SCI Qbank Flashcards
A 24 year-old male presents to your inpatient rehabilitation unit following a gunshot injury to his thoracic spine. On initial examination you note left lower limb weakness, intact right lower limb strength, and impaired coordination of the left lower limb. What else would you expect to see on exam?
Impaired pain and temperature sensation in the right lower limb
- This patient most likely suffers from Brown-Sequard Syndrome, which is classically the result of a knife or bullet wound to the spine, resulting in a spinal cord hemisection, essentially. This causes the classic pattern of ipsilateral loss of motor function, coordination, and light touch/proprioception below the level of injury (ipsilateral on either the left or right side of the cord, whichever side was stabbed or shot), and contralateral loss of pain/temperature sensation below the level of the injury. Remember that the spinothalamic tract fibers (pain/temp) enter the spinal cord, rise a couple of levels, and then decussate to the other side on its way up to the brain, which means that for most of its way up the spinal cord, it is carrying contralateral pain/temp information. The other answers would be correct if you switch their deficits to the other side.
A patient with an ASIA B cervical spinal cord injury (SCI) is best described as which of the following?
Sensory preservation, but no motor preservation
- A patient with ASIA B spinal cord injury (SCI) is defined as incomplete injury to the spinal cord involving some sensory sparing below the neurologic level of injury (NLI), with no motor function more than 3 levels below the motor level on each side. ASIA C and D injuries involve partial motor preservation below the NLI as well as voluntary anal contraction. ASIA A injury is classified as complete, while ASIA B, C, D, and E injuries are classified as incomplete.
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:
Detrusor-sphincter-dyssynergia
A 25 year-old female presents to your inpatient rehabilitation unit following a motor vehicle accident. On examination, 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?
T4 ASIA C
- This patient presents with a T4 ASIA D injury. 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). 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 involving 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), or normal exam in a patient with a previously documented ASIA injury (ASIA E).
What is the most optimal method for a C4 tetraplegic patient to independently operate a power wheelchair?
Both “sip and puff” or “head controls” are reasonable options
- Most power wheelchairs are driven by joystick controls. If the patient lacks arm or hand function, joystick control may not be practical. Sip and puff (breathing controls) or head controls (moving the head to tell the chair where a patient wants to go) would be useful in these cases.
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?
Yes, as female fertility is unaffected in the long term in SCI patients
- After several months following an SCI, normal menstrual cycles return in premenopausal female patients; thus, pregnancy is possible following an SCI.
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 50 colony-forming units/mL. What is the next best step?
Do not treat the bacteriuria
- 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 (pyuria, >100 colony-forming units/mL), 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.
A 79 year-old female presents to the ED with sudden-onset low back pain, urinary incontinence, and patchy flaccid weakness and sensory abnormalities in her lower limbs. On bladder scan she is noted to be holding 800 milliliters of urine. What is the most appropriate next step?
Stat neurosurgery consult
- This patient with acute cauda equina syndrome requires emergent surgical decompression as well as spinal imaging in order to give her nerves the best chance of recovery by decompressing the forces on her cauda equina nerve roots (likely due to vertebral body compression fracture with retropulsion vs. acute herniated disc).
A 37 year-old male patient who sustained a gunshot wound to his mid-back 3 weeks ago begins to complain of a pounding headache and excessive sweating in his upper chest and neck. What is the most appropriate initial action?
Sit the patient up
- This patient is suffering from autonomic dysreflexia (“autonomic SIX-reflexia”), which occurs classically in SCIs involving T6 or higher. AD is the result of a noxious stimulus causing massive reflex sympathetic surge that goes unregulated, resulting in bradycardia, hypertension, headache, and sweating above the level of the SCI. This can result in MI, stroke, and subarachnoid hemorrhage. The key to treating this is to immediately treat the most likely causes of a noxious stimulus. First, sit the patient up to reduce intracranial pressure and the risk of subarachnoid hemorrhage. Then, loosen the patient’s clothing, catheterize their bladder, check their skin for wounds, and finally evacuate their bowels with a suppository and digital stimulation. All of these factors (tight clothes, wounds, full bladder/bowel) are common causes of AD. Failing these initial measures, nifedipine, clonidine, and topical nitroglycerin can be effective pharmacologic interventions. Make sure you check vital signs as soon as possible to monitor blood pressure and heart rate in these patients.
A 77 year-old female is undergoing a vascular surgery procedure due to systemic vascular disease. Upon awakening she complains that she feels weak and can’t feel her legs. Which area of her spinal cord was most likely insulted?
Mid-low thoracic
- The mid to low thoracic cord is a watershed region of vascular blood supply and is the most likely area to suffer ischemic injury during surgical procedures such as vascular surgery procedures.
A 23 year-old patient is involved in a motor vehicle accident and suffers a unilateral cervical facet joint dislocation (“jumped facet”). This most likely occurred at what level of the spine?
