Spinal Trauma — MCQs

10 questions

Jefferson's fracture is:

An unconscious patient is brought to the Emergency Department with suspected cervical cord injury. Which of the following clinical signs is not suggestive of cervical spinal cord injury?

Spinal shock is characterized by all except-

A 25-year-old man is brought to the emergency department after sustaining a stab wound to the lower back. Examination shows right leg weakness in all muscle groups and loss of vibration and proprioception on the same side. There is loss of pain and temperature sensation but preserved motor strength in the left leg. He has no problems with bladder or bowel retention. Motor strength is preserved in the upper extremities. His presentation is most consistent with which one of the following spinal cord syndromes?

Which of the following is not a component of Brown-Sequard syndrome?

In an accident case, after the arrival of medical team, all should be done in early management except;

After a road traffic accident, a patient presented to casualty with vitals showing BP of 90/60 mm Hg and heart rate of 56 bpm. Which kind of shock occurs?

Which of the following statements about the brachial plexus is true?

Back examination of polytrauma patient is done by which method:-

Q10

Which is the most important initial step in managing a trauma patient with massive hemothorax?

Spinal Trauma Indian Medical PG Practice Questions and MCQs

Question 1: Jefferson's fracture is:

A. Avulsion fracture of C7
B. Fracture of Axis
C. Fracture of Atlas (Correct Answer)
D. Due to fracture of traumatic spondylolisthesis of C2 over C3

Explanation: ***Fracture of Atlas*** - A **Jefferson's fracture** specifically refers to a burst fracture of the **C1 vertebra** (atlas). - This type of fracture often results from an **axial loading injury** to the head, transmitting force through the occipital condyles to the C1 lateral masses. *Avulsion fracture of C7* - An **avulsion fracture of C7** is commonly known as a **clay-shoveler's fracture**, which is distinct from a Jefferson's fracture. - It typically results from **sudden powerful neck flexion** or muscle contraction, causing a spinous process to be pulled away. *Fracture of Axis* - The **axis (C2 vertebra)** is involved in fractures such as a **hangman's fracture**, which is a bilateral pedicle fracture. - While C2 fractures are also cervical spine injuries, they are anatomically and mechanistically different from C1 fractures. *Due to fracture of traumatic spondylolisthesis of C2 over C3* - **Traumatic spondylolisthesis of C2 over C3** describes a type of fracture-dislocation, often involving the pedicles of C2. - This specific injury is generally associated with different forces and bone involvement than a burst fracture of the C1 ring.

Question 2: An unconscious patient is brought to the Emergency Department with suspected cervical cord injury. Which of the following clinical signs is not suggestive of cervical spinal cord injury?

A. Flaccidity
B. Priapism
C. Increased Rectal sphincter Tone (Correct Answer)
D. Diaphragmatic Breathing

Explanation: ***Increased Rectal sphincter Tone*** - **Increased rectal sphincter tone** suggests **intact lower motor neuron function** and is not a clinical sign of cervical spinal cord injury. [2] - In a spinal cord injury, especially in the acute phase of **spinal shock**, there is typically **decreased or absent rectal tone** due to flaccid paralysis below the level of injury. [4] *Flaccidity* - **Flaccidity**, or hypotonia, is a common finding in the acute phase of **spinal shock** following a cervical spinal cord injury. [1] - It results from the temporary loss of spinal reflex activity below the level of injury, leading to **muscle weakness** and reduced tone. [4] *Priapism* - **Priapism** (persistent erection) is an important indicator of **cervical or high thoracic spinal cord injury**. - It occurs due to **disruption of autonomic pathways** that regulate penile detumescence, leading to unopposed parasympathetic activity. *Diaphragmatic Breathing* - **Diaphragmatic breathing** (belly breathing) can be a sign of **high cervical spinal cord injury** [3] because the intercostal muscles, responsible for chest wall expansion, are paralyzed. - The **phrenic nerve**, which innervates the diaphragm, originates from C3-C5, so if the injury is below C5, diaphragmatic breathing may be maintained even if other respiratory muscles are lost.

