TNCC Spinal Cord and Vertebral Trauma — Questions and Answers
Question 1: A patient with a C5 spinal cord injury would be expected to retain which motor function?
- Wrist extension
- Finger flexion and intrinsic hand muscles
- Biceps function and shoulder movement (Correct answer)
- Triceps function and elbow extension
Correct answer: Biceps function and shoulder movement
C5 innervates the deltoid and biceps muscles, allowing shoulder abduction/flexion and elbow flexion. Wrist extension (C6), triceps (C7), and hand intrinsics (T1) are lost.
Understanding spinal cord injury levels requires knowledge of myotomes (motor) and dermatomes (sensory). Key motor levels: C4 — diaphragm (spontaneous breathing preserved), shoulder shrug (trapezius). C5 — deltoid (shoulder abduction), biceps (elbow flexion). C6 — wrist extensors (extensor carpi radialis). C7 — triceps (elbow extension), wrist flexors. C8 — finger flexors. T1 — hand intrinsics (finger abduction/adduction). A complete C5 injury preserves C5 and above: the patient can shrug shoulders, abduct shoulders, flex elbows (biceps), but cannot extend wrists (C6), extend elbows (C7), grasp (C8), or use hand intrinsics (T1). This determines functional capacity: C5 injuries allow some self-feeding with adaptive equipment but require assistance for most ADLs. The ASIA (American Spinal Injury Association) Impairment Scale classifies injury completeness from A (complete) to E (normal), which significantly affects prognosis and rehabilitation goals.
Question 2: Spinal shock is characterized by:
- Permanent loss of all neurological function below the injury
- Temporary loss of reflexes, motor function, and sensation below the injury level (Correct answer)
- Cardiovascular collapse from spinal cord transection
- Chronic pain syndrome following spinal cord injury
Correct answer: Temporary loss of reflexes, motor function, and sensation below the injury level
Spinal shock is the temporary, physiological suppression of all spinal cord function (reflexes, motor, sensory, autonomic) below the injury level, which may last hours to weeks.
Spinal shock is distinct from neurogenic shock (cardiovascular manifestation) — it is a neurophysiological phenomenon where all spinal cord function below the injury level is temporarily suppressed. During spinal shock: (1) All reflexes are absent below the injury (areflexia) — including deep tendon reflexes, bulbocavernosus reflex, and cremasteric reflex. (2) Flaccid paralysis replaces any spasticity. (3) Sensation is absent. (4) Autonomic function is disrupted (bladder areflexia, bowel ileus, loss of temperature regulation). The resolution of spinal shock is marked by the return of the bulbocavernosus reflex (S2-S4 mediated reflex arc — anal sphincter contraction in response to squeezing the glans penis or tugging the Foley catheter). Once spinal shock resolves (hours to 6 weeks), the true extent of neurological injury can be assessed. Prognosis cannot be accurately determined during spinal shock. Any neurological function that returns after spinal shock resolution represents incomplete injury, which has a better prognosis.
Question 3: Which mechanism of injury is most associated with a Jefferson fracture (C1 burst fracture)?
- Hyperflexion of the cervical spine
- Axial loading (compression) force to the top of the head (Correct answer)
- Hyperextension with rotation
- Lateral bending of the neck
Correct answer: Axial loading (compression) force to the top of the head
A Jefferson fracture results from axial loading transmitted through the occipital condyles to the C1 lateral masses, causing the ring of C1 to burst outward. Common mechanisms include diving into shallow water or objects falling onto the head.
The Jefferson fracture is a burst fracture of the C1 (atlas) ring caused by axial compression — force transmitted vertically through the skull to the lateral masses of C1. The occipital condyles act as wedges, driving the C1 lateral masses apart and fracturing the anterior and posterior arches. Classic mechanisms: diving into shallow water (vertex impact), falling objects striking the crown of the head, or axial loading in MVCs. On open-mouth (odontoid) X-ray, the hallmark finding is bilateral lateral mass overhang — the C1 lateral masses extend beyond the borders of C2. CT with reconstructions confirms the fracture pattern. Jefferson fractures are inherently unstable if the transverse ligament is disrupted (total lateral mass overhang >7 mm suggests ligament rupture). Despite the dramatic mechanism, Jefferson fractures may have a relatively good prognosis because the spinal canal at C1 is the widest in the spine, and the burst pattern tends to expand the canal rather than compress the cord. However, associated C2 fractures and vertebral artery injuries must be evaluated.
Question 4: A patient with a T10 complete spinal cord injury is most likely to experience which bladder dysfunction?
