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ABPMR SCI Medicine study materials
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ABPMR SCI Medicine practice questions

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Question 1Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

A patient examined 72 hours after cervical trauma has no light-touch or pinprick perception at S4–5 and no voluntary anal contraction. What AIS grade does this indicate?

  1. AIS B
  2. AIS C
  3. AIS A Correct answer.
  4. AIS D

Explanation

AIS A is a complete injury, defined by absence of sacral sparing: no S4–5 light touch or pinprick and no deep anal pressure or voluntary anal contraction. The absent sacral findings in this patient therefore place the injury in AIS A, independent of motor activity above the injury.

Question 2Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

How is the neurological level of injury defined in the ISNCSCI examination?

  1. The initial level of complete paralysis before shock resolves
  2. The vertebral fracture level seen on CT
  3. The most rostral segment with any preserved pinprick
  4. The most caudal normal sensory and motor segment on both sides Correct answer.

Explanation

The NLI is the most caudal spinal cord segment with intact sensory and motor function on both sides. It is derived from the examination, not from imaging or the fracture level.

Question 3Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Which muscle is the ISNCSCI key muscle for the C5 myotome?

  1. Triceps brachii
  2. Biceps brachii Correct answer.
  3. Deltoid
  4. Extensor carpi radialis longus

Explanation

C5 motor testing uses biceps brachii with the elbow flexed and forearm supinated. Deltoid is not a key muscle; wrist extensors represent C6 and triceps represents C7.

Question 4Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Which pairing correctly describes the standard ISNCSCI sensory examination?

  1. Light touch with a cotton wisp; pinprick with a safety pin Correct answer.
  2. Vibration with a tuning fork; pinprick with a cotton wisp
  3. Light touch with a safety pin; pinprick with a cotton wisp
  4. Proprioception with a safety pin; light touch with a tuning fork

Explanation

Light touch is tested with a cotton wisp or cotton tip, and pinprick with a disposable safety pin. Vibration and proprioception are not part of the ISNCSCI sensory score.

Question 5Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Which findings constitute sacral sparing on the ISNCSCI examination?

  1. Biceps reflex or wrist extension
  2. Anal wink or bulbocavernosus reflex
  3. Perianal sensation or deep anal pressure Correct answer.
  4. Pinprick at T12 or hip flexion

Explanation

Sacral sparing is evidence of preserved sacral sensory or motor function: S4–5 light touch or pinprick, deep anal pressure, or voluntary anal contraction. Reflexes such as the bulbocavernosus or anal wink are not sacral sparing because reflex activity can persist through a complete injury.

Question 6Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Which description best characterizes spinal shock after acute SCI?

  1. Transient flaccid paralysis and loss of reflexes below the injury Correct answer.
  2. Progressive ascending sensory loss over several weeks
  3. Immediate spasticity with hyperreflexia below the injury
  4. Persistent hypotension with bradycardia from sympathetic interruption

Explanation

Spinal shock is the temporary depression of segmental reflex activity and flaccid tone below the injury after acute SCI. It is distinct from neurogenic shock, which is hemodynamic instability from loss of sympathetic tone.

Question 7Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

What is the maximum motor score obtainable in one upper extremity on the ISNCSCI examination?

  1. 25 Correct answer.
  2. 50
  3. 20
  4. 30

Explanation

Each upper extremity has five key muscles, each scored 0 to 5, so the maximum per upper limb is 25. The total upper-extremity motor score is 50, and the full motor score is 100.

Question 8Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Stimulation of which area tests the C6 dermatome?

  1. Thumb Correct answer.
  2. Umbilicus
  3. Nipple
  4. Little finger

Explanation

The C6 dermatome includes the thumb and radial side of the forearm. The little finger is C8, the nipple is T4, and the umbilicus is T10.

Question 9Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

A patient has sacral sensory sparing but no voluntary anal contraction and no motor function more than three levels below the NLI. Which AIS grade applies?

  1. AIS D
  2. AIS B Correct answer.
  3. AIS A
  4. AIS C

Explanation

AIS B is a sensory incomplete injury: sacral sensory sparing is present, but motor function is absent more than three levels below the NLI on either side. Voluntary anal contraction is not required for AIS B, and its presence would make the injury motor incomplete.

Question 10Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

On motor testing, C5 is grade 5, C6 is grade 3, and C7 is grade 0. What is the motor level?

