Spine (2008-2019)

Question 1

1. 4 features of Brown-Sequard Syndrome (2010, 2012)

Answer 1

• Ipsilateral voluntary motor loss
• Unilateral UMN findings
• Ipsilateral vibration loss
• Contra-lateral pain/temperature loss

Question 2

2. List 3 features of central cord syndrome. (2011, 2014)

Answer 2

JAAOS 2009 - Central Cord

• Upper extremities are more severely affected than lower
• Distal more than Proximal
• Sacral Sparing
• Bowel and bladder only in severe cases

Question 3

3. List 3 factors that would help you diagnose an incomplete spinal cord injury? (2015)

Answer 3

JAAOS - Thoracolumbar Spine Trauma: I. Evaluation and Classification

• Sensory function below the level of the injury
• Voluntary motor control below the level of the injury
• Sacral Sparing

Question 4

4. List 3 examination features suggestive of sacral sparing. (2013)

Answer 4

From ASIA worksheet:

• Presence of intact perianal sensation (light touch and pin prick)
• Presence of voluntary anal sphincter contraction
• Presence of deep anal sensation (to deep pressure) on digital rectal exam

Question 5

5. Formula for pelvic incidence (2012)

Answer 5

• Pelvic incidence = pelvic tilt + sacral slope

Question 6

6. ASIA score question. List the 11 myotomes and corresponding muscle groups. (Variations - 2011, 2012, 2013, 2014, 2016)

Answer 6

Question 7

7. 3 ways to do posterior C1-2 fusion (2012)

Answer 7

• Trans-articular Screws (Magerl)
• Sub-laminar wires
• Lateral Mass Screw Fixation

 

Question 8

8. What are two important considerations to take into account for placing C1-C2 trans-articular screws. (2011)

Answer 8

JAAOS - Posterior fixation of the cervical spine

• Location of vertebral artery
• Avoid Bicortical Screws because:
  
  • Location of internal carotid (anteromedial)
  • Hypoglossal nerve
• Limitations in head position/body habitus
  
  • Maintain reduction, severe thoracic kyphosis, ability to get trajectory
• Hypoplastic C2 pars (variable individual anatomy)
• Reducible C1-C2 articulation

Question 9

9. List 3 spine conditions that enhance with gadolinium enhanced MRI (2012, 2013, 2014)

Answer 9

JAAOS - MRI in the Spine

• Scar tissue enhances (including granulation tissue, i.e. TB)
• Infection
• Tumors
• ** Chronic disks are dark.

Question 10

Rubrospinal tracts in the spinal cord carry: (these were long answers; look up your spinal cord anatomy.)

1. Autonomic
2. Voluntary Motor Control – corticospinal tract
3. Flexor Muscles - rubrospinal
4. Loss of muscle tone and involuntary muscle movements. - spinocerebellar
5. Sexual Function - autonomic

Answer 10

ANSWER: C

2013 

Question 11

11.All of the following regarding spinal tracts true except:

1. Anterior corticospinal tracts carry less motor than lateral corticospinal tracts
2. Lateral corticospinal tracts are called pyramidal tracts
3. Lateral corticospinal tracts arranged so that cervical spine is more central than sacral spine
4. Posterior sensation tracts arranged so that the cervical spine ascending tracts are more central than sacral spine

Answer 11

ANSWER: D

2010, 2013, 2015 (variants)

Question 12

12.A patient sustains a gunshot wound to the right side of the neck. He develops a Brown-Sequard syndrome. Which of the following is true regarding his neurologic deficits?

1. Loss of motor function to right upper and lower extremities, ipsilateral loss of pain and temperature
2. Loss of motor function to right upper and lower extremities, contralateral loss of vibration and position sense
3. Loss of motor function to right upper and lower extremities, contralateral loss of pain and temperature sensation
4. Loss of motor function to right upper and lower extremities, contralateral loss of pain and vibration

Answer 12

 ANSWER: C

2014, 2015

Question 13

13.Given a sagittal MRI showing cervical stenosis and myelomalacia. Patient had fall and presents with neck pain. No neuro deficits described. What is the most likely physical exam finding

1. UE > LE weakness, distal > proximal
2. LE > UE weakness, distal > proximal
3. UE > LE weakness, proximal > distal
4. LE > UE weakness, proximal > distal

Answer 13

ANSWER: A

2008, 2015

JAAOS 2009 - Central Cord Syndrome

• Upper extremities affected more than lower extremities
• Hands most affected
• Urinary retention, bowel and sexual dysfunction in most severe cases

Question 14

14.Injury to what causes of retrograde ejaculation

1. Inferior hypergastic plexus
2. Superior hypogastric plexus
3. Inferior hypogastric plexus
4. Superior hypergastric plexus

Answer 14

ANSWER - B

2009, 2013,  2014

Retrograde Ejaculation After Anterior Lumbar Interbody Fusion: Transperitoneal Versus Retroperitoneal Exposure. Sasso, Burkus and LeHuec. Spine. 2003

• Damage to the superior hypogastric plexus during exposure of the anterior lumbosacral spine can denervate this bladder neck sphincter, resulting in retrograde ejaculation.

