CHAPTER 36
INTRACRANIAL AND
SPINAL TRAUMA
JOSH ABECASSIS AND AMY LEE
QUESTIONS
1. A 23-year-old man presents to the emergency depart-
ment after being involved in a motor vehicle crash.
On physical examination, he opens his eyes to painful
stimulation, he occasionally mumbles incomprehensible
sounds, he localizes to painful stimulation with his right
upper extremity, and he withdraws his left upper extrem-
ity to pain. His pupils are 4 mm bilaterally and reactive.
What is this patient’s Glasgow Coma Scale (GCS) score?
(A) 7
(B) 9
(C) 8
(D) 10
2. Cerebral perfusion pressure (CPP) is equal to
(A) Systolic blood pressure (SBP) – Intracranial
pressure (ICP)
(B) Diastolic blood pressure (DBP) – ICP
(C) Mean arterial pressure (MAP) + ICP
(D) MAP – ICP
3. All of the following are physical signs of a basal skull
fracture except
(A) Dilated and nonreactive pupil
(B) Bilateral periorbital ecchymosis (raccoon eyes)
(C) Ecchymosis over mastoids (Battle’s sign)
(D) Hemotympanum
4. Generally accepted criteria for elevating a depressed
skull fracture in the operating room include all of the fol-
lowing except
(A) Open fracture
(B) Coexistence of other traumatic lesion (i.e., hema-
toma) underlying fragment
(C) Dural tear with cerebrospinal fluid (CSF) leak
(D) Involvement of the anterior wall of the frontal sinus
825
5. Cardinal signs of intracranial hypertension include all of
the following except
(A) Flexor (decorticate) posturing
(B) Papilledema
(C) Aphasia
(D) Dilated and nonreactive pupil
6. A 42-year-old man presents to the emergency depart-
ment after being involved in a motor vehicle crash.
On initial examination, the patient has a GCS score
of 7 (localizes to pain, no eye opening, and no verbal
response) and multiple injuries including a long bone
fracture. The patient’s vital signs are normal. You consult
orthopedic surgery, and they want to take the patient to
the operating room (OR) to repair his fracture. A com-
puted tomography (CT) scan of the head shows mild-
to-moderate diffuse cerebral edema. What is the most
appropriate course of action to take with this patient?
(A) Allow the patient to go the OR immediately for
repair of his fracture.
(B) Consult neurosurgery to evaluate for placement of
an ICP monitor prior to his going to the OR.
(C) Consult neurosurgery to evaluate for placement of
an ICP monitor after he returns from the OR.
(D) Delay surgery indefinitely until the patient’s neuro-
logic status improves.
7. Initial routine measures for controlling ICP in a patient
with a closed head injury include all of the following
except
(A) Hyperventilation
(B) Elevate head of bed to 30–45 degrees
(C) Avoid hypotension
(D) Keep head midline
826
8. A 22-year-old woman presents to the emergency depart-
ment after falling off a horse and hitting her head on the
ground. She had brief loss of consciousness and is now
oriented to name and place only. A CT scan of the head
shows mild generalized cerebral edema. What is the
most appropriate intravenous fluid for this patient?
(A) Ringer’s lactate
(B) 0.225% normal saline (NS) with 20 mEq potassium
chloride (KCl)
(C) 0.45% NS with 20 mEq KCl
(D) 0.9% NS with 20 mEq KCl
9. Late complications of traumatic brain injury may include
all of the following except
(A) Seizures
(B) Communicating hydrocephalus
(C) Primary brain tumors
(D) Memory impairment
10. A 24-year-old man is taken to the emergency depart-
ment after being involved in a motor vehicle crash
approximately 3 hours ago. The patient was the unre-
strained driver, and he cannot recall the crash. He
complains of a left-sided headache, and you notice on
physical examination that he has a palpable deformity
over the left side of his skull and a boggy temporalis
muscle. You order a CT scan of the head. The nurse calls
you 20 minutes later to see the patient because he has
suddenly become unresponsive. A CT scan of the head is
most likely to reveal what type of lesion?
(A) Chronic subdural hematoma
(B) Diffuse subarachnoid hemorrhage
(C) Intraventricular hemorrhage
(D) Epidural hematoma
11. What category of subdural hematoma appears isodense
to brain on CT scans?
(A) Acute
(B) Subacute
(C) Chronic
(D) None of the above
12. A 19-year-old man presents to the emergency depart-
ment after being shot in the head with a handgun.
Appropriate initial steps in managing this patient include
all of the following except
(A) Begin Solumedrol (methylprednisolone) protocol
(B) Control scalp bleeding
(C) Elevate head of bed to 30–45 degrees
(D) Give mannitol 1 g/kg bolus
CHAPTER 36 INTRACRANIAL AND SPINAL TRAUMA
13. A mother brings her 14-month-old son into the emer-
gency department because he is difficult to arouse.
The mother states that the infant accidentally fell off a
changing table that is approximately 3 ft tall. On physi-
cal examination, you find that the infant has multiple
bruises and bilateral retinal hemorrhages. Skull radio-
graphs show a right frontal and a left parietal linear
fracture. A CT scan of the head shows a left convexity
chronic subdural hematoma. The most likely diagnosis is
(A) Coagulopathy
(B) Accidental trauma
(C) Child abuse
(D) Neglect
14. All of the following examination findings are consistent
with a diagnosis of brain death except
(A) Dilated and nonreactive pupils
(B) Absent oculocephalic reflex
(C) Extensor (decerebrate) posturing
(D) Absent gag reflex
15. Diffuse axonal injury (DAI) results from what type of
force acting on the brain?
(A) Direct impact
(B) Axial loading
(C) Linear acceleration
(D) Rotational acceleration
For Questions 16 through 20, match the following CT
scans with the appropriate diagnosis.
(A) Chronic subdural hematoma
(B) Subarachnoid hemorrhage
(C) Acute subdural hematoma
(D) Intracerebral hemorrhage
(E) Epidural hematoma
16. Figure 36-1
FIGURE 361. Computed tomography scan.
CHAPTER 36 INTRACRANIAL AND SPINAL TRAUMA 827