- Normal voluntary bladder control
- Upper motor neuron (spastic/reflex) bladder (Correct answer)
- Lower motor neuron (flaccid/areflexic) bladder
- No bladder dysfunction at this level
Correct answer: Upper motor neuron (spastic/reflex) bladder
Injuries above the conus medullaris (L1-L2) produce an upper motor neuron bladder — the sacral micturition reflex arc (S2-S4) is intact but disconnected from voluntary control, resulting in a spastic, reflex bladder.
Bladder function after SCI depends on the relationship between injury level and the sacral micturition center (S2-S4): (1) Upper motor neuron (UMN/spastic) bladder — injury ABOVE the conus (above L1-L2): the sacral reflex arc is intact but disconnected from voluntary cortical control. The detrusor muscle contracts reflexively when the bladder fills to a threshold, causing involuntary voiding with high intravesical pressures. Detrusor-sphincter dyssynergia (simultaneous contraction of detrusor and external sphincter) is common, causing incomplete emptying, high pressures, and risk of autonomic dysreflexia, vesicoureteral reflux, and upper tract damage. (2) Lower motor neuron (LMN/flaccid) bladder — injury AT or BELOW the conus (L1-L2 or cauda equina): the sacral reflex arc is destroyed. The bladder becomes atonic, distends without contracting, and overflows. T10 is above the conus, so this patient has a UMN bladder. Management includes intermittent catheterization, anticholinergic medications, and urodynamic monitoring to prevent renal damage.
Question 5: When logrolling a patient with a suspected spinal injury, the minimum number of personnel required is:
- Two — one at the head and one at the torso
- Three — one at the head directing, plus two supporting the body
- Four — one at the head plus three supporting the body (Correct answer)
- One experienced nurse can safely logroll a patient alone
Correct answer: Four — one at the head plus three supporting the body
A minimum of four persons is recommended for logrolling: one maintains manual in-line stabilization of the head/neck and directs the maneuver, while three support the torso, pelvis, and legs to maintain spinal alignment.
Proper logrolling technique for suspected spinal injury requires a minimum of four team members: (1) Person 1 — positioned at the head, maintains manual in-line stabilization (MILS) of the cervical spine and DIRECTS the roll by calling commands. This person does not move the head independently — the head moves with the body as a unit. (2) Person 2 — supports the shoulders and upper torso. (3) Person 3 — supports the hips and pelvis. (4) Person 4 — supports the legs. Some protocols call for five people (additional support at the mid-torso). The technique: on the leader's command, the team rolls the patient as a single unit ('like a log'), maintaining strict spinal alignment. Arms are positioned at the patient's sides or across the chest. Once on the side, the posterior is quickly examined and palpated, then the patient is rolled back. A fifth person may examine the posterior and/or place a backboard. Logrolling is performed for posterior examination, backboard placement/removal, and turning for care. Inadequate personnel leads to spinal malalignment and potential secondary cord injury.
Question 6: Which clinical finding differentiates Brown-Sequard syndrome from other incomplete spinal cord injury patterns?
- Loss of all motor and sensory function below the injury
- Ipsilateral motor loss and proprioception loss with contralateral pain and temperature loss (Correct answer)
- Bilateral loss of pain and temperature with preserved motor function
- Loss of motor function in upper extremities only with preserved lower extremity function
Correct answer: Ipsilateral motor loss and proprioception loss with contralateral pain and temperature loss
Brown-Sequard syndrome results from hemisection of the spinal cord, producing ipsilateral motor paralysis and proprioception loss (posterior columns) with contralateral pain and temperature loss (spinothalamic tract) below the injury.
Brown-Sequard syndrome is caused by lateral hemisection of the spinal cord, most commonly from penetrating trauma (stab wounds). The asymmetric presentation is explained by neuroanatomy: (1) Ipsilateral motor loss (corticospinal tract) — this tract crosses at the medulla (above any cervical/thoracic injury), so damage produces same-side paralysis. (2) Ipsilateral proprioception and vibration loss (dorsal columns) — these fibers ascend ipsilaterally and cross at the medulla. (3) Contralateral pain and temperature loss (spinothalamic tract) — these fibers cross within 1-2 levels of entry, so damage affects opposite-side sensation. Other incomplete SCI patterns: Central cord syndrome (upper > lower extremity weakness, often in elderly with hyperextension), Anterior cord syndrome (motor and pain/temperature loss with preserved proprioception — worst prognosis of incomplete injuries), and Posterior cord syndrome (rare, loss of proprioception with preserved motor and pain). Brown-Sequard has the BEST prognosis of incomplete SCI patterns, with over 90% of patients regaining functional ambulation.
