Spinal Cord Injury: Cord Syndromes, Neurogenic and Spinal Shock, and Dermatomes Practice Questions

25 multiple-choice questions on Spinal cord injury: cord syndromes, neurogenic and spinal shock, and dermatomes for paramedic and EMT students, from Chapter 35 (Head and Spine Trauma). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. Secondary spinal cord injury is damage that results from:

   1. A. The initial impact that compresses or tears the cord
   2. B. Hypoxia, hypotension, swelling, or later movement
   3. C. A second spinal fracture at a different spinal level
   4. D. Damage limited to the spinal nerves outside the cord
   Show answer

   Answer: B. Hypoxia, hypotension, swelling, or later movement

   Primary injury occurs at the moment of trauma, while secondary injury follows from ischemia, edema, and further movement of an unstable spine. EMS limits it by maintaining oxygenation, perfusion, and spinal motion restriction.

2. A complete spinal cord injury is defined by:

   1. A. Weakness in the arms that is greater than the weakness in the legs
   2. B. Loss of pain sensation on one side and of motor function on the other
   3. C. Return of reflexes within 24 hours along with some sensation in the toes and feet
   4. D. No motor or sensory function below the injury, including the sacral segments
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   Answer: D. No motor or sensory function below the injury, including the sacral segments

   In a complete injury there is no preserved function below the level, including perianal sensation and voluntary anal contraction. Any sacral sparing makes the injury incomplete, which carries a better prognosis.

3. A 70-year-old with arthritis of the neck falls forward and strikes his chin, hyperextending his neck. He has burning pain and marked weakness in both hands and arms but only mild weakness in his legs. This is most consistent with:

   1. A. Anterior cord syndrome
   2. B. Brown-Sequard syndrome
   3. C. Central cord syndrome
   4. D. Cauda equina syndrome
   Show answer

   Answer: C. Central cord syndrome

   Hyperextension in an older adult with a narrowed canal injures the center of the cord, where arm fibers lie medially, so the arms are weaker than the legs. Anterior cord syndrome affects motor function equally in arms and legs.

4. Anterior cord syndrome is characterized by loss of motor function and pain and temperature sensation below the injury, with preservation of:

   1. A. Motor function in the upper extremities
   2. B. Pain sensation on the opposite side
   3. C. Reflexes and muscle tone in the lower limbs
   4. D. Position sense, vibration, and light touch
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   Answer: D. Position sense, vibration, and light touch

   The dorsal columns, which carry proprioception and vibration, lie in the posterior cord and are spared when the anterior cord or its artery is damaged. Prognosis for motor recovery is poor.

5. After a diving injury with forced neck flexion, a 20-year-old cannot move his legs or feel a pinprick below the nipples, but he can tell whether his toes are pointing up or down. This suggests:

   1. A. Anterior cord syndrome
   2. B. Central cord syndrome
   3. C. Brown-Sequard syndrome
   4. D. Complete cord transection
   Show answer

   Answer: A. Anterior cord syndrome

   Lost motor and pain sensation with preserved position sense is anterior cord syndrome, often from flexion injury or disrupted anterior spinal artery flow. A complete transection would abolish position sense too.

6. A 28-year-old was stabbed in the back just to the left of the midline. His left leg is weak and he cannot tell its position, while his right leg moves well but cannot feel a pinprick. This pattern is:

   1. A. Central cord syndrome
   2. B. Brown-Sequard syndrome
   3. C. Anterior cord syndrome
   4. D. Cauda equina syndrome
   Show answer

   Answer: B. Brown-Sequard syndrome

   Hemisection of the cord causes loss of motor function and position sense on the same side and loss of pain and temperature on the opposite side, because the spinothalamic fibers cross soon after entering the cord. Penetrating trauma is the classic cause.

7. In Brown-Sequard syndrome, pain and temperature sensation are lost on the side opposite the injury because the spinothalamic fibers:

   1. A. Cross to the other side only in the medulla
   2. B. Do not cross and stay on the same side throughout the cord
   3. C. Cross to the other side soon after entering the cord
   4. D. Travel within the posterior columns of the cord
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   Answer: C. Cross to the other side soon after entering the cord

   Pain and temperature fibers enter, synapse, and cross within a segment or two, then ascend on the opposite side. The dorsal column and motor tracts cross higher, in the brainstem, so their loss is on the side of the injury.

8. A patient with a high cervical cord injury becomes suddenly bradycardic at 38/min while you suction his airway. The most likely cause and treatment are:

   1. A. Hypovolemia; give a large fluid bolus fast
   2. B. Unopposed vagal tone; give atropine
   3. C. Hyperkalemia; give calcium immediately
   4. D. Anxiety; reassure him and keep suctioning
   Show answer

   Answer: B. Unopposed vagal tone; give atropine

   High cord injuries cut sympathetic input to the heart, leaving vagal tone unopposed, so suctioning, intubation, or hypoxia can trigger severe bradycardia or even asystole. Stop suctioning, oxygenate, and give atropine per protocol, keeping suction brief afterward. The other options do not fit the trigger.