Question 15

15.Regarding anterior approach to T-spine, which is false?

1. Aorta blocks visualization of high to mid-T-spine on left
2. liver blocks visualization of lower T-spine on right
3. Resect T11 rib head to access T11-12 disc space – rib head 11 = T10/11
4. Resect a rib 1-2 levels above the area of interest during approach

Answer 15

ANSWER - C

2010, 2014

• Anterior Transthoracic thoracic spine approach– resect rib 2 levels above (see pic)
• Anterior Transabdominal thoracic spine – resent T10 rib for approach
• Combo AO, JAAOS, hoppenfelds
• Right sided for T2-T9 (aorta and heart on left)
• Left sided for T10-L2 avoids liver on right

Question 16

16.Regarding the anterior approach to the cervical spine, all of the following are true EXCEPT?

1. Omohyoid transection improves access to the lower C spine
2. The parasympathetic trunk is at risk
3. Sub-platysmal fascial dissection improves exposure
4. The recurrent laryngeal nerve runs in the tracheoesophageal groove

Answer 16

ANSWER - B 

2014

• OKU Spine 4
  
  • Course of recurrent laryngeal nerve
  • Branch of the vagus nerve
  • Right –> arises anterior to subclavian artery, curves behing it, ascends to side of trachea
  • Left –> loops under arch of aorta
  • At C7 the nerve lies deep within the esophagotracheal groove on the left, but anterior and lateral to it on the right
• Operative Techniques - Anterior approach to the cervical spine (p4507-4510)
  
  • “blunt dissection with scissors undermines the edges of the platysma
  • Allows for greater mobilization of the soft tissues, which is helpful in accessing the multiple disc levels
  • Dividing the omohyoid will allow for a more extensile cephalad-cuadal exposures and less tehnsion on the wound for easier placement of plates and screws

Question 17

17.Contents of the carotid sheath include the carotid artery, internal jugular vein, and what other structure?

1. Vagus nerve
2. phrenic nerve
3. Vagus and phrenic nerve
4. Vagus and sympathetic

Answer 17

ANSWER: A

2011

Hoppenfeld:

• The carotid sheath enclosing the common carotid artery, vein and vagus nerve can now be exposed

Question 18

18.How do you calculate the Power’s ratio where B=basion, A=anterior arch of atlas, O=opisthion, C=posterior arch of atlas

1. BA/CO
2. BC/AO
3. AC/BO
4. AB/CO

Answer 18

ANSWER: B

2013, 2016

Question 19

19. Can do PLIF/TLIF in all of the following except
20. Pseudoarthoris
21. Spondylolisthesis
22. Infection

Answer 19

ANSWER: C

2012

JAAOS 2008 - Posterior Lumbar Interbody Fusion

Question 20

20. All of the following associations are right except? REPEAT
21. Foot Dorsiflexion - L4
22. Sensation over patella L2
23. Hamstring reflex L5-S1
24. Hip abductors – L5

Answer 20

ANSWER: B

2012

• L3 provides sensation over patella

Question 21

21. Which of the following is associated with an increased risk of complications with halo treatment?
22. Re-tightening the screws at an appropriate interval
23. Placing the ring 2cm above the pinna
24. Placing the ring closer to the skull
25. Using 6 pins instead of 4

Answer 21

ANSWER: B

2011, 2014

JAAOS - The Halo Fixator

• More lateral pin insertion risks penetration of the thin temporal bone.
• More medial positioning risks injury to the supraorbital and supra- trochlear nerves.

