A 16-year-old girl is brought to the emergency room with hyperextension of the cervical spine caused by a trampoline injury. After ruling out the possibility of hemorrhagic shock, she is diagnosed with quadriplegia with neurogenic shock. The physical examination is most likely to reveal which of the following constellation of findings?

Pulse: 56/min; blood pressure: 88/40 mm Hg; respirations: 22/min; loss of rectal tone on DRE; reduced muscle power and absence of sensations in the limbs

Pulse: 110/min; blood pressure: 88/50 mm Hg; respirations: 26/min; normal rectal tone on digital rectal examination (DRE); normal muscle power and sensations in the limbs

Pulse: 116/min; blood pressure: 80/40 mm Hg; respirations: 16/min; loss of rectal tone on DRE; reduced muscle power and absence of sensations in the limbs

Pulse: 54/min; blood pressure: 88/44 mm Hg; respirations: 26/min; increased rectal tone on DRE; normal muscle power and sensations in the limbs

Pulse: 99/min; blood pressure: 188/90 mm Hg; respirations: 33/min; loss of rectal tone on DRE; reduced muscle power and absence of sensations in the limbs

A 44-year-old man is brought to the emergency department 25 minutes after falling off the roof of a house. He was cleaning the roof when he slipped and fell. He did not lose consciousness and does not have any nausea. On arrival, he is alert and oriented and has a cervical collar on his neck. His pulse is 96/min, respirations are 18/min, and blood pressure is 118/78 mm Hg. Examination shows multiple bruises over the forehead and right cheek. The pupils are equal and reactive to light. There is a 2-cm laceration below the right ear. Bilateral ear canals show no abnormalities. The right wrist is swollen and tender; range of motion is limited by pain. The lungs are clear to auscultation. There is no midline cervical spine tenderness. There is tenderness along the 2nd and 3rd ribs on the right side. The abdomen is soft and nontender. Neurologic examination shows no focal findings. Two peripheral venous catheters are placed. Which of the following is the most appropriate next step in management?

Focused Assessment with Sonography in Trauma

A 51-year-old woman comes to the physician because of progressively worsening lower back pain. The pain radiates down the right leg to the lateral side of the foot. She has had no trauma, urinary incontinence, or fever. An MRI of the lumbar spine shows disc degeneration and herniation at the level of L5–S1. Which of the following is the most likely finding on physical examination?

Exaggerated patellar tendon reflex

Diminished sensation of the anus and genitalia

Diminished sensation of the anterior lateral thigh

A 61-year-old man is found dead in his home after his neighbors became concerned when they did not see him for several days. The man was described as a "recluse" who lived alone and mostly kept to himself. Medical records reveal that he had not seen a physician in over a decade. He had a known history of vascular disease including hypertension, hyperlipidemia, and diabetes mellitus. He did not take any medications for these conditions. An autopsy is performed to identify the cause of death. Although it is determined that the patient suffered from a massive cerebrovascular accident as the cause of death, an incidental finding of a tumor arising from the spinal cord meninges is noted. The tumor significantly compresses the left anterolateral lower thoracic spinal cord. The right side of the spinal cord and the posterior spinal cord appear normal. Which of the following would most likely be impaired due to this lesion?

Pain sensation from the right side of the body

Proprioceptive sensation from the left side of the body

Temperature sensation from the left side of the body

Pressure sensation from the left side of the body

Vibratory sensation from the right side of the body

A 22-year-old man is brought to the emergency department 30 minutes after being involved in a high-speed motor vehicle collision in which he was the unrestrained driver. After extrication, he had severe neck pain and was unable to move his arms and legs. On arrival, he is lethargic and cannot provide a history. Hospital records show that eight months ago, he underwent an open reduction and internal fixation of the right humerus. His neck is immobilized in a cervical collar. Intravenous fluids are being administered. His pulse is 64/min, respirations are 8/min and irregular, and blood pressure is 104/64 mm Hg. Examination shows multiple bruises over the chest, abdomen, and extremities. There is flaccid paralysis and absent reflexes in all extremities. Sensory examination shows decreased sensation below the shoulders. Cardiopulmonary examination shows no abnormalities. The abdomen is soft. There is swelling of the right ankle and right knee. Squeezing of the glans penis does not produce anal sphincter contraction. A focused assessment with sonography for trauma shows no abnormalities. He is intubated and mechanically ventilated. Which of the following is the most appropriate next step in management?

Intravenous dexamethasone therapy

A 22-year-old man is rushed to the emergency department after a motor vehicle accident. The patient states that he feels weakness and numbness in both of his legs. He also reports pain in his lower back. His airway, breathing, and circulation is intact, and he is conversational. Neurologic exam is significant for bilateral lower extremity flaccid paralysis and impaired pain and temperature sensation up to T10-T11 with normal vibration sense. A computerized tomography scan of the spine is performed which shows a vertebral burst fracture of the vertebral body at the level of T11. Which of the following findings is most likely present in this patient?