9. A patient with a spinal cord injury has no movement in the legs but can feel you touch the skin around his anus. This finding suggests:

   1. A. An incomplete injury, better outlook
   2. B. A complete injury with no recovery at all
   3. C. A complete injury above the T6 level
   4. D. Cauda equina syndrome from a low lesion
   Show answer

   Answer: A. An incomplete injury, better outlook

   Preserved sensation or motor function in the lowest sacral segments (sacral sparing) means some pathways across the injury still work, so the injury is incomplete and the chance of recovery is better. Sacral sparing rules out a complete injury at every level, and cauda equina syndrome typically causes numbness around the anus and perineum rather than preserved sensation there.

10. Neurogenic shock is most likely when the spinal cord is injured at or above about:

    1. A. L2
    2. B. S1
    3. C. L5
    4. D. T6
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    Answer: D. T6

    Injuries at T6 or above interrupt enough sympathetic outflow to the heart and splanchnic vessels to cause vasodilation and bradycardia. Lumbar and sacral injuries spare most sympathetic outflow.

11. A man with a spinal cord injury shows paradoxical breathing and cannot lift his arms, but he can shrug his shoulders. Shoulder shrugging is preserved mainly because it is controlled by:

    1. A. The phrenic nerve from C3 to C5
    2. B. The C5 and C6 roots of the arm
    3. C. A cranial nerve, the accessory
    4. D. The thoracic intercostal nerves
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    Answer: C. A cranial nerve, the accessory

    The trapezius is supplied by the spinal accessory nerve (cranial nerve XI) with upper cervical roots, so a shrug may persist with a mid-cervical cord injury, which can mislead providers into underestimating the injury. The phrenic nerve drives the diaphragm, the C5 and C6 roots power shoulder abduction and elbow flexion, and the intercostal nerves move the chest wall; none of them produces the shrug.

12. A patient in neurogenic shock remains hypotensive after an appropriate crystalloid bolus. Per most protocols, the next step is:

    1. A. A vasopressor such as norepinephrine
    2. B. Additional large-volume fluid boluses
    3. C. High-dose methylprednisolone
    4. D. A loop diuretic to clear fluid
    Show answer

    Answer: A. A vasopressor such as norepinephrine

    After a modest fluid bolus, persistent hypotension in neurogenic shock comes from lost vascular tone, so a vasopressor is the next step. Norepinephrine is commonly chosen because it adds beta-1 support to heart rate and contractility; a pure alpha agent such as phenylephrine raises pressure but can worsen bradycardia, and dopamine is an alternative in some protocols. Symptomatic bradycardia is treated with atropine (or pacing). Large-volume fluid boluses do not fix vasodilation and risk pulmonary edema. High-dose methylprednisolone is no longer recommended for acute cord injury. A loop diuretic would lower preload and worsen the hypotension.

13. A patient with a spinal cord injury is hypotensive with a pulse of 128 beats/min and cool, pale skin. You should first assume:

    1. A. Neurogenic shock from the cord injury
    2. B. Hemorrhagic shock until proven otherwise
    3. C. Spinal shock from loss of cord reflexes
    4. D. Anxiety from fear of being paralyzed
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    Answer: B. Hemorrhagic shock until proven otherwise

    Tachycardia with cool, pale skin indicates compensatory sympathetic activity, which neurogenic shock lacks. Trauma patients with cord injuries also often have hidden bleeding, which must be sought and treated first.

14. A patient after a motorcycle crash has lost sensation below the level of the nipples. The most likely sensory level is:

    1. A. C4
    2. B. T10
    3. C. L1
    4. D. T4
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    Answer: D. T4

    The nipple line corresponds to the T4 dermatome. C4 covers the area just below the clavicles, T10 the umbilicus, and L1 the inguinal region.

15. When testing motor function in a patient with a suspected lower spinal injury, pushing the foot down against your hand (plantar flexion) mainly tests the:

    1. A. C5 nerve root
    2. B. T4 nerve root
    3. C. S1 nerve root
    4. D. C7 nerve root
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    Answer: C. S1 nerve root

    Plantar flexion (pushing the foot down like pressing a gas pedal) is mainly an S1 function, and lifting the foot or big toe (dorsiflexion) is mainly L4 to L5. C5 and C7 serve the arms, and T4 is a sensory level at the nipple line.

16. A patient with a spinal cord injury can bend his elbows and extend his wrists but cannot straighten his elbows or grip with his fingers. His injury is most likely at about:

    1. A. C5
    2. B. C7
    3. C. C6
    4. D. C8
    Show answer

    Answer: C. C6

    Using the ISNCSCI key muscles, elbow flexion is C5, wrist extension is C6, elbow extension is C7, and finger flexion (grip) is C8. He has C5 and C6 function but not C7 or C8, so the lowest intact level is about C6. A C5 injury would spare elbow flexion but not wrist extension. A C7 injury would preserve elbow extension (triceps), which he lacks. A C8 injury would preserve both elbow extension and some finger flexion.