  1. C5
  2. C6 Correct answer.
  3. C4
  4. C7

Explanation

The motor level is the most caudal key muscle with grade 3 or more, provided all more rostral key muscles are grade 5. C6 meets grade 3 and C5 is normal, so the motor level is C6.

Question 11Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Sensory examination shows normal C6, impaired C7, and absent C8. What is the sensory level?

  1. C6 Correct answer.
  2. C5
  3. C8
  4. C7

Explanation

The sensory level is the most caudal dermatome with normal light touch and pinprick on both sides. Because C6 is normal and C7 is impaired, the sensory level is C6.

Question 12Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

In an AIS A injury, what is the zone of partial preservation?

  1. The region of normal sensation above the injury
  2. The dermatomes and myotomes with preserved function below the NLI but without sacral sparing Correct answer.
  3. The levels with sacral sparing but no motor function
  4. The area of spasticity below the injury

Explanation

The ZPP records sensory or motor preservation below the NLI in a complete injury, with no sacral sparing. It is reported as the most caudal preserved segment for sensory and motor function.

Question 13Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

During the sacral examination, how is deep anal pressure interpreted?

  1. It is present when the bulbocavernosus reflex returns
  2. It is present when the anal wink reflex is elicited
  3. It is present when the patient feels the examining finger as light touch
  4. It is present when the patient reports pressure during digital rectal examination Correct answer.

Explanation

Deep anal pressure is a sacral sensory finding: the patient must report pressure during digital rectal examination. It is not inferred from anal reflexes, which can be present in complete injuries.

Question 14Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Which hemodynamic pattern is typical of neurogenic shock after cervical SCI?

  1. Hypertension with tachycardia
  2. Hypotension with marked tachycardia
  3. Hypotension with bradycardia Correct answer.
  4. Normal blood pressure with fever

Explanation

Neurogenic shock results from loss of sympathetic vascular tone and, in cervical or high thoracic injuries, unopposed vagal activity. This produces hypotension, often with bradycardia rather than the compensatory tachycardia seen in hypovolemic shock.

Question 15Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Which clinical pattern is most consistent with central cord syndrome?

  1. Contralateral motor loss with ipsilateral pain loss
  2. Isolated loss of vibration and proprioception
  3. Greater weakness in the legs than in the arms
  4. Greater weakness in the arms than in the legs Correct answer.

Explanation

Central cord syndrome typically causes more weakness in the upper extremities than the lower extremities because the cervical corticospinal fibers for the arms are located more medially. It often occurs after hyperextension in a stenotic cervical canal.

Question 16Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Which sensory pattern is characteristic of Brown-Séquard syndrome?

  1. Bilateral vibration loss with preserved pain
  2. Bilateral pain loss with preserved vibration
  3. Ipsilateral pain loss and contralateral vibration loss
  4. Ipsilateral vibration loss and contralateral pain loss Correct answer.

Explanation

Brown-Séquard syndrome is a hemisection: dorsal column loss produces ipsilateral vibration and proprioception deficits, while spinothalamic loss produces contralateral pain and temperature deficits. Motor weakness is ipsilateral.

Question 17Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Which finding is most typical of anterior cord syndrome?

  1. Preserved pain and temperature with loss of vibration
  2. Sacral sensory sparing with upper-limb weakness
  3. Ipsilateral pain loss with contralateral weakness
  4. Preserved vibration and proprioception with loss of motor and pain function Correct answer.

Explanation

Anterior cord syndrome injures the anterior spinal cord, including corticospinal and spinothalamic tracts, while sparing the posterior columns. Patients therefore lose motor function and pain/temperature below the lesion but retain vibration and proprioception.

Question 18Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

A patient has sacral sparing and motor incomplete injury, with three of ten key muscles below the NLI graded at least 3. Which AIS grade is correct?

  1. AIS A
  2. AIS C Correct answer.
  3. AIS B
  4. AIS D

Explanation

In motor incomplete injuries, AIS C applies when fewer than half of the key muscles below the NLI have grade 3 or more; AIS D applies when at least half do. Three of ten is fewer than half, so the grade is AIS C.

Question 19Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Return of which reflex is commonly used to mark the end of spinal shock?

  1. Anal wink
  2. Bulbocavernosus reflex Correct answer.
  3. Cremasteric reflex
  4. Babinski sign

Explanation

The bulbocavernosus reflex is the most commonly cited marker of spinal shock resolution, although return does not by itself indicate a good neurological prognosis. Its reappearance means reflex activity below the injury is recovering.