Flaccid paralysis at the level of the lesion

Spinal cord injury management for USMLE Step 1: High-Yield Surgery Lessons

💥 The Initial Hit

Primary Injury: Irreversible mechanical damage from trauma (e.g., fracture, dislocation). Causes immediate neuronal and glial cell death at the injury site.
Spinal Shock: A transient physiological shutdown of spinal cord function below the lesion.
- Features: Flaccid paralysis, areflexia (loss of deep tendon reflexes), and sensory loss.
- Duration: Lasts hours to weeks.

⭐ The end of spinal shock is heralded by the return of the bulbocavernosus reflex (BCR). The true extent of permanent injury (e.g., UMN signs) can be assessed after this point.

💥 Pathophysiology - Damage Cascade

Primary Injury: Irreversible mechanical damage from the initial trauma (e.g., compression, laceration). This sets the stage for further damage.
Secondary Injury: A delayed, progressive cascade that is a key therapeutic target. It evolves over hours to weeks, expanding the initial lesion.

⭐ Excitotoxicity is a major driver: excessive glutamate release overstimulates NMDA/AMPA receptors. This causes a massive influx of $Ca^{2+}$, activating proteases and lipases, leading to neuronal apoptosis and necrosis.

Spinal Cord Injury: Primary and Secondary Injury Mechanisms

⚠️ Clinical Manifestations - Signs of Trouble

Spinal Shock:
- Transient loss of all spinal reflexes and flaccid paralysis below the injury level.
- Duration: hours to weeks.
- 💡 The return of the Bulbocavernosus Reflex (BCR) signals its end.
Neurogenic Shock: (Injury at or above T6)
- Distributive shock from loss of sympathetic tone.
- Classic triad: Hypotension (unopposed vagal tone), Bradycardia, Poikilothermia.

⭐ Distinguishing Shock: Spinal shock involves loss of reflexes (neurologic deficit). Neurogenic shock involves loss of sympathetic tone (hemodynamic instability). A patient can have both.

Incomplete Cord Syndromes:
- Anterior Cord: Motor, pain, temp loss. Dorsal columns (proprioception, vibration) spared.
- Central Cord: Upper extremity weakness > lower. Common in elderly hyperextension injuries.
- Brown-Séquard: Hemisection. Ipsilateral motor/proprioception loss; contralateral pain/temp loss.

Incomplete Spinal Cord Syndromes Diagram

🎯 Diagnosis - Pinpointing the Lesion

Neurological Exam:
- Assess motor (myotomes), sensory (dermatomes: pinprick, light touch), and deep tendon reflexes.
- 📌 Key: Check for sacral sparing (S4-S5 sensation, voluntary anal contraction) to determine if injury is complete vs. incomplete.
ASIA Impairment Scale: Standardizes injury severity.
- A: Complete (no motor/sensory in S4-S5)
- B: Sensory Incomplete
- C/D: Motor Incomplete (differentiated by muscle grade <3 or ≥3)
- E: Normal
Imaging:
- CT (non-contrast): Best initial test for bony fractures & malalignment.
- MRI: Gold standard for cord parenchyma, ligaments, and hematomas.

⭐ Sacral sparing is the most critical finding distinguishing an incomplete (ASIA B-D) from a complete (ASIA A) injury, significantly impacting prognosis.

ASIA Impairment Scale (AIS) Chart

🚑 Management - The Rescue Mission

Pre-hospital: Immediate spinal immobilization (rigid collar, backboard).
Airway: Secure airway early; high cervical injuries (C3-C5) risk respiratory failure.
Circulation: Aggressively manage hypotension (neurogenic shock).
Medical:
- DVT prophylaxis (e.g., LMWH).
- Stress ulcer prophylaxis (e.g., PPIs).
Surgical: Decompression and/or stabilization for unstable fractures, cord compression, or progressive neurological deficit.
⚠️ Steroids: High-dose methylprednisolone is no longer recommended as standard practice due to increased risk of complications (infection, GI bleed).

⭐ Maintain Mean Arterial Pressure (MAP) at 85-90 mmHg for the first 7 days post-injury to optimize spinal cord perfusion and prevent secondary injury.

⚡ Biggest Takeaways

ABCDEs first, with strict cervical spine immobilization until cleared.

Neurogenic shock (injury ≥T6): hypotension + bradycardia. Treat with IVF and vasopressors.

Spinal shock: transient areflexia and flaccid paralysis. Ends with return of bulbocavernosus reflex.

High-dose steroids (methylprednisolone) are not standard of care due to high risk of complications.

Autonomic dysreflexia (injury ≥T6): severe HTN, bradycardia, sweating. Sit patient up, remove stimulus.

Injuries above C5 risk respiratory failure from diaphragmatic paralysis (phrenic nerve).

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