SCI SAEs

Question 1

A 22-year-old male with C6 ASIA B tetraplegia secondary to a motor vehicle accident 2 months

ago is undergoing inpatient rehabilitation. His bladder is managed with a suprapubic catheter and

he is on a daily bowel program using digital stimulation and a bisacodyl (Dulcolax) suppository.

While resting supine in bed one evening, he suddenly develops a pounding headache. His blood

pressure is found to be 180/100 and his heart rate is 56. His face is flushed. What is the first step

in the initial management of this patient?

(a) Flush his suprapubic catheter.
(b) Using a well lubricated finger, check his lower rectum for fecal impaction.
(c) Sit him up and loosen any restrictive clothing.
(d) Apply ½ inch of nitropaste to his anterior chest wall.

Answer 1

Answer: (c)

Commentary: This patient is presenting with autonomic dysreflexia (AD). Once diagnosed, the

first step in the management of AD is to sit the patient up, if supine, and loosen any restrictive

clothing. If the blood pressure remains elevated, the urinary system should be evaluated. In this

case, therefore, the second step would be to flush the suprapubic catheter. If the blood pressure

continues to be elevated after bladder distention has been ruled out, the lower bowels should be

evaluated for fecal impaction, but only after the systolic blood pressure is reduced to less than

150 mmHg, using medications if necessary. Medications, such as nitroglycerin paste (nitropaste),

should be used only after these first 3 steps are taken. In the acute setting the need is unlikely, but

to avoid life threatening hypotension in chronic SCI and AD avoid using nitrates with sildenafil

(Viagra) and other phosphodiesterase type 5 inhibitors.

Question 2

An 18-year-old female with a history of depression and C2 ASIA A spinal cord injury acquired in

a diving accident requires continuous ventilation. She is diagnosed with a major depressive

disorder 8 weeks after her injury. Which factor has increased her risk for developing depression

after her spinal cord injury?

(a) Ventilator use
(b) Prior history of depression
(c) Level of injury
(d) Traumatic nature of injury

Answer 2

Answer: (b)

Commentary: Prior history of depression is a general risk factor for depression after a spinal cord

injury. Etiology, level of injury and ventilator use are not risk factors.

Question 3

In persons with traumatic spinal cord injury (SCI), which statement regarding employment is

TRUE?

(a) The majority of patients are unemployed at the time of injury.
(b) Education is most strongly associated with postinjury employment.
(c) Employment status is similar between different ethnic groups.
(d) Employment status is highest within the first 5 years postinjury.

Answer 3

Answer: (b)

Commentary: The National Spinal Cord Injury (SCI) Statistical Center database states that at the

time of injury, 63% of people injured were employed, 19% were students, and 17% were

unemployed. While unemployment at the time of injury is a negative predictor for postinjury

employment, education has been found to be the factor most strongly associated with postinjury

employment, with only 5% of persons with less than 12 years of education being employed, and

69% of persons with doctoral degrees being employed. Overall, only about 25% of all persons

with SCI were employed. African Americans and Hispanics with SCI fared worse in employment

outcomes compared to Caucasians with SCI. Employment status increased over time, with the

odds of being employed at 1, 5 and 10 years after injury being 1.58, 2.55, and 3.02, respectively.

Question 4

Which finding is most closely associated with favorable motor recovery after a traumatic spinal

cord injury?

(a) Recovery from spinal shock in less than 4 weeks after injury
(b) ASIA B classification with retained pinprick sensation in the sacral dermatomes
(c) Detection of somatosensory evoked potentials in the first 2 weeks after injury
(d) Hemorrhage in the spinal cord of less than 1cm on MRI

Answer 4

Answer: (b)

Commentary: ASIA B patients with preservation of sacral pinprick sensation have a 70% to 90%

chance of motor recovery sufficient to ambulate. The concept of spinal shock has been poorly

defined and is generally not helpful to clinicians in predicting recovery. The detection of

somatosensory evoked potentials is not always associated with motor recovery. Hemorrhage of

any amount is generally associated with a poorer prognosis.

Question 5

Men with an upper motor lesion (UMN) and has ejaculatory dysfunction?

(a) Avoid ejaculation because of complications related to autonomic dysreflexia
(b) Use sildenafil (Viagra) 60 minutes before intercourse
(c) Consider a trial of vibratory stimulation
(d) Ejaculation dysfunction cannot be treated

Answer 5

Answer: (c)

Commentary: Men with an upper motor lesion (UMN) and an ejaculation reflex have a 30% to

96% ejaculation rate with vibratory stimulation, depending on the vibratory stimulator’s

waveform amplitude and frequency. If vibratory stimulation is unsuccessful, ejaculation can be

accomplished and sperm collected using a rectal probe with electroejaculation. Sildenafil is an

option for management of erectile dysfunction rather than ejaculation dysfunction. Although

autonomic dysreflexia may occur with ejaculation, it is more commonly a transient phenomenon

and does not lead to complications.

Question 6

A bladder neuroprosthesis applies electrical stimulation to intact sacral parasympathetic nerves

(S2-S4) to produce effective micturition and improve bowel function. A posterior rhizotomy from

S2-S4 is typically also performed at the same time in order to

(a) decrease pain and increase patient acceptance of the neuroprosthesis.
(b) improve bladder emptying and lower the postvoid residual.
(c) improve external urethral sphincter relaxation.
(d) decrease autonomic dysreflexia when the bladder is emptying.

Answer 6

Answer: (d)

Commentary: Micturition by electrical stimulation requires intact parasympathetic neurons to the

detrusor muscle. This stimulation is often combined with posterior sacral rhizotomy to increase

bladder capacity and decrease reflex incontinence and sphincter contraction. Detrusor sphincter

dyssynergia is avoided with rhizotomy, protecting the upper tracts and reducing autonomic

dysreflexia. The pudendal nerve controls the external sphincter via the somatic nervous system,

which is not affected by rhizotomy.

Question 7

25. Which therapeutic application of functional electrical stimulation is NOT applicable in the

population with spinal cord injury?

(a) Lower limb exercise in cauda equina syndrome
(b) Ventilatory assistance in a C2 ASIA class A injury
(c) Achieving lateral or palmar prehension in a C6 ASIA class A injury
(d) Electroejaculation to harvest sperm for assisted reproduction techniques

Answer 7

Answer: (a)

Commentary: Functional electrical stimulation (FES) strategies use applied electrical current to

activate weak or denervated muscle. FES is most effective in upper motor neuron injuries with

preservation of the anterior horn cells and motor nerve roots. Because of the amount of charge

density required to directly depolarize muscle, FES is not effective if large quantities of

musculature are denervated. FES can be applied to the skin surface, or by means of implanted

electrodes. One application in the population with SCI is its use in conjunction with a bicycle

ergometer to improve cardiac capacity. Generally, individuals with cauda equina syndrome will

not be good candidates for FES-assisted cycling, due to the extent of denervation associated with

this injury level. Phrenic nerve and diaphragmatic pacing have been used to wean standard

ventilator dependence in individuals with high tetraplegia and preserved phrenic nerve function.

Implanted FES systems have been used to generate hand grasp and release, with or without

tendon transplantation. External hand/forearm orthoses have also been developed primarily for

therapeutic stimulation, with the hope of developing future neuroprostheses. Patients with intact

parasympathetic efferent innervation to the detrusor have improved control of micturition, albeit

with the need for sacral deafferentation, resulting in the loss of perineal sensation and reflex

erection. Electroejaculation using a rectal probe has been highly successful at producing seminal

emission for sperm harvesting for the purpose of assisted reproduction in individuals with SCI.

Question 8

75. What is the most common cause of autonomic dysreflexia?
    a) Rectal distention
    b) Pressure ulcers
    c) Bladder distention
    d) Childbirth

Answer 8

Answer: (c)

Commentary: In a spinal cord injury, the most common cause of autonomic dysreflexia is bladder

distention. The other answers can also cause autonomic dysreflexia but due to the frequency of

bladder distention and potential problems of catheter blockage or bladder distention it is more

frequent than the other sources of painful stimulation listed.

Question 9

115. A pharmacologic treatment for orthostatic hypotension that involves fluid retention is
     a) fludrocortisone.
     b) ephedrine sulfate.
     c) midodrine hydrochloride.
     d) recombinant human erythropoietin.

Answer 9

Answer: (a)

Commentary: Fludrocortisones (0.05 mg once daily to 0.1 mg twice daily) is a potent

mineralocorticoid with little glucocorticoid activity. It has been used to manage orthostatic

hypotension (OH) related to autonomic dysfunction for more than 40 years. The pressor action of

fludrocortisones is a result of sodium retention, which occurs over several days. This delayed

action needs to be understood by the clinician as well as the patient to manage expectations and

time frame of benefit. Ephedrine (20mg to 30mg up to 4 times daily) acts primarily through the

release of stored catecholamines and has additional direct action on adrenoreceptors. It is a

nonselective and mimics epinephrine in its effects. Midodrine (2.5mg to 10mg 2 to 3 times daily)

is an alpha 1-adrenorecptor agonist and directly increases blood pressure by arteriolar and venous

constriction. Recombinant human erythropoietin has been shown in pilot studies to increase blood

pressure by about 10mmHg to 20mmHg in patients with OH. In addition to the increase in red

blood cell count and blood viscosity that occurs with epoeitien α, it may have a yet unrecognized

effect on the vasculature.

Question 10

25. Which artery provides the arterial vascular supply to the ventral grey matter of the spinal cord?
    (a) Anterior spinal
    (b) Posterior spinal
    (c) Vertebral
    (d) Radicular

Answer 10

Answer: (a)

Commentary: The single anterior spinal artery and its sulcal branches provide blood supply

directly to the anterior two-thirds of the spinal cord after arising from branches off the vertebral

arteries. The paired posterior spinal arteries similarly originate from the vertebral arteries, and

supply the posterior one-third of the cord. Radicular arteries are segmental branches from the

thoracic and abdominal aorta. These arteries provide vascular supply to the thoracic, lumbar,

sacral and coccygeal cord.

Question 11

45. According to the most recent data from the National Spinal Cord Injury Statistical Center and

Model Spinal Cord Injury Systems, which source of trauma is the leading cause of traumatic

spinal cord injury among individuals between the ages of 46 and 60 years?

(a) Motor vehicle accidents
(b) Acts of violence
(c) Sports-related injuries
(d) Falls

Answer 11

Answer: (d)

Commentary: Falls comprise the leading cause of traumatic spinal cord injury in the 46- to 60-

year-old age group, while motor vehicle crashes are the most common etiology for traumatic

spinal cord injury among people younger than age 46. Incidence rates for acts of violence and

sports-related injuries are lower in the 46-60 age group than in younger age groups.

Question 12

75. Bone loss following spinal cord injury is characterized by
    (a) greater loss of cortical rather than trabecular bone.
    (b) low bone mineral density in the spine.
    (c) predilection for regions below the level of injury.
    (d) new bone homeostasis that ensues by 6 months after injury.

Answer 12

Answer: (c)

Commentary: Bone loss occurs inevitably following spinal cord injury, and is uniquely

characterized by a predilection for trabecular more than cortical bone in regions below the level

of injury. This is associated with relative sparing of spine bone mineral density, possibly due to

continued functional loading of the spine. A new homeostasis in bone resorption and formation is

achieved by about 16 months.

Question 13

85. A 24 year-old man sustains an acute, traumatic C5 American Spinal Injury Association

Impairment Scale (AIS) A tetraplegia and a proximal left femur fracture following a motor

vehicle crash. His hemoglobin has remained stable. Based on the Consortium for Spinal Cord

Medicine’s Clinical Practice Guidelines, venous thromboembolic prophylaxis should include

sequential compression devices for a minimum of 2 weeks and

(a) coumadin for 4 weeks.
(b) low molecular weight heparin for 8 weeks.
(c) low molecular weight heparin for 12 weeks.
(d) prophylactic inferior vena cava placement.

