SCI SAEs Flashcards

Question

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 1

(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.

Answer 2

(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.

Answer 3

(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.

Answer 4

(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.

Answer 5

(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.

Answer 6

(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.

Answer 7

(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.

Answer 8

(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.

Answer 9

(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.

Answer 10

(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.

Answer 11

(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.

Answer 12

(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.

Answer 13

(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.

Answer 14

(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.

Answer 15

(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.

Answer 16

(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.

Answer 17

(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.

Answer 18

(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.

Answer 19

(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.

Answer 20

(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.

Answer 21

(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.

Answer 22

(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.

Answer 23

(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.

Answer 24

(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.

Answer 25

(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.

Answer 26

(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.

Answer 27

(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.

Answer 28

(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.

Answer 29

(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.

Answer 30

(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.

Answer 31

(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.

Answer 32

(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.

Answer 33

(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.

Answer 34

(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.

Answer 35

(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.

Answer 36

(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.

Answer 37

(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.

Answer 38

(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.

Answer 39

(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.

Answer 40

(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.

Answer 41

(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.

Answer 42

(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.

Answer 43

(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.

Answer 44

(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.

Answer 45

(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.

Answer 46

(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.

Answer 47

(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.

Answer 48

(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.

Answer 49

(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.

Answer 50

(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.

Answer 51

(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.

Answer 52

(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.

Answer 53

(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.

Answer 54

(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.

Answer 55

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

Answer 56

(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.

Answer 57

(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.

Answer 58

(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.

Answer 59

(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.

Answer 60

(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.

Answer 61

(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.

Answer 62

(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.

Answer 63

(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.

Answer 64

(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.

Answer 65

(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.

Answer 66

(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.

Answer 67

(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.

Answer 68

(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

Answer 69

(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.

Answer 70

(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.

Answer 71

(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.

Answer 72

(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.

Answer 73

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).

Answer 74

(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.

Answer 75

(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.

Answer 76

(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%).

Answer 77

(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.

Answer 78

(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.

Answer 79

(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.

Answer 80

(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.

Answer 81

(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.

Answer 82

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.

Answer 83

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.