Another test

Testy

Traumatic Brain Injury 1

What can be done to prevent reinjury in a teenager who sustained TBI?
• Decrease fatality of MVA: airbags and seatbelts reduce fatalities by 50%
• Use of helmet in motorcycle
• Discourage drugs and alcohol
• Prevention of falls (more important in elderly) by decreasing polypharmacy, minimizing sedating medications, and addressing postural hypotension and addressing gait/balance abnormalities.

What are important prognostic factors after severe TBI?
• Avoid telling family percentages
• Initial GCS score
• Length of coma (time until following commands)
• Duration of PTA*: measured by Galveston Orientation and Amnesia Test. The GOAT is a standard technique for assessing PTA, involving orientation questions and memory. It is scored out of 100 pts and 75 is normal. A score of >75 on 2 days in a row marks the end of PTA. 5-10 minutes PTA is mild, 1-24hrs is moderate, 1-7 days is severe, 1-4weeks is very severe, greater than 4 weeks is extremely severe. For moderate severity or less, a quick and full recovery should be expected. For a severe injury, residual deficits are expected.
• Results of early MRI/CT
• Age
• Pupillary reaction to light
• Time since injury (recovery less likely after 6 months)

Why might a teenager with a CT-negative TBI still remain unresponsive 1 week after injury?
• Diffuse axonal injury: can be primary or secondary
• Systemic hypoxia
• Poor cerebral circulation
• Excitotoxicity

What are the national guidelines for early management of severe TBI?
• IVC to monitor intracranial pressure if needed
• Avoid prophylactic hypoventilation
• Use of steroids not recommended (increases mortality)
• Mannitol and saline solution are not TBI treatment standards, but can be used
• Recommend maintenance of Cerebral Perfusion Pressure at > 60 mmHg

Spinal Cord Injury 6

What are the lifelong economic costs of complete tetraplegia after SCI?
• Costs include: hospital charges, rehab, home and vehicle modifications, assistance with ADLs, loss of wages

What is a life care plan for T6 paraplegia?
• Comprehensive interdisciplinary document of future medical and rehab needs
• Should be undertaken after patient has stabilized medically and functionally
• Components: medical problems, psychological, vocational, recreational, social, rehab, prognosis, equipment needs, preventive medicine, aging complications

What are factors predicting return to work in T6 paraplegia?
• 14% RTW at year one, 40% at 20 years
• Educational level, functional status, driving, pre-employment in white collar job, computer experience, fewer medical complications

What is key legislation to advance rights in SCI?
• Rehabilitation Act: guaranteed civil rights of people with disabilities within federal programs
• Americans with Disabilities Act (ADA): broad nondiscrimination law

Spinal Cord Injury 5

What are common medical complications one year post-injury in a 20 year old C4 ASIA A?
• Pressure ulcers most common complication: risks include cigarettes, sleep meds
• Pneumonia (more common in tetraplegics) leading cause of death from SCI
• UTI: ppx antibiotics not supported
• Urolithiasis: risks are recurrent UTI, indwelling catheters, vesicoureteral reflux, prior stones, hypercalciuria --> can treat with shock wave lithotripsy
• Bladder cancer: risk including indwelling catheters, smoking, kidney stones
• OSA
• Loss of bone mineral density --> no strong evidence for use of bisphosphonates
• Fractures

What are the health maintenance recommendations for this 20 year old C4 ASIA A?
• Question about B/B, BP control, skin, pain, spasticity, sexual function, equipment needs, changes in strength or function
• Counsel on smoking cessation
• Annual renal US for upper urinary tract, video urodynamics for lower urinary tract
• For a woman, there may be increased spasticity, dyautonomia during menstruation --> hormone contraceptives may help; pregnancy at high risk for UTI, AD; no higher risk of cancers or osteoporosis

What are options for a male with C4 ASIA A regarding sexual function and fertility?
• 92% of men can get an erection, but only about half can have successful intercourse, and less than 5% can have unassisted ejaculation
• Vacuum suction and constrictor ring, penile implants (metal rod or inflatable implant)
• PDE-5 inhib (Viagra) used, side effects mimic AD (HA, facial flushing)
• Penile vibratory stimulation is first line treatment for anejaculation --> other treatments are electroejaculation, rectal probes
• Sperm count may be normal, but quality and motility can be poor --> intrauterine insemination, IVF

