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ACEM Fellowship Written 2026 > Ortho spine > Flashcards

Ortho spine Flashcards

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1
Q

Which part of the cervical spine is most often injured?

A

C7 - T1
Cervicothoracic transition zone

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2
Q

Thoracic spine injuries are associated with what other injuries?

A

Intrathoracic injury

Thoracic spine is rigid and stiffness enhanced by rib cage. Thoracic fracture implies severe traumatic force
Also narrower so increased risk of cord injury

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3
Q

Which vertebrae make up the thoracolumbar junction?

A

T11 - L2

Transition zone so increase risk of fracture. However due to wider spinal canal, less risk of cord injury here

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4
Q

Sacral fractures involving the central sacral canal are associated with what organ dysfunction?

A

Bowel and bladder

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5
Q

How do you assess if a spinal fracture is stable or unstable in ED?

A

You can’t
Assume all are unstable until expert opinion sought

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6
Q

What is the secondary injury to the spinal cord?

A

Delayed injury that follows the primary insulting event
- haemorrhage into spinal cord
- oedema
- vasospasm and thrombosis of small arterioles within grey and white matter causing ischaemia
- neural membrane dysfunction due to abnormal electrolyte and neurotransmitter release
- oxidative stress

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7
Q

How is a complete spinal cord injury defined?

A

No motor or sensory function below level of injury

Must perform DRE to check anal tone, reflex, sensation
Complete = minimal chance of motor recovery

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8
Q

How is an incomplete spinal injury defined?

A

Motor or sensory function below level of injury partially present

Must perform DRE to check anal tone, reflex, sensation

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9
Q

What is spinal shock (note: not neurogenic shock)

A

Complete loss of reflexes below area of injury in acute phase of injury

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10
Q

What does the corticospinal tract do?

A

descening motor pathway

decussate at medulla

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11
Q

What examination findings would you expect with damaged to the corticospinal tract?

A

Ipsilateral
- motor weakness
- spasticity
- increased deep tendon reflexes
- Babinski’s sign

Upper motor neuron injury

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12
Q

What examination findings would you expect with injury to the spinothalamic tracts?

A
  • Loss of pain
  • Loss temperature control
    On contralateral side of boy
    beginnig one or two levels below injury

ascending tract. Ascend one or two levels then decussate

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13
Q

What findings would you expect with injury to hte dorsal columns?

A

Ipsilateral loss of
- vibration
- proprioception
- altered fine touch

Fine touch transmitted through both spinothalamic and dorsal colum so not completely lost
Decussates in medulla

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14
Q

Name the motor movement affected by injury at the following spinal cord levels:
- C5/C6
- C6/C7
- C7/C8
- C8/T1

A
  • C5/C6 = arm abduction and elbow flexion
  • C6/C7 = wrist extension
  • C7/C8 = elbow extension
  • C8/T1 = finger abduction, hand grasp
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15
Q

Name the motor function affected by inuury at the following spinal levels
- L1/L2/L3
- L2/L3/L4
- L4/L5/S1/S2
- L5/S1
- S1/S2
- S2/S3/S4

A
  • L1/L2/L3 = Hip flexion
  • L2/L3/L4 = Knee extension
  • L4/L5/S1/S2 = Knee flexion
  • L5/S1 = Ankle dorsiflexion
  • S1/S2 = Great toe extension
  • S2/S3/S4 = Voluntary rectal tone
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16
Q

An injury at C5 or above should have what procedure done promptly?

A

Intubation

Even if pt still breathing ok now, likely usig intercostal muscles or abdominal muscles and will tire
Also progressive oedema of spinal cord may worsening injury from that seen currently

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17
Q

The cause of hypotension in a pt with a spinal cord injury should be presume to from what until proven otherwise?

A

Bleeding

74% of hypotensive pts with penetrating spinal cord injury has major blood loss causing injury.
Also of course may be due to neurogenic shock, cardiac injury, cardiac tamponade, tension pneumothorax

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18
Q

A pt with a suspected C spine injury has dyspnoea, palpitations, abdominal breathing and is anxious. What does this imply?

A

high c-spine injury

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19
Q

A pt has complete motor and sensory loss below the level of a spinal injury but retrains the anogenital reflexes, what does this mean?

A

Sacral sparing indicates incomplete spinal injury

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20
Q

You are trying to decide if a pt has a complete or incomplete spinal injury. They have priapism. What does this suggest?

A

Likely complete injury

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21
Q

What does a power score of 2/5 mean?

A

Movement with gravity eliminated

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22
Q

Draw all the dermatomes

A
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23
Q

What are the mechanisms of injury for anterior cord syndrome?

