Spine Flashcards
(123 cards)
1
Q
What is the most common presenting sign of cauda equina syndrome?
A
Back and leg pain
2
Q
- ) What column is involved in a compression fracture?
2. ) What is typical treatment and what additional surgical tx can be considered?
A
- ) Anterior column ONLY; usually < 50% height loss (axis of rotation is around the middle column)
- ) Bracing; Kyphoplasty -> balloon allows for higher volume, lower pressure, use of highly viscous cement = LOWER EXTRAVASATION RATE
3
Q
What is the mechanism of injury of a vertebral compression fx vs burst fx?
A
Compression -> flexion/loading (only involves anterior column!)
Burst -> axial compression (involves anterior and middle column +/- posterior column)
4
Q
- ) What are the surgical indications for treatment of a burst fracture?
- ) If don’t have surgical indications w/ burst fx what is the treatment?
A
- ) Neuro deficit and/or deformity: > 30 degrees jxn kyphosis, > 50% loss of anterior height
- ) Extension bracing!!
5
Q
In the case of a burst fracture how do you treat:
- ) Deformity w/ no neurodeficit
- ) Neurodeficit
- ) Lamina fx
A
- ) Posterior spinal fusion
- ) Anterior decompression (+/-) posterior instrumentation (remember that if at level of cord and you need to do a decompression that you need to go anterior!!)
- ) Posterior decompression (b/c nerve can get entrapped in fracture when it springs open and closed)
6
Q
What is the typical treatment for an L5 burst fx?
A
Typically nonop b/c can have significant canal compression w/o deficit b/c just roots at this level.
**Though can only accept up to 20 degrees kyphosis (whereas at other L-spine < 30 degrees is nonop)
7
Q
- ) What is the axis of rotation for a flexion-distraction spine injury?
- ) What columns are involved?
A
- ) Anterior longitudinal ligament
2. ) Typical all 3…sometimes does not involve anterior column!! (but NO translation)
8
Q
What associated injuries should you think about in a flexion-distraction spine injury?
A
Intra-abdominal injuries!
9
Q
What is the treatment for:
- ) Bony flexion/distraction TL injury?
- ) Ligamentous flexion/distraction TL injury?
A
- ) Bracing
2. ) Surgery - posterior tension band
10
Q
- ) What columns are involved in a fracture-dislocation TL spine injury?
- ) What other quality makes it different from a flexion/distraction injury?
A
- ) All 3 columns
2. ) There is associated translation
11
Q
What did the TLICS (Thoracolumbar Injury Classification & Severity) Score helped to highlight?
A
Significance of the PLC injury in the management of TL injuries (it gets 3 points…so gives high push to become surgical intervention needed!)
12
Q
What are the 3 groups involved in using the TLICS classification?
A
- ) Injury Morphology
- ) PLC Integrity
- ) Neuro Status
13
Q
How do you score TLICS?
What number needs surgery?
A
- Injury Morphology: Compression: 1 Burst: 2 Translation/rotation: 3 Distraction: 4
- PLC Integrity:
Intact: 0
Indeterminate: 2
Disrupted: 3
-Neuro Status: Intact: 0 Nerve Root Injury: 2 Complete: 2 Incomplete: 3
Score of 4 or more needs surgery!!
14
Q
On XR imaging of the C-spine what must you make sure that you see?
A
C7/T1 - common area to have a fracture!!
15
Q
What is the difference b/t neurogenic shock and spinal shock?
A
- ) Neurogenic shock = hypotension + bradycardia due to loss of sympathetic tone; typically occurs w/ lower C and upper T injuries
- ) Spinal shock (due to metabolic derangement) = indicated by loss of bulbocavernosus reflex (most distal reflex arc)…lasts up to 48 hours -> after this declared out of spinal shock! (if bulbocavernosus reflex never returns = conus medullaris syndrome)
16
Q
How is motor involvement effected most in:
- ) Central Cord
- ) Anterior Cord
A
- ) Upper > Lower
2. ) Lower > Upper
17
Q
What is the reasoning behind performing spine surgery in a patient with a complete spinal cord injury?
A
Expedite rehab and prevent late pain and/or deformity at fracture level.