How is diffuse pain assessed in a 20 year old tetraplegic?
• Pain in 64-80% of SCI
• 15% report visceral pain
• 19-24% have neuropathic pain
• 42% have msk pain: most common in shoulders, followed by wrists, hands, and elbows --> treat with stretching and strengthening, local injections, NSAIDs, occasional opiates

Spinal Cord Injury 3

What are the functional goals for the first 6 months after rehab in a 20 year old C4 ASIA A?
• C1-4: C4 may wean off vent, need rehab for caregiver training, equipment, and prevention of complications, intro to advanced technology
• C5: Prevention of elbow flexion and supination contractures, power wheelchair
• C6: Tenodesis, which may allow patient to do ICP
• C7-C8: C7 is key level for independence at transfers, weight shifts, light meal prep, may do bowel program
• T1-12: Household ambulation may be possible for lower levels of thoracic injury
• L1-2: Ambulation for short distances, but WC for functional ambulation
• L3-4: Usually lower motor neuron, so sacral reflexes are lost. Bowel management through contraction and manual disimpaction. Bladder through ICP. Ambulation with AFO.
• Community ambulation requires b/l hip flexors to be > 3/5, 1 knee extensor at least 3/5

How can you prevent and treat common medical complications in the first 6 months postinjury for a 20 year old man with C6 ASIA A injury?
• Autonomic dysreflexia: rise in BP of 20-40 mmHg above baseline, reflex bradycardia, HA. Can lead to stroke, hemorrhage, seizure, MI, death. Other signs are flushing, sweating, and nasal congestion above level of injury. Causes include: overdistended bladder, kidney or bladder stones, ingrown toenails, menstrual cramps, infection, bowel impaction, pressure ulcers, msk conditions, abdominal pathology. Treated by sitting patient upright and identifying underlying cause.
• Neurogenic bowel: Bowel program daily to q3days. Use of digital stimulation, adequate fluid, high fiber, oral meds, rectal evacuants. If changes in bowel meds, give at least three cycles to see effects. Colostomy if bowel program too difficult.
• Orthostatic hypotension: Compensation with gradual position changes, ace wraps, compression stockings, abdominal binders, midodrine (alpha agonist), fludrocortisones (mineralocorticoid). Usually resolves with spinal reflexes return.
• Immobilization hypercalcemia: N/V, decr appetite, lethargy, polyuria, usually presents 1-2 months postinjury. Treat with IV fluids or bisphosphonates.
• HO: Incidence between 16-53% in SCI. Presents in hips, followed by knees, elbows, shoulders. Swelling, decr ROM. Confirmed with bone scan, treat with etidronate at 20mg/kg orally for 3-6 months. Surgery if functional limitations, but wait until HO is mature.
• Spasticity: Treat with ROM, look for noxious stimuli (UTI), baclofen, benzo, dantrolene, alpha-2 agonists. Botox or phenol for localized spasticity.
• Depression 20-45%

What discharge planning is required for a 20 year old C4 ASIA A?
• Equipment: lift for transfers, padded commode or shower chair, power wheelchair with head, chin, or breath control (and independent pressure relief), manual WC for back-up, mouth stick, computer, van
• Housing evaluation and modifications

What advances are available for SCI?
• FES: improve hand grasp, lower extremity use, bladder control, respiration, and cardiovascular health
• Tendon transfers
• Wheelchairs: pushrum-activated power assist, iBOT 4000 Mobility System for climbing stairs
• Partial body weight support treadmill training
• Brain-based command signals