Answer 13

Answer: (c)

Commentary: According to the Clinical Practice Guidelines, venous thromboembolic

prophylaxis for uncomplicated motor-complete tetraplegia and AIS C injuries should be

comprised of low molecular weight heparin or adjusted dose unfractionated heparin for 8 weeks.

However, in the presence of complicating factors (eg, lower limb fractures, advanced age,

obesity, heart failure, cancer) prophylaxis with low molecular weight or unfractionated heparin

should continue for a total of 12 weeks or until discharge from Rehabilitation. Individuals with

AIS D paraplegia without other complications require chemoprophylaxis with unfractionated

heparin only until the rehabilitation discharge. Prophylactic intravenous chemotherapy filter

placement is recommended only if there are contraindications or high risk associated with

anticoagulation, and prophylaxis should be initiated as soon as hemostasis is achieved or

contraindications resolved.

Question 14

125. An individual with T4 American Spinal Injury Association Impairment Scale (AIS) A paraplegia

is 2 months postinjury and acutely develops pounding headache, flushing of the face and upper

trunk, anxiety and piloerection of the lower body. Blood pressure is 120/80 with a usual blood

pressure of 100/60. After loosening all tight garments, what should be the next intervention?

(a) Assess bladder for distention.
(b) Check bowel for impaction.
(c) Apply topical nitroglycerin immediately.
(d) Lay the patient supine immediately.

Answer 14

Answer: (a)

Commentary: The scenario depicts a typical presentation for autonomic dysreflexia (AD).

Treatment should consist of checking the blood pressure, elevating the head, loosening tight

clothing or garments, and proceeding with systematic investigation and elimination of causative

factors. Because bladder distension is the most common stimulus for AD, the algorithm proposed

in the clinical practice guideline begins with assessment for bladder-related causes and treatment

of any distension. Because bowel obstruction or distension is the second most common stimulus

and it, therefore, should be evaluated next if urinary evaluation fails to reveal the cause. The

guideline recommends consideration for antihypertensive pharmacotherapy if the individual’s

systolic blood pressure is above 150.

Question 15

15. An individual with T4 ASIA C paraplegia must have
    (a) normal sensory function below T4.
    (b) sensation in the sacral segments S4–S5.
    (c) a muscle grade of 3 or greater in at least half of the key muscles below T4.
    (d) voluntary sphincter contraction.

Answer 15

Answer: B

Commentary: All ASIA levels except ASIA A must include sensation through the sacral segments S4–S5. The ASIA C classification can include voluntary sphincter contraction but it is not required. An injury classed as T4 ASIA C would include sensation below T4 but the sensation may be normal or impaired. A muscle grade of less than 3 in more than half of the key muscles below the neurologic level would be expected with ASIA C.

Question 16

In response to a request for information regarding ejaculation, you advise a 22-year-old man with T4 ASIA A paraplegia who is 1 year postinjury to

(a) avoid ejaculation, because of the risk of autonomic dysreflexia.
(b) use sildenafil (Viagra) 60 minutes before intercourse.
(c) use vibratory stimulation.
(d) see a urologist for direct sperm harvest.

Answer 16

Answer: C

Commentary: In men with spinal cord injury who have an ejaculation reflex (upper motor neuron lesion), there is a 30% to 96% ejaculation rate, depending on the amplitude and frequency of vibratory stimulation. Sildenafil is an option for erectile dysfunction, rather than for ejaculation-related problems. Autonomic dysreflexia can occur with ejaculation but is more commonly a transient phenomenon and does not lead to complications.

Question 17

85. Which of the following is a benefit of a phrenic pacemaker in an individual with tetraplegia
    (a) elimination of ventilator support
    (b) improved speech
    (c) improved hearing acuity
    (d) longer life expectancy

Answer 17

Answer: B

Commentary: Benefits of p hrenic pacemaking include improved speech, improved smell, ease of transfers and out of home mobility, reduced incidence of respiratory tract infections, and reduced volume of repiratory secretions.

Question 18

86. Hydrocolloid dressings facilitate debridement through which mechanism?
    (a) Enzymatic
    (b) Autolytic
    (c) Sharp
    (d) Mechanical

Answer 18

Answer: B

Commentary: Hydrocolloid dressings maintain a moist wound environment. Subsequently, proteases and collagenase digest eschar that is in contact with the wound fluid. This process is called autolysis. In enzymatic debridement, chemical agents such as papain-urea break down necrotic tissue. Sharp debridement is performed using an instrument such as a scalpel. An example of mechanical debridement would be wet-to-dry dressing or whirlpool treatment.

Question 19

105. What function would be expected in a 24-year-old healthy woman with C7 ASIA A tetraplegia?
     (a) Requires minimal assistance for level transfers
     (b) Requires minimal assistance for side-side weight shifts
     (c) Independent manual wheelchair use on uneven terrain
     (d) Independent dressing and bathing with adaptive equipment

Answer 19

Answer: D

Commentary: The C7 level is considered the key level for becoming independent in most activities at a wheelchair level. Persons with a C7 motor level who are in good health are usually independent for weight shifts, transfers between level surfaces, feeding, grooming, and upper body dressing. Some assistance may be required for wheelchair propulsion on uneven terrain. Bathing can be performed independently with the appropriate adaptive equipment.

Question 20

125. A 48-year-old is admitted to your rehabilitation facility 3 weeks after sustaining a spinal cord injury. The motor and sensory examination is as follows:

R Motor L Motor

Deltoid 5 5

Biceps 5 5

Wrist extensor 5 5

Triceps 3 3

Finger flexors 1 1

Intrinsics 1 1

Hip flexors 0 0

Knee extensors 0 0

Dorsiflexors 0 0

Plantarflexors 0 0

Sensory exam revealed intact pinprick and light touch sensation through C7. Sensation is absent below C7 except for intact perianal sensation.

What is the patient’s ASIA score?

(a) C7 ASIA B
(b) C6 ASIA B
(c) C6 ASIA C
(d) C7 ASIA C

Answer 20

Answer: A

Commentary: Based on the ASIA classification system this patient would be classified as C7, given the normal sensation in that myotome and a muscle grade of 3/5 at C7 with the level above being 5/5. The trace activity in finger flexors and intrinsics are within 3 segments of the level of injury and cannot be used to suggest the patient is motor incomplete (ASIA C). The patient is classified as ASIA B because of the retained sacral sensation.

Question 21

145. Autonomic dysreflexia is
     (a) best treated by placing the patient supine.
     (b) a common occurrence in patients with T8 spinal cord injuries.
     (c) predominantly characterized by parasympathetic activity.
     (d) rarely occurs earlier than 1 month after injury.

Answer 21

Answer: D

Commentary: Autonomic dysreflexia is most commonly found in patients with spinal cord injury at T6 and above. It is associated with a release of sympathetic activity, which results in regional vasoconstriction. It is usually present by 6 months to 1 year after injury. Initial treatment involves prompt removal of the noxious stimulus and sitting the patient up.

Question 22

155. Which statement is TRUE concerning traumatic spinal cord injury (SCI)?
     (a) More than 80% of individuals identified as having motor incomplete SCI at 72 hours after their injury will walk.
     (b) There is a plateau of functional recovery after incomplete SCI that occurs after the first 3 months.
     (c) More than 80% of individuals with complete tetraplegia will regain 2 motor levels below their initial injury level.
     (d) Approximately one-third of individuals with SCI have complete injuries and two-thirds have incomplete injuries.

Answer 22

Answer: A

Commentary: The majority of patients with complete tetraplegia regain 1 level below their original injury. Up to 87% of motor incomplete subjects (ASIA C) identified at 72 hours postinjury were ambulating at 1 year. The ratio of complete to incomplete SCI is close to 50:50. Recovery after incomplete SCI is often most rapid up to 6 months postinjury but can still occur at a slower rate after 2 years.

Question 23

15. Based on the revised edition of the American Spinal Injury Association (ASIA) Impairment Scale,

published in 2000, which condition would be sufficient to categorize a spinal cord injury as motor

incomplete?

(a) Some motor function more than 1 level below the motor level
(b) Voluntary anal sphincter contraction
(c) A well-defined zone of partial preservation
(d) An anterior spinal artery syndrome

Answer 23

(b)

For an individual to receive an ASIA classification of motor incomplete (ASIA C or D), he/she must have either voluntary anal sphincter contraction or sensory sacral sparing with sparing of motor function more than 3 levels below the motor level. The zone of partial preservation is used only in complete injuries. Individuals with anterior spinal artery syndrome are often motor complete.

Question 24

25. A 24-year-old man with T6 complete paraplegia whose injury occurred 16 weeks ago. He is concerned he can no longer reach down to put on and tie his right shoe. Upon evaluation, he has significant loss of range of motion in the right hip with mild warmth at the hip. There is no swelling at the knee, lower leg, ankle, or foot. The most likely diagnosis is
    (a) hip dislocation.
    (b) deep vein thrombosis.
    (c) heterotopic ossification.
    (d) iliopsoas abscess.

Answer 24

(c)

Heterotopic ossification (HO) may develop as early as 17 days after a neurologic injury. However, it typically takes up to 6 weeks to begin to mineralize and decrease range of motion at the affected joint. Persons with spinal cord injury are prone to develop HO below their level of injury. This patient’s progressive loss of range of motion accompanied by a loss of function points toward HO. With no history of trauma, early fracture is unlikely, lack of systemic signs such as fever render an abscess unlikely, and with a deep vein thrombosis (DVT) one would expect edema distal to the clot. Persons with spinal cord injury are at highest risk for DVT within the first 6 to 8 weeks after injury.

Question 25

45. Which statement is correct regarding the management of labor and delivery for women with cervical spinal cord injuries?
    (a) Pre-eclampsia is 3 times more likely to occur than in able-bodied women.
    (b) Vaginal delivery is contraindicated.
    (c) Autonomic dysreflexia occurs 60%–80% of the time.
    (d) Spinal and epidural anesthesia are contraindicated

Answer 25

(c)

Women with paraplegia or tetraplegia can give birth vaginally and caesarean delivery is rarely necessary. Patients with neurologic levels above T6 are at risk for autonomic dysreflexia during pregnancy, labor, and delivery. Autonomic dysreflexia is reported to occur in 60% to 80% of women with SCI with lesions above T6. Preeclampsia occurs with the same frequency in able-bodied women and women with disabilities. Complications from autonomic dysreflexia may be severe and include encephalopathy, cerebrovascular accidents, death of the mother, and severe fetal asphyxia. Spinal or epidural anesthesia extending to the T10 level is the treatment of choice and the most reliable method of preventing and treating autonomic dysreflexia during labor and delivery.

Question 26

52. During the initial, acute evaluation of a young spinal cord injury patient, which factor would make you suspicious of a concomitant brain injury?
    (a) Fall as the mechanism of injury
    (b) Female patient
    (c) Higher level spinal cord injury
    (d) African-American patient

Answer 26

(c)

The following factors, evidenced at the time of a spinal cord injury, place an individual at higher risk for a concomitant traumatic brain injury: Male sex and a higher level of spinal cord injury. Up to the age of 74 years-old, a transportation accident is the major source of traumatic brain injury (TBI) and not falls. Studies have shown a potential relationship between race and the incidence of TBI, but there are too many confounding variables and no study has shown a clear evidence of a relationship.