Question 22

22. Spinal Associations; all of the following are true except
23. Isthmic Spondylolisthesis and spina bifida occulta
24. Isthmic Spondylolisthesis and pars abnormality
25. Folate and Neural Tube defects (worded exactly like this)
26. Degenerative spondylolisthesis and spondylosis

Answer 22

Answer: D

Miller’s 8th edition:

• A: Spina bifida occulta, thoracic hyperkyphosis and cheuermann disease have been associated with spondylolisthesis
• B: basically the definition of isthmic spondy
• Neural tube defect dx in utero with increased level of alpha-fetoprotein
• Related to folate deficiency in utero

Question 23

23. With regards to proteoglycans, all of the following are true except
24. Proteoglycans are hydrophilic
25. Proteoglycans are hydrophobic
26. Proteoglycans are sulfated
27. Proteoglycans are bound to a protein core

Answer 23

ANSWER: B

2012

AAOS Core Review 2:

• Proteoglycans can trap water in the ECM by their negative charge, regulating matrix hydration

Question 24

24. During the posterior approach to the spine, the thecal sac can be retracted?
25. Above the level of the conus
26. Below the level of the conus
27. Below T12
28. Never

Answer 24

ANSWER: B

2014

Question 25

25. All of the following are correct landmarks for inserting an L3 pedicle screw EXCEPT? 1. Inferolateral aspect of L2-3 facet joint 2. Inferolateral aspect of L3-4 facet joint 3. Junction of the middle third of transverse process and a line through the center of the facet joint 4. Junction of the middle third of transverse process and a line through the mammillary process and pars

Answer 25

ANSWER: B (old answer C) 2014 * B would be an L4 pedicle screw * AO Surgical Reference - Pedicle Screws * "the entry point of the pedicle screw is defined as the confluence of any of the four lines" * Pars interarticularis * Mammillary process * Lateral border of the superior articular facet * Mid transverse process

Question 26

26. Patient with complete spinal cord injury; C7 spinal level. What is most likely to still be working? 1. Wrist flexion, finger flexion, brachioradialis reflex, radial sensation 2. Wrist flexion, finger extension, triceps reflex, absent medial forearm sensation 3. Wrist extension, finger abduction, biceps reflex, medial forearm sensation 4. Wrist extension, finger flexion, triceps reflex, radial sensation

Answer 26

ANSWER: B 2015 * MABCN emerges from medial cord C8-T1 * Wrist Flexion (C7), Wrist Extension (C7) * BR reflex (C6), triceps reflex (C7), Biceps reflex (C5) * Radial nerve – C5-T1 * C8 – Finger flexion

Question 27

27. Benefit to cross-links in spine instrumentation: 1. Increased resistance to flexion/extension 2. Increased resistance to lateral bend 3. Increased resistance to torsion 4. Increased fusion rate

Answer 27

ANSWER: C 2011, 2015 * Brodke (Spine 2001) Segmental Pedicle Screw Fixation or Cross-Links in Multilevel Lumbar Constructs: A Biomechanical Analysis * "There were no significant changes in flexion/extension stiffness with the addition of either the cross-links or segmental pedicle screws. In Lateral bending, although no significant difference was measureable because of the cross-links…" * "There was a **progressive increase in torsional stiffness** of three-level constructs with one and two cross-links"

Question 28

28. All of the following are associated with spinopelvic alignment, except: 1. Isthmic spondylolisthesis is associated with decreased pelvic incidence 2. Pelvic tilt does not change with position 3. Pelvic incidence is a constant variable that does not change after skeletal maturity

Answer 28

ANSWER: A 2015 JAAOS 2009 Adult Isthmic Spondy/OKU Spine 4 * Pelvic Incidence --\> correlated with HIGH PI * Hanson (Spine 1976) * “pelvic incidence \>68.5o correlates strongly with the degree of slip * Huber L (Spine 2004) * PI is significantly greater in subjects with spondylolisthesis * Severity of listhesis correlates with PI

Question 29

29. What is not associated with cervicomedullary syndrome: 1. Hypotension 2. Facial numbness 3. LE \> UE symptoms 4. Complete or incomplete paralysis is possible

Answer 29

ANSWER: C 2015 * The Cervical Spine (p. 188) * The essential clinical features are respiratory insufficiency or arrest, hypotension, varying degrees of tetraparesis, sensory changes from C1-C4 and sensory loss over the face in the onion skin or Dejerine pattern * The spinal trigeminal nucleus (STN) is the longest cranial nerve nucleus, extending caudally from the medulla to the upper cervical segment of the spinal cord.1–3) The STN has somatotopic arrangement, the central area represented rostrally, and the lateral face caudally.1–3) Therefore, upper cervical lesion has a potential to cause dysesthesia of face sparing the central area, which is called onion-skin pattern.1–3) * Arm \> Leg weakness * More severe involvement the more rostral the injury