Question 20Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Which finding supports a diagnosis of autonomic dysreflexia in a patient with SCI above T6?

  1. Diastolic pressure 5 mm Hg above baseline without symptoms
  2. Systolic pressure 10 mm Hg below baseline with bradycardia
  3. Systolic pressure unchanged with fever and hypotension
  4. Systolic pressure 20 mm Hg above baseline with headache and sweating Correct answer.

Explanation

Autonomic dysreflexia is a sudden sympathetic surge, usually in injuries at T6 or above, with a systolic rise of at least 20 mm Hg from baseline accompanied by symptoms such as headache, flushing, or sweating. The trigger is often bladder or bowel distention.

Question 21Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Which feature favors conus medullaris syndrome over cauda equina syndrome?

  1. Progressive foot drop with preserved bowel control
  2. Absent ankle reflexes with patchy sensory loss
  3. Early symmetric bladder dysfunction with saddle anesthesia Correct answer.
  4. Unilateral radicular pain with asymmetric leg weakness

Explanation

Conus medullaris injury typically causes early, symmetric bowel and bladder dysfunction and saddle anesthesia, often with less severe leg weakness. Cauda equina lesions more often produce asymmetric radicular pain and lower-limb weakness.

Question 22Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Which imaging study best detects intramedullary hemorrhage or cord edema after acute SCI?

  1. Computed tomography without contrast
  2. Magnetic resonance imaging Correct answer.
  3. Bone scan
  4. Plain radiography

Explanation

MRI is the preferred modality for evaluating the spinal cord, ligaments, and discs after acute SCI. CT is better for bony injury, but it cannot reliably show intramedullary hemorrhage or edema.

Question 23Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Why does central cord syndrome typically affect the upper limbs more than the lower limbs?

  1. Arm fibers of the corticospinal tract lie more medial in the cervical cord Correct answer.
  2. The dorsal columns for the legs are more vulnerable to compression
  3. The spinothalamic fibers for the arms cross at a lower level
  4. The anterior horn cells for the legs are more lateral in the cord

Explanation

In the cervical corticospinal tract, fibers destined for the arms are located more medially and those for the legs more laterally. A central lesion therefore injures the arm fibers first, producing greater upper-extremity weakness.

Question 24Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

A patient has no sacral sparing yet has weak hip flexion three levels below the motor level. How should this be classified?

  1. AIS C
  2. AIS D
  3. AIS B
  4. AIS A Correct answer.

Explanation

AIS A is defined by absence of sacral sparing; motor activity below the NLI is recorded as part of the zone of partial preservation and does not make the injury motor incomplete. Therefore the grade remains AIS A.

Question 25Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

What is the correct order for assigning an AIS grade from the ISNCSCI examination?

  1. Vertebral fracture level, cord signal, then motor score
  2. Total motor score, pinprick score, then light-touch score
  3. Sacral sparing, motor completeness, then proportion of grade ≥3 muscles Correct answer.
  4. Motor level, sensory level, then sacral reflex status

Explanation

AIS grading first asks whether sacral sparing is present; if absent, the injury is AIS A. If present, the next step is to determine motor incomplete status using voluntary anal contraction or motor sparing more than three levels below the NLI, and then AIS C versus D uses the proportion of key muscles below the NLI graded 3 or more.

Question 26Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Which muscle is the designated key muscle for the L5 myotome in the ISNCSCI motor examination?

  1. Tibialis anterior
  2. Iliopsoas
  3. Extensor hallucis longus Correct answer.
  4. Gastrocnemius

Explanation

The ISNCSCI motor examination uses one key muscle per myotome from C5 through S1, and L5 is represented by the extensor hallucis longus, graded 0 to 5. Tibialis anterior represents L4 and gastrocnemius represents S1, which are the segments most often confused with L5 at the bedside.

Question 27Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

What is the highest light touch score obtainable on one side of the body on the ISNCSCI sensory examination?

  1. 56 Correct answer.
  2. 28
  3. 224
  4. 112

Explanation

Light touch is scored 0, 1, or 2 at each of 28 key sensory points on each side, so the maximum is 56 per side. Combining pinprick and light touch across both sides yields the total sensory score of 224.

Question 28Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Under the AIS, when is grade E assigned?