A

Flexion of cervical spine: direct anterior cord compression
OR
Thrombosis of anterior spinal artery

Poor prognosis for recovery

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24
Q

What examinations findings will be present with anterior cord syndrome?

A
  • paralysis below the level of lesion
  • loss of pain
  • loss of temperature

preservation or proprioception and vibration

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25
What is the MOI for central cord syndrome?
- Hyperextension injury - cervical canal stenosis - disruption blood flow to spinal cord
26
What are the examination findings for central cord syndrome?
- Bilateral weakness, worse in upper limbs - Some loss pain, temperature, sensation also worse in upper limbs
27
What is the MOI for brown-sequard syndrome?
- **penetrating injury** - **disc protrustion** - **haematoma** - **spine fractures** - infections - spinal cord infarction - multiple sclerosis - tumour
28
What are the examination findings with brown-sequard syndrome?
Ipsilateral loss: - motor function - proprioception - vibration Contralateral loss - pain - temperature
29
What are the examination findings for cauda equina syndrome?
- bowel/bladder dsyfunction - decreased anal tone - "saddle" anaesthesia - variable motor and sensory loss in lower limb - decreased reflexes (is lower motor neurone lesion) - sciatica ## Footnote not all features need to be present. Bowel and bladder function may be normal. Anal tone may be spared. Look for saddle anaesthesia. Need urgent MRI if any symptoms as none 100% predictive
30
How will a patient examine with neurogenic shock (note: not spinal shock)
- warm - peripherally vasodilated - hypotensive - relative bradycardia ## Footnote If T1 - T4 level compromised, loss of sympathetic tone to the heart leaves unopposed vagal stimulation
31
What is spinal shock (note: not neurogenic shock)
below level of injury, temporary: - loss of spinal reflexes - flaccid paralysis ## Footnote Can make incomplete spinal injury look like a complete. Can last days to weaks or even up to 6 months
32
What is the NEXUS criteria?
- absence of midline cervical tenderness - abscence of focal neurological deficis - normal level of alertness - no evidence of intoxication - absence of painful distracting injury ## Footnote 34,000 pts < 65 years old 99% sensitive for clinically significant c-spine injury 13% specific Retrospective Australian study using NEXUS but > 65 years 95% sensitive 15% specific Study created when xray was used to clear c-spine In CT validation study only 83% sensitive 45% specific
33
What are the canadian c-spine rules?
## Footnote 100% sensitive 42% specific May be better than Nexus. Using either or is acceptable
34
What are the downsides of using plane filmn to assess the c-spine for fractures?
- may need assitant to pull down shoulder - poor imaging to C1 and C2 - visualistion of entir c-spine difficult in obese, elderly and muscular esp with c-spine collar in-situ - misses injury comparted to CT ## Footnote Need to see dow to upper border of T1 AP + lateral + adontoid. Lateral will detect 90% of fractures
35
When is an MRI of the c-spine indicated?
- neurology consistent with a cord injury but negative CT - pt with positive CT to assess for cord injury
36
What are features of a purely ligamentous spine injury when the bones have spontaneously relocated (normal CT)
- persistent midline pain - focal neurology | Need an MRI ## Footnote If sole symptom is pain, get expert opinion
37
There are some vessels of the neck that may be injuryed with a c-spine injury but symptoms are not always immediately apparent, which vessels are these?
- carotid a. - verebral a. ## Footnote dissection may not be apparent for days until neurology becomes evidence
38
How well does clinical examination of the thoracolumar do at detecting fractres?
Poorly 50% sensitive for all 78% for clinically significant
39
What are the AAST - TL spine clinical decision rules for imaging of thoracolumar spine after blunt trauma
Imaging needed if any criteria met: - > 60 years old - not alert - pain ,tenderness to palpation, deformity, neurological deficity - mechanism of injury was high risk: fall from > 5 steps, crush, MVA with rollover/ejection, unenclosed vehicle, automobile vs pedestrian
40
What is the sensitivity of CT vs plane film for detecting clinically significant thoracolumbar fractures?
97% (CT) vs 33% (XR)
41
If you detect a spinal fracture, why should you then imaging the entire spine
20% will have a non-contiguous spinal fracture elsewhere
42
Can you remove spinal precautions on an obtunded pt with a normal CT?
controversial CT of c-spine will detect 98.5% for c-spine injury ## Footnote depends on local policy. Probably keep in spinal precautions and discuss with spinal expert
43
What injuries are thoracolumbar fractures associated with?
Aortic intrabdominal
