights of people with disabilities within federal programs * Americans with Disabilities Act (ADA): broad nondiscrimination law

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