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PM&R > SCI > Flashcards

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

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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)

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3
Q

At what level does the spinal cord end?

A

L1

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4
Q

common site for osteoporotic fracture in SCI patients?

A

distal femur

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5
Q

describe posterior cord injury

A

injury to dorsal columns causing loss of light touch/proprioception and impaired ambulation

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6
Q

Diameter of absolute stenosis in the spinal canal

A

less that 10mm

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7
Q

Does likelihood of pregnancy after SCI change?

A

No, fertility is unimpaired

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8
Q

Extradural spinal tumors are commonly metastases from what three areas of the body?

A

lung, breast, and prostate

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9
Q

female fertility after SCI

A

normal menstruation returns in 6-12 months so long-term fertility is unaffected

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10
Q

gold standard to dx pulmonary embolism

A

pulmonary arteriogram

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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
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12
Q

How does Brown-Sequard syndrome present?

A

ipsilateral loss of motor function, light touch/proprioception and contralateral loss of pain and temperature

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13
Q

How does cauda equina differ from conus medullaris syndrome?

A

Cauda equina is asymmetric, areflexia/hyporefleic, and can involve lumbar roots

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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
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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
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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
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17
Q

How does subacute combined degeneration present?

A

insidious onset of sensory symptoms followed bilateral spastic paresis of lower limbs

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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

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19
Q

How is baclofen cleared from the body?

A

renally (use lower doses in CKD)

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20
Q

How is diazepam cleared from the body?

A

hepatically (use lower doses in liver disease)

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21
Q

How long does it take for resolution of areflexic bladder seen in patients with spinal shock?

A

2 - 12 weeks

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22
Q

In general, are prophylactical antibiotics to treat UTIs in SCI patients indicated?

A

No

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23
Q

leading cause of death in acute SCI?

A

pulmonary embolism

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24
Q

leading cause of death in chronic SCI?

A

pneumonia

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25
Q

leading cause of death in paraplegia?

A

heart disease

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26
Q

male fertility after SCI

A

decreased due to poor semen quality and impaired erections

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27
Q

mechanism of action of baclofen

A

GABA B agonist

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28
Q

mechanism of action of botulinum toxins

A

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.

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29
Q

mechanism of action of dantrolene

A

binds to ryanodine receptor on sarcoplasmic reticulum (SR) to inhibit calcium influx from SR in to cell.

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30
Q

mechanism of action of diazepam

A

GABA A agonist (Cl channel activator)

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31
Q

Mechanism of action of mirabegron?

A

Beta-3 agonist causing bladder relaxation

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32
Q

mechanism of action of mirabegron?

A

beta-3 agonist to cause bladder relaxation

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33
Q

mechanism of action of tamsulosin?

A

alpha-1 blocker causing internal sphincter relaxation

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34
Q

mechanism of action of tizanidine

A

alpha-2 agonist (inhibits spinal reflex arc)

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35
Q

Mneumonic for remembering Gaba receptor agonist and ion channels

A
  • CLACK
  • Gaba A: increase presynaptic Cl into neuron
  • Gaba B1: increase presynaptic Ca2+ into neuron
  • Gaba B2: increase postsynaptic K out of the neuron
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36
Q

most commmon cause of emergency abdominal surgery in chronic SCI patients?

A

cholecystitis

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37
Q

most common cause of death in acute SCI

A

pulmonary embolism

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38
Q

Most common cause of SCI?

A

MVC

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39
Q

most common level for central cord with hyperextension of the c-spine?

A

C4-C5

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40
Q

most common level for cervical compression fracture with flexion and axial load?

A

C5

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41
Q

most common level of injury of paraplegia?

A

T2

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42
Q

most common level of SCI

A

C5

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43
Q

most common presentation of myelopathy?

A

gait disturbance followed by UE paresthesias, decreased fine motor coordination, and hand weakness

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44
Q

most common presenting sign of syringomyelia in SCI patient?

A

ascending loss of deep tendon reflexes

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45
Q

Most common site for heterotopic ossification in SCI patients?