Question 7: A patient with a suspected unstable cervical spine fracture has vomited. To manage the airway while protecting the spine, the nurse should:
- Turn the patient's head to the side while keeping the body supine
- Logroll the patient to a lateral position while maintaining spinal alignment, then suction (Correct answer)
- Sit the patient upright for better airway drainage
- Perform a finger sweep without repositioning the patient
Correct answer: Logroll the patient to a lateral position while maintaining spinal alignment, then suction
The patient should be logrolled as a unit to a lateral position to allow vomitus to drain by gravity, while maintaining strict spinal alignment to prevent secondary cord injury.
Vomiting in a patient with cervical spine precautions creates a dangerous situation — aspiration risk versus spinal cord injury risk. The correct approach: logroll the patient to a lateral position while maintaining strict spinal alignment (cervical collar stays on, manual in-line stabilization maintained, the entire body moves as a unit). In the lateral position, gravity assists drainage of vomitus from the oropharynx. Simultaneously, suction should be applied aggressively to clear the airway. Once the airway is clear, the patient can be logrolled back to supine. Turning the head alone would cause cervical spine movement in an unstable fracture. Sitting upright is contraindicated with unstable spine injuries. A finger sweep without repositioning risks pushing material deeper and does not clear the airway effectively. Pre-emptive measures: have suction immediately available, administer antiemetics if the patient is nauseated, decompress the stomach with an orogastric tube (NOT nasogastric if basilar skull fracture is suspected), and ensure the backboard has a head strap that allows lateral turning.
Question 8: Central cord syndrome is most commonly seen in which patient population and mechanism?
- Young adults after high-speed MVCs with flexion injuries
- Elderly patients with pre-existing cervical spondylosis after hyperextension injuries (Correct answer)
- Children after diving accidents
- Athletes after axial loading injuries
Correct answer: Elderly patients with pre-existing cervical spondylosis after hyperextension injuries
Central cord syndrome most commonly occurs in elderly patients with pre-existing cervical spondylosis (narrow spinal canal) who sustain a hyperextension injury, often from a ground-level fall.
Central cord syndrome is the most common incomplete SCI pattern. The typical patient is elderly with pre-existing cervical spondylosis (degenerative osteophytes and ligamentum flavum hypertrophy that narrow the spinal canal). A hyperextension mechanism (often from a relatively minor fall or rear-end MVC) causes the ligamentum flavum to buckle inward, compressing the central portion of the spinal cord. The central region contains the corticospinal tracts arranged somatotopically with cervical (upper extremity) fibers medially and sacral (lower extremity) fibers laterally. Therefore, compression affects the more centrally located cervical fibers disproportionately: upper extremity weakness is greater than lower extremity weakness, with variable sensory changes and possible bladder dysfunction. Notably, MRI may show no fracture or dislocation — just cord edema or contusion at the spondylotic level. Prognosis is generally favorable: lower extremity function recovers first, then bladder function, then upper extremity function. Fine hand motor function recovers last and often incompletely. Management is typically non-operative with cervical collar and rehabilitation, though surgery may be indicated for significant cord compression.
Question 9: During the secondary survey, the nurse palpates a palpable step-off deformity in the thoracolumbar spine. This finding suggests:
- Normal anatomical variation
- Ligamentous sprain without bony injury
- Vertebral fracture with possible posterior element disruption (Correct answer)
- Muscle spasm only
Correct answer: Vertebral fracture with possible posterior element disruption
A step-off deformity (one spinous process displaced anteriorly or posteriorly relative to adjacent processes) indicates a vertebral fracture-dislocation with disruption of the posterior spinal elements, suggesting an unstable injury.
A palpable step-off deformity during spinal palpation is a critical physical examination finding indicating vertebral malalignment. The spinous processes normally form a smooth, aligned column. A step-off — where one spinous process is displaced relative to its neighbors — suggests fracture-dislocation with disruption of posterior elements (spinous process, laminae, facet joints, posterior ligamentous complex). According to the Denis three-column model: the anterior column (anterior longitudinal ligament, anterior vertebral body), middle column (posterior vertebral body, posterior longitudinal ligament), and posterior column (pedicles, laminae, facet joints, interspinous ligaments). Disruption of two or more columns indicates an unstable injury with high risk of spinal cord compromise. Associated findings may include: localized tenderness, swelling or ecchymosis over the spine, widened interspinous gap (suggesting ligamentous disruption), and neurological deficits. CT with sagittal reconstructions is the imaging modality of choice for characterizing the fracture pattern. MRI evaluates ligamentous integrity and cord injury.
Question 10: Which medication used in spinal cord injury management acts by reducing secondary injury from free radical damage?
