Spinal Cord 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.
Reference: Consortium for Spinal Cord Injury Medicine. Acute management of autonomic dysfunction: adults with spinal cord injury presenting to health-care facilities. J Spinal Cord Med. 2002;25:S67-S88.
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.
Reference: (a) Consortium for Spinal Cord Injury Medicine. Depression following spinal cord
injury: a clinical practice guideline for primary care physicians. Washington (DC): Paralyzed
Veterans of America; 1998. (b) 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 136-7.
A 42-year-old woman with multiple sclerosis comes to you describing profound afternoon
fatigue. You recommend
(a) tizanidine (Zanaflex).
(b) amantadine (Symmetrel).
(c) azathioprine (Imuran).
(d) glatiramer acetate (Copaxone).
Answer: (b)
Commentary: Many medications are indicated for multiple issues relating to multiple sclerosis
(MS). Medications for fatigue include amantadine (Symmetrel) and modafinil (Provigil). Medications for use in exacerbations include prednisone, ACTH and Solu-Medrol. These drugs are supposed to decrease the length and severity of exacerbation. Disease altering medications including the interferons beta 1A and beta 1B as well as glatiramer acetate (Copaxone) can decrease the number of exacerbations. Medications for chronic MS include cyclophosphamide (Cytoxan), azathioprine (Imuran), and cyclosporine (Sandimmune), which are supposed to slow progression in chronic MS. Medications for spasticity include baclofen (Lioresal), dantrolene (Dantrium), tizanidine (Zanaflex), and diazepam (Valium). Medications for ataxia can include
clonazepam (Klonopin) as well as isoniazid (Nydrazid).
Reference: Kraft GH, Cui JY. Multiple sclerosis. In: Delisa JA, Gans BM, Walsh NE, editors.
Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia: Lippincott-
Raven; 2005. p 1758- 63.
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.
Reference: Ditunno JF, Flanders AE, Kirshblum S, Graziani V, Tessle. Predicting outcome in
traumatic spinal cord injury. In: Kirshblum S, Campagnolo DI, DeLisa JA, editors. Spinal cord
medicine. Philadelphia: Lippincott-Williams & Wilkins; 2002. p 108-22.
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.
Reference: (a) Linsenmeyer TA. Sexual function and fertility following spinal cord injury. In: Kirshblum S, Campagnola D, DeLisa J, editors. Spinal cord medicine. Philadelphia: Lippincott Williams & Wilkins; 2002. p 322-30. (b) Elliott S. Sexual dysfunction and infertility in men with spinal cord injury. In: Lin VW, editor. Spinal cord medicine: principles and practice. New York:
Demos Medical; 2010. p 420-23.