A

Hip

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46
Q

Most common site for pressure injuries in children?

A

occiput

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47
Q

Most common site for pressure injuries in SCI patients?

A

sacrum

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48
Q

most common presenting symptom of syringomyelia in SCI patient

A

aching/buring pain worse with coughing or straining

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49
Q

most common timing of DVT related to SCI

A

in the first two weeks

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50
Q

most common to least common type of SCI

A

incomplete tetra, incomplete para, complete para, complete tetra

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51
Q

most common type of multiple sclerosis

A

relapsing-remitting

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52
Q

Most common type of neurogenic bladder seen in SCI?

A

DSD (detrusor-sphincter-dyssynergia)

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53
Q

What are the key muscles and their root level for the ASIA exam?

A
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54
Q

What are key sensory points for the ASIA exam?

A
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55
Q

onset, peak, and duration of action of botox

A

3 days, 3 weeks, 3 months

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56
Q

Pressure injury staging

A
  1. nonblanchable erythema 2. into dermis 3. through dermis 4. muscle, tendon, or bone exposed
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57
Q

Receptor type in bladder wall that allow for contraction?

A

ACh

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58
Q

Receptor type in bladder wall that allows for relaxation?

A

Beta-2

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59
Q

Sympathetic nerve that allows for bladder storage?

A

Hypogastic nerve (T11 - L2) “makes bladder as big as a Hippo”

60
Q

Treatment for hypercalcemia in SCI patients?

A

IV fluids (increases urinary excretion) or Pamidronate (inhibits osteoclast-mediated bone resorption)

61
Q

Treatment for neuromyelitis optica?

A

IV glucocorticoides, may follow with plasmapheresis

62
Q

treatment for vertebral body compression fractures

A

Jewett or CASH brace to limit hyperflexion

63
Q

Treatment options for adynamic ileus after SCI?

A

NGT, IVF, metoclopromide, erythromycin, neostigmine

64
Q

two common tendon transfers for C5 SCI patient?

A
  • brachioradialis to ECRB
  • deltoid to triceps
65
Q

type of lung pattern seen in SCI patients?

A

restrictive (all volumes decreased except residual volume)

66
Q

What allows parasympathetic micturition action?

A

sacral micturition center

67
Q

What are common vital sign findings in autonomic dysreflexia?

A

hypertension and bradycardia

68
Q

What are four pharmacologic agents (and their associated mechansims) used to treat orthostatic hypotension in SCI patients?

A
  • salt tabs
  • midodrine (alpha-1-agonist)
  • fludrocortisone (mineralocorticoid)
  • droxidopa (norepinephrine pro-drug that can cross the blood-brain barrier)
69
Q

What are the earliest changes seen in neurogenic bladder?

A

irregular thickend bladder wall with small diverticuli

70
Q

What are the three phase of a triple phase bone scan?

A
  • blood flow phase: check for vasoconstriction or dialation
  • blood pool phase: check for edema
  • delayed tracer uptake: indicates osteoblastic activity or bone turnover
71
Q

What are three causes of incomplete spinal cord injuries?

A
  • unilateral facet joint dislocation
  • fall in the setting of cervical spondylosis
  • gsw or stab wound that does not penetrate the spinal canal.
72
Q

what are three reasons to treat an asymptomatic UTI in an SCI patient?

A
  • pending bladder study,
  • bladder pathology such as VUR
  • growing urease-prodding bug
73
Q

what are three risk factor for epidural abscess?

A

IVDA, diabetes, immunocompromised

74
Q

What are three alpha-1 agonists that can be used to treat retrograde ejaculation?

A

midodrine, imipramine and pseudoephedrine

75
Q

What are two areas to commonly see MS lesions

A

spinal cord, periventricular region

76
Q

what are two uses for E-stim in SCI patients

A
  • to move a extremity for functional activity
  • to avoid complications of muscle inactivity
77
Q

What bacteria is the most common cause of epidural abscess?

A

Staph aureus

78
Q

What can cause abdomina pain, nausea, and vomiting after rapid weight loss and prolonged supine position?