Question 3: Spinal shock is characterized by all except-

A. Sensory loss
B. Areflexia
C. Spastic paralysis (Correct Answer)
D. Flaccid paralysis

Explanation: ***Spastic paralysis*** - **Spinal shock** is characterized by the *absence* of reflexes and tone immediately following a spinal cord injury [1]. - **Spasticity** develops *after* the resolution of spinal shock, due to the loss of descending inhibitory control [1]. *Sensory loss* - **Spinal shock** typically results in a complete **loss of sensation** below the level of the spinal cord injury due to disruption of ascending sensory pathways. - This **sensory deficit** is a hallmark symptom during the acute phase of spinal cord trauma. *Areflexia* - During **spinal shock**, there is a **complete loss of spinal reflexes** below the level of injury (e.g., deep tendon reflexes, bulbocavernosus reflex) [1]. - This **areflexia** is a key diagnostic feature indicating the acute phase of spinal cord dysfunction. *Flaccid paralysis* - **Spinal shock** presents with **flaccid paralysis** below the lesion due to the abrupt cessation of descending motor signals and the temporary loss of spinal cord reflex activity [1]. - The muscles become **limp and powerless** because they are disconnected from higher brain control and local reflex arcs are suppressed.

Question 4: A 25-year-old man is brought to the emergency department after sustaining a stab wound to the lower back. Examination shows right leg weakness in all muscle groups and loss of vibration and proprioception on the same side. There is loss of pain and temperature sensation but preserved motor strength in the left leg. He has no problems with bladder or bowel retention. Motor strength is preserved in the upper extremities. His presentation is most consistent with which one of the following spinal cord syndromes?

A. Anterior cord syndrome
B. Cauda equina syndrome
C. Central cord syndrome
D. Hemisection of the cord (Correct Answer)

Explanation: ***Hemisection of the cord*** - This syndrome, also known as **Brown-Séquard syndrome**, is characterized by ipsilateral motor paralysis and loss of proprioception/vibration below the lesion, and contralateral loss of pain and temperature sensation [1]. The patient's presentation perfectly matches these findings. - The **stab wound** to the lower back suggests a highly localized injury, which is consistent with a hemisection rather than a more diffuse cord injury. *Anterior cord syndrome* - This syndrome typically results in **bilateral motor paralysis** below the lesion and bilateral loss of pain and temperature sensation. - **Proprioception and vibration sensation are preserved** in anterior cord syndrome because the posterior columns are spared [1]. *Cauda equina syndrome* - This syndrome involves injury to the **nerve roots below the spinal cord** and typically presents with bilateral leg weakness, **saddle anesthesia**, and bladder/bowel dysfunction. - The patient in this case has unilateral motor and sensory deficits and no bladder/bowel issues, which is inconsistent with cauda equina syndrome. *Central cord syndrome* - This syndrome usually results in **greater motor weakness in the upper extremities** than in the lower extremities, along with a variable sensory loss [1]. - It often occurs after hyperextension injuries in older individuals with cervical spondylosis, and the patient's presentation of a stab wound and specific unilateral deficits does not fit this pattern.

Question 5: Which of the following is not a component of Brown-Sequard syndrome?

A. Contralateral loss of pain and temperature sensation
B. Contralateral posterior column involvement (Correct Answer)
C. Ipsilateral extensor plantar response
D. Ipsilateral loss of proprioception

Explanation: ***Contralateral posterior column involvement*** - **Brown-Séquard syndrome** is caused by hemisection of the spinal cord, affecting pathways as they ascend or descend. [1] - The **posterior columns** (involved in proprioception, vibration, and fine touch) transmit sensory information **ipsilaterally**, meaning symptoms would be on the same side as the lesion, not contralateral. [1] *Ipsilateral extensor plantar response* - This is a feature of **upper motor neuron (UMN) damage** affecting the corticospinal tract, which descends ipsilaterally before crossing in the medulla. - In Brown-Séquard syndrome, the **ipsilateral corticospinal tract** is damaged, leading to UMN signs below the lesion. [1] *Ipsilateral loss of proprioception* - **Proprioception** is carried by the posterior columns, which ascend **ipsilaterally** in the spinal cord. [2] - Damage to the posterior column on one side of the spinal cord (as in a hemisection) results in **ipsilateral loss** of proprioception, vibration, and discriminative touch. [1] *Contralateral loss of pain and temperature sensation* - The **spinothalamic tracts** carry pain and temperature sensations and cross within one or two spinal cord segments after entering. [2] - Therefore, a lesion on one side of the spinal cord will result in **contralateral loss** of pain and temperature sensation, typically a few segments below the level of the lesion. [1]

