Spinal Cord Flashcards
An individual with T3 ASIA A paraplegia complains of burning pain in his legs. Additional review of symptoms includes urinary leakage between catheterizations and difficulty sleeping. The best pharmacologic intervention at this time would be
(a) fluoxetine (Prozac).
(b) amitriptyline (Elavil).
(c) alprazolam (Xanax).
(d) trazodone (Desyrel)
Answer: (b)
Commentary: Amitriptyline, a tricyclic antidepressant, can be effective in the treatment of neuropathic pain but has a significant side effect profile that includes an anticholinergic and sedative effect. These side effects would be desirable in this patient with leaking and difficulty sleeping.
Prozac may be helpful with pain but may actually cause insomnia and has little anticholinergic effects. Trazodone is a mild sedative with slight anticholinergic properties.
Alprazolam is primarily a sedative and is not commonly used for neuropathic pain.
Reference: Bockenek WL, Stewart, JB. Pain in patients with spinal cord injury. In: Kirshblum S, Campagnola DI, DeLisa JA, editors. Spinal cord medicine. Philadelphia: Lippincott Williams & Wilkins; 2002. p 389-408
2013
What is the overall leading cause of death for individuals with paraplegia?
(a) Pulmonary embolism
(b) Suicide
(c) Septicemia
(d) Heart disease
Answer: (d)
Commentary: In paraplegia, the overall leading cause of death is heart disease, followed by septicemia and then suicide. In tetraplegia, pneumonia is the leading cause of death.
Reference: DeVivo MJ. Epidemiology of traumatic spinal cord injury. In: Kirshblum S,
Campagnola DI, DeLisa JA, editors. Spinal cord medicine. Philadelphia: Lippincott Williams & Wilkins; 2002. p 78-9.
2013
A 50-year-old man with metastatic renal cell carcinoma status post nephrectomy 1 year ago was found to have to have a T10 lesion on recent post-operative imaging done as part of a work-up for right sided mid back pain. The patient’s pain is not relieved with recumbency and is not affected by thoracic rotation. He has a normal thoracic kyphosis and is neurologically intact on physical examination. An MRI scan of the thoracic spine shows a T10 lytic lesion, normal alignment, no discernable vertebral body collapse, and unilateral involvement of the T10 posterior elements.
You recommend
(a) Neurosurgical consultation for decompression and segmental stabilization.
(b) radiation oncology consultation for palliative radiotherapy treatments.
(c) T10 kyphoplasty.
(d) custom molded thoracic lumbosacral orthosis (TLSO).
Answer: (b)
Commentary: Palliative radiotherapy treatments directed at the T10 vertebral body will provide symptomatic pain relief from metastatic tumor involvement. The patient has a Spinal Instability Neoplastic Score (SINS) of 6out of 18. A T10 lesion in the semirigid portion of the thoracic spine scores 1, non-mechanical pain scores 1, lytic bone lesion scores 2, normal alignment scores 0, no collapse with > 50% vertebral body involvement scores 1, and unilateral involvement of the posterior spinal elements scores 1. Neurosurgical decompression and segmental stabilization is not required for a stable T10 lesion in a neurologically intact patient. Similarly, a T10 kyphoplasty is not indicated in the absence of significant vertebral body collapse. A custom molded TLSO is unlikely to benefit this patient with no mechanical symptoms of back pain.
Reference: (a) Fourney D, et al. Spinal instability neoplastic score: an analysis of reliability and validity from the spine oncology study group. J Clin Oncol 2011;29(22):3072-077. (b) Fisher CG, DiPaola CP, Ryken TC, Bilsky MH, Shaffrey CI, Berven S, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert
2013
After completing inpatient rehabilitation, an 18-year-old male with complete tetraplegia is able to
feed himself with adaptive equipment and requires some assistance with upper body dressing and
grooming. He is able to assist with bed mobility, but is dependent for transfers. He is also able to
use a manual wheelchair with rim projections indoors on flat surfaces, but when outdoors he
prefers to use a power wheelchair with a joystick. His physical therapist reports that he has
achieved his maximal expected outcome. What is his level of injury?