17. Figure 36-2 19. Figure 36-4

FIGURE 364. Computed tomography scan.

20. Figure 36-5

FIGURE 362. Computed tomography scan.

18. Figure 36-3

FIGURE 365. Computed tomography scan.

21. What percentage of patients who present with a major

spinal injury will have a second spinal injury at another
FIGURE 363. Computed tomography scan.
level?
(A) 2%
(B) 10%
(C) 20%
(D) 40%
828 CHAPTER 36 INTRACRANIAL AND SPINAL TRAUMA

22. A 20-year-old woman presents to the emergency depart-
ment after being involved in an all-terrain vehicle crash.
Her initial vital signs are normal. Her only complaint is
back pain, but she is unable to move her legs and has no
sensation below her nipples. On physical examination,
she has a step-off deformity in her upper thoracic spine.
Her abdominal examination is benign. Chest and pelvis
x-rays are normal. Ten minutes later, her blood pressure
suddenly falls to 75/35 mmHg. A focused assessment
with sonography for trauma (FAST) exam shows no
fluid in the abdomen, and her blood pressure does not
respond to boluses of intravenous fluids. The most likely
cause of the hypotension is
(A) Spinal shock
(B) Myocardial infarction
(C) Intra-abdominal hemorrhage
(D) Neurogenic shock
23. The most appropriate treatment for refractory hypoten-
sion related to neurogenic shock is
(A) Aggressive intravenous hydration
(B) Dopamine
(C) Trendelenburg position
(D) Phenylephrine
24. Appropriate steps in the initial management of a patient
with a suspected spinal cord injury include all of the fol-
lowing except
(A) Maintain on backboard until cervical spine is cleared
(B) Regulate temperature
(C) Place nasogastric tube to suction
(D) Place bladder catheter
(C) Anteroposterior (AP) and lateral cervical spine
(D) No imaging is necessary
27. An inebriated 62-year-old man presents to the emer-
gency department after a motor vehicle crash. He has
ecchymosis and a small laceration on his forehead. His
strength is 3/5 in his upper extremities and 4+/5 in his
lower extremities. Sensation to pain and temperature is
mildly decreased in his upper extremities, and he has
urinary retention. The most likely diagnosis is
(A) Brown-Sequard syndrome
(B) Anterior cord syndrome
(C) Central cord syndrome
(D) Cervical herniated disk
28. All of the following are true statements regarding spinal
cord injury without radiographic abnormality
(SCIWORA) except
(A) Higher incidence in children <9 years of age
(B) Radiographs including flexion/extension views are
normal
(C) Immobilization for up to 3 months is often
recommended
(D) Magnetic resonance imaging (MRI) studies are
normal
29. Death related to an atlanto-occipital dislocation is most
often the result of
(A) Respiratory arrest
(B) Cardiac arrest
(C) Spinal shock
(D) Hemorrhagic shock