18
Q
What is the artery of Adamkiewicz (aka anterior radiculomedullary artery) and what spinal cord syndrome can it cause?
A
Artery that comes off the the posterior intercostal artery and supplies the anterior spinal cord - largely helps to supply the lower spinal cord/reinforces the anterior spinal artery.
Injury can occur during thoracic surgery around T8/9 -> Anterior Cord Syndrome
19
Q
- ) What is autonomic dysreflexia?
- ) In what type of injuries does it typically occur?
- ) What instances can make it occur?
A
- ) Sympathetic overdrive (sudden hypertension, pounding headache, blurred vision, etc)
- ) Typically spinal cord injury above T5
- ) Fracture, fecal impaction, urinary retention
20
Q
What is the rule for abx administration for the follow types of GSW to spine:
- ) No abdominal injuries
- ) Solid organ injury
- ) Hollow organ/GI injury
A
- ) Oral abx
- ) Oral abx
- ) IV abx x 7-14 d, tetanus
21
Q
What do you do in GSW to spine with the bullet if the bullet is:
- ) Outside spinal canal
- ) Within spinal canal at T12 or above (cord level)
- ) Within spinal canal below T12
A
- ) Observe
- ) Observe - unless has deteriorating neuro fxn may consider removal; if not leave it alone b/c you may cause more damage by removing it
- ) Consider removal to prevent lead poisoning
**Essentially GSW to spine is nonop unless direct passage through GI system or progressive neuro deterioration w/ proven neuro compression w/ bullet, bony fragments or hematoma
22
Q
What is the treatment for Cauda Equina Syndrome?
A
Immediate MRI or CT myelogram for eval and emergent/urgent surgery for decompression w/in 48 hrs
23
Q
What is the difference between Cauda Equina Syndrome and Conus Medullaris Syndrome?
A
CES -> motor deficit + bowel/bladder problems
CMS -> bowel/bladder problems ONLY (conus ends at L1 -> so this involves an injury at T11/12 or T12/L1)
24
Q
What is the difference in using a TLSO vs a Jewett orthosis for treating TL spine fx?
A
TLSO gives rotational control; Jewett does not
25
What is the best study to order to look a recurrent disc herniation?
MRI w/ Gad
26
What is the natural history of HNP by 1 month?
90% of patients are better (this is why nonop therapies of activity modification, NSAIDS, muscle relaxants/narcotics/oral steroids should be tried for 4-6 weeks!!)
27
What position increases the intradiscal pressure the most? The least?
```
Most = sitting and leaning forwards
Least = supine
```
28
What is the innervation of the facet joint?
Medial branch of the dorsal primary rami aka sinuvertebral nerve aka primary posterior ramus of the lumbar spinal nerve
29
In what areas of the spine should you never do a lami alone? Why?
C and T spine -> b/c will fall into kyphosis
30
What is the name given to signs that tell you the patient has non-organic back pain (ie. neg SLR when distracted, non-dermatomal distribution, etc)
Waddell's signs
31
When working up back pain w/o red flag signs what is acceptable?
NO XR needed for 6-8 weeks!
32
If can't order an MRI due to cardiac implants, etc; what other test can you order?
CT Myelogram
33
What is the most sensitive test to ID isthmic spondy?
SPECT
34
Degen Spondylolisthesis:
1. ) MC in male or female?
2. ) What level is most common?
3. ) What nerve root effected most commonly?
1. ) Female
2. ) L4/5
3. ) L5 (L4 has already exited!)
35
Isthmic Spondylolisthesis:
1. ) MC in male or female?
2. ) What level is most common?
3. ) What nerve root effected most commonly?
4. ) What is firstline treatment?
5. ) What is treatment if fail firstline?
1.) Male
2.) L5/S1
3.) L5 (L5 effected b/c in isthmic spondy there is a fibrocartilagenous reparative process that takes place and forms s "Gil nodule" which compresses the exiting nerve root = L5!)
4.) PT, bracing, NSAIDS, activity modification (MOST patients can be treated this way!) Trial for 6 months
5.) Uncommon to fail - but if fail:
Low Grade slip L5/S1 PSF
High Grade slip (> 50%): L4-S1 PSF (w/ partial reduction to reduce injury to L5 nerve root!)