Question 6: In an accident case, after the arrival of medical team, all should be done in early management except;

A. Glasgow coma scale
B. Check BP (Correct Answer)
C. Stabilization of cervical vertebrae
D. Check Respiration

Explanation: ***Check BP*** - In the **immediate/early management** of trauma (primary survey), while circulation assessment is crucial, the **initial assessment of circulation** focuses on: - **Pulse rate and quality** (radial, carotid) - **Capillary refill time** - **Skin color and temperature** - **Active hemorrhage control** - **Formal blood pressure measurement** with a cuff, while important, is typically recorded during or after these rapid initial assessments, as it takes more time to obtain an accurate reading. - In the context of this question, among the four options listed, BP measurement is relatively less immediate compared to the other life-saving priorities (airway protection, breathing assessment, C-spine stabilization, and GCS). - **Note:** This is a nuanced distinction - BP is assessed during primary survey, but the other three options have more immediate life-threatening implications if not addressed. *Glasgow coma scale* - **GCS assessment** is part of the **"D" (Disability)** step in the ATLS primary survey. - It is performed early to assess neurological status and level of consciousness. - GCS <8 indicates need for **definitive airway protection** (intubation). - This is a critical early assessment that guides immediate management decisions. *Stabilization of cervical vertebrae* - **C-spine immobilization** is part of the **"A" (Airway)** step - "Airway with cervical spine protection." - It is performed **simultaneously** with airway assessment using a **rigid cervical collar**. - This is the **first priority** in trauma management to prevent secondary spinal cord injury. - All trauma patients should be assumed to have C-spine injury until proven otherwise. *Check Respiration* - **Respiratory assessment** is part of the **"B" (Breathing)** step in the ATLS primary survey. - This involves checking: - **Respiratory rate and pattern** - **Chest wall movement** - **Air entry bilaterally** - **Signs of tension pneumothorax or flail chest** - This is an immediate life-saving priority and must be assessed early.

Question 7: After a road traffic accident, a patient presented to casualty with vitals showing BP of 90/60 mm Hg and heart rate of 56 bpm. Which kind of shock occurs?

A. Cardiogenic
B. Neurogenic (Correct Answer)
C. Hypovolemic shock
D. Septic shock

Explanation: ***Neurogenic*** - This patient presents with **hypotension** (BP 90/60 mm Hg) and **bradycardia** (heart rate 56 bpm), which is a classic presentation of neurogenic shock due to **loss of sympathetic tone** following a spinal cord injury [2]. - The road traffic accident suggests a potential **spinal cord injury**, leading to disruption of the autonomic nervous system's control over heart rate and vascular tone. *Cardiogenic* - Cardiogenic shock is characterized by **hypotension** and **tachycardia**, often due to the heart's inability to pump blood effectively, such as in a myocardial infarction [1]. - The reported **bradycardia** in this patient makes cardiogenic shock unlikely. *Hypovolemic shock* - Hypovolemic shock results from significant **fluid loss**, leading to **hypotension** and a compensatory **tachycardia**. - The presence of **bradycardia** rules out hypovolemic shock, as the body would typically try to increase heart rate to compensate for volume depletion. *Septic shock* - Septic shock is caused by a severe **infection**, leading to widespread vasodilation, **hypotension**, and often **tachycardia** with signs of systemic inflammation. - There is no indication of infection, and the **bradycardia** is inconsistent with the typical presentation of septic shock.

Question 8: Which of the following statements about the brachial plexus is true?