(a) C4
(b) C5
Answer: (b)
Commentary: Although each person is different, individuals with C5 tetraplegia are in general able to feed themselves with adaptive equipment after set-up and are able to assist with some upper body dressing. Some are able to independently use a manual wheelchair, but most require some assistance, especially on carpets, non-level surfaces and outdoors. Many prefer to use a power wheelchair. People with complete C4 levels of injury are not able to feed themselves, assist with activities of daily living (ADLs), or propel a manual wheelchair, especially if they
have no zone of partial preservation. People with C6 and C7 levels of injury are often capable of transferring (independently or with assistance) and of attaining more independence with ADLs.
Reference: (a) Consortium for Spinal Cord Injury Medicine. Outcomes following traumatic
spinal cord injury: Clinical practice guidelines. Washington (DC): Paralyzed Veterans of
America; 1999. (b) Bryce TN, Ragnarsson KT, Stein AB, Biering-Sorensen F. Spinal cordiInjury. In: Braddom, editor. Physical medicine and rehabilitation.Philadelphia: Saunders; 2011. p 1310-1
2013
A 23-year-old woman with C7 ASIA B tetraplegia resulting from an accident 8 months ago is
complaining of nausea for several days and has vomited non-bloody, non-bilious food particles
the last 3 evenings when placed back to bed after dinner. She also reports some abdominal
tightness and bloating. Her symptoms are relieved when lying on the left side. Her bowel training
program is going well, resulting in regular, effective bowel movements. She recently lost 25
pounds and appears quite thin on exam. Which study will confirm this patient’s most likely
diagnosis?
(a) Abdominal x-ray
(b) Head computed tomography (CT) scan
(c) Serum calcium level
(d) Upper gastrointestinal (GI) series
Answer: (d)
Commentary: Superior mesenteric artery (SMA) syndrome is a condition in which the third segment of the duodenum is compressed between the SMA and the aorta. Although it occurs rarely, it is more common in people with tetraplegia, especially if the person lost weight and is immobilized in the supine position. An upper GI series confirms the diagnosis with an abrupt cessation of barium in the third part of the duodenum. In addition to lying on the left side, some individuals get relief with metoclopramide (Reglan). A serum calcium level could be used to diagnose immobilization hypercalcemia, which is a common cause of nausea and vomiting in patients with tetraplegia. Hypercalcemia is not, however, alleviated with positioning and it usually occurs within the first few months after injury. Abdominal x-ray could identify chronic constipation, but since her bowel program is going well, constipation is not likely to be the cause of her symptoms. Although hydrocephalus would be identified by means of a head CT scan, it is
the least likely diagnosis in this case.
Reference: Kirshblum S. Rehabilitation of spinal cord injury. In: DeLisa JA, Gans BM, Walsh NE, editors. Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia: Lippincott-Raven; 2005. p 1729
2013
A 45-year-old man with T4 paraplegia secondary to transverse myelitis is in acute inpatient
rehabilitation. Your physical therapist reports to you that the patient is asking whether he will
ever be able to have sexual intercourse with his wife again. The next day you decide to address
sexuality with your patient on morning rounds. What is the best way to approach this patient?
(a) Explain that there are important medical needs that should be addressed first.
(b) Offer to answer any questions that he has about his injury and sexual function.
(c) Provide him with specific examples of how to treat erectile dysfunction.
(d) Refer him to a therapist for intensive counseling on sexual techniques
Answer: (b)
Commentary: The PLISSIT model is a framework for educational interventions related to sexuality. It is an acronym for 4 levels of intervention: Permission, Limited Information, Specific Suggestions, and Intensive Therapy. “Permission” is the first level of intervention and refers to creating an atmosphere in which it is clear that discussion about sex will be well received. In this case, answer (b) is most consistent with this level of intervention.
2013
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.
2012
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.
2012
A 47-year-old woman with T8 ASIA A spinal cord injury (SCI) applied for a position as a store
clerk. She felt that she was being discriminated against because of her SCI. Under the Americans
with Disabilities Act (ADA), she may have a right to file a complaint if
(a) the employer requested a pre-employment physical to see if she qualified.
(b) the employer hired her, but then requested a pre-placement physical to determine the
most appropriate position for her.
