Spinal Cord and Root Disease Flashcards Preview

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Flashcards in Spinal Cord and Root Disease Deck (26):
1

421. A 57-year-old woman began having weakness and trouble walking 1 year ago. Current exam findings include weak, wasted muscles with spas-ticity, fasciculations, extensor plantar responses, and hyperreflexia. This
case is most suggestive of
a. Dorsal spinal root disease
b. Ventral spinal root disease
c. Arcuate fasciculus damage
d. Motor neuron disease
e. Purkinje cell damage

The answer is D

( Rowland, pp 708–713.) Motor neuron disease in
the anterior horns of the spinal cord and damage to the corticospinal tracts or motor neurons contributing axons to the corticospinal tracts would
account for these neurologic signs. Damage to the dorsal spinal root would be expected to produce sensory, rather than motor, deficits and would pro-duce areflexia, rather than hyperreflexia, at the level of the injury. Damage to the ventral spinal roots would produce weakness and wasting, but no
spasticity or hyperreflexia would develop. Purkinje cell damage would be expected to produce ataxia without substantial weakness. The arcuate fas-ciculus connects elements of the cerebral cortex not involved in the regula-tion of strength or motor tone.

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422. A 36-year-old man is being evaluated for left hand weakness. On examination, it is readily apparent the he has atrophy of the first dorsal interosseous muscle. This may indicate damage to spinal roots
a. C5 and C6
b. C6 and C7
c. C7 and C8
d. C8 and T1
e. T1 and T2

The answer is D

( Rowland, pp 424–429.)The first dorsal interosseous
muscle is innervated by the ulnar nerve. The fibers of the ulnar nerve reach-ing this muscle originate at the C8 and T1 roots. If the ulnar nerve itself is the
neural element injured, it is usually because of damage at the elbow, where the ulnar nerve runs superficially in the groove over the ulnar condyle. All
the interosseous muscles of the hand are supplied by the ulnar nerve: com-plete  transection  of  that  nerve  will  produce  interosseous  wasting  and impaired finger adduction and abduction. Although the lumbrical muscles are situated alongside the interosseous muscles of the hand, only two lum-bricals—those on the ulnar metacarpals—are innervated by the ulnar nerve. The other two lumbricals are innervated by the median nerve. All four lum-bricals insert on the extensor sheaths of the fingers and participate in exten-sion of the digits.

3

423. A 35-year-old woman falls 12 ft off of a ladder and fractures her c-spine, causing damage at the C4 level. She is initially a flaccid quadriplegic with areflexia. This areflexia and flaccidity usually evolve into hyperreflexia and spasticity within
a. 2 to 4 months
b. 1 to 2 months
c. 3 days to 3 weeks
d. 1 to 3 h
e. 5 to 25 min

The answer is C

( Victor, p 56.) Spinal shock is a transient phenomenon that occurs with damage to fibers from upper motor neurons. The spasticity that usually develops within a few days of the spinal cord injury is presumed to represent exaggeration of the normal stretch reflexes in the limbs disconnected from upper motor neuron control. The evolution fromspinal shock to spasticity is much more typical of spinal cord injuries than it is of cerebrocortical injuries, but even with cerebrocortical injuries there is usually an interval of hours to days during which limbs that eventually become hyperreflexic and spastic are hyporeflexic and flaccid.

4

424. After biopsy resection of a lymph node in her neck, a 23-year-old woman notices instability of her shoulder. Neurologic examination reveals winging of the scapula on the side of the surgery. During surgery, she probably suffered damage to the
a. Deltoid muscle
b. Long thoracic nerve
c. Serratus anterior muscle
d. Suprascapular nerve
e. Axillary nerve

The answer is B

( Victor, p 1432.) Winging of the scapula most often
occurs with weakness of the serratus anterior muscle. This is innervated by the long thoracic nerve, whose course starts high enough and runs super-
ficially enough to allow injury to the nerve with deep dissection into the root of the neck. The long thoracic nerve is derived from C5, C6, and C7. Winging is elicited by having the patient push against a wall with the hands at shoulder level. With this maneuver, the scapula with the weak serratus anterior will be pulled away from the back and the vertical margin of the scapula will stick out from the back. Injuries to the long thoracic nerve are usually unilateral and are often due to trauma or surgical manipulation.