Question 30

30. Regarding MRI with gadolinium, all of the following are TRUE except? a. Epidural abscess rim enhances b. Discitis enhances on T2 c. Epidural fibrosis does not enhance d. Recurrent disc material does not enhance

Answer 30

ANSWER: C 2008, 2010, 2015 (variants) JAAOS 2009 - MRI of the Spine * "Contrast enhancement is used to distinguish scar tissue, which enhances on MRI scans, from fragments of disk tissue in the epidural space that, lacking capillaries, do not enhance"

Question 31

31. There is a patient that sustained a fall and now has radicular arm pain and neck pain. Given an xray showing 25% vertebral body translation indicative of a C4/5 unilateral jumped facet. What would you find on physical exam? 1. Supraclavicular numbness 2. Weakness of elbow flexion with lateral shoulder numbness 3. Supraclavicular numbness + something else 4. Hand weakness

Answer 31

ANSWER: B 2016 * C5 radiculopathy --\> ASIA Score * Unilateral jumped facets present with unilateral radiculopathy, corresponds to lower level (because that is the level where the nerve root is exiting; C5 root exists straight out at C4/5)

Question 32

32. Regarding spinal infection, all true, EXCEPT:  1. CRP and ESR decreasing are effective signs that medical management is working 2. Most have an elevated WBC 3. Greater than half are staph aureus

Answer 32

ANSWER: B 2016 * Carraggee (JBJS 1997) Pyogenic Vertebral Osteomyelitis * CRP and ESR are almost always elevated * Leukocytosis in \< 45%

Question 33

33. Where to put screws in occiput for strongest construct 1. Midline because of thickest bone 2. Inferior to nucchal line 3. Laterally 4. Medially and laterally  

Answer 33

ANSWER: A 2008 * JAAOS 2011 - Posterior fixation of the upper cervical spine * Occipital plate can be applied midline, where the thick midline keel provides the greatest resistance to pullout * Lateral fixation may be better to resist lateral bending, while midline fixation is better suited to resist axial rotation * Thickest occipital portion is midline on the superior nuchal line * At external occipital protuberance * Screws are inserted below the superior nuchal line to avoid intracranial venous sinus

Question 34

34. Which would not alter your approach for a C-spine myelopathic patient 1. Previous incision 2. Sagittal alignment 3. Location of compression 4. Presence of radiculopathy

Answer 34

ANSWER: D 2008 * Previous incision important with ACDF * Cannot do posterior only approach if spine is kyphotic * Ideally like to approach from the side of the compression

Question 35

35. Size of lumbar central canal is largest in which position 1. Flexion 2. Extension 3. Supine 4. Standing

Answer 35

ANSWER: A 2008, 2010

Question 36

36. Use of stiffer instrumentation for spinal fusion results in which of the following in the fusion mass: 1. lower modulus of elasticity 2. decreased volume density of bone 3. lower load to failure 4. increased vascularity 5. higher pseudarthrosis rate

Answer 36

ANSWER: D 2008 Yasumitsu - Vascularization of the Fusion Mass in a Posterolateral Intertransverse Process Fusion - Spine 1998 * Rigid Posterior Spinal Instrumentation * - More rigid constructs allow for a Stronger Fusion Mass to Form * - There is a risk of stress shielding with more Rigid constructs = Stress shielding of Peri-Fusion Mass bones * - Bone Mineral density is HIGH at the fusion mass level, but decreases with increasing distance from fusion level * - Fusion mass is vascularized with more stability

Question 37

37. Which of the following structures contain free nerve endings: 1. PLL, Annulus, Facet joint capsule 2. Joint capsule, Annulus 3. Annulus fibrosis and Nucleus pulposis 4. Annulus, Nucleus, PLL, joint capsule

Answer 37

ANSWER: A 2008 * Annulus does not have nerve fibres, but if degenerative it gets them * Jackson (JBJS 1966) * Pacini endings concentrated around facet joint capsules and ventrolateral surface of the annlus fibrosus, free nerve endings found in the ALL and PLL, **none found in nucleus pulposis**

Question 38

38. List 4 dysplastic features in a developmental spondylolisthesis that predicts the risk for progression. (2013)

Answer 38

JAAOS 2006 - Spondylolisthesis in Children and Adolescents * Dysplastic Features predictive of getting spondy: * Maloriented or hypoplastic facets * Sacral deficiency * Poorly developed pars * Risk factors for progressive slip once you have it: * Dysplastic vs isthmic spondylolisthesis (32 vs 4%) * Diagnosis before growth spurt * Girls * Presentation with \>50% slip * Bilateral defects * Slip angle \>50o