  1. Sacral sparing is present but no motor function can be detected
  2. All segments grade normal in a patient with a known spinal cord injury Correct answer.
  3. Light touch is normal while pinprick remains impaired below the level
  4. Every key muscle and sensory point is scored as zero throughout

Explanation

AIS E requires that every key sensory point and key muscle be graded normal, including the sacral segments, in a patient with a documented spinal cord injury. A person with a normal examination and no history of cord injury is not assigned an AIS grade at all.

Question 29Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

How is the neurological level of injury defined?

  1. The most rostral segment showing any preserved motor function
  2. The most caudal segment with antigravity strength on one side
  3. The segment located at the center of the bony injury on imaging
  4. The most caudal segment that is normal on both sides Correct answer.

Explanation

The neurological level of injury is the most caudal spinal segment with intact sensory and motor function on both the right and left sides; where no key muscle exists, normal sensation with normal motor function above serves as the proxy. It is a clinical determination and often differs from the level of fracture or dislocation.

Question 30Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Where is the key sensory point for the S4-5 dermatome tested?

  1. Anal mucocutaneous junction Correct answer.
  2. Perineum at the ischial tuberosity
  3. Glans penis or clitoris
  4. Medial aspect of the thigh

Explanation

The S4-5 key point is tested at the anal mucocutaneous junction, the same region used to document sacral sparing. This point is essential because sacral sparing is what separates complete from incomplete injuries.

Question 31Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

In a patient whose injury lies between T2 and L1, how is the motor level determined?

  1. It cannot be assigned, so only the NLI is reported instead
  2. It is determined by manual testing of the thoracic paraspinal muscles
  3. It is the lowest rib level at which muscle contraction is visible
  4. It equals the sensory level when motor above is normal Correct answer.

Explanation

Because there are no key muscles for the thoracic and upper lumbar segments, the motor level for injuries from T2 through L1 is defined as the sensory level, provided the key muscles above are graded normal. This convention keeps the motor level consistent with the segmental examination.

Question 32Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

The Modified Ashworth Scale is used to quantify which impairment?

  1. Maximal voluntary muscle contraction force
  2. Amplitude of the deep tendon reflex
  3. Resistance to passive stretch Correct answer.
  4. Endurance during a six-minute walk test

Explanation

The Modified Ashworth Scale grades the resistance felt during passive movement of a limb and is used as a clinical measure of spasticity. It is quick at the bedside but has only modest reliability and does not capture clonus frequency or functional impact.

Question 33Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Which test detects heterotopic ossification earliest in a patient with spinal cord injury?

  1. Diagnostic ultrasound of the hip
  2. Three-phase bone scan Correct answer.
  3. Plain radiography of the hips
  4. Serum alkaline phosphatase level

Explanation

A three-phase bone scan becomes positive within the first weeks of heterotopic ossification, well before plain films show calcification. Alkaline phosphatase may rise early but is nonspecific, and radiographs may remain normal for several weeks after symptoms begin.

Question 34Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

A 7-year-old is struck by a car and has transient arm weakness that has resolved; plain radiographs and CT of the cervical spine are normal. Which study is most appropriate next?

  1. Flexion-extension radiographs
  2. CT myelography
  3. MRI of the whole spine Correct answer.
  4. Repeat plain radiographs in six weeks

Explanation

This presentation suggests spinal cord injury without radiographic abnormality, which occurs mainly in children because of flexible ligaments and immature vertebrae. MRI identifies cord edema, hemorrhage, or ligamentous disruption that CT cannot show and helps guide clearance of the spine.

Question 35Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Which blood pressure change meets the consensus definition of orthostatic hypotension?

  1. Any fall in systolic pressure that produces symptoms
  2. A systolic fall of at least 30 mm Hg with a diastolic fall of 15
  3. Systolic fall of 20 mm Hg or diastolic fall of 10 mm Hg Correct answer.
  4. A systolic fall of at least 10 mm Hg with any diastolic fall

Explanation

Orthostatic hypotension is defined as a fall of at least 20 mm Hg systolic or 10 mm Hg diastolic within three minutes of assuming an upright position. The definition rests on the magnitude of the fall, not on whether symptoms occur.

Question 36Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Three years after a T4 AIS A injury, a patient reports new hand weakness and loss of pain and temperature sensation across the neck and shoulders, while position sense is preserved. What is the most likely diagnosis?