- Methylprednisolone (Correct answer)
- Dantrolene
- Baclofen
- Gabapentin
Correct answer: Methylprednisolone
Methylprednisolone was historically used in acute SCI as a neuroprotective agent to reduce secondary injury from lipid peroxidation and free radical damage, though its use is now controversial.
Methylprednisolone sodium succinate (MPSS) was introduced based on the NASCIS II and III trials (1990, 1997) which suggested modest neurological improvement when high-dose MPSS was administered within 8 hours of acute SCI. The proposed mechanism: MPSS reduces lipid peroxidation, inhibits free radical-mediated secondary injury, maintains spinal cord blood flow, and limits the inflammatory cascade. The NASCIS protocol: 30 mg/kg IV bolus over 15 minutes, followed by 5.4 mg/kg/hour for 23 hours (if started within 3 hours) or 47 hours (if started 3-8 hours post-injury). However, these trials have been extensively criticized for methodological flaws. Current guidelines (AO Spine 2017, Congress of Neurological Surgeons): MPSS may be offered as an option for acute SCI within 8 hours, but is NOT recommended as a standard of care. Risks include increased GI bleeding, wound infection, pneumonia, sepsis, and hyperglycemia. Many trauma centers have abandoned routine MPSS use. Dantrolene treats spasticity, baclofen treats spasticity, and gabapentin treats neuropathic pain — all are chronic SCI medications, not acute neuroprotective agents.
Question 11: A patient is brought in on a long spine board after a motorcycle collision. The nurse should prioritize removing the patient from the board because:
- Spine boards are needed for other incoming patients
- Prolonged immobilization on rigid boards causes pressure injuries and respiratory compromise (Correct answer)
- The board interferes with X-ray imaging
- Spine boards are only for transport and have no clinical benefit
Correct answer: Prolonged immobilization on rigid boards causes pressure injuries and respiratory compromise
Rigid spine boards cause pressure ulcers (within 30 minutes on bony prominences), restrict respiratory excursion, increase pain, and provide no therapeutic benefit beyond transport. Patients should be transferred off the board as soon as possible.
Long spine boards are extrication and transport devices, NOT treatment devices. Prolonged immobilization on a rigid board causes multiple complications: (1) Pressure injury — tissue interface pressures on a rigid board exceed capillary closing pressure (32 mmHg) at the sacrum, scapulae, occiput, and heels within minutes. Skin breakdown can begin in as little as 30 minutes, and SCI patients are at even higher risk due to lack of sensation and vasomotor dysfunction. (2) Respiratory compromise — the rigid surface limits chest wall expansion, particularly problematic for patients with thoracic injuries, obesity, or increased work of breathing. (3) Pain — amplifies discomfort, increases agitation, and makes examination more difficult. (4) Aspiration risk — supine position on a flat surface. Current guidelines (NAEMSP, ACS-COT, Wilderness Medical Society) recommend: transfer the patient off the spine board as soon as possible (within the first assessment), ideally onto a firm hospital mattress with continued spinal precautions (cervical collar, logroll precautions). Vacuum mattress splints are an alternative that provides immobilization with better pressure distribution.
Question 12: SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) is most common in which population?
- Elderly patients with osteoporosis
- Pediatric patients under age 8 (Correct answer)
- Young adult athletes
- Middle-aged patients with degenerative disc disease
Correct answer: Pediatric patients under age 8
SCIWORA occurs predominantly in children under 8 due to the hypermobility of the pediatric spine — elastic ligaments and cartilaginous vertebrae allow the spine to stretch beyond the tolerance of the spinal cord without bony fracture.
SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) accounts for up to 35% of pediatric spinal cord injuries, most commonly in children under 8 years. The pediatric spine has unique biomechanical properties: (1) Ligaments are more elastic and allow greater physiological movement. (2) Vertebral bodies are cartilaginous and wedge-shaped. (3) Facet joints are more horizontal, allowing greater translation. (4) The uncinate processes are underdeveloped. (5) Paraspinal muscles are less developed. These features allow the spinal column to stretch up to 2 inches without disruption, but the spinal cord can only stretch about 0.25 inches before injury occurs. The spine can momentarily displace beyond the cord's tolerance and then recoil to its normal position — the cord is injured but imaging (plain X-rays, CT) shows no fracture or dislocation. MRI is the key diagnostic modality, showing cord edema, contusion, hemorrhage, or ligamentous injury. Neurological deficits may be delayed up to 48 hours after the initial injury. The term has evolved with MRI availability — many previously called SCIWORA cases now show identifiable cord or ligamentous abnormalities on MRI.
TNCC Spinal Cord and Vertebral Trauma
A patient with a C5 spinal cord injury would be expected to retain which motor function?
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Sources & references
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- ena.org — Score validity, eligibility, retake policy · verified Oct 2026
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