(c) the job description required climbing ladders and working from heights.
(d) the employer did not make all accommodations to allow her to work from her wheelchair.
Answer: (a) Commentary: The Americans with Disabilities Act (ADA) is a federal law designed to help
protect the rights of disabled citizens. Employers must not discriminate against hiring a disabled applicant if that person is able to perform the key components of the job. Pre-employment physicals are not allowed under the ADA, but a pre-placement physical can be used after an individual is hired to help determine the most appropriate job for that person. An employer may decline to hire a disabled individual if that person is unable to perform the essential functions of the job, so long as the employer has attempted to make reasonable accommodations to allow the
disabled individual to perform these job functions. This individual would not be able to climb ladders or work from heights because of her SCI, despite any accommodations
2012
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.
2011
A 30-year-old man with a T12 fracture and a spinal cord injury has the following findings on
neurologic exam:
Motor Exam Sensory Exam* Page11 of 33
Nerve
R L R L
C5 5/5 5/5 2 2
C6 5/5 5/5 2 2
C7 5/5 5/5 2 2
C8 5/5 5/5 2 2
T1 5/5 5/5 2 2
T2-T12
N/A N/A 2 2
L1 N/A N/A 2 2
L2 3/5 3/5 1 1
L3 3/5 3/5 1 1
L4 1/5 1/5 1 1
L5 1/5 1/5 1 1
S1 1/5 1/5 1 1
S2-5 - - 1 1
* Light touch and pin prick testing
Abbreviations: L, left; R, right, N/A, not applicable.
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.
2011
A 45-year-old man with T4 paraplegia secondary to transverse myelitis is in acute inpatient rehabilitation. Your physical therapist reports to you that the patient is asking whether he will ever be able to have sexual intercourse with his wife again. The next day you decide to address sexuality with your patient on morning rounds. What is the best way to approach this patient?
(a) Explain that there are important medical needs that should be addressed first.
(b) Offer to answer any questions that he has about his injury and sexual function.
(c) Provide him with specific examples of how to treat erectile dysfunction.
(d) Refer him to a therapist for intensive counseling on sexual techniques
Answer: (b)
Commentary: The PLISSIT model is a framework for educational interventions related to sexuality. It is an acronym for 4 levels of intervention: Permission, Limited Information, Specific Suggestions, and Intensive Therapy. “Permission” is the first level of intervention and refers to creating an atmosphere in which it is clear that discussion about sex will be well received. In this case, answer (b) is most consistent with this level of intervention.
2013
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
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
2010
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.
2010
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.
2010
Which cervical orthosis is the most restrictive?
a) Four-poster brace
(b) Philadelphia collar
(c) Sterno-occipital mandibular immobilizer (SOMI
(d) Halo
Which cervical orthosis is the most restrictive?
(a) Four-poster brace
(b) Philadelphia collar
(c) Sterno-occipital mandibular immobilizer (SOMI)
(d) Halo
Answer: (d)
Commentary: The halo device provides the greatest restriction of cervical motion for
flexion/extension, lateral bending and rotation, as shown in the table below:
Table 1: Percentage of Cervical Motion Permitted by 4 Cervical Orthoses
Orthosis; Flexion/extension; Lateral Bending; Rotation Philadelphia collar 28.9 66.4 43.7 SOMI brace 20.6 65.6 33.6 Four-poster brace 20.6 45.9 27.1 Halo device 4.0-11.7 4.0-8.4 1.0-2.4
2010
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.
2010
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.
2010
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 restrictiveclothing. If the blood pressure remains elevated, the urinary system should be evaluated. In thiscase, therefore, the second step would be to flush the suprapubic catheter. If the blood pressurecontinues to be elevated after bladder distention has been ruled out, the lower bowels should beevaluated for fecal impaction, but only after the systolic blood pressure is reduced to less than150 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.
2012
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.
2012
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.
2012
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 first2 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.
2012
What advice would you provide to a 22-year-old man with chronic T4 ASIA A paraplegia who
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.
2012
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.