  1. Post-traumatic syringomyelia Correct answer.
  2. Late spinal shock
  3. Tethered cord syndrome
  4. Heterotopic ossification of the hip

Explanation

A new ascending level with dissociated sensory loss, in which pain and temperature are affected while dorsal column function is spared, is the classic presentation of a post-traumatic syrinx. MRI of the spine confirms the cavity and defines its extent before surgical planning.

Question 37Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Which urodynamic finding best predicts upper urinary tract deterioration in a patient with cervical spinal cord injury?

  1. A postvoid residual volume measured at 150 mL
  2. Detrusor pressure above 40 cm H2O with dyssynergia Correct answer.
  3. A maximum bladder capacity measured at 500 mL
  4. An absent bulbocavernosus reflex on examination

Explanation

Sustained high detrusor storage pressures, particularly with detrusor-sphincter dyssynergia, promote vesicoureteral reflux and renal scarring. Pressures above roughly 40 cm H2O are the usual threshold for recommending treatment to protect the upper tracts.

Question 38Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

When the two sides of the body differ in strength after spinal cord injury, how are motor levels documented on the ISNCSCI worksheet?

  1. One motor level is recorded for each side Correct answer.
  2. A single level calculated as the average of both sides
  3. A single level determined by the stronger upper limb
  4. A single level determined by the weaker upper limb

Explanation

Motor and sensory levels are determined independently for the right and left sides, and each side's level is reported separately. The neurological level of injury is then the single most rostral segment that is normal bilaterally.

Question 39Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

Pinprick and light touch are normal through C6 on both sides. At C7, pinprick is reduced on the right but normal on the left, and light touch is normal bilaterally. Upper limb motor testing is normal. What is the neurological level of injury?

  1. C6 Correct answer.
  2. C8
  3. C7
  4. C5

Explanation

The neurological level of injury is the most caudal segment with normal sensory and motor function on both sides. Because C7 pinprick is impaired on the right, the right sensory level is C6 while the left sensory level is C7, leaving C6 as the most caudal segment that is normal bilaterally.

Question 40Assessment, Evaluation, and Diagnosis in Spinal Cord Injury

In the International Spinal Cord Injury Pain classification, pain felt within the dermatome of the neurological level and up to three dermatomes below it is classified as which type?

  1. Nociceptive musculoskeletal pain
  2. At-level neuropathic pain Correct answer.
  3. Visceral pain
  4. Below-level neuropathic pain

Explanation

At-level neuropathic pain is defined as pain within the dermatome of the neurological level and up to three dermatomes below that level. Pain extending more than three dermatomes below the level is classified as below-level neuropathic pain.

Question 41Acute Management and Medical Complications of Spinal Cord Injury

A 26-year-old man with a C6 ASIA A injury sustained 14 hours ago has a blood pressure of 76/48 mm Hg, a heart rate of 46 beats/min, and warm, dry extremities. Which mechanism best explains these findings?

  1. Raised intracranial pressure producing a Cushing reflex
  2. Loss of sympathetic outflow with unopposed vagal tone Correct answer.
  3. Hemorrhagic shock from associated injuries with compensatory tachycardia
  4. Early sepsis causing vasodilation and fever

Explanation

Injuries at or above T6 interrupt descending sympathetic pathways, producing hypotension from loss of vascular tone together with bradycardia from unopposed vagal activity; the skin stays warm and dry rather than clammy. Hemorrhage still must be excluded, but compensatory tachycardia is the expected response to blood loss and is absent in this patient.

Question 42Acute Management and Medical Complications of Spinal Cord Injury

Autonomic dysreflexia is most likely to develop after a spinal cord injury at which level?

  1. T6 or above Correct answer.
  2. T10
  3. L1
  4. S3-S4

Explanation

Dysreflexia requires disconnection of supraspinal control from the splanchnic and peripheral sympathetic outflow, which happens with lesions at T6 or above. Lesions below that level leave enough sympathetic circuitry connected to mount a coordinated vascular response.

Question 43Acute Management and Medical Complications of Spinal Cord Injury

Which spinal cord segments give rise to the phrenic nerve that innervates the diaphragm?

  1. C6-T1
  2. C1-C2
  3. T4-T6
  4. C3-C5 Correct answer.

Explanation

The phrenic nucleus lies in the C3-C5 segments, and the nerve descends through the neck to supply the diaphragm. Injuries above C3 abolish spontaneous diaphragmatic breathing, while lower cervical injuries spare the diaphragm but weaken the intercostal and abdominal muscles.