*Note: in young pt that failed nonop, has no neuro deficit, no listhesis but continues to have pain w/ spondylolysis at L4 or above -> can do a pars repair instead of fusion!
**Note: relatively few patients w/ spondylolysis develop spondylolisthesis -> can predict who will have listhesis by Slip Angle and High PI
36
What are the 3 main causes of iatrogenic spondylolisthesis?
1. ) Iatrogenic removal of pars
2. ) Unilateral total facetecomty (1x100% = 100%)
3. ) Bilateral facetecomy w/ each taking out 50% or more (2x50% = 100%)
37
What decompression is needed for lumbar:
1. ) Central canal stenosis
2. ) Lateral recess stenosis
1. ) laminectomy
| 2. ) medial facetectomy
38
Where is the pars (between what and what?)
Pars is the bone b/t the superior and inferior facets
39
1. ) What is the primary treatment for lumbar spinal stenosis?
2. ) What is the next level of treatment and when might you jump to this more quickly?
NONOP! (PT, injections, NSAIDS, activity modification) x 6-12 weeks!
2.) Surgery -> progressive neurologic deficit, Cauda Equina, severe uncontrolled pain
40
In lumbar spinal stenosis that you have decided to do surgery on - what surgery do you do and how do you decide?
1. ) Decompression alone (laminectomy for central canal stenosis vs medial facetectomy for lateral recess stenosis)
2. ) Add fusion if have:
- Instability (accidentally/iatrogenic thin out pars too much or remove too much facet..>50% of each bilaterally, or 100% unilaterally)
- Deformity (spondylolisthesis or scoliosis)
41
What is the main symptom for:
1. ) Lumbar central canal stenosis
2. ) Lumbar lateral recess stenosis
1. ) Neurogenic claudication
| 2. ) Radicular symptoms
42
What is the treatment for thoracic disc dz?
If no myelopathic sx -> Nonop!
If myelopathic sx (UMN signs - Babinski and clonus present...realize that since is below the C-spine you should not have a +Hoffman sign!) -> operative (NEVER laminectomy alone b/c at cord level and will still be draped over the thoracic/kyphotic spine...also going posterior for a T level disc herniation is a/w highest risk of paraplegia!!)
43
What is the relationship b/t PI, SS, PT?
PI = SS + PT
44
In the initial evaluation of acute (< 4 weeks) low back pain - a patient taking what medication would make you want to order an XR?
Prolonged steroid use -> looking for a compression fracture
45
1. ) What is the study of choice to evaluate osteodiscitis?
| 2. ) What is the treatment?
1. ) MRI w/ gad
| 2. ) Get biopsy -> then, IV Abx x 6 weeks, followed by oral course
46
What are indications for surgical treatment of osteodiscitis?
1. ) Failure of IV abx
2. ) Abscess
3. ) Progressing neuro deficit or mechanical instability
Typically go anterior - especially if there is a psoas abscess!
47
What is the most common symptom of osteodiscitis?
Pain
48
What is the most common change first seen on XR w/ osteodiscitis?
Disc space narrowing (any changes lag behind clinical symptoms for up to 2-8 weeks)
49
What is the likely prognosis/expected outcome of an adequately treated osteodiscitis w/ IV abx?
Spontaneous arthrodesis (most occur in under 1 year!)
50
What are 3 main differences of TB spondylitis compared to other bacterial infectious organisms?
In TB:
1. ) Disc space more preserved
2. ) Large paraspinal abscesses are more common
3. ) Usually cause greater amount of deformity (more likely to need surgery; but just like other abx is the mainstay)
51
What is the difference b/t patients w/ osteodiscitis vs those with epidural abscess?
Epidural abscess patients are more sick!! (osteodiscitis patients just present w/ pain)
52
What is common primary treatment for epidural abscess?
Surgical management! (most typically via anterior approach +/- posterior approach, especially at cord level of spine...essentially go right over the abscess). Okay to instrument despite infection! - only do it if there is instability though!
53
After spine surgery when are ESR and CRP expected to normalize?
CRP at 2 weeks (by 1st postop visit)
| ESR at 6 weeks (by 2nd postop visit)
54
What is the most powerful tool for reducing postop infections?