17. A 25-year-old after a cervical spine injury is breathing with paradoxical abdominal movement: the abdomen rises while the chest wall sinks. This finding suggests:

    1. A. A flail segment of the anterior chest wall
    2. B. Intercostal paralysis with intact diaphragm
    3. C. Complete paralysis of both hemidiaphragms
    4. D. A tension pneumothorax on the left side
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    Answer: B. Intercostal paralysis with intact diaphragm

    Diaphragmatic breathing occurs when a lower cervical injury paralyzes the intercostals but spares the phrenic nerve (C3 to C5). These patients tire quickly and may need assisted ventilation.

18. A male trauma patient with a suspected spinal injury has a persistent erection. This finding:

    1. A. Suggests a spinal cord injury
    2. B. Indicates a pelvic fracture
    3. C. Is unrelated to the trauma
    4. D. Signals an injury to the brain
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    Answer: A. Suggests a spinal cord injury

    Priapism results from loss of sympathetic tone with unopposed parasympathetic stimulation and is a sign of cord injury, often cervical. It should be documented and reported.

19. Patients with a high spinal cord injury lose heat rapidly because:

    1. A. Their metabolic rate rises sharply in the hours after the injury
    2. B. Their skin becomes thicker and retains less heat
    3. C. They sweat heavily over the entire body surface
    4. D. They cannot shiver or constrict vessels below the injury
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    Answer: D. They cannot shiver or constrict vessels below the injury

    Without sympathetic control, skin vessels below the injury stay dilated and shivering is lost, so these patients become poikilothermic. Keep them warm and protect them from cold surfaces.

20. Current evidence regarding high-dose methylprednisolone for acute spinal cord injury is that it:

    1. A. Should be given in the field within 8 hours
    2. B. Is not recommended because harm outweighs benefit
    3. C. Is required for all patients with complete injury
    4. D. Prevents neurogenic shock if given before transport
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    Answer: B. Is not recommended because harm outweighs benefit

    Large trials did not show meaningful neurologic benefit, and steroids increased infection and other complications, so major guidelines do not recommend routine use. The 8-hour window came from early studies that did not hold up.

21. A 52-year-old with a lumbar fracture reports numbness of the buttocks and inner thighs and is unable to urinate. You should suspect:

    1. A. Central cord syndrome
    2. B. Neurogenic shock
    3. C. Cauda equina syndrome
    4. D. Anterior cord syndrome
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    Answer: C. Cauda equina syndrome

    Compression of the nerve roots below the conus causes saddle anesthesia, bladder retention or incontinence, and leg weakness. It is a surgical emergency.

22. A swimmer dives into shallow water and strikes the top of his head on the bottom. The mechanism most likely to injure his spine is:

    1. A. Axial loading
    2. B. Distraction
    3. C. Lateral bending
    4. D. Rotation
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    Answer: A. Axial loading

    Force driven down through the top of the skull compresses the vertebrae, causing burst and compression fractures, often in the cervical spine. Distraction, as in hanging, stretches the cord rather than compressing it.

23. A fracture through the pedicles of C2 caused by hyperextension, as in judicial hanging or a chin striking a dashboard, is called a:

    1. A. Jefferson fracture
    2. B. Clay-shoveler fracture
    3. C. Chance fracture
    4. D. Hangman fracture
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    Answer: D. Hangman fracture

    The hangman fracture involves both pedicles of C2. A Jefferson fracture is a burst fracture of C1 from axial loading, and a Chance fracture is a lap-belt flexion-distraction injury of the lumbar spine.

24. In a conscious patient with suspected spinal injury, motor function in the lower extremities is best checked by asking him to:

    1. A. Lift both legs high off the stretcher
    2. B. Push his feet against your hands
    3. C. Tell you whether he feels your touch
    4. D. Grip your fingers tightly
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    Answer: B. Push his feet against your hands

    Plantar flexion against resistance, and pulling the toes up, tests the lower extremities without moving the spine. Lifting the legs high puts load on an unstable spine. Asking whether he feels your touch tests sensation rather than motor function, and gripping your fingers tests the arms rather than the legs.

25. A 22-year-old with a C5 cord injury has an SpO2 of 92% and shallow breathing at 28 breaths/min that is becoming weaker. You should:

    1. A. Assist ventilations with a bag-mask device
    2. B. Wait until the SpO2 falls below 85%
    3. C. Place him sitting upright at 90 degrees to ease breathing
    4. D. Give a fluid bolus to improve breathing
    Show answer

    Answer: A. Assist ventilations with a bag-mask device

    With intercostal paralysis and a partially affected diaphragm, respiratory fatigue can progress quickly, and edema can ascend to higher segments. Support ventilation early rather than waiting for severe hypoxia.