5

425. A 25-year-old woman is involved in a motor vehicle accident. Among her injuries is a lumbar vertebral body fracture. Which of the following most likely contributed to this injury?
a. Flexion
b. Extension
c. Torsion
d. Spondylolisthesis
e. Subluxation

The answer is A

( Victor, p 213.) Extreme flexion of the lumbar spine
is likely in automobile accidents and in falls where the person is upright. Fracture of a lumbar vertebral body may be seen in vehicular accidents when the victim is restrained during a high-speed impact by a seat belt
without a shoulder harness. The rapid and extreme forward flexion of the lumbar spine may produce a variety of spinal injuries, ranging from frac-tures to dislocations. Fractures suffered during falls in which the person is upright, such as may occur when someone jumps off a building, are usu-ally compression fractures of the vertebral body. Fracture of the vertebral body will usually produce pain coincidental with the injury. Patients with fractures of the vertebral body that occur without trauma or with inconse-quential trauma must be investigated for malignant processes, such as metastatic carcinoma, multiple myeloma, and unsuspected osteomyelitis.

6

426. A 35-year-old man injured his thoracic spine in a motor vehicle acci-dent 2 years ago. Initially he had a bilateral spastic paraparesis and urinary
urgency, but this has improved. He still has pain and thermal sensation loss
on part of his left body and proprioception loss in his right foot. There is
still a paralysis of the right lower extremity as well.


This patient has which spinal cord condition?
a. Brown-Séquard (hemisection) syndrome
b. Complete transection
c. Posterior column syndrome
d. Syringomyelic syndrome
e. Tabetic syndrome

The  answer  is  A

( Victor,  p  170.) Hemisection of the spinal cord
results  in  a  contralateral  loss  of  pain  and  thermal  sensation  due  tospinothalamic damage, and ipsilateral loss of proprioception due to poste-rior column damage. Th ere is also an ipsilateral motor paralysis due to destruction of the corticospinal and rubrospinal tracts as well as motor neurons. Complete transection of the spinal cord would cause a bilateral spastic paralysis, and there would be no conscious appreciation of any cutaneous or deep sensation in the area below the transection. Posterior column syndrome would result in a bilateral loss of proprioception below the lesion, with relative preservation of pain and temperature sensation.
Syringomyelic syndrome results from a lesion of the central gray matter. Pain and temperature fibers that cross at the anterior commissure are affected, which may result in bilateral loss of these sensations over several dermatomes.  However,  tactile  sensation  is  spared.  The  most  common cause of this type of syndrome is syringomyelia. Trauma, hemorrhage, or
tumors are other possible etiologies. If the lesion becomes large enough, then other spinal cord systems become affected as well. Tabetic syndrome
results from damage to proprioceptive and other dorsal root fibers. It is classically caused by syphilis. Symptoms include paresthesias, pain, and
abnormalities of gait. Vibration sense is most affected.

7

427. A 35-year-old man injured his thoracic spine in a motor vehicle acci-dent 2 years ago. Initially he had a bilateral spastic paraparesis and urinary urgency, but this has improved. He still has pain and thermal sensation loss on part of his left body and proprioception loss in his right foot. There is still a paralysis of the right lower extremity as well.

In this patient, where would you expect the pain and temperature abnormalities to begin?
a. Exactly at the level of the lesion
b. Four or five segments above the lesion
c. Four or five segments below the lesion
d. One or two segments above the lesion
e. One or two segments below the lesion

The  answer  is E

( Victor,  p  170.) The  spinothalamic  system  is
responsible for pain and temperature sensation. It enters the spinal cord through the dorsal root ganglion. The second-order neurons then ascend one or two levels as they cross in the anterior gray commissure. Thus a
lesion of the right spinothalamic tract at the T8 spinal cord level would result in a contralateral loss of pain and temperature on the left body beginning at approximately the T9–10 dermatome.