Preop ppx abx administered 30-60 min prior to incision
55
What is the most likely etiology of:
| back pain worse w/ flexion
Discogenic back pain
56
What is the most likely etiology of:
| back pain worse w/ extension
Facet arthropathy
| Spondylolysis
57
What is the most likely etiology of:
| Leg pain worse w/ flexion
Herniated disc
58
What is the most likely etiology of:
| Leg pain worse w/ extension
Spinal stenosis
59
1. ) When working up back pain - how long can you go w/o needing to order an XR?
2. ) What are qualities of the patient/presentation that will make you order an XR early on?
1. ) First 4-6 wks of sx
| 2. ) Patient on chronic steroids (look for compression fx's), history of trauma or cancer, any red flag signs
60
In which 3 main settings should the MRI be ordered w/ Gad?
1. ) Tumor
2. ) Infection
3. ) Recurrent disc herniation
61
What do you do if evaluating a patient w/ lumbar stenosis who has trouble with their gait and/or difficulty with buttons and clumsiness of their hands?
Order C-spine MRI b/c they are presenting with myelopathic features!!! 20% of people have concomitant lumbar and cervical pathology!
62
What is risk of treating a patient w/ OPLL w/ anterior approach C spine surgery?
High rate of dural tear! - think in my mind that it's a posterior dz so go posterior!!
63
What are 6 physical findings in cervical myelopathy?
1. ) Intrinsic wasting
2. ) Difficulty with grip and release
3. ) Difficulty in tandem gait
4. ) Lhermitte's signs (neck flexion -> shock down spine and into extremities)
5. ) Hoffmans test (snapping distal phalanx of MF leads to flexion of other fingers/thumb)
6. ) Hyperreflexia
64
What are the prognostic factors for outcome of cervical myelopathy in regards to:
1. ) SAC
2. ) transverse cord area
3. ) Most important indicator of poor outcome?
1. ) SAC < 13 is a prognostic indicator of badness
2. ) Transverse cord area > 70 mm2 is a prognostic indicator of goodness
3. ) Severity of symptoms at treatment: JOA < 14
65
What is the treatment for cervical myelopathy in regards to Japanese Orthopaedic Association (JOA) Classification?
Score is out of 17 and higher = better = more function
> 14: Nonop - symptoms mild and/or no progression
< 14: Op - symptoms moderate/severe and/or progression
66
1. ) What is the approach used for cervical myelopathy involving 1-2 levels?
2. ) What is the approach involving 3 or more levels?
1.) Anterior ONLY!
(Doesn't matter if alignment is > 10 kyphosis or < 10 kyphosis/or lordotic)
2.) Depends on alignment!!! (look at "K"line = draw line down spinal cord and see if hits vertebral bodies)
> 10 degrees Kyphosis: need anterior & posterior (anterior is needed to decompress since cord is draped over vertebral bodies)
< 10 degrees Kyphosis/or Lordosis: Posterior alone, or A&P
67
What are the 2 possible procedures for posterior-based treatment of cervical myelopathy?
1. ) Posterior laminoplasty - which just opens up lamina on one side and hinges on other side (good for pts w/ no neck pain and want faster return to work!)
2. ) Posterior laminectomy AND fusion (NEVER DO POSTERIOR LAMINCETOMY ALONE!!! THEY WILL FALL INTO KYPHOSIS LATER!)
68
What are the 3 main pathologies seen in the C-spine of RA patients?
1. ) Atlantoaxial subluxation -> MOST COMMON
2. ) Basilar invagination/migration
3. ) Subaxial instability/subluxation
69
What is the treatment for basilar invagination in an RA patient?
Depends on brain stem compression:
1. ) If NO compression -> posterior only surgery (reduce and fuse occiput to C1 or C2)
2. ) If compression -> anterior decompression and then posterior fusion
70
For atlantoaxial subluxation in an RA patient what do ADI and PADI/SAC tell you?
ADI > 3.5 = instability
ADI > 10 OR PADI/SAC < 14 = surgery (C1/2 or occiput to C2 fusion)
PADI/SAC > 13 = best predictor for good outcome
71
For subaxial instability in an RA patient what values indicate:
1.) Instability
2.) Neurologic issues
3.) Predictive for neuro compromise
How do you decide what surgery to do anterior vs posterior or both?