C5-C6
- As a general rule it is always useful to remember that most pathologies in the cervical spinal cord occur at the C5 or C5-C6 level.
Which of the following spinal cord injury levels is most likely to necessitate ventilatory support?
C3
You are examining a 55 year-old chronic spinal cord injury patient who sustained a C8 ASIA B injury 10 years ago. He has been battling spasticity in his arms and legs over the years. On examination, when attempting to extend his elbow, you note that the elbow is easily ranged, but there is a catch with resistance to movement for about 25% of the range of motion. What is this patient’s Modified Ashworth Scale (MAS) score for his elbow spasticity?
1+
A 54 year-old male with a past medical history of benign prostatic hyperplasia, hyperlipidemia, and gout presents to your skilled nursing facility following an injury. He reports that 2 weeks ago he was walking his dog when he tripped on a rock and landed forward on his chin with his neck extended. He noted immediate onset weakness. He was treated at the acute care hospital and presents for skilled rehabilitation. On examination he exhibits 4/5 elbow flexion, elbow extension, and wrist extension strength bilaterally. Bilateral finger flexion and abduction strength is 1/5. Bilateral lower extremity strength is 4+/5 throughout. There is diminished sensation to light touch and pinprick in his upper extremities to a greater degree than the lower extremities. He indicates bladder incontinence since his injury. Which of the following is the most likely diagnosis?
Central cord syndrome
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:
4
What is the most common site for pressure injuries in adults?
Sacrum
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?
Obtain urinalysis
What is the most common site for pressure injuries in children?
Occiput
A 28-year-old female suffers T12 ASIA B spinal cord injury. After a few weeks in acute rehabilitation, she is discharged home. You see her in clinic for a 1 month follow up; if she develops heterotopic ossification, where would it most likely arise?
Hip
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?
Males experience decreased fertility following an SCI
What is the most common incomplete spinal cord injury syndrome?
Central cord syndrome
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?
Cervical spine MRI with contrast
- This patient is developing syringomyelia
An 82 year-old male sustains a fall, resulting in spinal cord injury. Neurosurgery performs a spinal decompression and fusion. You are consulted on this patient 2 weeks following his injury. On examination you note impaired sensation to light touch and 0/5 strength in bilateral lower extremities. You also note absent Babinski, anal wink, and bulbocavernosus reflexes. Which test may ultimately offer prognostic information in this patient?
EMG
Where does the spinal cord become the cauda equina?
L1
A 44 year-old male with a past medical history of aortic stenosis, hypertension, and diabetes mellitus presents for skilled rehabilitation following a traumatic T10 ASIA B spinal cord injury. His neurologic deficits include bilateral lower extremity weakness and numbness along with bowel and bladder incontinence. During his first week on the rehabilitation unit, he begins to complain of a fairly constant burning band-like pain wrapping from his low back around his trunk bilaterally into the umbilicus. He states this pain has been ongoing since his injury, but has gradually been worsening over time. Advanced imaging prior to hospital discharge was stable. Which of the following is the most appropriate treatment for this pain?
Pregabalin
-This patient presents with a painful thoracic (T10) sensory level, which can occur in patients with spinal cord injury (SCI)
The most common wheelchair armrest contains all of the following features except:
Full-length
The most common bladder/micturition pathophysiology in patients with cervical or thoracic spinal cord injury involves which of the following processes?
The detrusor and bladder sphincters fail to coordinate properly
A 27 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 4 hours, and produces about 400 ml of urine with each catheterization. However, she notes small to moderate amounts of urine leakage in between catheterization attempts. She has already attempted to reduce her water intake during the day. What is the most appropriate next step?
Start oxybutynin
You are examining a patient who sustained a C3 ASIA A spinal cord injury 2 months ago. During velocity-driven passive extension of the left elbow, you detect in the left biceps brachii resistance to this passive stretch; in fact, you are able to fully extend the elbow, but it is difficult throughout the entire range of motion secondary to biceps brachii resistance to passive stretch. Which of the following represents the grade of spasticity in the left biceps brachii of this patient, as determined by the Modified Ashworth Scale (MAS)?
3
A 52 year-old male with a history of thoracic paraplegia presents to your office with complaints of bilateral shoulder pain. He achieves mobility using a manual wheelchair. On physical examination, you document positive Neer, Hawkins, and Speed tests bilaterally. He is able to achieve full shoulder abduction with significant pain. What is your next best step?
Start physical therapy
You are rounding on a patient who sustained a C4 ASIA A spinal cord injury (SCI). During physical examination, your patient asks you to explain what you mean as you refer to their spasticity. Which of the following is the definition of spasticity?
Velocity-dependent resistance to passive stretch of a muscle
Which type of patient is most at risk for experiencing autonomic dysreflexia (AD)?
Complete SCI at T4
For a tenodesis splint to be effective, what level of innervation is required to promote passive finger flexion?
C6