8

428. A 35-year-old man injured his thoracic spine in a motor vehicle acci-dent 2 years ago. Initially he had a bilateral spastic paraparesis and urinary urgency, but this has improved. He still has pain and thermal sensation loss on part of his left body and proprioception loss in his right foot. There is still a paralysis of the right lower extremity as well.

The posterior column neurons decussate at what level?
a. At the medulla
b. At the midbrain
c. At the pons
d. At the thalamus
e. Within one or two levels after entering the spinal cord

The answer is A

( Victor, pp 160–162.) After the primary sensory fiber
enters the spinal cord, the ascending branch enters the dorsal columns and travels to the medulla. The fibers from the legs and trunk travel medially in the fasciculus gracilis, while those from the arm and neck travel laterally in the fasciculus cuneatus. These first-order neurons synapse in the medulla, and then the second-order neurons decussate as the internal arcuate fibers and ascend in the medial lemniscus. The second-order fibers synapse in the ventroposterolateral nucleus of the thalamus, which then synapses on the somatosensory cortex.

9

429. A 35-year-old man injured his thoracic spine in a motor vehicle acci-dent 2 years ago. Initially he had a bilateral spastic paraparesis and urinary urgency, but this has improved. He still has pain and thermal sensation loss on part of his left body and proprioception loss in his right foot. There is still a paralysis of the right lower extremity as well.

The lateral corticospinal tract decussates at what level?
a. At the junction of the medulla and the spinal cord
b. At the junction of the midbrain and the medulla
c. At the junction of the pons and the medulla
d. At the thalamus
e. Within one or two levels after entering the spinal cord

The answer is A

( Victor, p 51.) The lateral corticospinal tract origi-
nates primarily in the precentral gyrus (primary motor cortex). These axons then travel in the posterior limb of the internal capsule, and then the middle section of the cerebral peduncle. They enter the basal pons and
continue as the pyramids in the medulla. At the decussation of the pyramids, the lateral corticospinal tract crosses and then continues down the spinal cord.

10

430. A 61-year-old man, who smokes five packs of cigarettes per day and has hypertension, had an abdominal aortic aneurysm repair 8 h ago. The
surgery went very well, and there were no reported perioperative compli-cations. Now the patient is unable to move his legs and states that they are
“numb.” On examination, he has a flaccid paresis of both lower extremities and has impaired pinprick sensation to a T9 level bilaterally. Joint proprio-ception is normal.


The most likely diagnosis in this case is
a. Cerebral stroke
b. Conversion disorder
c. Multiple sclerosis
d. Spinal cord compression
e. Spinal cord infarct

The answer is E

( Victor, pp 171, 1317–1318.)This patient probably
has a spinal cord infarction from an anterior spinal artery occlusion. The posterior cord may be spared, preserving joint proprioception. Bilateral lower extremity deficits without cranial nerve or mental status findings would be an exceedingly unusual cerebral stroke presentation. There is no information, such as psychological stressors or a non-physiologic exam, to suggest a conversion disorder in this case. Multiple sclerosis causes neurological deficits over space and time. In this case we have a single deficit at a single point in time. History of metastatic cancer or trauma might make the physician suspect spinal cord compression.

11

431. A 61-year-old man, who smokes five packs of cigarettes per day and has hypertension, had an abdominal aortic aneurysm repair 8 h ago. The
surgery went very well, and there were no reported perioperative compli-cations. Now the patient is unable to move his legs and states that they are
“numb.” On examination, he has a flaccid paresis of both lower extremities and has impaired pinprick sensation to a T9 level bilaterally. Joint proprio-ception is normal.

The  arteria  radicularis  magna  (artery  of  Adamkiewicz)  enters  at approximately what level?
a. C2–C5
b. C5–C8
c. T2–T8
d. T10–L1
e. L4–S4

The answer is D

( Victor, p 1315.) The artery of Adamkiewicz is a
major anterior radicular artery and may supply the lower two-thirds of the spinal cord. It is at risk of occlusion during abdominal aortic aneurysm repair. Other branches off of the aorta or internal iliac arteries may also supply the thoracic and lumbar cord. The upper segments of the spinal cord are usually supplied off the vertebral arteries.