Question 27

86. A 24-year-old man with T4 paraplegia has a sacral pressure ulcer measuring 2 cm by 2 without depth. The ulcer base has pink granulation tissue. Which dressing is LEAST appropriate in this case?
    (a) Tegaderm (transparent adhesive dressing)
    (b) Duoderm (hydrocolloid wafer dressing)
    (c) Curasol (gel dressing)
    (d) Accuzyme (enzymatic debridement)

Answer 27

(d)

This man has a stage II pressure ulcer. Debridement with an agent such as Accuzyme is indicated in wounds with necrotic tissue. Since no necrotic tissue is present in this patient’s wound, Accuzyme is not appropriate. A transparent adhesive dressing such as Tegaderm, a hydrocolloid wafer dressing such as Duoderm, and a gel dressing such as Curasol are all appropriate for clean wounds such as the ulcer described.

Question 28

96. Vacuum-assisted closure marketed as “Wound VAC” works primarily by
    (a) increasing blood flow in the wound and adjacent tissue.
    (b) drawing the edges of the wound together.
    (c) sealing out potentially harmful bacteria from the wound.
    (d) maintaining a moist, anaerobic environment.

Answer 28

(a)

The Wound VAC device increases blood flow to the wound and adjacent tissue, resulting in increased oxygen delivery, increased clearance of bacteria from infected wounds, and wound healing.

Question 29

105. A 23-year-old man with C8 tetraplegia requests your opinion regarding routine urologic evaluations after spinal cord injury. You advise that
     (a) an intravenous pyelogram (IVP) should be performed every 1 to 2 years.
     (b) annual abdominal plain films are sufficient to detect early hydronephrosis.
     (c) renal ultrasound should be performed every 5 years.
     (d) it is reasonable to wait 10 years before getting his first cystoscopy.

Answer 29

(d)

Renal ultrasound should be included in the annual assessment of renal function and is more sensitive for detecting early hydronephrosis than are plain films. An IVP is not required on a regular basis unless a specific indication exists, such as localizing a renal stone. Patients with indwelling catheters should have a cystoscopy after the first 10 years postinjury.

Question 30

145. Compared to individuals without spinal cord injury, individuals with spinal cord injuries have a
     (a) lower risk of osteoporosis.
     (b) higher risk of diabetes.
     (c) lower rate of dyslipidemia.
     (d) higher rate of prostate cancer.

Answer 30

(b)

Individuals with spinal cord injury are at an increased risk for carbohydrate intolerance, cardiovascular disease, and dyslipidemia. There does not appear to be an added risk for prostate cancer in men with chronic SCI.

Question 31

155. A 37-year-old woman with C5 ASIA A tetraplegia from trauma 1 month ago is admitted to your

acute rehabilitation unit. She has a retrievable inferior vena cava (IVC) filter and no history of chemical prophylaxis for deep vein thrombosis (DVT). Her surgical team reports to you that they are no longer concerned with an acute bleeding potential related to her trauma and her hematocrit is stable. What should you do first?

(a) Order a lower extremity doppler study to look for DVT
(b) Start mechanical prophylaxis with sequential compression devices
(c) Tell the patient she is completely protected from pulmonary emboli
(d) Leave the IVC filter in place for a minimum of 4 months

Answer 31

(a)

If anticoagulation is delayed for more than 72 hours after injury, a test to exclude the presence of clots in the legs should be performed. In complete injuries, low molecular weight heparin should be used when starting chemical prophylaxis. Pulmonary embolisms may occur as a result of upper extremity DVT and are not prevented by the IVC filter. In general, the longer you wait to remove the IVC filter, the more problems you may experience in the filter retrieval process.

Question 32

195. Trauma to the sacral roots would most likely result in
     (a) vesicoureteral reflux.
     (b) incontinence.
     (c) detrusor hyperreflexia.
     (d) small bladder capacity.

Answer 32

(b)

Damage to the sacral roots usually results in a flaccid bladder. Incontinence often occurs due to a weak sphincter mechanism, particularly if the patient has increased bladder volume or an increase in intra-abdominal pressure. However, the external sphincter may not always be affected to the same degree as the detrusor. This imbalance results in bladder overdistension and the possibility of upper tract deterioration.

Question 33

25. An individual with C7 ASIA D tetraplegia must have
    (a) a bulbocavernosus reflex and voluntary sphincter contraction.
    (b) a muscle grade of 3 or greater in at least half of the key muscles below C7.
    (c) normal pinprick and light touch sensation through the sacral dermatomes.
    (d) normal strength (5/5) in the C7 myotome.

Answer 33

(b) A bulbocavernosus reflex does affect American Spinal Injury Association (ASIA) scoring, and voluntary sphincter contraction is not a mandatory component of ASIA C or D. Muscle grade of less than 3 in at least half of the key muscles below C7 would be characterized as ASIA C. Someone with ASIA B through E must have some retained sensation in the sacral segments S4-S5 but that sensation can be normal or impaired. To classify the injury as C7 ASIA D would require a motor score of at least 3 out of 5 in the C7 myotome with normal strength in C6. American Spinal Injury Association, International Medical Society of Paraplegia. International standards for neurological and functional classification of spinal cord injury patients. Chicago: American Spinal Injury Association; 2002.

Question 34

45. According to data from the Model Spinal Cord Injury Care System, the leading cause of traumatic spinal cord injury in the United States is
    (a) motor vehicle accidents.
    (b) violence.
    (c) falls.
    (d) diving accidents.

Answer 34

(a) The top three causes of traumatic spinal cord injury in the United States are motor vehicle accidents, falls, and violence. Nobunaga AI, Go BK, Karunas RB. Recent demographic and injury trends in people served by the Model Spinal Cord Injury Care Systems. Arch Phys Med Rehabil 1999;80:1372-82.

Question 35

65. A 21-year-old man is evaluated in your spinal cord injury clinic 12 months after a C2 complete spinal cord injury requiring full-time mechanical ventilation. You recommend
    (a) avoiding a breath control system for his power wheelchair.
    (b) aggressive diaphragmatic strengthening exercises.
    (c) initiating a weaning protocol by slowly decreasing tidal volume.
    (d) an electrodiagnostic study to evaluate for a phrenic nerve pacemaker.

Answer 35

(d) It is unlikely that an individual will be able to wean from a ventilator if he is still completely dependent on mechanical ventilation 12 months after a C2 complete injury, so a weaning protocol and diaphragmatic strengthening are not indicated. An individual who requires mechanical ventilation can use a breath control system effectively. If electrodiagnostic testing indicate that the phrenic nerves are intact, then a phrenic pacemaker could be implanted, which would significantly reduce the need for mechanical ventilation. Gorman PH. Functional electrical stimulation. In: Lin VW, editor. Spinal cord medicine principles and practice. New York: Demos; 2003. p 737-8.

Question 36

75. A 60-year-old woman is seen in consultation by your rehabilitation team after elective surgery. She has a new finding of 1/5 strength in her lower extremities, but retained propioception and vibratory sense. You make the diagnosis of
    (a) posterior spinal cord syndrome.
    (b) central cord syndrome.
    (c) anterior spinal cord syndrome.
    (d) conversion disorder.

Answer 36

(c) In anterior spinal cord syndrome there is usually paralysis below the level of the lesion, along with bilateral loss of pain and temperature sensation. Proprioception and vibratory sense are partially preserved. This syndrome often occurs after significant intraoperative hypotensive events. Central cord syndrome refers to weakness that is greater in the upper extremities than the lower extremities. Posterior cord syndrome shows loss of proprioception and is the least common of the incomplete spinal cord injury syndromes. Woolsey RM, Martin DS. Acute nontraumatic myelopathies. In: Lin VW, editor. Spinal cord medicine principles and practice. New York: Demos; 2003. p 407-12.

Question 37

85. Autonomic dysreflexia is most commonly precipitated by
    (a) bladder distension
    (b) bowel impaction
    (c) heterotopic ossification
    (d) atelectasis

Answer 37

(a) Autonomic dysreflexia occurs in individuals with spinal cord injuries at the level of T6 and above. It occurs because of sympathetic discharge resulting from a stimulus below the injury level. The most common cause is bladder distension, which can result from a clogged or kinked indwelling urinary catheter or from delayed intermittent catheterization. Bowel impaction is the second most common cause of autonomic dysreflexia. Campagnolo DI, Merli GJ. Autonomic and cardiovascular complications of spinal cord injury. In: Kirshblum S, Campagnola D, DeLisa J, editors. Spinal cord medicine. Philadelphia: Lippincott Williams & Wilkins; 2002. p 125-7.

Question 38

86. An 80-year-old man with peripheral neuropathy and multiple medical conditions fell at home and was found several hours later. He was admitted to the hospital for a sacral insufficiency fracture and failure to thrive. During your initial consultation, you notice a skin ulcer in which the entire thickness of the skin is involved without involvement of the underlying fascia. According to the National Pressure Ulcer Advisory Panel, the patient’s ulcer is classified as stage
    (a) 1
    (b) 2
    (c) 3
    (d) 4

Answer 38

(c) Stage 1: Nonblanchable erythema of intact skin not resolved within 30 minutes; epidermis intact. Stage 2: Partial-thickness skin loss involving the epidermis, possibly into dermis. Stage 3: Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Stage 4: Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (eg, tendon or joint capsule). rehabilitation: principles and practice. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p 1608.

Question 39

105. A 32-year-old man is admitted to your rehabilitation facility 3 weeks after sustaining a spinal cord injury. The motor (right/left) examination reveals

R Motor L Motor

Deltoids 2 5

Biceps 2 5

Wrist extensor 2 5

Triceps 2 3

Finger flexors 1 1

Intrinsics 1 1

Hip flexors 0 0

Knee extensors 0 0

Dorsiflexors 0 0

Plantarflexors 0 0

Sensory exam reveals intact pinprick and light touch sensation through C4 on the right and C7 on the left. Sensation is absent below C5 on the right and C7 on the left.
What is this patient’s ASIA score?

(a) C4 ASIA A
(b) Right C4/ Left C7 ASIA A
(c) C6 ASIA A
(d) Right C4/ Left C7 ASIA B

Answer 39

(b) Based on the ASIA classification system revised in 2000, the lowest intact level on the left would be C7 (a motor score ≥ 3/5 with the level above being 5/5). On the right, the ASIA score is determined by the last intact sensory level, which is C4. When motor/sensory scoring differences exist between the 2 sides, then each side should be reported separately. This example indicates that there is no sacral sparing, so it can only be ASIA A.

Question 40

115. Etidronate disodium (Didronel) is used in the management of heterotopic ossification to
     (a) improve range of motion.
     (b) reverse immature ossification.
     (c) reverse mature ossification.
     (d) prevent ossification.

Answer 40

(d) Etidronate blocks the late phase of bone formation (mineralization), by preventing the conversion of amorphous calcium phosphate to hydroxyapatite. The drug has no effect on the early phase of ossification.

Question 41

A 46-year-old man with a 1-year history of C8 ASIA A spinal cord injury presents to your clinic with a 1-month history of increasing bilateral upper extremity weakness and pain. There is no history of trauma. You would

(a) observe for 2 to 4 weeks and repeat ASIA exam.
(b) perform electrodiagnostic testing to rule out peripheral nerve compression.
(c) order a magnetic resonance imaging study to look for posttraumatic syringomyelia.
(d) initiate a workup for pernicious anemia.

Answer 41

(c) Posttraumatic syrinx results in neurologic decline in 3% to 8% of patients with spinal cord injuries and can develop 2 months to 30 years after spinal cord injury. Prompt diagnosis is essential and magnetic resonance imaging is usually definitive for diagnosing posttraumatic syrinx. Surgical treatment is usually indicated when there is clear neurological decline.