A

Superior mesenteric artery syndrome: duodenum is intermittently compressed between the SMA and aorta

79
Q

What coordinates bladder contraction with internal urethral sphincter relaxation?

A

pontine micturition center

80
Q

what direction does syringomyelia progress in the spinal cord?

A

cephalad and caudal

81
Q

what finding is associated with a good prognosis in multiple sclerosis?

A

optic neuritis

82
Q

What is a Chance fracture?

A

transverse fracture of the thoracic or lumbar spine from posterior to anterior

83
Q

what is a common level in the cervical region for facet dislocation?

A

C5-C6

84
Q

What is a Hangman fracture?

A

C2 burst fracture due to rapid decelerations injury of the head

85
Q

What is a Jefferson fracture?

A

C1 burst fracture due to high impact axial load

86
Q

What is a key difference between sildenafil (Viagra) and tadalafil (Cialis)?

A

Duration of action is longer with tadalafil (up to 36hrs) vs about 5 hours with sildenafil

87
Q

What is a quick way to tell if a patient is ASIA A?

A

“NOON” sign on ASIA sheet

88
Q

What is an ASIA B?

A
  • “Sensory Incomplete”
  • Intact sensory at S4-S5 or deep anal pressure
  • No motor function more than three levels below motor level.
89
Q

What is an ASIA C?

A
  • “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
Q

What is an ASIA D?

A
  • 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
Q

What is detrusor sphincter dyssynergia?

A

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
Q

What is first and last to recover in central cord syndrome?

A
  • first to recover - lower extremity function
  • last to recover - intrisic hand function
93
Q

What is Lhermitte sign?

A

passive neck flexion causes shooting electrical pain in the neck and shoulders. classically seen in MS

94
Q

What is LMN bladder?

A

flacid bladder causing overflow incontinence. Cannot urinate due to blocking of sacral micturition center

95
Q

What is neuromyelitis optica?

A

An immune mediated combination of optic neuritis and transverse myelitis

96
Q

What is recommended during delivery of the baby in a pregnant SCI patient?

A

spinal anesthesia if injury is at T6 or above

97
Q

What is seen on CSF studies in MS?

A

oligoclonal IgG bands (markers of CNS inflammation)

98
Q

What is seen on radiographs with vertebral body compression fractures?

A

anterior wedging, sometimes retropulsed bony fragments into spinal canal

99
Q

What is spinal shock?

A

absence of all spinal reflex activity below level of injury for 24 hours

100
Q

What is the “3-2-1” bowel program?

A
  • colace 100mg 3 x a day
  • senna 2 x a day
  • suppository (dulcolax or magic bullet) 1 x a day after meal
101
Q

What is the bulbocavernosus reflex and its significance?

A
  • squeezing tip of penis/clitoris causes anal sphincter contraction
  • absense after 24hrs indicates lower motor neuron injury (unlikley to get reflexogenic erection)
102
Q

What is the cause of detrusor overactivity in upper motor neuron bladder (lesion above S2)?

A

lack of descending inhibition of sacral micturition center

103
Q

What is the cause of retrograde ejaculation in SCI patients?

A

lack of coordination between urinary sphincters ie abnormally open internal and closed external sphincter

104
Q

What is the etiology of autonomic dysreflexia?

A

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
Q

What is the fasciculus gracilis?

A

medial dorsal column providing light touch and vibration sensation to the leg

106
Q

What are the steps in treatment of autonomic dysreflexia?

A
  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
Q

What is the highest ASIA A level for being modified independent with driving?

A

C5

108
Q

What is the highest possible ASIA A level that can live independently?

A

C6 (extremely motivated)

109
Q

What is the mechanism for a cervical compression fracture?

A

axial load with the neck flexed

110
Q

What is the mechanism for orthostatic hypotension in SCI patients?

A

lack of vasoconstriction due to block in sympathetic outflow

111
Q

what is the mechanism for spasticity in SCI?

A

loss of descending inhibition of spasticity arc

112
Q

What is the mechanism of injury that will cause central cord syndrome?