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432. A 61-year-old man, who smokes five packs of cigarettes per day and has hypertension, had an abdominal aortic aneurysm repair 8 h ago. The
surgery went very well, and there were no reported perioperative compli-cations. Now the patient is unable to move his legs and states that they are
“numb.” On examination, he has a flaccid paresis of both lower extremities and has impaired pinprick sensation to a T9 level bilaterally. Joint proprio-ception is normal.

 Which of the following would you expect to find in this patient 6 months from now?
a. Fasciculations
b. Fibrillations
c. Flaccid paralysis
d. Hyporeflexia
e. Spastic paralysis
 

The answer is E

( Victor, pp 55–58.) This patient has an upper motor
neuron lesion. The damage has been done proximal to the synapse of the anterior horn of the spinal cord. He will therefore develop a spastic paralysis. Fasciculations, fibrillations, flaccid paralysis, and hyporeflexia are all
found following lower motor neuron lesions (at the anterior horn cell or more distally).

13

433. A 61-year-old man, who smokes five packs of cigarettes per day and has hypertension, had an abdominal aortic aneurysm repair 8 h ago. The
surgery went very well, and there were no reported perioperative compli-cations. Now the patient is unable to move his legs and states that they are
“numb.” On examination, he has a flaccid paresis of both lower extremities and has impaired pinprick sensation to a T9 level bilaterally. Joint proprio-ception is normal.

The periumbilical area is innervated by which sensory dermatome?
a. C6
b. T2
c. T5
d. T10
e. S3

The answer is D

( Victor, p 160.) There can be some interindividual
variation; however, T10 is clearly the best choice.

14

434. This patient noticed ulcers on the fingers of both of his hands. They were associated with no pain and appeared to be the residua of burns. The probable site of damage responsible for this defect is the
a. Posterior column
b. Anterior horn
c. Clarke’s column
d. Spinothalamic tract
e. Spinocerebellar tract

Q image thumb

The answer is D

( Patten, pp 256–257.) There is a cystic lesion in the
spinal cord of this patient. It has probably destroyed the anterior decussation of the spinothalamic tract at the upper thoracic and cervical cord levels. There has probably been damage to additional components of the
cervical spinal cord, but this may not become symptomatic until the spinal cord is much more compromised.

15

435. Examination of this patient might reveal which of the following abnormalities?
a. Third-nerve palsy
b. Calf atrophy
c. Charcot joints
d. Atrophy of the intrinsic hand muscles
e. Grasp reflexes

Q image thumb

The answer is D

( Patten, pp 256–257.) As the lesion in this region
of the spinal cord increases in size, it may also affect the lower motor neuron in the anterior horn of the spinal cord, producing weakness in thedistribution of the affected motor neurons. Because it is a lower motor neuron lesion, reflexes will be lost rather than increased in the upper extremities, which may at first seem counterintuitive in a spinal cord lesion. The more laterally placed corticospinal tract may be spared, leaving leg function and reflexes relatively normal.

16

436. The most likely cause of the spinal cord abnormality evident on this T1-weighted magnetic resonance image (MRI) is
a. Neoplasia
b. Syrinx
c. Infarction
d. Hemorrhage
e. Abscess

