Spinal Cord Flashcards

1
Q

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)

A

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

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2
Q

What is the overall leading cause of death for individuals with paraplegia?

(a) Pulmonary embolism
(b) Suicide
(c) Septicemia
(d) Heart disease

A

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.

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3
Q

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).

A

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

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4
Q

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

A

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

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5
Q

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

A

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

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6
Q

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

A

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.

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7
Q

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.

A

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

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8
Q

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

A

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

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9
Q

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.

A

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

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10
Q

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

A

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

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11
Q

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

A

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.

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12
Q

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

A

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.

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13
Q

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

A

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

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14
Q

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

A

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

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15
Q

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.

A

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

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16
Q

Which cervical orthosis is the most restrictive?

a) Four-poster brace
(b) Philadelphia collar
(c) Sterno-occipital mandibular immobilizer (SOMI
(d) Halo

A

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 

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17
Q

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.

A

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

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18
Q

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

A

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

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19
Q

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.

A

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

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20
Q

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

A

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

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21
Q

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.

A

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

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22
Q

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

A

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

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23
Q

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

A

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

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24
Q

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.

A

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

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25
Q

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

A

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

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26
Q

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

A

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

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27
Q

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

A

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

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28
Q

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.

A

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

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29
Q

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

A

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

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30
Q

Which patient is most likely to be treated conservatively?

a. A young man who fell from roof and is experiencing bladder incontinence, numbness and tingling in the sacral distribution
b. A woman with T12 compression fracture following a motor vehicle collision
c. A person with chronic low back pain, grade 3 spondylolisthesis and neurological symptoms
d. A 40-year-old woman with progressive foot drop and herniated disc L4-L5

A

Option b is correct.

Compression fractures are most often treated conservatively. The man who fell from the roof has cauda equina syndrome, an absolute surgical indication. Progressive motor loss, such as the woman with the herniated disc, is also an absolute indication for surgical intervention. Relative indications for surgery include intractable pain and static motor loss, and surgery is often considered in these cases following failed conservative treatments. A grade 3 spondylolisthesis may be treated conservatively when no neurological symptoms are present. Although most discogenic low back pain can be treated conservatively, progressive neurological deficits are treated surgically.

2014

31
Q

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

A

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

2009

32
Q

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

A

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

2009

33
Q

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
A

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

2009

34
Q

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
A

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

2009

35
Q

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

A

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.

2009

36
Q

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

A

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

2009

37
Q

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.

A

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.

2009

38
Q

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.

A

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.

2009

39
Q

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.

A
(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.

2008

40
Q

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

A

(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

2008

41
Q

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

A

(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.

2008

42
Q

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)

A

(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.

2008

43
Q

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.

A

(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.

2008

44
Q

A 3-year-old child has a high thoracic spinal cord injury. At age 10, which of the following is the most likely complication?

(a) Severe lordosis without scoliosis
(b) Scoliosis requiring surgical treatment
(c) Deep venous thrombosis
(d) Heterotopic ossification

A

(b)
Children who sustain cervical or high thoracic spinal cord injuries at an early age are at high risk of developing progressive scoliosis that requires surgical management.

2008

45
Q

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.

A

(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.

2008

46
Q

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

(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

2008

47
Q

Trauma to the sacral roots would most likely result in

(a) vesicoureteral reflux.
(b) incontinence.
(c) detrusor hyperreflexia.
(d) small bladder capacity.

A

Trauma to the sacral roots would most likely result in

(a) vesicoureteral reflux.
(b) incontinence.
(c) detrusor hyperreflexia.
(d) small bladder capacity.

2008

48
Q
Which respiratory measure declines when a patient with tetraplegia moves from a supine to
seated position?
a) Total lung capacity
b) Functional residual capacity
c) Vital capacity
d) Residual volume
A

Answer: (c)
Commentary: With the exception of vital capacity (VC), the direction of change in total lung capacity and functional residual capacity decrease in the supine position and increase in the
seated position, similar to an individual without a spinal cord injury. In contrast, patients with
tetraplegia or high paraplegia have a decrease in the VC in the seated position, which is the result of an increase in the residual volume (RV) caused by the effect of gravity on the abdominal contents, causing the diaphragm to move down into a less efficient position and increasing the
RV.

2011

49
Q

What is the most common cause of autonomic dysreflexia?

a) Rectal distention
b) Pressure ulcers
c) Bladder distention
d) Childbirth

A

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
Page 19 of 33
bladder distention and potential problems of catheter blockage or bladder distention it is more
frequent than the other sources of painful stimulation listed.

2011

50
Q

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

A

(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.

2007

51
Q

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

(a) The top three causes of traumatic spinal cord injury in the United States are motor vehicle accidents, falls, and violence.

2007

52
Q

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

A

(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.

2007

53
Q

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

A

(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.

2007

54
Q

Autonomic dysreflexia is most commonly precipitated by

(a) bladder distension
(b) bowel impaction
(c) heterotopic ossification
(d) atelectasis

A

(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

2007

55
Q

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

A

(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.

2007

56
Q

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.

A

(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.

2007

57
Q

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

A

(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

2007

58
Q

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

A

(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.

2006

59
Q

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

(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

2006

60
Q
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
A

(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.