25. Which of the following statements regarding the use of 30. A fracture through the arches of the atlas, usually result-
methylprednisolone for the treatment of acute spinal ing from an axial load, is referred to as a
cord injuries is correct? (A) Hangman’s fracture
(A) Greatest benefits are noted when it is given greater (B) Odontoid fracture
than 8 hours after the time of injury. (C) Jefferson fracture
(B) The appropriate dose is a 2-g bolus followed by (D) Avulsion fracture
350 mg/h for 23 hours.
(C) It is not recommended for treatment of spinal cord 31. A fracture through the base of the odontoid is classified
injury. as
(D) Complications from its use are rare. (A) Type I
(B) Type II
26. A 32-year-old man presents to the emergency depart- (C) Type III
ment after being involved in a low-velocity motor vehicle (D) Type IV
crash. He is wearing a cervical collar that was placed by
paramedics. He is awake; alert; oriented to name, place, 32. How should locked or perched facets in the cervical
and time; and sober and does not complain of neck pain. spine be treated initially?
On physical examination, he has no cervical tender- (A) Open reduction and internal fixation
ness and no other significant injury. He has full range of (B) Closed reduction with cervical traction
motion in his neck without any pain. The most appropri- (C) Keep patient immobilized in cervical collar
ate x-rays to order are (D) No treatment is necessary
(A) Lateral cervical spine only
(B) CT scan of the cervical spine
CHAPTER 36 INTRACRANIAL AND SPINAL TRAUMA 829

33. A clay-shoveler fracture is a fracture of what part of the ANSWERS AND EXPLANATIONS
vertebra? 1. (B) The GCS is the most widely used scale for predict-
(A) Pedicle ing outcome following head trauma. It was developed
(B) Odontoid process by Teasdale and Jennett as a practical means of assessing
(C) Body and categorizing a patient’s level of arousal and neuro-
(D) Spinous process logic function. The scale is divided into three catego-
ries: eye opening, best verbal response, and best motor
34. A 20-year-old man presents to the hospital with a spine response. Eye opening is rated on a scale of 1–4, verbal
fracture and a complete spinal cord injury. Potential response is rated on a scale of 1–5, and motor response is
benefits of early surgical stabilization would include all rated on a scale of 1–6 (Table 36-1). Therefore, the lowest
of the following except possible score is 3, and the highest possible score is 15.
(A) Earlier mobilization The patient in this question receives 2 points for opening
(B) Psychological benefit his eyes to painful stimulation, 2 points for verbalizing
(C) Improved neurologic function incomprehensible sounds, and 5 points for localizing to
(D) Reduced comorbidities stimulation since this represents his best motor response.
Pupillary size and reactivity do not factor into the GCS
35. Which of the following types of thoracolumbar spine score. Therefore, the patient’s total score in this question
fractures is considered unstable? is 9. A major disadvantage of using the GCS is that endo-
(A) Burst fracture tracheal intubation prevents the use of the best verbal
(B) Transverse process fracture response category. In such cases, the letter “T” follows
(C) Articular process fracture the combined score of the remaining two categories. For
(D) Spinous process fracture example, if the patient in this case had been intubated,
then his score would have been 7T. When using the GCS,
36. According to the three-column model of the spine, a seat one must keep in mind that although it is an effective
belt–type fracture involves disruption of which columns?
(A) All three
(B) Anterior and middle TABLE 361 Glasgow Coma Scale
(C) Anterior and posterior
Measure No. of Points
(D) Middle and posterior
Eye opening
37. Indications for operating on gunshot wounds to the
spine include all of the following except Spontaneous 4
(A) Persistent CSF leak To speech 3
(B) Neurologic deterioration To pain 2
(C) Compression of a nerve root
(D) All gunshot injuries require surgical exploration No eye opening 1
Best verbal response
38. The overall mortality rate from deep venous thromboses
in patients with spinal cord injuries is Oriented and appropriate 5
(A) 1% Confused 4
(B) 5%
Inappropriate words 3
(C) 10%
(D) 20% Incomprehensible sounds 2
No verbal response 1
39. A 22-year-old man presents after being in a motor vehicle
accident. Imaging is concerning for a spinal cord injury Best motor response
at the T10 level. He is moving his lower extremities but Obeys commands 6
with significant weakness, such that he cannot resist grav-
ity. He has decreased sensation from the navel down. His Localizes to pain 5
American Spinal Injury Association (ASIA) grade is Withdraws to pain 4
(A) A Flexor (decorticate) posturing 3
(B) B
(C) C Extensor (decerebrate) posturing 2
(D) D No motor response 1
(E) E