Q image thumb

The answer is B

( Patten, p 256.) The sausage-shaped structure in the
spinal canal is a syrinx extending from C2 down into the thoracic spinal cord. This is filled with a fluid that appears similar to CSF on MRI. That this patient has syringomyelia independent of neoplasia, infarction, or intraspinal hemorrhage is suggested by the protrusion of cerebellar structures below the
foramen magnum. The combination of a low-lying vermis or cerebellar ton-sils and syringomyelia points to a Chiari malformation. Although it is inap-parent  on  this  MRI  scan,  the  posterior  fossa  would  be  expected  to  be abnormally small and the tentorium cerebelli would insert relatively low on the cranium. Other spinal or spinal cord problems, such as spina bifida and tethered spinal cord, would not be unusual features in association with a Chiari malformation. Even an imperforate anus might be found in the infant
with a Chiari malformation, but damage to the cord sufficient to produce paraplegia is most likely with a lumbosacral myelomeningocele. With this
lesion, there is a defect in the dorsal aspect of the spinal column with an attendant outpouching of meninges and neural elements from the spinal
cord. Potential treatment modalities of syrinxes include laminectomy (to reduce damage to the spinal cord from pressure that develops between the
intraspinal cyst and the vertebrae), cyst aspiration, marsupialization (slicing open and leaving open the cyst), and shunting.

17

437. This type of lesion is most likely to evolve after neck trauma if there has been intraspinal
a. Hyperthermia
b. Hypothermia
c. Transient ischemia
d. Contusion
e. Demyelination

Q image thumb

The answer is D

( Patten, p 256.) After cervical cord contusion, cyst
formation may occur as damaged tissue is removed. This is especially likely if there has been extensive intraspinal hemorrhage. Ischemic damage may
produce similar changes, but the ischemia must be substantial and persistent enough to produce infarction of spinal cord tissue. Demyelination does not lead to syringomyelia, even in cases with extensive intraspinal demyelination.

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438. A 19-year-old man goes swimming in an inland pond in Puerto Rico. Within a few days, he notices itching of his skin over several surfaces of his
body. He is unconcerned until several weeks later when he develops lancinating pains extending down his legs and all of his toes. Over the course of
just a few days, he develops paraparesis and problems with bladder and bowel control. Within 1 week, he is unable to stand and has severe urinary
retention.


The most appropriate plan of action on an emergency basis is to
a. Initiate anticoagulation
b. Perform sensory-evoked potential testing
c. Order an MRI scan
d. Place a cervical collar
e. Perform spinal angiography

The answer is C

( Victor,  pp  1293–1296.) A number of spinal cord
processes could have produced this evolving paraplegia. Rapid investigation is essential to maximize the likelihood that this young man will recover cord function once the lesion has been treated. Even a reversible lesion left untreated for days or weeks will lead to permanent disability. Magnetic resonance imaging scanning is the best emergent test when available, as it will show compressive lesions as well as processes, such as tumors, inflammation, or infection, which may affect the parenchyma of the spinal cord itself. Vascular lesions, such as spinal cord AVMs, may also be seen on MRI, although spinal angiography is often required to confirm the lesion and guide therapy. Anticoagulation is ill advised because any one of several
processes, such as tumors, vascular malformations, or infections, may have already led to bleeding into the spinal cord or be susceptible to bleeding.

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439. A 19-year-old man goes swimming in an inland pond in Puerto Rico. Within a few days, he notices itching of his skin over several surfaces of his
body. He is unconcerned until several weeks later when he develops lancinating pains extending down his legs and all of his toes. Over the course of
just a few days, he develops paraparesis and problems with bladder and bowel control. Within 1 week, he is unable to stand and has severe urinary
retention.

 A myelogram is performed and the cerebrospinal fluid (CSF) is checked. Both are unremarkable except for a slight increase in the CSF protein content. A computed tomography (CT) scan of the lumbar spinal cord is unrevealing. Plain films of the spine are completely normal. An MRI of the lumbar cord with gadolinium reveals patchy enhancement at about the
L4–L5 spinal cord level. These findings suggest
a. An intraspinal hemorrhage
b. An extraparenchymal meningioma
c. An intraparenchymal ependymoma
d. A transverse myelitis
e. A syringomyelia

The answer is D

( Victor, pp 1304–1305.) With an intraspinal hem-
orrhage, the CT scan would be expected to reveal the clot as a relatively dense mass within the spinal canal. Tumors, such as meningiomas and
ependymomas, should have been obvious on MRI if they were producing such dramatic symptoms and signs. Similarly, a syringomyelia should be
evident as a cyst that extends over several levels of the spinal cord. With a transverse myelitis, inflammation is largely limited to the substance of the
cord and there need not be an apparent mass effect. This type of reaction may occur with a variety of noninfectious processes, such as MS and sar-
coid, or infectious processes, such as viral and parasitic infections.