Question 42

145. What is one reason for placing a suprapubic catheter in a person with a complete cervical spinal cord injury who currently uses intermittent catheterization?
     (a) Decreased rate of bladder/kidney infections
     (b) Decreased high bladder pressures
     (c) Decreased rate of bladder/kidney stone formation
     (d) Reduced risk of developing autonomic dysreflexia

Answer 42

(b) The rates of infections and stones are higher with suprapubic catheters. An indwelling catheter results in a slight increased risk of bladder cancer. High internal bladder pressures may occur as a result of detrusor sphincter-dyssynergia and avoiding reflux by allowing continuous drainage can be safer than intermittent catheterization for some individuals.

Question 43

165. For an individual who has C5 tetraplegia, orthotic splinting attempts to maintain the functional position of the hand. This usually includes
     (a) closing the thumb web space.
     (b) 30º to 40º of metacarpophalangeal flexion.
     (c) promoting flattening of the palmar arch.
     (d) supporting the wrist in 20º to 30º of extension.

Answer 43

(d) The functional position of the hand includes supporting the wrist in 20º to 30º of extension, supporting the palmar arch with the 4th and 5th metacarpals slightly anterior to the second and third digits. Metacarpophalangeal flexion of 30° to 40° would be excessive. The thumb web space should be preserved.

Question 44

182. Which statement is TRUE about the relative responses of the brain and the spinal cord after concussive trauma?
     (a) The brain is more sensitive to trauma than the spinal cord.
     (b) The spinal cord is more sensitive to trauma than the brain.
     (c) The brain and the spinal cord are equally sensitive to trauma.
     (d) The brain’s neurologic recovery is less predictable than the spinal cord’s in its response to a given amount of trauma.

Answer 44

(b) Concussive injuries of the spinal cord are more varied in gradation than injuries to the brain. Seemingly mild spinal concussions, seen most frequently in cervical hyperextension, may lead to complete tetraplegia, even in the absence of penetration of the spinal canal or even vertebral fracture. Mild concussive trauma to the brain results in a more mild brain injury and a more severe concussive trauma to the brain results in a more severe neurologic dysfunction.

Question 45

185. Five weeks after sustaining a T6 complete spinal cord injury, your patient is noted to have new urinary incontinence with intermittent catheterization volumes of less than 150cc. Work-up is negative for a urinary tract infection. You consider starting
     (a) tamsulosin (Flomax).
     (b) tolterodine (Detrol).
     (c) terazosin (Hytrin).
     (d) bethanechol (Urecholine).

Answer 45

(b) The patient is likely developing spontaneous detrusor contractions. You would consider using an anticholinergic agent to decrease detrusor (and hence bladder) pressures. Ideally, you would obtain urodynamic studies to ascertain bladder pressures and detrusor-sphincter coordination and would use these findings to guide treatment.

Question 46

25. A 27-year-old man with a T12 ASIA class A spinal cord injury for 10 years presents with right

shoulder pain that is worse with use, particularly when reaching and doing transfers. He plays

basketball twice weekly. Recommendations should include

(a) no wheeling or transfers for 2 weeks.
(b) immobilization of the elbow and shoulder.
(c) electrodiagnostic study of the upper extremity.
(d) strengthening of the scapular stabilizers.

Answer 46

(d) Shoulder and neck pain are common following spinal cord injury (SCI). The pain may arise from

the neck, shoulder girdle, or the glenohumeral joint. Pain may be a symptom of post-traumatic

syringomyelia or a manifestation of cervical disc degeneration. The prevalence of shoulder pain in

persons with SCI is estimated to be 30% to 50%. Rotator cuff tear, bursitis, tendonitis and

impingement have all been reported. While the diagnosis of these disorders is similar to that in the

able-bodied population, the treatment is not. In a person with SCI and upper limb pain, rest is often

not possible. Pain is often related to overall posture and poor biomechanics. Strengthening of

scapular stabilizers can help to correct this imbalance. Immobilization should be avoided. Pain

relief is the focus, and may include: relative rest (not to interfere with a person’s independence),

medications, injections, icing, ultrasound, transcutaneous electrical nerve stimulation, and/or

acupuncture.

Question 47

45. You are caring for a patient with a T3ASIA class A spinal cord injury who complains of burning

pain in his legs. Additional review of systems includes urinary leakage between catheterizations, and

difficulty sleeping. The best pharmacologic intervention at this time would be

(a) amitriptyline (Elavil).
(b) paroxetine (Paxil).
(c) trazodone (Desyrel).
(d) fluoxetine (Prozac).

Answer 47

(a) Amitriptyline, a tricyclic antidepressant is among the classic first line treatments in neuropathic
pain. Most common side effects related to tricyclic antidepressants are related mainly to the

anticholinergic effects and include dry mouth, urinary retention, and sedation. For this patient who

has difficulty sleeping, as well as urinary leakage between catheterizations, the anticholinergic sideeffects

may prove to be of benefit. Trazodone has not been demonstrated to reduce pain in for

spinal cord injury. Paroxetine causes insomnia and sexual dysfunction and therefore would not be

appropriate in this patient. Venlafaxine, sertraline, and fluoxetine have proven to be of limited

benefit for neuropathic pain.

Question 48

55. For persons with spinal cord injury who survive the first 24 hours, what is the leading cause of death

the first year postinjury?

(a) Pulmonary embolism
(b) Pneumonia
(c) Renal insufficiency
(d) Nonischemic heart disease

Answer 48

(b) The leading cause of death for persons with spinal cord injury who survive more than 24 hours is

pulmonary dysfunction (pneumonia, adult respiratory distress syndrome) followed by nonischemic

heart disease, septicemia and pulmonary embolus.

Question 49

66. You are taking care of a 72-year-old man who fell at home and remained on the ground for several
    hours. He subsequently developed a sacral pressure ulcer that now has large areas of necrotic tissue

without fluctuance. Which intervention is most appropriate?

(a) Proteolytic enzymes
(b) Triple antibiotic ointment
(c) Incision and drainage
(d) Oral antibiotics

Answer 49

(a) The necrotic tissue in this wound needs debridement. This may be accomplished with surgical

sharp debridement, mechanical nonselective debridement, such as with a wet-to-dry dressing, or

enzymatic debridement with a chemical agent that uses proteolytic enzymes. Topical and oral

antibiotics are not necessary in this patient, as necrotic tissue does not signify an infection. An

incision and drainage would not be appropriate, since no abscess is present.

Question 50

85. Compared with able-bodied individuals, persons with spinal cord injury are likely to have
    (a) equivalent percentage of regional and total body lean tissue.
    (b) higher testosterone levels.
    (c) equivalent incidence of dyslipidemia.
    (d) a lower resting metabolic rate.

Answer 50

(d) In persons with spinal cord injury, there is an initial dramatic loss of muscle mass after the acute
paralysis. However, even decades after injury, there is continuous loss of lean body tissue

compared to that observed in an able-bodied person. It is of particular interest that the arms of

persons with paraplegia have significantly less percent lean tissue compared with controls. No

differences in the cross sectional rate of loss of lean body mass is noted between persons with

tetraplegia and paraplegia. Men with spinal cord injury can be expected to lose about 3.2% per

decade of the total lean body tissue vs. 1% per decade in able-bodied males. Individuals with spinal

cord injury have a pattern of metabolic alteration that is atherogenic with dyslipidemia, glucose

intolerance, insulin resistance, and reduction in metabolic rate. Although the literature in persons

with spinal cord injury is conflicting regarding anabolic hormonal changes in persons with spinal

cord injury, there are subsets of individuals with relative androgen deficiency states. The etiology

of a relative deficiency of testosterone in persons with spinal cord injury has not yet been

established. However, it is conceivable that prolonged sitting and euthermia of the scrotal sack and

testes may itself have a deleterious local effect on testosterone production.

Question 51

125. The best expected functional outcome for a person with C7 ASIA class A spinal cord injury is
     (a) dependent with bladder management, independent with bed mobility, and some assist with all
     transfers.
     (b) dependent with bladder management, independent with bed mobility, and independent with

level transfers.

(c) independent with bladder management, some assist with bed mobility, and independent with

some transfers.

(d) independent with bladder management, independent with bed mobility, and independent with

level transfers.

Answer 51

(d) Expected functional outcomes after traumatic spinal cord injury have been delineated in the clinical

practice guidelines for health care professionals. A person who has sustained a spinal cord injury at

the C7-8 level can best be expected to need assistance in clearing secretions, may need partial to

total assistance with a bowel program, and may be independent with respect to bladder

management, bed mobility, and transfers to level surfaces.

Question 52

145. For a person who has C5 tetraplegia, orthotic splinting attempts to maintain the functional position

of the hand. This usually includes

(a) 1° to 20° of metacarpophalangeal flexion.
(b) supporting the wrist in 30° flexion.
(c) inhibiting metacarpophalangeal flexion.
(d) promoting flattening of the palmar arch.

Answer 52

(a) The functional position of the hand includes supporting the wrist in neutral to 30° extension,

supporting the palmar arch with the fourth and fifth metacarpals slightly anterior to the second and

third, 1° to 20° of metacarpophalangeal flexion, unimpeded, and preserving the thumb web space.

Question 53

165. A 25-year-old man with C6 tetraplegia, in a rehabilitation facility 6 weeks after injury, is having

difficulties with orthostatic hypotension. General measures including compression stockings,

abdominal binder, tilt table treatment, and daily salt tablets have been unsuccessful. Your next step

may be to prescribe

(a) bethanechol (Urecholine).
(b) baclofen (Lioresal).
(c) etidronate disodium (Didronel).
(d) fludrocortisone (Florinef).

Answer 53

(d) Fludrocortisone is a steroid with potent mineralocorticoid activity which acts on the renal distal

tubule, enhancing reabsorption of sodium and increasing fluid retention. Its property of increasing

the circulating plasma volume makes it an appropriate choice for reducing blood pressure drops in

patients with orthostatic hypotension.

Question 54

175. In the management of the neurogenic bowel, bisacodyl (Dulcolax) tablets and suppositories are
     (a) colonic stimulants that stimulate and enhance the gastrocolic reflex and thereby induce

peristalsis in the colon.

(b) stool softeners that aid in softening the stool by emulsifying fats in the gastrointestinal tract.
(c) colonic stimulants that are primarily effective by being directly absorbed through the mucosa

of the small intestine or colon.

(d) contact irritants that act directly on the colonic mucosa to produce peristalsis throughout the

colon.

Answer 54

(d) Bisacodyl (Dulcolax) tablets and suppositories are contact irritants that act directly on the colonic

mucosa, and produce peristalsis throughout the colon. Administered orally, the drug exerts its

effect through direct contact on the colon, not through absorption in the small intestine.

Question 55

185. The best test to diagnose a suspected post-traumatic syrinx in the cervical cord is
     (a) cervical spine x-ray.
     (b) spiral computerized tomography.
     (c) magnetic resonance imaging.
     (d) contrast myelogram.

Answer 55

(c) Magnetic resonance imaging (MRI) is considered the best imaging study available for diagnosing

posttraumatic syringomyelia. MRI findings often associated with clinical neurological decline

include a spinal cord syrinx that is longer and wider, a syrinx with poorly demarcated T2-weighted

signal hyperintensity at the rostral extent, syrinxes associated with spinal stenosis, or a flow void

sign on T2-weighted images suggesting high pressure. A large syrinx however may be seen

without any symptoms noted.

Question 56

5. According to the Consortium for Spinal Cord Medicine’s Clinical Practice Guidelines for the

Prevention of Thromboembolism in Spinal Cord Injury, individuals with motor complete (ASIA A

or B) spinal cord injury should receive

(a) warfarin (Coumadin), international normalized ratio target: 2–3.
(b) low-molecular-weight heparin or adjusted-dose unfractionated heparin.
(c) inferior vena cava filter.
(d) unfractionated heparin, 5000 units every 12 hours.