1. ) > 3.5 mm translation or 11 degrees (MOST IMPORTANT!!)
2. ) > 4 mm or 20% translation
3. ) Cervical height index (body height/width ratio) < 2
* *PICK ANTERIOR AND POSTERIOR BASED SURGERY B/C THEY ARE AT HIGH RISK FOR PSEUDOARTHROSIS!!
72
What physical exam finding is seen in cervical radiculopathy?
Myotomal weakness, dermatomal sensory changes, and/or pain
(+) Shoulder abduction test which relieves sx
(+) Spurlings
73
What is the treatment of Cervical Radiculopathy?
1. ) First line is NONOP! (75% resolve) - PT, injections, NSAIDS
2. ) Surgical indications = SIGNIFICANT PROGRESSIVE WEAKNESS (DO NOT TRIAL NONOP!...*NOTE: progressive sensory changes don't matter - these don't necessarily get better either after tx), continued sx despite 6-12 wks nonop tx
74
What are 3 possible types of surgeries for cervical radiculopathy?
* *Use same tx algorithm as for cervical myelopathy for deciding anterior and/or posterior approach**
1. ) ACDF - up to 2 levels, > 2 add posterior, ~2%/yr progression of adjacent segment dz
2. ) Disc replacement - up to 2 levels, maybe < adjacent segment dz, ONLY appropriate for YOUNG pt, NO NECK PAIN, NO arthritis on XR
3. ) Foraminotomy - faster return to work and cheaper, but higher rate of reoperation at same level
* **NOTE: you will not be asked to pick between these options - just need to know that these are all feasible!
75
What is the appropriate treatment for a patient that has significant signs of cervical canal stenosis w/ no or very minimal myelopathic sx?
OBSERVE!!!
76
In a younger patient that presents with sx that make you think of myelopathy, what other diagnosis should you think of and what test can help you tell?
MS! - key is that will be in YOUNGER pt!
| Get MRI and will see several lesions in MS pt
77
```
What are the anatomical land marks for:
C2
C3
C4/5
C5/6
C6
```
```
C2 -> angle of mandible
C3 -> Hyoid bone
C4/5 -> Thyroid cartilage
C5/6 -> 1st ring cricoid cartilage
C6 -> carotid tubercle
```
78
```
What nerve roots are responsible for the following reflexes?
Biceps
Brachioradialis
Triceps
Patella
Achilles
```
```
Biceps - C5
Brachioradialis - C6
Triceps - C7
Patella - L4
Achilles - S1
```
79
In the C-spine, where does the majority of the following motion come from?
Flex/ext
Rotation
Lateral bend
Flex/ext - 50 degrees occiput/C1 then 10 degrees/level
Rotation - 50 degrees C1/2 then 10 degrees/level
Lateral bend - 8 degrees occiput/C1 then 12 degrees/level
80
What makes up the occipital safe zone?
Stay below the External Occipital Protuberance (EOP) to avoid the sinuses!
Stay within triangle that is below EOP and extends 2 cm distal and 1 cm medial and lateral of midline.
Screw length 4-12 mm
81
1. ) What is the trajectory for C1 lateral mass screws?
2. ) What are you at risk of injuring?
3. ) What is the approximate length and type of screw to use?
1.) Aim: straight to 10 degrees medial/22 degrees cephalad
2.) Risk:
Internal carotid -> if place bicortical screw and go through anterior cortex
Vertebral artery -> if screw goes out superiorly or lateral (if hit it - put screw in and let tamponade and DO not place other screw b/c can live w/ 1 vert!)
3.) ~24 mm, smooth shanked to avoid irritation to C2
82
1. ) What plate placement w/ ACDF can cause adjacent level disease?
2. ) Otherwise, what is the rate of adjacent segment dz after ACDF?
3) What patient factors are increase risk of adjacent segment dz?
1. ) Plate placed w/in 5 mm of disc!!
2. ) ~1.5-2%/year
3. ) Smoking and DM, F>M
83
What nerve palsy can occur after cervical surgery?
C5 (deltoid, biceps effected)
Equally common w/ anterior or posterior surgery!
Just observe - can take up to 1 year to resolve!
84
If you place retractor lateral to longus coli muscle what nerve injury can occur?