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440. A 19-year-old man goes swimming in an inland pond in Puerto Rico. Within a few days, he notices itching of his skin over several surfaces of his
body. He is unconcerned until several weeks later when he develops lancinating pains extending down his legs and all of his toes. Over the course of
just a few days, he develops paraparesis and problems with bladder and bowel control. Within 1 week, he is unable to stand and has severe urinary
retention.

 A biopsy of the spinal cord is performed, and widespread granulomas are found at the level of the patchy irregularity seen on MRI. In the midst of one granuloma is an ovoid mass with a spine extending from one side. The pathologist interprets this as a parasitic ovum. If the pathologist is correct, the most likely cause of the lesion is
a. Taenia solium
b. Entamoeba histolytica
c. Schistosoma mansoni
d. Schistosoma japonicum
e. Treponema pallidum

 The answer is C

( Victor, p 1309.) T. pallidum may produce a granu-
lomatous lesion (gumma) in the spinal cord, but this young man has an ovum in the granuloma, which suggests the much more common transverse myelitis attributable to schistosomiasis. Both S. mansoniand  S. japonicum embolize eggs to the CNS, but it is S.  mansoni that is endemic in Puerto Rico and in locations in South America and that embolizes to the lumbar spinal cord. This patient should be treated with an antischistosomal agent such as praziquantel. Even with treatment, the reversal of disability produced by this spinal cord injury is usually negligible.

21

441. A 72-year-old man complains of pain about the waist at the level of the umbilicus. The pain is often burning and occasionally shooting. It does not
extend down his legs, but he has noticed some weakness in his legs at the time of the pain. With exertion, such as walking, he develops pain in his legs and a tingling sensation in his feet. He has been taking aspirin for the discomfort, but has noticed no substantial change in the sensation. X-rays of his
spine reveal no abnormalities. Pain and weakness have become increasingly frequent over the course of several months. Because the man complains of
urinary hesitancy and frequency in association with an enlarged prostate, he is advised to have a transurethral prostatectomy. A general anesthetic is given for the surgery. On recovering consciousness postoperatively, the man cannot move his legs and has persistent pain at the level of the umbilicus. His plantar responses are bilaterally extensor.


The most appropriate emergency evaluation for this patient would be
a. Voiding cystometrogram
b. Electroencephalogram (EEG)
c. Somatosensory evoked potentials (SSEPs)
d. Aortogram
e. Penile-brachial index (PBI)

The  answer  is  D

( Rowland,  pp  271–274.) This patient has com-
plaints suggestive of ischemic spinal cord disease. The principal source of blood for the spinal cord is the aorta. Vessels that supply the cord are some what variable in their origins, but they most commonly arise as branches of the vertebral and hypogastric arteries, as well as of the aorta at the level of the upper and lower thoracic vertebrae. The artery most implicated in a patient with this constellation of complaints is the great anterior medullary artery (of Adamkiewicz), which arises from the aorta at the level of T10–L1 and supplies the anterior median spinal artery.

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442. A 72-year-old man complains of pain about the waist at the level of the umbilicus. The pain is often burning and occasionally shooting. It does not
extend down his legs, but he has noticed some weakness in his legs at the time of the pain. With exertion, such as walking, he develops pain in his legs and a tingling sensation in his feet. He has been taking aspirin for the discomfort, but has noticed no substantial change in the sensation. X-rays of his
spine reveal no abnormalities. Pain and weakness have become increasingly frequent over the course of several months. Because the man complains of
urinary hesitancy and frequency in association with an enlarged prostate, he is advised to have a transurethral prostatectomy. A general anesthetic is given for the surgery. On recovering consciousness postoperatively, the man cannot move his legs and has persistent pain at the level of the umbilicus. His plantar responses are bilaterally extensor.