2012
A 38-year-old woman with C8 ASIA B tetraplegia resulting from a gunshot wound presents to your outpatient clinic. Upon discharge from acute rehabilitation, she managed her bladder with intermittent catheterization. Due to worsening obesity and hip adductor spasticity, however, she is now having difficulty performing her intermittent catheterization. She wants to continue to be independent with her bladder management and is willing to consider surgery. Which surgical procedure is she most likely to benefit from?
a. Bladder augmentation
b. Continent urinary diversion
c. Cutaneous ileovesicostomy
d Transurethral sphincterotomy
B is correct
Continent urinary diversion is the best surgical option for this patient because she would be able to remain independent performing intermittent catheterizations. Cutaneous ileovesicostomy, a specific variant of incontinent urinary diversion, would maintain her independence, but she would have to adapt to using an external collection device. Bladder augmentation would not resolve the problem associated with performing catheterizations via her urethra. Transurethral sphincterotomy is not a good option for females because few good external collection devices for women exist.
2014
A 35-year-old woman with T12 ASIA A paraplegia due to a motor-vehicle collision is on your inpatient rehabilitation unit. She has no other risk factors for the development of peptic ulceration. In order to prevent a stress ulcer, you suggest that she take a proton-pump inhibitor (PPI) for a total of how many weeks after her injury?
A 2
B 4
C 8
D 12
Option b is correct.
According the Consortium for Spinal Cord Injury Clinical Practice Guidelines, it is recommended to initiate stress ulcer prophylaxis after acute traumatic spinal cord injury. Most stress ulcers happen within the first 4 weeks, and prolonged used of PPIs has been associated with increasing rate of Clostridium difficile infection. Therefore, 4 weeks of stress ulcer prophylaxis is indicated in most uncomplicated situations. If other risk factors for peptic ulceration are present one can consider a longer duration of treatment.
2014
A 35-year-old office worker presents with 1 week of right neck and upper limb pain that radiates down her arm and forearm to her long finger. She does not remember any inciting trauma or exertion associated with the onset of her symptoms. Her biceps reflex is preserved and the triceps reflex is diminished in the affected arm. Which nerve root is most likely affected?
A C5
B C6
C C7
D C8
Option c is correct.
The C7 root is the most likely affected nerve root in this case, since the biceps reflex is preserved and the triceps reflex is diminished, and the patient’s pain radiates into the long finger. A history of trauma or physical exertion preceding the onset of symptoms occurs in less than 15% of patients.
2014
A 48-year-old man with C6 tetraplegia from a skiing accident 23 years ago presents for his annual evaluation. He has noticed weakness in bilateral wrist extension over the last 3 months. In addition to confirming his new weakness on exam, you note a loss of his left biceps reflexes since last year. To confirm your diagnosis you order
A computed tomography (CT) of his head.
B electromyography (EMG) of his upper extremities.
C lumbar puncture for cerebral spinal fluid (CSF) evaluation.
D magnetic resonance imaging (MRI) of his cervical spine.
Option d is correct.
New neurologic deficits in the upper extremities are not uncommon in patients with traumatic injury to the cervical spinal cord. In this case, given the bilateral and ascending nature of the symptoms, the most likely diagnosis is syrinx, which would be diagnosed with MRI. Ulnar and median nerve entrapments are the most common cause of upper extremity neurologic deficits, which can be confirmed by EMG. This patient, however, has a loss of wrist extension, which would be caused by damage to the radial nerve, not the ulnar or median. Head CT and lumbar puncture are least likely to provide diagnostic information.
2014
A 28-year-old man with C4 ASIA B tetraplegia after a bicycle accident one week ago is in the intensive care unit. Four days after his injury he was electively intubated due to a progressive decrease in his vital capacity. Aside from his spinal cord injury, he suffered no other injuries in his accident. You are consulted to help facilitate weaning him off the ventilator. In order to facilitate the fastest wean and to minimize atelectasis, you suggest starting with a tidal volume of how many milliliters/kilogram (ml/kg) of ideal body weight?
a. 5
b. 10
c. 15
d. 20
Option c is correct.
When initially ventilating a patient with tetraplegia and no significant associated lung tissue injury, it is recommended to start at 15ml/kg of ideal body weight. Tidal volumes can be increased in small increments if needed to treat any atelectasis that develops, and peak airway pressure should be kept under 40cm of water.
2014