Sympathetic chain injury b/c it lies on the longus coli muscle! So will see Horner's Syndrome!
Tx: observation
85
1. ) What is the location of safe placement for Halo pins?
| 2. ) What nerves are at risk if too medial?
1.) Anterior: 1 cm above supraorbital ridge (above eye brow) and lateral 2/3. Stay BELOW equator!
Posterior: aim to be 180 degrees off of the anterior and stay below equator!
2.) Supraorbital n. (sensory only so numbness to eyelid/forehead) and Abducens Nerve Palsy (CN VI)
86
During high cervical anterior approach (C2/3 or C3/4) what nerve injury can occur?
Hypoglossal nerve injury
Tongue deviates to the side of injury
Tx: Observation
87
1. ) What is the ASIA Classification for grading spinal cord injury?
2. ) How is level determined?
```
A = Complete, no sensory or motor distal
B = Incomplete, no motor distal but some sensory
C = Incomplete, motor and sensory w/ motor 2 or less in 50% of muscles distal
D = Incomplete, motor and sensory w/ motor 3 or more in 50% of muscles distal
E = Normal motor and sensory
```
Level determine by most distal level that has bilateral 4/5 or more strength and sensory intact
***REMEMBER CANNOT GRADE SCI UNTIL OUT OF SPINAL SHOCK = BULBOCAVERNOUSUS REFLEX HAS RETURNED!
88
When evaluating C-spine trauma what XR views are needed?
AP/Lateral (that includes T1...most common reason to miss an injury is that didn't go down far enough!)/Open Mouth Odontoid
89
In SCI - what important function do the following levels give?
C5
C6
C7
C5 - vent dependent, electric wheelchair w/ hand control
C6 - can feed self, independent living, manual wheelchair
C7 - can use manual wheelchair and independent transfer
90
1. ) What is injury mechanism for central cord syndrome?
2. )What are sx?
3. ) What is treatment?
1.) Hyperextension injury in person w/ existing central canal stenosis
2.) UE and distal muscle effected more than LE's and proximal muscles
3.) Nonop: if improving sx and no pre-existing myelopathy
Op: if not improving and/or pre-existing myelopathy
91
1. ) What is injury mechanism for anterior cord syndrome?
2. ) What are sx?
3. ) What is treatment?
1. ) Direct compression or injury to anterior spinal artery - supplies anterior 2/3 of cord!! (like Adamkwitz at T8/9 level)
2. ) Will see LE motor more effected than UE motor (opposite of central cord syndrome!), loss of pain/temp but preservation of vibration/proprioception
3. ) Operative if have direct compression that can be relieved - otherwise not much to do and has WORST PROGNOSIS! (10-20% chance recovery)
92
1. ) What is the injury mechanism for Brown-Sequard?
2. ) What are sx?
3. ) What is prognosis?
1. ) Cord hemi-transection (penetrating trauma)
2. ) Ipsilateral motor deficit, contralateral pain/temp deficit
3. ) BEST prognosis - 99% ambulatory!
93
After SCI - when should surgery be done for:
Incomplete injury
Complete injury
Incomplete < 12 hrs! (Emergent - want to try to get back as much fxn as possible!)
Complete < 24 hrs
94
Compare Ankylosing Spondylitis (AS) vs Diffuse Idiopathic Skeletal Hyperostosis (DISH) in regards to:
1. ) Syndesmophytes
2. ) XR findings
3. ) Disc space
4. ) Osteopenia
5. ) HLA
6. ) Age
7. ) SIJ involvement
8. ) A/w DM?
```
1.) Syndesmophytes
AS - Marginal/ DISH - nonmarginal
2.) XR findings
AS - Bamboo spine, shiney corners/DISH - flowing candle wax
3.) Disc space
AS - ossification/DISH - NOT affected
4.) Osteopenia
AS - yes/DISH - no
5.) HLA
AS - HLA-B27/DISH - HLA-B8
6.) Age
AS - younger/DISH - older/middle age
7.) SIJ involvement
AS - yes, bilateral/DISH - None
8.) A/w DM?
AS- NOPE/DISH - yep!