2006

61
Q

You are called to see your 3-year-old inpatient with a C5 ASIA class A spinal cord injury. She has a
headache and complains of not feeling well. Vital signs are pulse 60, respirations 20, blood pressure
120/80. Weight 33 lbs (15kg). Physical examination is unchanged from previously. You order:
(a) Place the patient in the supine position.
(b) Administer acetaminophen (Tylenol) orally.
(c) Empty the bladder.
(d) Obtain computed tomography of the head

A

(c) The child is experiencing autonomic dysreflexia. The 90th percentile for blood pressure in an average sized 3-year-old girl is 103/62. A child with C5 tetraplegia would be expected to have even lower average blood pressure. Initial treatment consists of positioning the patient in an upright position and emptying the bladder. If this does not correct the problem, medications should be considered. If medications are needed, either nitropaste 2% or nifedipine may be used. For a child weighing 15kg the correct initial dose is 0.25 to 0.5 mg/kg/dose (3.75–7mg) of nifedipine or ½ inch of nitropaste

2006

62
Q

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.

A

(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.

2006

63
Q

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

A

(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

2006

64
Q

Which statement about carpal tunnel syndrome is TRUE?

(a) A prolonged median motor distal latency is mandatory for diagnosis.
(b) Symptoms improve after splinting the wrist in flexion for 2 weeks.
(c) X-ray and magnetic resonance imaging studies have been standardized for diagnosis.
(d) The syndrome is a complex of numbness and pain in a median nerve distribution.

A

(d) Carpal tunnel syndrome is a symptom complex that includes numbness, tingling, and pain in a median nerve distribution. Although objective testing such as nerve conduction studies can help confirm the diagnosis, evaluation must include the patients’ symptoms. Magnetic resonance imaging and ultrasound measurements will likely add objective evidence to help confirm the diagnosis, although standards are not in place at this time. Symptom reduction may occur after
splinting in neutral, but is not diagnostic

2006

65
Q
What is a reasonable long-term rehabilitation goal for a 6-year-old child with a C6 ASIA class A
spinal cord injury?
(a) Independent lower extremity dressing
(b) Bed mobility
(c) Independent bathing
(d) Independent feeding
A

(d) A child with C6 ASIA class A spinal cord injury would be expected ultimately to independently self-feed, but not bathe, do lower extremity dressing, or perform bed mobility

2006

66
Q

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

(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.

2006

67
Q

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).

A

(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

2006

68
Q

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.

A

(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.

2006

69
Q

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.

A

(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.

2006

70
Q

What is the best possible expected outcome for an individual with C7 ASIA class A tetraplegia?

A. bladder, dependent; bed mobility, independent; some assist with all transfers.
B. bladder, dependent; bed mobility, independent; modified independent with level transfers.
C. Bladder, independent; bed mobility, some assist; independent with some transfers
D. bladder, independent; bed mobility, independent; modified independent with level transfers.

A

D

Expected functional outcomes after traumatic spinal cord injury have been delineated in the Clinical Practice Guidelines for health care professionals. A motivated individual with C7 spinal cord injury may use a tenodesis grasp to manage bladder catheterization. Using Tricep strength to stabilize the upper limb, turning in the bed and level transfers are also possible.

2015

71
Q

The use of an abdominal binder in a sitting patient who has tetraplegia due to spinal cord injury will:

a. decrease risk of autonomic dysreflexia
b. eliminate the need for lateral wheelchair supports
c. result in a need for more frequent bladder catheterizations.
d. improve pulmonary function by elevating the diaphragm.

A

d.

when sitting, the abdominal contents pull down on the diaphragm, placing the muscle in a mechanically disadvantaged position and limiting the ability to take a deep breath. The abdominal binder will help to restore the diaphragm to a position more functionally conducive to maintaining vital capacity. The binder can be used to help reduce orthostatic hypotension and it does not appear to alter bladder capacity. An abdominal binder will not decrease the risk of autonomic dysreflexi or eliminate the need for lateral wheelchair supports.

2015

72
Q

A 13 year old girl a T6 ASIA D spinal cord injury since the age of 2 years complains of right knee pain with ambulation. You find that she has decreased right hip abduction and a shorter right leg. Knee examination is normal except for tenderness to palpation anteriorly. The most likely finding on radiographs would be
a. heterotopic ossification
b. avascular necrosis of the femoral head
c hip subluxation
d. fracture of the patella

A

c

Children with SCI that occur prior to age 10 years are at high risk of hip subluxation (93% had hip subluxation compared to 9% with SCI occurring over age 10). Classic signs of hip subluxation are knee pain, decreased hip abduction, and apparent shortening of the thigh length. Hip subluxation on radiographs is defined as migration index greater than 20% and medial joint space greater than 7mm

2015

73
Q

A 20 year old man is involved ina diving accident resulting in C6 ASIA A tetraplegia with trace motor function in C7 and C8. You confirm this ASIA score 30 days after his injury and make the following statement regarding his 1 year prognosis.

a. his chance of regaining motor function (3/5) in the C7 myotome is 80% or better
b. most upper extremity recovery occurs in the first 2 months
c. the initial strength of a muscle does not predict the rate of strength recovery.
d. there is up to a 10% chance of his becoming a community ambulator.

A

a.

most upper extremity recovery occurs in the first 6 months, and the greatest rate of change occurs the first 3 months. The initial strength of a muscle is a significant predictor of achieving antigravity strength and the rate of recovering strength. There is only a 2% to 3% chance of recovery from ASIA class A to ASIA class D in the clinically complete patient and it is unknown what percentage of that small group will become ambulatory. Most individuals with ASIA class A designation and trace function 1 level below will gain motor function (3/5) in the myotome with trace activity.

2015.