The patient has a greatly dilated abdominal aorta with a normal thoracic aorta. The most likely cause of this damage is
a. Syphilis
b. Trauma
c. Chronic hypertension
d. Diabetes mellitus
e. Atherosclerosis

 The answer is E

( Rowland, pp 271–274.) Syphilis may produce an
aortic aneurysm, but this is characteristically at the level of the thoracic aorta (the arch of the aorta). With aneurysmal dilatation of the aorta, defects
in the wall of the vessel may be exacerbated and dissection of the aortic wall may develop. As this dissection extends into branches of the aorta, it usually narrows and may occlude the lumen of the vessels. Diabetes mellitus may contribute to the formation of atherosclerotic damage in the wall of the aorta, but it is the atherosclerosis itself that is most implicated in the eventual deterioration of the vascular wall. Chronic hypertension may develop with damage that involves the renal arteries, but hypertension would not be expected to be the cause of the aortic pathology.

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443. A 72-year-old man complains of pain about the waist at the level of the umbilicus. The pain is often burning and occasionally shooting. It does not
extend down his legs, but he has noticed some weakness in his legs at the time of the pain. With exertion, such as walking, he develops pain in his legs and a tingling sensation in his feet. He has been taking aspirin for the discomfort, but has noticed no substantial change in the sensation. X-rays of his
spine reveal no abnormalities. Pain and weakness have become increasingly frequent over the course of several months. Because the man complains of
urinary hesitancy and frequency in association with an enlarged prostate, he is advised to have a transurethral prostatectomy. A general anesthetic is given for the surgery. On recovering consciousness postoperatively, the man cannot move his legs and has persistent pain at the level of the umbilicus. His plantar responses are bilaterally extensor.

 Physical examination just after transurethral resection of the prostate (TURP) reveals preservation of some sensation in the feet. The most intact
modality would be
a. Vibration
b. Pain
c. Temperature
d. Two-point discrimination
e. Graphesthesia

The  answer  is A

( Rowland,  pp  271–274.) Spinal cord ischemia is
usually most severe in the distribution of the anterior spinal artery. The posterior spinal artery is more a plexus of arteries with extensive anastomoses
than a discrete pair of blood vessels running along the dorsal aspect of the spinal cord. With a lesion of the spinal cord from ischemia or pressure, the
spinothalamic tracts, which are responsible for pain and temperature perception and for providing information for two-point discrimination and graphesthesia, are more vulnerable to injury than are the posterior columns. The posterior columns, which are primarily responsible for vibration and position sense, are supplied by the posterior spinal arteries.

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444. A 72-year-old man complains of pain about the waist at the level of the umbilicus. The pain is often burning and occasionally shooting. It does not
extend down his legs, but he has noticed some weakness in his legs at the time of the pain. With exertion, such as walking, he develops pain in his legs and a tingling sensation in his feet. He has been taking aspirin for the discomfort, but has noticed no substantial change in the sensation. X-rays of his
spine reveal no abnormalities. Pain and weakness have become increasingly frequent over the course of several months. Because the man complains of
urinary hesitancy and frequency in association with an enlarged prostate, he is advised to have a transurethral prostatectomy. A general anesthetic is given for the surgery. On recovering consciousness postoperatively, the man cannot move his legs and has persistent pain at the level of the umbilicus. His plantar responses are bilaterally extensor.

444. In retrospect, the pain and weakness described by the patient with exertion was probably a manifestation of
a. Myotonia
b. Myokymia
c. Spinal claudication
d. Spondylolisthesis
e. Spondylolysis

 The answer is C

( Rowland, pp 271–274.) With exertion, blood that
would be available to the spinal cord under resting conditions might be shunted to the more patent blood vessels of the limb muscles. Unlike more
typical claudication, in which leg pains develop because of poor blood flow to leg muscles, the leg pains of spinal claudication develop because of
shunting of blood to the leg muscles. The pain is a reflection of ischemia to the sensory neurons in the spinal cord. Spondylolisthesis (the slippage of
vertebral elements) and spondylolysis (the idiopathic dissolution of vertebral elements) may lead to pain with exertion because of the vertebral instability associated with these commonly linked conditions. Myotonia and myokymia are disturbances of muscle activity that would not be expected in association with ischemic spinal cord disease.