```
95
What do the following embryologic parts develope into:
1. ) Notochord
2. ) Neural Tube
3. ) Neural Crest
1. ) Notochord - becomes vertebral bodies and disc
2. ) Neural Tube - becomes CNS/spinal cord -> failure results in myelomenigocele & spina bifida
3. ) Neural Crest - becomes PNS
96
What are the types of Odontoid fractures?
Type I: tip
Type II: waist
Type III: body
97
What is the treatment for Type I, II, and III Odontoid fx's?
Type I & III -> Rigid Orthosis (in type III in a young pt can consider Halo)
Type II -> Young (<50 yo) vs Old (>50 yo)
Young: if no risk factors for nonunion -> Halo; if risk factors for nonunion -> surgery
Old: if poor surgical candidate -> Orthosis (NEVER HALO IN OLD - WILL KILL THEM!); if operative candidate -> surgery (b/c being old is a risk factor for nonunion!!)
Surgery = Posterior C1/2 fusion or in young w/ appropriate fx line C2 screw
98
What are the main risk factors for Odontoid nonunion?
```
Displacement > 6 mm (greatest a/w nonunion and strongest indication to do surgery!!)
Posterioir Angulation > 10 degrees
Comminution
Treatment delay (> 4 days)
Smoker
Age > 50 yo
```
99
What 2 arteries create the watershed area of an Odoing Type II fx?
Internal carotid a. (apex)
| Vertebral a. (= vertebral body easy to remember!)
100
What are the Types of Atlas/C1 injuries and what are their associated treatments?
Type I: isolated anterior or posterior arch fx. Tx: orthosis or Halo
Type III: lateral mass fx. Tx: orthosis or Halo
Type II: burst fx w/ bilateral anterior and posterior arch fx. Tx: depends on stability = TAL integrity (which you can tell by sum of lateral mass displacement). If TAL intact (sum of lateral mass < 8.1) -> Orthosis or Halo. If TAL bony avulsion fx -> Halo. If TAL w/ intrasubstance tear (sum of lateral mass > 8.1) -> C1/C2 fusion or occiput-C2 fusion
101
What fractures do Halo's not work for?
Subaxial C-spine! (only works for C1 and C2 related injuries...Halo is good at controlling rotation...NOT lateral bend!)
102
What is recommendation regarding sport participation in patients w/ os odontoideum?
DO NOT ALLOW THEM TO PARTICIPATE IN CONTACT SPORTS!!
103
In regards to injury to TAL, apical and alar ligaments - which values let you know this?
ADI 3-5: injury to TAL
| ADI > 5: Injury to TAL, apical and alar ligaments
104
What is the typical outcome of an occipitocervical dislocation?
Death!! (if do survive -> occipitocervical fusion)
105
How do you treat traumatic spondylolisthesis of axis:
1. ) Type I: < 3 mm horizontal displacement, C2/3 disc intact, no angulation
2. ) Type II that has > 5 mm horizontal displacement, C2/3 disc and PLL disrupted
1. ) Stable -> rigid orthosis
2. ) Unstable -> reduction w/ C1/2 stabilization
**Neither of these typically have neurodeficit b/c the canal opens up more!
106
In cervical facet dislocations - what are the 3 MAIN rules?
| How do you decided if posterior or anterior approach surgery?
1. ) If significant deficits and alert & oriented -> emergent closed reduction w/ traction and Gardner-Wells Tongs. (CANNOT perform closed reduction if patient not A&O!!). If exam worsens during reduction -> abort and MRI
2. ) ALWAYS get MRI (looking for disc herniation) prior to surgery!
3. ) ALL of these injuries (whether unilateral or bilateral) GET surgery!!
Anterior surgery ->
* If closed reduced
* If anterior disc that you need to address
Posterior surgery ->
* If failed closed reduction
* If need more stabilization
107
1. ) What type of presenting problem does a unilateral cervical facet dislocation typically have?
2. ) What other structures is often injured in cervical facet dislocations?
1. ) Monoradiculopathy
| 2. ) Spinal cord injury (high chance in bilateral) and vertebral artery injury -> eval w/ CT angio or MRI angio
108
How do you tell whether a cervical facet dislocation is unilateral vs bilateral on XR?
On lateral XR:
Unilateral has < 25% spondylolisthesisl
Bilateral has > 25-50%
109
What other injuries should you look for when you see a patient with subaxial C-spine fractures?