Question 44Acute Management and Medical Complications of Spinal Cord Injury

A patient is admitted 6 hours after a T4 ASIA A injury. Which bladder management approach is most appropriate at this stage?

  1. External condom catheter alone
  2. Indwelling urethral catheter Correct answer.
  3. Immediate suprapubic catheter placement
  4. Timed voiding every 2 hours

Explanation

During the acute phase an indwelling catheter with continuous drainage allows accurate output monitoring and prevents bladder overdistension while the patient is immobilized and hemodynamically labile. Intermittent catheterization is usually started once fluids and diuresis have stabilized.

Question 45Acute Management and Medical Complications of Spinal Cord Injury

A patient with a T4 injury develops a pounding headache with a blood pressure of 196/110 mm Hg and a heart rate of 52 beats/min. What is the most appropriate first action?

  1. Administer sublingual nifedipine first
  2. Sit the patient upright Correct answer.
  3. Give intravenous labetalol as initial therapy
  4. Insert a new urinary catheter immediately

Explanation

Sitting the patient upright produces gravitational pooling that lowers blood pressure while the underlying stimulus is sought, since bladder distension, fecal impaction, and skin or nail problems are the usual triggers. Drug therapy is reserved for episodes that persist after positioning and removal of the trigger.

Question 46Acute Management and Medical Complications of Spinal Cord Injury

A patient with a C5 ASIA A injury has a heart rate of 38 beats/min with hypotension that persists after positioning. Which medication is most appropriate initially?

  1. Adenosine 6 mg IV push
  2. Atropine 0.5 mg IV Correct answer.
  3. Amiodarone 150 mg IV over 10 minutes
  4. Epinephrine 1 mg IV push

Explanation

Bradycardia in high cervical injury reflects unopposed vagal tone, and atropine blocks muscarinic receptors to restore rate in symptomatic patients. Adenosine and amiodarone treat tachyarrhythmias, while a 1 mg epinephrine push is a cardiac arrest dose.

Question 47Acute Management and Medical Complications of Spinal Cord Injury

How frequently should an immobilized patient with acute spinal cord injury be repositioned in bed to reduce pressure injury risk?

  1. Once per shift
  2. Every 8 hours
  3. Every 2 hours Correct answer.
  4. Every 6 hours

Explanation

Pressure over bony prominences must be relieved before capillary perfusion is compromised, which is why a turning interval of about 2 hours is standard for immobilized patients. Intervals are individualized for tissue tolerance, support surface, and skin condition.

Question 48Acute Management and Medical Complications of Spinal Cord Injury

Which thromboprophylaxis is preferred for a patient with acute spinal cord injury who has no bleeding contraindication?

  1. Graduated compression stockings alone
  2. Low-molecular-weight heparin Correct answer.
  3. Aspirin 81 mg daily
  4. Prophylactic IVC filter placement

Explanation

Acute spinal cord injury is a high-risk state for venous thromboembolism, and early low-molecular-weight heparin reduces deep vein thrombosis and pulmonary embolism compared with mechanical measures alone. Mechanical prophylaxis is used as an adjunct or when anticoagulation is contraindicated.

Question 49Acute Management and Medical Complications of Spinal Cord Injury

Which finding best marks the end of the period of spinal shock after spinal cord injury?

  1. Bulbocavernosus reflex return Correct answer.
  2. Resolution of orthostatic hypotension
  3. Normalization of bladder emptying
  4. Return of voluntary motor function

Explanation

Spinal shock is the transient areflexia and flaccidity below the lesion, and return of the bulbocavernosus reflex signals that spinal reflex arcs are recovering, usually within days to weeks. Voluntary motor return depends on the completeness of the lesion and is not what defines the end of spinal shock.

Question 50Acute Management and Medical Complications of Spinal Cord Injury

A patient with a T10 injury develops a swollen, warm, painful hip 6 weeks after injury, with an elevated alkaline phosphatase. What is the most likely diagnosis?

  1. Heterotopic ossification Correct answer.
  2. Femoral neck fracture
  3. Septic arthritis
  4. Deep vein thrombosis

Explanation

Heterotopic ossification appears weeks to months after injury, most often at the hip, with localized swelling, warmth, pain, and rising alkaline phosphatase, and it can mimic deep vein thrombosis or cause low-grade fever. Imaging confirms maturity before any surgical resection.