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445. A 72-year-old man complains of pain about the waist at the level of the umbilicus. The pain is often burning and occasionally shooting. It does not
extend down his legs, but he has noticed some weakness in his legs at the time of the pain. With exertion, such as walking, he develops pain in his legs and a tingling sensation in his feet. He has been taking aspirin for the discomfort, but has noticed no substantial change in the sensation. X-rays of his
spine reveal no abnormalities. Pain and weakness have become increasingly frequent over the course of several months. Because the man complains of
urinary hesitancy and frequency in association with an enlarged prostate, he is advised to have a transurethral prostatectomy. A general anesthetic is given for the surgery. On recovering consciousness postoperatively, the man cannot move his legs and has persistent pain at the level of the umbilicus. His plantar responses are bilaterally extensor.

Because the patient’s signs suggest spinal cord disease, a myelogram is performed and CSF is obtained. The CSF analysis associated with spinal
cord infarction may reveal
a. An increase in the CSF gamma globulin content
b. A depressed CSF glucose content
c. A protein content of greater than 45 mg/dL
d. More than 100 white blood cells (WBCs) per  µL
e. More than 100 red blood cells (RBCs) per  µL

The answer is C.

( Rowland, pp 271–274.) With spinal cord infarc-
tion, as with cerebral infarction, the CSF is relatively normal. If there is an bnormality, it is most likely to be an elevated CSF protein. The gamma globulin content is not disproportionately increased, as it would be with
MS. The cell count of the fluid should be normal. If the RBC content is increased, the physician must suspect hemorrhage into the CNS. An elevated WBC count suggests a wide variety of diseases, including infection,
meningeal carcinomatosis, and meningeal lymphomatosis.

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446. A 72-year-old man complains of pain about the waist at the level of the umbilicus. The pain is often burning and occasionally shooting. It does not
extend down his legs, but he has noticed some weakness in his legs at the time of the pain. With exertion, such as walking, he develops pain in his legs and a tingling sensation in his feet. He has been taking aspirin for the discomfort, but has noticed no substantial change in the sensation. X-rays of his
spine reveal no abnormalities. Pain and weakness have become increasingly frequent over the course of several months. Because the man complains of
urinary hesitancy and frequency in association with an enlarged prostate, he is advised to have a transurethral prostatectomy. A general anesthetic is given for the surgery. On recovering consciousness postoperatively, the man cannot move his legs and has persistent pain at the level of the umbilicus. His plantar responses are bilaterally extensor.

446. Because of the obvious aortic aneurysm discovered on aortography, the vascular surgeon consulting on the case recommends a bypass procedure. Preoperatively, the patient showed substantial recovery of leg strength and sensation, despite the persistence of bilateral Babinski (plantar extensor) signs. The patient submits to the surgery and is paraplegic postoperatively with dense loss of sensation of pain and temperature below the level
of T10. A follow-up aortogram should reveal
a. Complete occlusion of the bypass graft
b. Complete occlusion of the hypogastric artery
c. Complete occlusion of the aorta below the tenth thoracic vertebra
d. No flow through the artery of Adamkiewicz
e. No flow through the external iliac artery

 The answer is D.

( Rowland, pp 271–274.)Collateral flow may develop
with spinal cord ischemia, but the collateral supply to the anterior cord is likely to fail if the vascular system that supplies the cord is stressed. With the aortic bypass graft, pressure is reduced in the aortic aneurysm and the risks imposed by the dissection in the aortic wall may be reduced, but the pressure forcing blood through the partially obstructed artery of Adamkiewicz is also reduced. With complete failure of flow through this spinal artery, the spinal cord infarction may extend substantially and produce irreversible deficits. Bladder and bowel control is disturbed along with the loss of strength and
sensation in the legs.