Other spine injuries!! -> make sure to get CT T and L spine (10-15% will have other spine injuries!)
110
What other injury typically occurs with a cervical burst fracture?
What is treatment?
SCI
| Anterior vs Anterior+Posterior surgery for decompression and stabilization
111
When you see a flexion tear drop C-spine injury what is the anterior-inferior fragment attached to?
What other injury is associated?
ALL (note: this piece is fairly large...unlike the extension tear drop which is a very small fleck!). The posterior/inferior fragment (rest of the vertebral body!) is retropulsed into canal!!
SCI
Tx: w/ Anterior vs Anterior+Posterior Surgery
112
What is the typical treatment for cervical compression fracture?
Orthosis
| Not typically a/w SCI or neuro injury! (posterior cortex intact, no retropulsion)
113
What fracture is seen with an extension tear drop type injury?
What is treatment?
Small bony fleck off of anterior inferior corner (MUCH smaller than the bone fragment off of flexion tear drop!)
NOT a/w neuro injury (the flexion tear drop is!). Tx w/ orthosis
114
What is the treatment for a floating lateral mass fracture of the subaxial C-spine?
Surgery! - 2 level fusion!!
Anterior 2 level fusion if well-reduced fragment and no reduction needed.
Posterior fusion if need to perform reduction -> and then perform 2 level fusion
115
Neuromonitoring: SSEPs vs MEPs -
1. ) What function is monitored?
2. ) How does it work?
3. ) Which one can be effected by anesthesia?
4. ) What level of change in reading is significant for each?
5. ) Which is more sensitive of injury to spinal cord?
1. ) SSEPs = dorsal sensory column; MEPs = lateral and ventral motor tracts
2. ) SSEP = stimulation of UE or LE -> record transcranial leads (afferent arrives at CNS); MEPs = stimulate motor cortex -> muscle in UE or LE contract (efferent exits the CNS)
3. ) MEPs effected by anesthesia
4. ) SSEP = 50% decrease in amplitude or 10% increase in latency; MEP = 75% decrease in amplitude sustained
5. ) MEPs
116
What are the 4 main nerves that can be injured in anterior approach to C-spine?
Where are they each located/what puts them at risk/what is deficit?
1. ) Superior laryngeal nerve - think about in high cervical surgery (C2-4). Needed for high note phonation
2. ) Recurrent laryngeal nerve - more predictable on the left due to aortic arch (crosses from lateral to medial earlier out of surgical field). Found in tracheoesophageal interval. Injury gives vocal cord paralysis on side of injury = hoarseness
3. ) Sympathetic chain - lateral to longus coli muscle. Injury will cause Horner's Syndrome
4. ) Hypoglossal nerve injury - typically occurs during C2/3 surgery; tongue deviation to side of injury
117
What is the greater occipital nerve and where is it located?
| What dz is a/w compression of this nerve?
C2 nerve root, exits above C2 and lies posterior to C1/2 joint - gives sensation to upper posterior neck and back of head.
Can see compression in RA
118
What structures are at risk during bone graft harvest:
1. ) Anterior pelvis
2. ) Posterior pelvis
1. ) LFCN = anterolateral thigh numbness
| 2. ) Superior cluneal nerve = buttock numbness
119
1. ) Where is the bifurcation of the aorta?
| 2. ) What structures lies just inferior to the bifurcation? What happens if this structure is injured?
1. ) L4/5 disc space
| 2. ) (Superior) Hypogastric plexus -> sympathetic innervation (Shoot!); w/ injury get retrograde ejaculation
120
1. ) Where does the Genitofemoral nerve lay?
| 2. ) Where does the sympathetic chain lay in the abdomen?
1. ) Anterior medial surface of psoas muscle
| 2. ) Medial to psoas running along the vertebral bodies -> injury will cause loss of sweating of leg
121
What level is the Iliolumbar vein located at ?
L5
122
What tumors tend to be located in posterior elements of the spine (3)?
Osteoid Osteoma
Osteoblastoma
ABC
123
In a patient w/ AS who has neck pain from minimal/no trauma, what should you think of?
Fracture - get XRs but also need CT so that you don't miss it! (they are so osteopenic!)