Spinal Cord Injury 2

How would you acutely manage a 20 year old male with a C4 ASIA A SCI from snowboarding?
• Decompression within 24 hours may improve neurologic recovery, but data inadequate
• High dose steroids called into question: may cause infection or bleeding
• Avoid hypotension, can try abdominal binders, lower limb compression, oral vasopressors (midodrine)
• Autonomic dysfunction is common: bradycardia, neurogenic shock, autonomic dysreflexia (after spinal shock over)
• Spinal shock: loss of reflex neurologic activity in spinal cord (loss of reflexes)
• Neurogenic shock: hypotension of neurogenic origin --> need volume resuscitation and vasopressors
• Bradycardia may occur due to unopposed vagal tone --> usually self-limited but can use atropine
• “quad fever” without identified source can occur in early weeks
• Anticoagulation for DVT or IVC filter within 72 hours
• High risk of stress ulcers --> should start PPI for 4 weeks

What physiatric interventions in acute care can prevent complications in this patient?
• Early ROM, especially in shoulders
• Splinting and orthosis to preserve joint ROM in hands and feet
• Bowel program after starting enteral feeding
• Can remove Foley when patient no longer requires IV fluid --> avoid cath volumes greater than 500 cc
• Pulmonary complications at all levels
• Clearance of secretions: difficult with weak abdominal muscles, manual assisted cough better at clearing secretions than suctioning (hands placed over lower rib cage), mechanical insufflators-exsufflator is effective
• Atelectasis present in 60% of SCI patients on admission, support of use of high tidal volumes
• High rate of dysphagia, especially in patients with C-spine surgery, trachs, prolonged intubation, halo, TBI
• Pressure ulcers: early most common in sacrum, heels, and occiput --> minimize time on backboard, use pressure-relief beds, routine turning q2hrs

How is neurologic recovery prognosticated in SCI?
• Exam at 72 hours better than at 24 hours for prediction
• Most UE recover occurs in first 6 months, mostly in first 3 months
• Most patients recover 1 root level of function with cervical lesions
• UE motor recovery twice as great in incomplete tetraplegia --> more favorable if pinprick spared
• 80% of patients with incomplete paraplegia regain antigravity hip flexors and knee extensors
• 6% of ASIA A convert to ASIA B and none developed volitional motor below injury
• Spinal shock: worse prognosis
• Crossed adductor response to patellar tendon taps is highly predictive of functional motor recovery
• Normal cord on MRI is positive predictor for recovery

What is the acute evaluation of a 30 year old woman with profound and rapid onset of nontraumatic incomplete tetraplegia?
• DDx: Myelopathy, motoneuron disease, MS
• MRI for MS very sensitive but nonspecific
• Spinal angio for diagnosis of spinal cord AV malformations
• CT for bone mets
• CSF: diagnosis of inflammatory disorders
• Labs: test for Lyme, syphilis, HIV, DM, APA

Spinal Cord Injury 1

What are the epidemiologic factors relevant to a 70 year old man who fell and sustained an incomplete C4 injury?
• Average age of onset of SCI has been increasing
• Most common cause of SCI is MVA (50%), but rate for falls has been progressively increasing, rate for sports is decreasing
• Increasing percentage of cervical injuries

What are common causes of nontraumatic SCI in a 30 year old woman with subacute onset of paraplegia with a T6 sensory level?
• Nontraumatic SCI more likely to be incomplete and less likely to have spasticity, DVT, autonomic dysreflexia
• DDx: MS, degenerative CNS diseases, neoplasm, vascular disease, inflammatory disease, spinal stenosis, spinal cord tumors, epidural abscess, epidural hematoma
• Transverse myelitis: can be primary or secondary to vasculitis or rheum d/o, more common in females
• Radiation myelopathy can occur months after treatment

What are the epidemiologic factors related to a girl born with L2 spinal bifida?
• Spina bifida has decreased due to folic acid
• Most common is myelomeningocele: neural elements exposed, complete neurologic deficits --> closure within 24 hours
• Meningocele: dural sac exposed, neural elements may be intact
• Occult spina bifida: closed spinal deficits including lipoma, tethered cord --> should be investigated
• Hydrocephalus seen in 90% of patients with myelomeningocele --> most require VP shunt --> underlying Chiari II malformation
• Hydrosyringomyelia (syrinx) are common in myelomeningocele --> presents with cervical pain, new weakness, spasticity, and scoliosis (can also be a sign of tethered cord)
• Scoliosis affects people with myelomeningocele at thoracic levels --> monitor curvature less than 25 degrees, greater may require TLSO or surgery