SCI SAEs Flashcards
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: (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.
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: (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.
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: (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.
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: (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.
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: (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.
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: (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.
- 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: (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.
- What is the most common cause of autonomic dysreflexia?
a) Rectal distention
b) Pressure ulcers
c) Bladder distention
d) Childbirth
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.
- A pharmacologic treatment for orthostatic hypotension that involves fluid retention is
a) fludrocortisone.
b) ephedrine sulfate.
c) midodrine hydrochloride.
d) recombinant human erythropoietin.
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.
- 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: (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.
- 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: (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.
- 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: (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.
- 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: (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.
- 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: (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.
- 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: 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.
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: 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.
- 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: 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.
- Hydrocolloid dressings facilitate debridement through which mechanism?
(a) Enzymatic
(b) Autolytic
(c) Sharp
(d) Mechanical
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.
- 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: 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.
- 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: 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.
- 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: 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.
- 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: 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.
- 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
(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.
- 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.
(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.
- 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
(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.
- 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
(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.
- 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)
(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.
- 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.
(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.
- 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.
(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.
- 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.
(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.
- 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
(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.
- Trauma to the sacral roots would most likely result in
(a) vesicoureteral reflux.
(b) incontinence.
(c) detrusor hyperreflexia.
(d) small bladder capacity.
(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.
- 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.
(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.
- 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.
(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.
- 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.
(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.
- 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.
(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.
- Autonomic dysreflexia is most commonly precipitated by
(a) bladder distension
(b) bowel impaction
(c) heterotopic ossification
(d) atelectasis
(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.
- 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
(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.
- 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
(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.
- 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.
(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.
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.
(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.
- 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
(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.
- 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.
(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.
- 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.
(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.
- 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).
(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.
- 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.
(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.
- 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).
(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.
- 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
(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.
- 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
(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.
- 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.
(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.
- 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.
(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.
- 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.
(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.
- 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).
(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.
- 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.
(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.
- 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.
(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.
- 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.
(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.
- 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.
(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.
- 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
(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.
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
(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.
- 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
(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.
- 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.
(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.
- 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.
(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.
- 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.
(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.
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.
(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.
- 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.
(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.
- 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
(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.
- 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.
(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.
- 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.
(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.
- The management of acute spinal cord compression due to tumor includes
(a) nerve growth factor.
(b) thoracolumbosacral orthosis (TLSO).
(c) corticosteroids.
(d) urecholine.
(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.
- 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.
(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.
- 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
(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.
- 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)
(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.
- 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.
(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.
- 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
(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.
- 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.
(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.
- 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.
(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.
- 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.
(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.
- 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.
(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.
- 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.
(a) Wrist extension via extensor carpi radialis results in passive shortening of the (finger) flexor
tendons. This phenomenon is termed tenodesis.
- 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.
(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.
- 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.
(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.
- 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.
(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.
- 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.
(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.
- 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).
(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.
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).
(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.
- 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.
(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.
- 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
(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.
- 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.
(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.
- 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.
(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.
- 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.
(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.
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.
(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.
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.
(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
- 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.
(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.
- 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
(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.
- 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.
(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.
- 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.
(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.
- 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.
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).
- 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.
(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.
- 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).
(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.
- 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.
(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%).
- 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
(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.
- 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
(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.
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.
(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.
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.
(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.
- 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.
(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.
- 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
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.
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: (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.