44
What % of thoracolumbar burst fracture are wrongly diagnosed as wedge fractures on plane film?
20% ## Footnote Chance fractures can also get diagnosed as wedge fractures on plane film. Also wedge fracture may be due to pathological fracture, not appreciable on plane film. Get a CT to evaulate all fractures seen on xray
45
46
What % loss of height of wedge fractures of thoracolumbar region are likely stable and can be discharge?
< 40% ## Footnote still discuss with expect though
47
What neurology may be present with sacral fractures?
If central canal: bowel and bladder If transverse: radiculopathy ## Footnote Rare but associated with pelvic fractures. Get expert opinion
48
How to you diagnose and treat coccyx fractures?
Clinically. No imaging needed Symptomatic with anaglesia and donut pillow Do not need to consult anyone
49
The administration of corticosteroids is debatable in spinal injury but in what group of spinal injuries are steroids clearly contraindicated?
Contraindicated in penetrating spinal injury
50
What is the BP target with spinal injury?
Debatable Has bean **MAP > 85** and systolic > 90 but evidence isn't great and those with central cord injury (likely older pts) increased risk of cardiovascular complications) Go by case-by case basis If in neurogenic shock use fluids and inotropes
51
What is this injury called?
Anterior subluxation ## Footnote due to hyperflexion sprain causing ligamentous failure and may have no associated fracture. May be stable or unstable
52
What space do you measure to spot an atlantoaxial dislocation?
Predental space (anterior aspect of odontoid to post aspect of ant ring of C1) Adult <3mm or 2mm on CT Peds <5mm ## Footnote Unstable
53
What is the name of this fracture?
Bilateral interfacetal dislocation | unstable ## Footnote disruption of all ligaments. Vertebral body dislocated anteriorly > 50% of its width
54
What type of fractures is this?
wedge ## Footnote differentiated from a burst by absence of vertical fractures of vertebral body and lack of bulging of posteior vertebral border
55
Is a spinous process avulsion fracture stable?
In isolation stable ## Footnote Also called the Clay Shoveller's fracture. Discuss with expects
56
57
What spinal cord injury is associated with a flexion "teardrop" fracture of the c-spine?
Anterior spinal cord syndrome *highly unstable* ## Footnote Due to hyperflexion causing anterior spinal ligament to pull anterioinferior portion of vertebral body anteriorly
58
Is a unilateral faecet joint dislocation stable or unstable?
Stable Unless associated with associated with articular mass fracutre)
59
What is the name of this fracture?
## Footnote Can be unstable and associated with brown sequard syndrome, and vertebral artery injury
60
What do chance fractures get misdianosed as sometimes on xray?
a wedge fracture ## Footnote Chance fractre is anterior compression with transverse fracture through vertebral body. Unstable
61
What measurement can help diagnose a Jefferson fracture?
Radiographs odontoid view will show asymmetry in the odontoid view with the displacement of the lateral mass(es) away from the odontoid peg (dens). A distance of greater than 6 mm suggests ligamentous injury. ## Footnote may be stable or unstable
62
What is the name of this fracture?
Burst ## Footnote Look for any retropulsed fragments Unstable
63
If a hyperextension dislocation spontaneously reduces what feature on imaging may suggest a clue to this ligamentous injury?
Prevertebral soft tissue swelling ## Footnote Plane film: C2/3: <7 mm C6/7: <21 mm CT C2: 6 mm C6/C7: 18 mm Unstable
64
What age group tends to get hypertextension teardrop fracture?
Elderly osteoporotic ## Footnote Unstable in extension Height of fracture segment tends to excess it's width
65
What part of the atlas is fractured?
Posterior arch ## Footnote stale
66
What part of the vertebrae is fractured?
Lamina ## Footnote may be associated with spinous process # Usually stable
67
What is this fracture called?
Hangman's frature ## Footnote Traumatic spondylolithesis C2 on C3. Large spinal canal at C2 so neurological injury is uncommon
68
Where is the fracture?
Occipial condyle ## Footnote Usually stable but neurlogical injury common: lower cervical nerves and or lower limb weakness
69
What is the name of this fracture?
Atlanto-occipital dislocation ## Footnote Highly unstable Paralysis upper extremity or lower cranial nerve difificits, lack of lower limb weakness
70
71
What is fractured?
Odontoid ## Footnote Unstable 25% associate with neurology: mild sensory or motor loss to quadriplegia Felt as severe high cercial pain radiating to occiput
72
What is the name of this fracture?
Translation-dislocation ## Footnote Unstable Severe neurology Though those above T7 due to rib cage may me stable
73

ACEM Fellowship Written 2026 (48 decks)

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