Answer 56

(b) Clinical practice guidelines for spinal cord injury (SCI) have been established for the prevention of
thromboembolism. Anticoagulant prophylaxis either with low-molecular-weight heparin or

adjusted-dose unfractionated heparin should be initiated within 72 hours after SCI. Inferior vena

cava filter placement is indicated in SCI patients who have failed to respond to or have

contraindications to anticoagulation. Filter placement is not considered a substitute for

thromboprophylaxis.

Question 57

25. A 25-year-old man with L5 complete paraplegia is admitted to your rehabilitation service 2 weeks

after his injury. On admission you note that he is tolerating an oral diet but has not produced a

bowel movement for 6 days. At this point, you recommend

(a) oxybutynin (Ditropan) 3 times a day.
(b) a contact irritant suppository with digital stimulation daily.
(c) manual removal of stool from the rectum 1–2 times daily.
(d) nasogastric decompression for a presumed ileus.

Answer 57

(c) Individuals with lower lumbar and sacral level injuries usually experience areflexic bowel function.

The use of suppositories are usually not useful in these individuals, because of the absence of spinal

reflex activity. Manual evacuation is often required for an effective bowel program in a lower

motor neuron injury. Anticholinergic medications may lead to constipation.

Question 58

65. You are told by a physical therapist that your patient with acute C5 ASIA A tetraplegia is having

difficulty breathing, but only when sitting upright. Appropriate lab tests and radiologic studies are

unremarkable. To address the patient’s breathing difficulty, you suggest
(a) bilateral above-knee compression stockings.
(b) a tilt table program.
(c) intermittent positive pressure breathing treatments.
(d) the use of an abdominal binder

Answer 58

(d) In the acute complete tetraplegic patient there is a lack of abdominal muscle tone. An abdominal

binder can help because when the patient using it sits upright the abdominal contents are pulled

caudally and also are pushed inward. This action pushes up on the diaphragm and allows it to start

in a position of mechanical advantage when inhaling while upright. Compression stockings and tilt

table programs can be useful for a decrease in blood pressure that accompanies upright posture.

Orthostatic hypotension is associated with lightheadedness, dizziness, nausea, syncope. Intermittent

positive pressure breathing can be useful to decrease atelectasis.

Question 59

Based on the revised edition of the American Spinal Injury Association (ASIA) Impairment Scale,

published in the year 2000, which condition would be sufficient to categorize a spinal cord injury as

motor incomplete?

(a) Some motor function more than 2 levels below the motor level
(b) Voluntary anal sphincter contraction
(c) A well-defined zone of partial preservation
(d) An anterior spinal artery syndrome

Answer 59

(b) For an individual to receive an ASIA classification of motor incomplete injury (ASIA C or D),

he/she must have either voluntary anal sphincter contraction or sensory sacral sparing with sparing

of motor function more than 3 levels below the motor level. The zone of partial preservation is used

5 of 11

only in complete injuries. Individuals with anterior spinal artery syndrome are often motor

complete.

Question 60

105. In regards to quality of life after spinal cord injury, which factor has the LEAST correlation with

life satisfaction?

(a) Level of injury (paraplegia versus tetraplegia)
(b) Access to leisure activities
(c) Marriage
(d) Number of hospitalizations

Answer 60

(a) The highest levels of life satisfaction for individuals with spinal cord injuries have been correlated

with employment, education, number of hospitalizations, marriage, time since injury, leisure

activities, social support, and adequate finances. Little correlation has been found between level of

injury and life satisfaction.

Question 61

115. Which statement is TRUE regarding treatment of spasticity in individuals with spinal cord injuries?
     (a) Over 75% of individuals require treatment for their spasticity at the time of discharge from
     rehabilitation.
     (b) The use of a muscle relaxant such as carisoprodol (Soma) is effective in spasticity of spinal
     origin.
     (c) Botulinum toxin injections are effective because of their long (6–12 month) duration of
     effect.
     (d) Intrathecal baclofen delivery often eliminates the need for oral antispasticity medication.

Answer 61

(d) Less than 40% of individuals with spinal cord injuries require treatment for their spinal cord injury

at the time of discharge from acute rehabilitation. There is no evidence to support the use of

carisoprodol in spasticity of spinal origin. The average duration of effect for botulinum toxin is 3 to

6 months.

Question 62

125. The majority of new spinal cord injuries in the United States are a result of
     (a) violence.
     (b) falls.
     (c) motor vehicle accidents.
     (d) sports.

Answer 62

(c) Automobile accidents account for 34.5% of new spinal cord injuries, falls 22.0%, gunshot wounds
17. 2%, diving 4.5%, and motorcycle crashes 4.4%. These figures represent all races combined.

Question 63

135. Which statement is TRUE regarding spasticity in the individual with spinal cord injury?
     (a) Most antispasticity medications can completely eliminate spasticity.
     (b) The incidence of spasticity is higher in individuals with lower thoracic spinal cord injury than

in those with cervical spinal cord injuries.

(c) Spasticity can offer a functional benefit to some individuals with spinal cord injuries.
(d) Clonus is an example of a tonic stretch reflex.

Answer 63

(c) No single medication for spasticity is universally beneficial and reduction of spasticity, rather than

elimination of it, is the more likely outcome. The incidence of spasticity is higher in individuals

with cervical and upper thoracic injury than in those with lower thoracic injury. Lower extremity

tone may be helpul for activities such as transfers, standing, and ambulation. Spasticity is often

characterized as either phasic or tonic. Tonic spasticity is seen as increased tone. Phasic spasticity is

usually seen in hyperactive tendon jerks.

Question 64

According to the Consortium for Spinal Cord Medicine’s Clinical Practice Guidelines for the

Prevention of Thromboembolism in Spinal Cord Injury, individuals with motor incomplete (ASIA

class C or D) spinal cord injury should receive

(a) warfarin (Coumadin), international normalized ratio target: 2–3.
(b) low molecular weight heparin.
(c) inferior vena cava filter.
(d) unfractionated heparin, 5000 units every 12 hours.

Answer 64

(d) According to the guidelines for the prevention of thromboembolism in spinal cord injury, patients

with low risk motor incomplete injuries require only compression hose and compression boots;

those with intermediate risk require unfractionated heparin, 5000 units every 12 hours. Patients

with a motor complete injury should receive either unfractionated heparin to a high normal

activated partial thromboplastin time (aPTT) or low molecular weight heparin twice daily. Persons

with a motor complete injury with other risk factors including lower limb fracture, risk of

thrombosis, cancer, heart failure, or other compromising factors may require an inferior vena cava

filter in addition to the prescribed drugs.

Question 65

15. Compared to persons with traumatic spinal cord injury, persons with non-traumatic spinal cord

injury are more likely to be

(a) under the age of 35 years.
(b) female.
(c) tetraplegic.
(d) single.

Answer 65

(b) Persons with nontraumatic spinal cord injury (SCI) are older, more likely married, female, retired,

and have significantly more paraplegia and incomplete injury than persons with SCI of traumatic

etiology, with neoplasm (53%) and cervical spondylosis (25%) as the leading causes of

nontraumatic injury.

Question 66

25. What is the leading cause of traumatic spinal cord injury in the United States?
    (a) Falls
    (b) Sports related injury
    (c) Gunshot wound
    (d) Motor vehicle crash

Answer 66

(d) The leading cause of traumatic spinal cord injury in the United States is motor vehicle crash. The

incidence of spinal cord injury from gunshot wounds is decreasing nationally; falls are now the

second most common cause nationwide, followed by sports related injuries.

Question 67

55. The occurrence of renal calculi during the first 3 months after spinal cord injury is related to
    (a) level of injury.
    (b) immobilization hypercalciuria.
    (c) method of bladder management.
    (d) number of urinary tract infections.

Answer 67

(b) Renal calculi occur in approximately 8% of patients with spinal cord injury. Approximately 98% of

renal calculi in persons with spinal cord injury are composed either of calcium phosphate or

magnesium ammonium phosphate. These stones are typically associated with urinary tract

infections (UTIs). Early stone formation is likely secondary to immobilization hypocalcemia,

whereas later stone formation is secondary to repeated UTIs and long term use of an indwelling

catheter.

Question 68

85. A 22-year-old woman with a C5 ASIA class A spinal cord injury sustained in a car crash 2 weeks

ago complains of lightheadedness, dizziness, and nausea during her physical therapy session. In

response to her therapist’s call, you recommend

(a) sitting the patient up and loosening tight garments.
(b) placing the patient in Trendelenburg position.
(c) using elastic abdominal binders and elastic stockings.
(d) adjustment of HALO vest.

Answer 68

(c) Orthostatic hypotension (OH) is a decrease in blood pressure that results from a change in body

position toward the upright posture. Symptoms include lightheadedness, dizziness, nausea. This

form of hypotension is most likely to occur in persons with high levels of injury. Treatment

involves daily tilting with gradual change to upright posture. Elastic binders help compress the

abdomen, thus limiting blood accumulation in the abdominal vasculature. Elastic stockings limit

blood accumulation in lower extremities. Patients must be adequately hydrated. Salt tablets, 1

gram 4 times daily, ephedrine, 20–30mg up to 4 times daily, Florinef, and Midodrine may be used

as pharmacologic adjuncts.

Question 69

115. The management of acute spinal cord compression due to tumor includes
     (a) nerve growth factor.
     (b) thoracolumbosacral orthosis (TLSO).
     (c) corticosteroids.
     (d) urecholine.

Answer 69

(c) Corticosteroids are indicated in acute spinal cord compression in an effort to reduce the tumorrelated

inflammatory changes and prostaglandin production. The dose, however, is controversial.

Radiation therapy is indicated for patients with spinal cord compression due to soft tissue

encroachment. It can be employed as monotherapy in cases of spinal stability, with or without

neurologic changes, or as an adjunctive therapy to surgery for patients with spinal instability. The

major complications of radiation treatment include the development of radiation myelopathy,

radiation plexopathy, and tumor recurrence. However, radiation therapy is indicated for these

individuals to provide decompression of neural structures and cytoreduction of the tumor,

prevention of neurologic progression and prevention of local recurrence, and for relief of pain.

Most surgeons will not consider surgical intervention if the patient has a prognosis of less than 3

months’ survival when faced with the question of surgical management of tumors. With either a

primary or metastatic spine tumor, commonly a corpectomy will be performed. In this procedure

most of the involved vertebral body and the intervertebral disk above and below the involved

vertebra are excised. Since the majority of corpectomies for spine tumors involve metastatic

disease, the goal of surgery is palliation rather than surgical cure.

Question 70

125. Treatment is indicated in asymptomatic bacteriuria when an individual with a spinal cord injury

has

(a) chronic use of an indwelling Foley catheter.
(b) bladder augmentation.
(c) pyuria of 10–20 white blood cell count (WBC).
(d) ureteral reflux or hydronephrosis.

Answer 70

(d) Bacteruria is a common problem in patients with voiding dysfunction. At approximately 1 year

postinjury, 66% to 100% of all individuals with spinal cord injury have had at least 1 episode of

bacteruria, depending upon their bladder management program. Asymptomatic bacteruria has been

found to be present in 1%–-25% of community dwelling patients and 25%–40% of nursing home

patients older than 65. There is general agreement that asymptomatic bacteruria in a patient using a

Foley catheter should not be treated. Attempts should be made to eradicate asymptomatic

bacteruria and bacteruria associated with high grade reflux before urologic instrumentation and

hydronephrosis, or in the presence of urea splitting agents.