A

excessive hyperextension (fall on outstretched chin)

113
Q

What is the most common cause of autonomic dysreflexia?

A

bladder overdistention or infection

114
Q

What is the most common cause of progressive myelopathy after SCI?

A

syringomyelia

115
Q

What is the most common medical complication after SCI?

A

UTI

116
Q

What is the most common type of dens (odontoid) fracture?

A

Type 2 (fracture through the base), often requires surgery

117
Q

What is the most restrictive removable cervical brace?

A

Minerva brace

118
Q

What is the usual ASIA A level for achieving independence?

A

C7

119
Q

What is UMN bladder?

A

spastic bladder due overactive detrusor caused by loss of descending inhibition to sacral micturition center from the frontal lobe and pontine micturition center.

120
Q

What vertebral level does cauda equina occur at?

A

below L1-L2

121
Q

What level of SCI are at risk for impaired temperature regulation?

A

T8 and above

122
Q

What level of SCI can ambulate with assistive devices?

A

T10

123
Q

What level of SCI injury puts a patient at risk for autonomic dysreflexia?

A

T6 and above

124
Q

What long tracts in the spinal cord have both lateral and anterior/ventral locations?

A
  • corticospinal (lateral and anterior)
  • spinothalamic (lateral and ventral)
  • spinocerebellar (lateral and ventral)
125
Q

What nerve fiber is critical for a psychogenic errection?

A

hypogastric nerve (T11-L2, sympathetic)

126
Q

What nerve fiber is critical for a reflexogenic erection?

A

pelvic nerve (S2-4, parasympathetic)

127
Q

What percentage of SCI patients develop detrusor sphinceter syssynergia?

A

85%

128
Q

What percentage of SCI patients have returned to work at 5 years post injury

A

25%

129
Q

What portion of SCI patients develop upper extremity compression neuropathies?

A

Nearly 2/3

130
Q

What provides innervation to the external urethral sphincter?

A

pudendal nerve (S2- S4) - voluntary action

131
Q

What provides parasympathetic innervation to the bladder and bowel?

A

pelvic nerve “parasympathetics pee pelvic”

132
Q

What three nerves innervate the bladder and sphincter?

A
  • pudendal (somatic)
  • pelvic (parasympathetic, S2-4, cholinergic receptors)
  • hypogastric (sympathetic, T11-L2, alpha-1, beta-2/3)
133
Q

What two ADL areas can a ASIA C4 be modified independent?

A

weight shifts and wheelchair propulsion (both in a power WC)

134
Q

What type of exercise is recommended for MS patients?

A

submaximal

135
Q

When can you wean an SCI patient off a ventilator?

A

Vital capacity > 15-20 ml/kg

136
Q

When does hypercalcemia present in SCI patients?

A

usually 4 to 8 weeks post injury

137
Q

When is a patient not a candidate for phrenic nerve pacing?

A

There is damage to the phrenic nerve nucleus or C3-C5 nerve roots

138
Q

When is onset of heterotopic ossification most commonly after SCI injury?

A

2 months

139
Q

When should you consider mechanical ventilation in an SCI patient?

A
  • Vital capacity < 1L
  • PO2 < 50 mmHg
  • PCO2 > 50 mmHg
140
Q

where is the watershed region between the anterior spinal artery and artery of adamkiewicz?

A

lower thoracic region

141
Q

Why are lumbar root unaffected in conus medullaris syndrome?

A

They have already come off the cord at this point

142
Q

Why does bladder wall hypertrophy increase the risk of vesicoureteral reflux?

A

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
Q

Why is birth control problematic in women with SCI?

A
  • OCPs raise risk of thromboembolism (avoided in first year after injury)
  • IUDs can increase risk for pelvic inflammatory disease and related autonomic dysreflexia
144
Q

Women with SCI injury above what level are at risk to not percieve uterine contractions and have AD be the only sign of labor?

A

T10

145
Q

work-up for suspected syringomyelia

A

MRI with contrast

PM&R (21 decks)

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