A. Formed by spinal nerves C5-C8 and T1 (Correct Answer)
B. The radial nerve arises from the medial cord of the brachial plexus.
C. Injury to the brachial plexus may occur during shoulder dystocia, often affecting the lower trunk.
D. The lower trunk is a common site of injury in brachial plexus trauma.

Explanation: ***Formed by spinal nerve C5- C8 and T1*** - The brachial plexus is indeed formed by the **ventral rami** of spinal nerves **C5, C6, C7, C8, and T1**. - These roots then arrange into **trunks, divisions, cords, and branches** to innervate the upper limb. *The radial nerve arises from the medial cord of the brachial plexus.* - The **radial nerve** is the largest branch of the **posterior cord** of the brachial plexus, not the medial cord. - The **ulnar nerve** and medial root of the median nerve arise from the medial cord. *Injury to the brachial plexus may occur during shoulder dystocia, often affecting the lower trunk.* - **Shoulder dystocia** typically causes injury to the **upper roots (C5-C6)**, leading to **Erb's palsy**, not the lower trunk. - Injury to the lower trunk (C8-T1) is more commonly associated with **Klumpke's palsy**, which is rarer and often due to traction on an abducted arm. *The lower trunk is a common site of injury in brachial plexus trauma.* - The **upper trunk (C5-C6)** is the most common site of injury in brachial plexus trauma, especially in conditions like **Erb's palsy**. - While the lower trunk can be injured, it is much less frequent than upper trunk injuries.

Question 9: Back examination of polytrauma patient is done by which method:-

A. Barrel roll
B. Primary survey
C. Logroll (Correct Answer)
D. Chin lift

Explanation: ***Logroll*** - The **logroll technique** is used to safely turn a polytrauma patient onto their side to examine their back while maintaining spinal immobilization. - It requires multiple personnel (typically 3-5) to turn the patient as a single unit, preventing **unnecessary spinal movement** and potential injury. *Barrel roll* - This term is not a recognized medical technique for examining a polytrauma patient's back. - It might refer to a maneuver in aviation or gymnastics, unrelated to patient care. *Primary survey* - The **primary survey** is the initial rapid assessment of a trauma patient focusing on life-threatening injuries (ABCDE: Airway, Breathing, Circulation, Disability, Exposure). - While back examination is part of the "Exposure" component, the **logroll** is the *method* used for the examination, not the survey itself. *Chin lift* - The **chin lift** maneuver is used to open the airway in an unresponsive patient by lifting the chin upwards and supporting the jaw. - It is an airway management technique and does not involve assessing the patient's back.

Question 10: Which is the most important initial step in managing a trauma patient with massive hemothorax?

A. Thoracotomy
B. IV fluids
C. Chest tube (Correct Answer)
D. Blood transfusion

Explanation: ***Chest tube*** - A **chest tube** (thoracostomy) is crucial for both diagnosing and treating a massive hemothorax, allowing immediate drainage of blood and assessing the rate of ongoing bleeding. - Rapid evacuation of blood from the pleural space improves **lung re-expansion**, ventilation, and helps to reduce pressure on the mediastinum. *Thoracotomy* - **Thoracotomy** is indicated if there is persistent significant bleeding (e.g., >1500 mL initially or >200 mL/hr for 2-4 hours), but the initial step is always chest tube insertion. - Performing a thoracotomy as the *first* step is generally reserved for situations with profound hemodynamic instability or suspicion of major vascular injury not amenable to less invasive measures. *IV fluids* - While **IV fluids** are essential for maintaining hemodynamic stability in a trauma patient with massive blood loss, they do not address the source of bleeding or relieve the compression caused by the hemothorax. - Administering fluids without evacuating the blood from the chest can transiently improve vital signs but does not resolve the underlying problem or prevent further complications. *Blood transfusion* - **Blood transfusion** is vital for correcting hypovolemic shock and improving oxygen-carrying capacity in patients with massive hemorrhage. - However, it is a supportive measure and does not evacuate the blood from the pleural space or stop the bleeding, which is the primary goal of the initial management of a massive hemothorax.

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