Question 71

135. Which factor is associated with successful phrenic nerve pacing for independent respiration in

patients with tetraplegia?

(a) Initiation of pacing shortly after injury
(b) Location of injury at or above C2
(c) The presence of central sleep apnea
(d) Ability to breathe on t-piece for 15 minutes

Answer 71

(b) Electrophrenic respiration or phrenic nerve pacing should not be performed until at least several

months after injury, since some patients recover diaphragmatic function over a period of several

months. Criteria for use of phrenic nerve pacing include an injury at or above C2, with intact

phrenic nerves. Most patients injured at C3, C4, or C5 should be able to wean from the ventilator.

Some risk exists with phrenic pacing because the electric transmitter can fail. Additionally, patients

may not be able to develop a deep enough breath with this technique to prevent atelectasis.

Electrophrenic pacing is expensive and requires extensive training of personnel who will care for

patients. There must be a backup ventilator in the event of electrophrenic failure.

Question 72

155. Which antispasticity medication is relatively contraindicated in individuals who have motor

incomplete spinal cord injury?

(a) Baclofen (Lioresal)
(b) Dantrolene (Dantrium)
(c) Diazepam (Valium)
(d) Tizanidine (Zanaflex)

Answer 72

(b) Dantrolene sodium depresses the release of calcium from the sarcoplasmic reticulum and is unique

in having a direct effect on skeletal muscles. It acts on all skeletal muscles and may weaken

partially innervated muscles, causing muscles which are functional to becoming nonfunctional.

Question 73

185. Which statement is TRUE regarding the vascular supply to the spinal cord?
     (a) The paired anterior spinal arteries provide circulation to the anterior two-thirds of the

spinal cord.

(b) The posterior spinal artery is a single vessel that provides circulation to the posterior onethird

of the spinal cord.

(c) The watershed region is supplied only via the radicular arteries.
(d) The artery of Adamkiewicz provides circulation to the lumbosacral region.

Answer 73

(c) There is a watershed zone from approximately T4 to T6 that is highly vulnerable to ischemia. The

zone has 1 anterior and 2 posterior spinal arteries. The artery of Adamkiewicz enters between

about T9 and T10.

Question 74

15. What function is expected in an individual with a C7 ASIA class A spinal cord injury?
    (a) Need assistance to perform level transfers
    (b) Pressure reliefs primarily by side-to-side weight shift
    (c) Independence in bowel and bladder management
    (d) Independent dressing and bathing with adaptive equipment

Answer 74

(d) 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. Persons

with motor level C7 ASIA class A should be able to independently feed, dress, and bathe

themselves, using adaptive equipment and built up utensils. They should be 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 at level T1 and lower.

Question 75

25. Regarding spinal shock in acute spinal cord injury,
    (a) duration of spinal shock is correlated with long term outcome.
    (b) reflex activity typically returns over the course of days.
    (c) a reliable ASIA classification can be performed during spinal shock.
    (d) it is more common in tetraplegia than in paraplegia.

Answer 75

(c) Spinal shock is a condition in which upper motor neuron sensory motor loss is associated with

areflexia below the level of injury. It is a poorly defined phenomenon. Reflex activity can often be

detected by electrophysiologic study when it is not clinically apparent. Reflex activity typically

returns over the course of weeks or months. The presence of spinal shock is of marginal prognostic

significance. A reliable ASIA classification can be carried out when spinal shock is present.

Question 76

45. Your patient has a C6 ASIA class A spinal cord injury which he sustained 8 weeks ago. He has been

noncompliant about attending therapy. Today he refuses to participate in therapy because he states

he has a headache. The nurses report poor urine output from the Foley catheter in the last 3 hours.

You order 
(a) intravenous bolus of normal saline. 

(b) push oral fluids and go to therapy.
(c) replacement of catheter.
(d) visit from peer mentor.

Answer 76

(c) Autonomic dysreflexia must be ruled out. A Foley kink, or plugged catheter can distend the

bladder, causing autonomic dysreflexia with headache (and, ultimately, hypertension, piloerection

and flushing). The catheter should be checked for twists and kinks and be flushed. If urine/flush

return is poor, the catheter should be changed.

Question 77

55. Regarding the American Spinal Injury Association (ASIA) classification in prognosticating recovery,
    (a) ASIA class A has a reasonable probability of improvement if there is no concurrent brain
    injury.
    (b) preservation of pinprick in ASIA class B carries a better potential for ambulation than

preservation of light touch sensation.

(c) recovery statistics for ASIA class C do not include the central-cord syndrome.
(d) Brown-Séquard’s syndrome has the worst potential for ambulation in ASIA class D.

Answer 77

(b) The presence of sensation in the sacral (S3–S5) dermatomes in patients with motor complete injury

indicates a favorable prognosis in terms of motor recovery, with pinprick sparing having the closest

correlation for motor recovery. Motor segments in the zone of injury in patients with complete

injury and an initial strength of 0/5 were more likely to recovery strength of 3/5 or more at 1 year if

the sensation in the corresponding dermatomes was intact. Most patients originally categorized as

ASIA (or Frankel) class A who progressed to ASIA class D or E had sustained traumatic brain

injury with cognitive impairment and were incorrectly diagnosed initially as class A.

Question 78

85. A 28-year-old with T11 paraplegia for 6 months comes to your office to discuss treatment options

for erectile dysfunction. A trial of sildenafil (Viagra) was unsuccessful. He asks about constriction

rings. You tell him
(a) they should not be used in men with sickle cell disease.
(b) they can be kept in place for up to 2 hours.
(c) they cannot be used without a vacuum pump.
(d) they are not effective for erectile dysfunction in spinal cord injury.

Answer 78

(a) Constriction rings (cock rings) to occlude venous outflow can be used if a person is having a poorly

sustained erection. A vacuum pump and constriction rings can be used if a person is having no

erections. To prevent skin breakdown from prolonged venous congestion within the penis, the ring

should not be kept in place for more than 30 minutes. They should not be used in men with sickle

cell disease. Anticoagulants are a relative contraindication to their use.

Question 79

115. In an individual with a C6 complete spinal cord injury, the ability to generate a “pinch” is produced

by

(a) wrist extension.
(b) elbow supination
(c) wrist flexion.
(d) elbow pronation.

Answer 79

(a) Wrist extension via extensor carpi radialis results in passive shortening of the (finger) flexor
tendons. This phenomenon is termed tenodesis.

Question 80

125. Individuals with spinal cord injury who are at the highest risk of developing bladder cancer have as a

risk factor

(a) multiple urinary tract infections.
(b) indwelling Foley catheter.
(c) history of bladder calculi.
(d) ASIA class A.

Answer 80

(b) Bladder cancer is the fifth most common neoplasm and the twelfth leading cause of cancer

mortality in the United States. Known risk factors for bladder cancer include male gender, smoking,

occupational exposure to aromatic amines and schistosomiasis. In studies of spinal cord injury

featuring age-matched and gender-adjusted standardized data, however, bladder cancer has

generally been found to be far more prevalent. When looking at independent variables, which point

to a higher risk of bladder cancer, only bladder management method and age at spinal cord injury

significantly predicted bladder cancer. ASIA classification, level of spinal cord injury and a history

of bladder calculi did not contribute significantly. Risk of bladder cancer is the highest in

individuals who have used an indwelling catheters for longer than 10 years. The relative risk of

bladder cancer from indwelling catheter use is relatively unchanged when adjusted for smoking

status. Multiple urinary tract infections is not a risk factor.

Question 81

135. In spinal cord injury, increased reports of pain are seen more commonly in patients with
     (a) complete spinal cord injury.
     (b) hypercalcemia.
     (c) gunshot wound.
     (d) surgical stabilization.

Answer 81

(c) The prevalence of pain in spinal cord injury (SCI) has been reported to be as high as 94%. It is

reported to interfere with activities of daily living in 5% to 45% of patients with spinal cord injury.

The onset of SCI pain typically occurs within the first year of injury in the majority of patients. Pain

is reported to decrease in intensity and frequency over time. Factors related to self-reported pain

include patients with older age, incomplete spinal cord injury, cauda equina injuries, cervical spinal

cord injury, central cord syndrome, gunshot wound injury, and syringomyelia.

Question 82

145. A 27-year-old man with a T12 ASIA A spinal cord injury for 10 years presents with right shoulder

pain that is worse with use, particularly when reaching and doing transfers. He plays basketball

twice weekly. Recommendations should include

(a) no wheeling or transfers for 2 weeks.
(b) immobilization of the elbow and shoulder.
(c) electrodiagnostic study of the upper extremity.
(d) strengthening of the scapular stabilizers.

Answer 82

(d) Shoulder and neck pain are common following spinal cord injury (SCI). The pain may arise from

the neck, shoulder, girdle, or the glenohumeral joint. Pain may be a symptom of post-traumatic

syringomyelia or a manifestation of cervical disc degeneration. The prevalence of shoulder pain in

persons with SCI is estimated to be 30% to 50%. Rotator cuff tear, bursitis, tendonitis and

impingement have all been reported. While the diagnosis of these disorders is similar to that in the

able-bodied population, the treatment is not. In a person with SCI and upper limb pain, rest is often

not possible. Pain is often related to overall posture and poor biomechanics. Strengthening of

scapular stabilizers can help to correct this imbalance. Immobilization should be avoided. Pain

relief is the focus, and may include: relative rest (not to interfere with a person’s independence),

medications, injections, icing, ultrasound, transcutaneous electrical nerve stimulation, and/or

accupuncture.

Question 83

155. Indications for bullet removal after a gunshot wound injury to the spinal cord include
     (a) cauda equina location.
     (b) the need to reduce the risk of lead toxicity.
     (c) pain reduction.
     (d) the need to reduce risk of infection.

Answer 83

(a) The role of surgery is controversial in fractures of the thoracic spine and thoracolumbar junction.

Patients with complete injuries do not have significantly improved neurologic function after

decompression. However, individuals with incomplete injuries may benefit from surgical
intervention. Indications for emergent surgical treatment include progressive neurologic

deterioration, and expanding epidural hematoma. Because it may destabilize the spine,

laminectomy is infrequently indicated in acute spinal cord injury. Initial management of penetrating

spinal injury differs from that of other traumatic spinal cord injury. Operative treatment is often not

warranted since neither bullet removal nor spinal debridement has been associated with a lower risk

of infection, diminished pain, or enhanced neurologic recovery. The risk of lead toxicity rarely

necessitates bullet removal. Indications for surgery after penetrating injury include persistent

cerebral spinal fluid leak, early progressive neurologic deterioration with bone, missile fragments,

or hematoma in the spinal canal, and injuries involving the cauda equina.

Question 84

165. You are caring for a patient with a T3ASIA class A spinal cord injury who complains of burning

pain in his legs. Additional review of systems includes urinary leakage between catheterizations,

sexual dysfunction, and difficulty sleeping. The best pharmacologic intervention at this time would

be

(a) amitriptyline (Elavil).
(b) paroxetine (Paxil).
(c) trazodone (Desyrel).
(d) fluoxetine (Prozac).

Answer 84

(a) Amitriptyline, a tricyclic antidepressant is among the classic first line treatments in neuropathic
pain. Most common side effects related to tricyclic antidepressants are related mainly to the

anticholinergic effects and include dry mouth, urinary retention, and sedation. For this patient who

has difficulty sleeping, as well as urinary leakage between catheterizations, the anticholinergic sideeffects

may prove to be of benefit. Trazodone has not been demonstrated to reduce pain in for

spinal cord injury. Paroxetine causes insomnia and sexual dysfunction and therefore would not be

appropriate in this patient.

Question 85

You are performing urodynamic studies on an individual with a T10 ASIA class A spinal cord injury

sustained 2 years previously. He performs intermittent catheterization every 6 hours and reports no

episodes of urinary incontinence between catheterizations. You find that the filling pressure or leak

point pressure is 20cm of water. At this time, you recommend

(a) oxybutinin (Ditropan).
(b) initiation of Credé maneuver.
(c) continuation of current bladder program.
(d) urecholine (Bethanechol).

Answer 85

(c) The primary risk factor for serious urologic complications such as vesicoureteral reflux and

deterioration of renal function in persons with detrusor external sphincter dyssynergia is that of

elevated intravesical pressure. For this reason, it is essential to determine urinary storage and leak

point pressures. In general, damage to the upper urinary tract can be avoided if voiding pressure is

maintained less than 60cm of water while the maximum filling pressure or leak point pressure

should be less than 40cm of water. For this patient who is having no episodes of leaking between

his every 6-hour catheterizations, continuation of current program is reasonable. If on follow-up,

his leak point pressure exceeds 40cm of water, conversion to a low pressure system via

anticholinergics would be reasonable. The use of a cholinergic agonist (Urecholine) would be

contraindicated, since this agent may increase the intravesical pressure.

Question 86

5. Which change is included in the revised edition of the American Spinal Injury Association (ASIA)

Impairment Scale, published in the year 2000?

(a) The zone of partial preservation (ZPP) is defined as the most rostral segment with sensory
function.
(b) The Functional Independence Measure (FIM) has been added to the standards.
(c) The definition of a motor incomplete injury requires some motor function more than 3 levels

below the motor level.

(d) The sensory exam now includes a 5-point scale to include sharp and dull sensations,

proprioception, and vibration.

Answer 86

(c) The 2000 revisions have clarified a few issues from the previous standards. For a person to receive

a classification of motor incomplete spinal cord injury (ASIA C or ASIA D) they must have either

1) voluntary anal sphincter contraction or 2) sacral sensory sparing with sparing of motor function

more than 3 levels below the motor level. Previously, the person needed only to have sparing more

than 2 levels below the motor level. The FIM was eliminated from the standards. The ZPP is to be

documented as the most caudal segment with some sensory and/or motor function. There has been

no change in the 3-point (0-2) scale for the sensory exam.

Question 87

15. For persons with spinal cord injury who survive the first 24 hours, what is the leading cause of death

the first year post-injury?

(a) Pulmonary embolism
(b) Pneumonia
(c) Renal insufficiency
(d) Nonischemic heart disease

Answer 87

(b) The leading cause of death for persons with spinal cord injury who survive more than 24 hours is

pulmonary dysfunction (pneumonia, adult respiratory distress syndrome) followed by nonischemic

heart disease, septicemia and pulmonary embolus.

Question 88

25. In the emotional stages of recovery from spinal cord injury, most individuals
    (a) have prolonged feelings of guilt or worthlessness.
    (b) undergo a true depressive episode.
    (c) experience bereavement.
    (d) feel diminished interest or pleasure in almost all activities.

Answer 88

(c) Although the pattern of emotional reaction is unique to every person, coping with a spinal cord

injury normally involves sadness, yearning, and intense feelings of loss. While bereavement might

appear similar to depression, it does not ordinarily involve prolonged feelings of guilt,

worthlessness, self-reproach or thoughts of death as seen in depressive disorders. Because grieving

or bereavement is universal in the context of spinal cord injury, it is important to differentiate

bereavement from a depressive disorder.

Question 89

35. You are called to the bedside of an individual with a T3 spinal cord injury sustained 7 ½ weeks
    earlier. The person complains of pounding headache and appears to have piloerection on the upper

extremities, neck, and face, as well as flushing. Blood pressure is 150/90. The first thing you do is

(a) instill a topical anesthetic into the rectum in order to decrease sensation for a rectal check.
(b) apply 1 inch of topical nitropaste above the level of injury.
(c) irrigate the indwelling urinary catheter with a small amount of normal saline.
(d) sit the person up and loosen any clothing.

Answer 89

(d) This individual is experiencing autonomic dysreflexia, seen typically in individuals with spinal cord

injury with lesions at or above T6. A treatment algorithm that outlines the timing of treatment

recommendations was established by the consortium for spinal cord medicine in 1997. When an

individual presents with autonomic dysreflexic symptoms including elevated blood pressure

(systolic blood pressure greater than 150mm Hg), the very first thing to do is to sit the patient up

with his/her clothing and constrictive devices loosened. If the blood pressure remains elevated and

the individual has an indwelling catheter, kinks and twists should be removed. If there is no urine

flow, the catheter then needs to be irrigated. If the individual does not have an indwelling catheter,

a Foley catheter must be inserted and again if there is no urine flow, it should be irrigated. If there

is good urine flow and/or the blood pressure drops down to normal, then the work-up as well as

other interventions would cease. If the blood pressure remains elevated after irrigation or initiation

of catheter, and the systolic blood pressure remains above 150mm Hg, a short-acting

antihypertensive medication such as topical nitropaste is initiated. After this, if the individual

continues to be hypertensive, he/she may have to be admitted to a hospital to control blood

pressure. If, after the short-acting antihypertensive, the blood pressure drops, evaluation of the

rectum for fecal impaction begins, including installation of lidocaine into the rectum and allowing it

to sit for approximately 5 minutes to decrease sensation before probing the rectum with a gloved

finger and subsequently attempting to disimpact.

Question 90

45. You are called to the neurology intensive care unit to evaluate a patient with new spinal cord injury;

you determine that the patient has sustained a C7 ASIA A spinal cord injury. Which change in the

respiratory system would be expected?

(a) Residual volume will decline to 30% of predicted value.
(b) Pulmonary function will not improve after the first 2 weeks postinjury.
(c) Expiratory reserve volume increases 40% 6 weeks postinjury.
(d) Vital capacity of 60% predicted value may be obtained within the first 6 months post-injury.

Answer 90

(d) Tetraplegic patients usually have a reduction in all measures of pulmonary function with the

exception of residual volume. Residual volume is increased due to lack of active expiratory effort.

Vital capacity will continue to improve. Tracheostomy is usually not necessary for pulmonary

hygiene, especially with adequate hydration and techniques for facilitating cough. Since the

diaphragm is supplied by cervical roots C3, C4, and C5, it is common for persons injured above the

C4 level to need ventilator support. In acute spinal cord injury, 67% experience significant

pulmonary complications, most commonly atelectasis. Ventilatory failure and aspiration occur the

earliest (mean, 4.5 days), followed by atelectasis (mean, 17 days) and pneumonia (mean, 24 days).

The late decline coincides with the onset of mucus hypersecretion and muscle fatigue. Ventilator

weaning has been demonstrated in 80% of C4 spinal cord injury patients and 57% of C3 patients.

Considerable patience is required and respiratory muscle fatigue must be closely monitored.

Question 91

Which statement is TRUE regarding persons with complete spinal cord injury with concurrent

posterior rhizotomy who receive functional neuromuscular stimulation via an implanted device to

restore bowel and bladder function?

(a) Stimulation of the posterior S2, S3, S4 nerve roots will produce micturition.
(b) Stimulation will enhance reflex voiding.
(c) Stimulation will improve reflexogenic erection.
(d) Stimulation will increase bladder capacity.

Answer 91

(d) (This question has been eliminated from the exam, therefore, it was not scored.)

Because electrical stimulation for bladder and bowel function depends on the ability to activate

intact motor neurons from the sacral segments of the cord, it is at this time limited to persons with

suprasacral lesions. Micturition is produced by stimulation of the anterior (motor) S2, S3, and S4

nerve roots. Continence has been greatly improved by concurrent posterior rhizotomy of the

(sensory) sacral nerve roots. The advantages of posterior rhizotomy include increasing bladder

capacity and abolishing reflex voiding, reducing dyssynergia and abolishing episodes of autonomic

dysreflexia. The primary disadvantage of posterior rhizotomy is the loss of reflex erection and

reflex ejaculation (if these are present). The hardware cost is approximately $40,000 with the

projection that after factoring in the cost of medications, supplies, medical procedures, durable

medical equipment, and attendant care, the device pays for itself in 5 to 7 years.

Question 92

On hospital rounds, you note that your patient, who has a T10ASIA B spinal cord injury is now

using a rigid frame wheelchair in the therapy gym. In his attempt to show off as he propels toward

you, he suddenly flips over backward. What is the most likely problem?

(a) The rear axles are located directly under his center of gravity.
(b) The rolling resistance is increased.
(c) There is too much caster flutter.
(d) There is asymmetry in the chair’s camber angle from side to side.

Answer 92

(a) The center of gravity for a hypothetical wheelchair rider is typically located slightly forward of the

rear axle. Moving the rear axle directly under the wheelchair user makes the person and the chair

more likely to flip backwards (wheelie). However, the advantages to having the center of gravity

near the rear axles include decreased tendency for caster flutter, decreased rolling resistance, since

most of the weight is borne by the larger rear wheels, and minimization of the turning torque. Cooper RA. Wheelchair selection and configuration. New York: Demos Medical; 1998. p 199-226

Question 93

105. Compared with able-bodied individuals, persons with spinal cord injury are likely to have
     (a) equivalent percentage of regional and total body lean tissue.
     (b) higher testosterone levels.
     (c) equivalent incidence of dyslipidemia.
     (d) a lower resting metabolic rate.

Answer 93

(d) In persons with spinal cord injury, there is an initial dramatic loss of muscle mass after the acute
paralysis. However, even decades after injury, there is continuous loss of lean body tissue

compared to that observed in an able-bodied person. It is of particular interest that the arms of

persons with paraplegia have significantly less percent lean tissue compared with controls. No

differences in the cross sectional rate of loss of lean body mass is noted between persons with

tetraplegia and paraplegia. Men with spinal cord injury can be expected to lose about 3.2% per

decade of the total lean body tissue vs. 1% per decade in able-bodied males. Individuals with spinal

cord injury have a pattern of metabolic alteration that is atherogenic with dyslipidemia, glucose

intolerance, insulin resistance, and reduction in metabolic rate. Although the literature in persons

with spinal cord injury is conflicting regarding anabolic hormonal changes in persons with spinal

cord injury, there are subsets of individuals with relative androgen deficiency states. The etiology

of a relative deficiency of testosterone in persons with spinal cord injury has not yet been

established. However, it is conceivable that prolonged sitting and euthermia of the scrotal sack and

testes may itself have a deleterious local effect on testosterone production.

Question 94

115. A 15-year-old presents to the trauma unit at your hospital after a gunshot wound to the right upper

back, with an exit wound at the posterior left neck. Physical exam is as follows

R L

Biceps 5/5 5/5

wrist extensors 2/5 2/5

triceps 3/5 2/5

finger flexors 2/5 2/5

intrinsics 2/5 2/5

hip flexors 4/5 4/5

knee extensors 4/5 4/5

dorsiflexors 4/5 4/5

extensor hallicus 4/5 4/5

plantarflexors 4/5 4/5

Rectal exam reveals volitional sphincter control.

You determine that his ASIA level and class are

(a) C5 ASIA C
(b) C6 ASIA C
(c) C5 ASIA D
(d) C6 ASIA D

Answer 94

(c) Based on the ASIA classification revised in 2000, the highest intact level would be C5 (normal

muscle strength or >3/5 with the next level being normal). 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 less than 3/5. ASIA D is also motor

incomplete, with at least half of the muscle groups greater than 3/5. In this case, 11/18 muscle

groups are 3/5 or greater, making this person an ASIA D. The highest intact level is C5.

Question 95

125. Which of the following is true regarding first-year costs for persons with complete spinal cord

injury?

(a) Average hospital charges for tetraplegia are almost double those for paraplegia.
(b) Average costs for medications and supplies are equivalent to those for paraplegics and
tetraplegics.
(c) Average costs for home modifications equal those for the acute rehabilitation hospitalization.
(d) Annual recurring costs for medical care and treatment of secondary complications approach

those for that of initial injury costs.

Answer 95

(a) Initial acute care and rehabilitation costs average $223,261 per person. Acute care charges are

higher for persons with tetraplegia compared with persons who have paraplegia at the equivalent

severity of injury. Charges approach $157,000 for ASIA A, B, or C tetraplegia and vary from

$69,000 to $ 87,000 for other persons with spinal cord injury. Hospital costs for rehabilitation are

more than twice as high for persons with severe tetraplegia compared with severe paraplegia.

Average annual medical costs (excluding medications, supplies, and physician costs) are just over

$9,000 per year. Given a prevalence of 180,000 persons with spinal cord injury beyond their first

year of injury, this approaches $1.65 billion for the spinal cord injury population. Costs for supplies

and medications are 30% greater for tetraplegics than for paraplegics ($3,308 vs. $2,470). Home

modifications to the residence of a person with spinal cord injury is more than $15,000, and the cost

to modify other homes owned by the person, family, or friends is an additional $5,000.

Question 96

135. In a 22-year-old man who incurred an acute C5-6 fracture-subluxation (complete C5 tetraplegia),

from diving with an initial restoration of arm function includes

(a) upper extremity tendon transfers as early as possible to enhance goals for acute rehabilitation.
(b) splinting in a flat hand position to avoid tightening of the flexor tendons.
(c) a short opponens orthosis or utensil cuff to initiate self-care activities.
(d) exclusive use of a manual wheelchair to enhance upper extremity muscle strength.

Answer 96

(c) For persons with tetraplegia, proper hand position is maintained by resting hand splints that allow

tightening of the flexor tendons; this tightening promotes the use of tenodesis for hand function.

Functional activities improve significantly with the addition of wrist extensor muscles at the C6

level. Active wrist extensor result in tenodesis of the hand. With wrist control, patients can use a

short opponens orthosis or utensil cuff to feed themselves. While patients with tetraplegia usually

benefit from a lightweight, manual wheelchair, these patients are often appropriate for powered

mobility. The energy saved from pushing the wheelchair can be used for transfers, weight shifts,

and other activities, reducing the wear and tear on joints and soft tissues. Tendon transfers and

upper limb reconstructive surgery are considered 1 year postinjury, keeping in mind that upper limb

muscle recovery can occur over the course of up to 2 years.

Question 97

15. The best possible expected functional outcome for a person with C7 ASIA A spinal cord injury is
    (a) dependent with bladder, independent with bed mobility, and some assist with all transfers.
    (b) dependent with bladder, independent with bed mobility, and independent with level transfers.
    (c) independent with bladder, some assist with bed mobility, and independent with some
    transfers.
    (d) independent with bladder, independent with bed mobility, and independent with level

transfers.

Answer 97

d) Expected functional outcomes after traumatic spinal cord injury have been delineated in the

clinical practice guidelines for health care professionals. A person who has sustained a C7-8-level

spinal cord injury can best be expected to need assistance in clearing secretions, may need partial

to total assistance with a bowel program, and may be independent with respect to bladder

management, bed mobility, and transfers to level surfaces. Adaptive equipment is listed in these

tables (FIM (functional independent measures) purists can argue that these persons really are only

modified independent).

Question 98

25. Outcomes of inpatient rehabilitation for neoplastic versus traumatic spinal cord injury reveal that
    (a) indices for depression were significantly higher in patients with neoplastic injury.
    (b) patients with neoplastic spinal cord injury had significantly shorter lengths of stay.
    (c) rate of functional change was significantly better in the traumatic population.
    (d) neoplastic spinal cord injury was associated with a significantly higher rate of discharge to

the community.

Answer 98

(b) Patients with neoplastic spinal cord compression tend to be older than their traumatic counterparts,

with a peak incidence between 50 and 70 years. Significant differences exist with regard to the

level of injury; tumors involving the spinal cord tend to involve the thoracic and lumbar regions

more than the cervical region. There was a shorter rehabilitation length of stay in patients with

neoplasms. (This may allow patients to have more time at home with their families. These patients

had an increased percentage of paraplegia and incomplete injury.) Patients with tumors did

demonstrate a trend toward lower rate of discharge to the community, but this was not significant.

Question 99

35. Five weeks after sustaining a T6 spinal cord injury, your patient is noted to have urinary

incontinence with intermittent catheterization volumes of less than 200mL. Urinalysis is

unremarkable. You consider starting
(a) sodium etidronate (Didronel).
(b) oxybutynin (Ditropan).
(c) urecholine (Bethanechol).
(d) terazosin (Hytrin).

Answer 99

(b) This patient is probably developing spontaneous detrusor contractions but is emptying
incompletely. You would consider using an anticholinergic agent to decrease detrusor (and hence
intravesical) pressures. Ideally, you would obtain urodynamic studies to delineate detrusorsphincter
coordination. One should not initiate a cholinergic agonist without knowing of possible

detrusor -sphincter dyssynergy.

Question 100

45. The most common cause of upper limb pain in long-standing tetraplegia is
    (a) shoulder pain of radicular origin.
    (b) shoulder pain of musculoskeletal origin.
    (c) elbow pain of radicular origin.
    (d) elbow pain of musculoskeletal origin.

Answer 100

(b) In patients with quadriplegia, 55% reported pain in at least one region of the upper extremity. The

shoulder was reported as painful in 46% of subjects; the most frequent diagnoses for shoulder pain

were orthopedically related—tendinitis, bursitis, and osteoarthritis. Referred pain of cervical origin

accounted for 33% of shoulder pain. In patients with paraplegia, symptoms of carpal tunnel

syndrome were the most common complaint (66%).

Question 101

55. Functional outcomes after the use of methylprednisolone in persons with penetrating spinal cord

injury as compared with blunt injury are

(a) markedly improved.
(b) better.
(c) unchanged.
(d) worse

Answer 101

(d) worse
(c) The administration of methylprednisolone did not significantly improve functional outcomes in

patients with gunshot wounds to the spine or increase the number of complications experienced by

patients during their hospitalization.

Question 102

65. Persons with neurogenic bowel often use laxatives such as senna (Senokot), which acts by
    (a) decreasing intraluminal fluid.
    (b) lubricating the intestinal mucosa.
    (c) stimulating the myenteric plexus.
    (d) increasing the time for electrolyte resorption

Answer 102

(c) Stimulant laxatives act by enhancing intestinal motility and thereby decreasing time available for

water and electrolyte resorption. Senna is a glycoside that is split by colonic bacteria into

absorbable anthraquinones. It generates increased propulsive activity by altering electrolyte

transport and increasing intraluminal fluid. It exerts a direct stimulant effect on the myenteric

plexus which increases intestinal motility. Senna works best in persons with upper motor neuron

level injuries, and it facilitates bowel movements in 6 to 12 hours.

Question 103

The primary advantages associated with standing frames and standing wheelchairs for persons with

spinal cord injury include

(a) reduction in lower extremity edema.
(b) reduction in cost to make a workplace accessible.
(c) ease in transportation for everyday use.
(d) increased bone density in the hips.

Answer 103

(b) Standing wheelchairs are often used as second wheelchairs for a particular activity or vocation.

Although their weight has been reduced over the years, they still weigh at least 50lb, which

continues to be the main factor precluding their use in everyday mobility. Third-party payors and

departments of rehabilitation services have funded standing wheelchairs for persons returning to

careers; this can reduce the modifications and costs necessary to make a workplace accessible.

Physiologic benefits include decreased spasticity, a reduction in urinary tract infections, and a

reduction in pressure ulcers. One issue noted is that most standing wheelchairs do not come to a

full 90° position because of instability, which may limit a person’s reach. Problems reported by

users include ankle instability and lower extremity edema.

Question 104

You have been following a person with a T4 spinal cord injury for 20 years. He is now 38, and he

presents with recent onset of frequent episodes of incontinence between catheterizations. His

intermittent catheterization volumes have increased to 600mL every 4-6 hours (they had been

300mL). He acknowledges an increase in his fluid intake, which he feels accounts for the increased

volumes. Your first priority is to order
(a) a blood glucose level.
(b) a urodynamic study.
(c) a basic metabolic panel.
(d) a prostate-specific antigen test.

Answer 104

(a) Polydipsia and polyuria are strong indicators of new-onset diabetes. Diabetes is more common in

the spinal cord injured person than in the uninjured population. Although the differential diagnosis

may include detrusor hyperreflexia or urinary tract infection, this would not provide a reason for

the new high catheterization volumes in this person with chronic spinal cord injury. Evaluation for

diabetes should be done immediately.

Question 105

145. Women who have sustained a spinal cord injury and become pregnant after injury are noted to have

pregnancy-related complications including

(a) high-birth-weight babies.
(b) late-onset labor.
(c) pressure sores.
(d) higher than average spontaneous abortions.

Answer 105

(c) Women who become pregnant after sustaining a spinal cord injury undergo spontaneous abortions

in the first trimester at the same rate as uninjured women; however, the incidence of premature and

small-for-date babies is higher than normal. In addition, the spinal-cord-injured woman is known to

have pregnancy-related complications such as urinary tract infections and pressure sores.

Question 106

185. A 25-year-old man is admitted to your rehabilitation facility 3 weeks after sustaining a spinal cord
     injury. His motor and sensory examination is as follows:

format: R-L
deltoid- 5-5
biceps- 5-5
wrist extensor- 5-5
triceps 3-3
finger flexors 1-1
intrinsics 0-0
hip flexors- 0-0
knee extensors- 0-0
dorsiflexors 1-0
plantar flexors 0-1

Sensory exam reveals intact pinprick and light touch sensation through C7. Sensation is absent

below C7 except for intact perianal sensation.

What is the patient’s ASIA score?

(a) C7 ASIA C
(b) C6 ASIA C
(c) C6 ASIA B
(d) C7 ASIA B

Answer 106

a) Based on the American Spinal Injury Association (ASIA) classification system revised in 2000, the

highest intact level would be C7 (a motor score greater than or equal to 3/5 with the level above

being 5/5). ASIA B indicates sensation below the injury level that must include sacral sensory

sparing. ASIA C indicates sacral sparing, as well, with more than half the muscle groups below the

level of injury having a muscle grade of less than 3/5.

Question 107

35. A 30-year-old man with a T12 fracture and a spinal cord injury has the following findings on neurologic exam: 
MOTOR (R-L)
C5-T1: 5/5-5/5
T2-L1: N/A
L2-L3: 3/5-3/5
L4-S1: 1/5-1/5

SENSORY:
C5-L1: 2/2-2/2
L2-S5: 1/2-1/2

The patient’s ASIA classification would be

a) T12 ASIA class D
b) L1 ASIA class C
c) L2 ASIA class B
d) L3 ASIA class C

Answer 107

Answer: (b)

Commentary: The motor level is defined as the most distal motor level with functional strength

(at least 3/5), so long as the motor level immediately superior is 5/5 or normal; if there is no

defined myotome (ie, T2-T12) the last normal dermatome is used. In the example given, the

myotome is L2, because the L1 dermatome is normal and is used as the myotome. The sensory

level is defined as the most distal dermatome with normal sensation, and the neurologic

dermatome is L1. So the neurologic level is L1, since it is the most distal level with a normal

myotome and dermatome. The ASIA impairment classification is C because more than half (6 of

10) of the key muscles below the neurologic level have a muscle grade less than 3/5.