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Flashcards in Spine Deck (367):
1

Safe zone for occipital screw placement

 

Triangular region created by connecting 2 dots 2cm lateral to the external occipital protuberance, and a point 2 cm inferior to it

Point B on the pictures

2

Slip angle greater than what degree is associated with greater risk of progression?

>50 degrees

3

6 things to do if a neuro alert during scoliosis surgery

  1. check equipment
  2. check blood pressure >90mmHg
  3. check Hgb
  4. reverse or lessen correction
  5. wake up test
  6. remove implants if spine stable

4

Risks of postoperative spinal infection

Longer OR time

Immunocompromised state

Increased blood loss (decreases circulating Abx)

Poor nutritional status

Obesity (BMI >35kg/m^2)

Use of instrumentation or OR microscope

Prior spinal surgery or local radiation

Longer constructs or more extensive procedures

Tobacco or alcohol use

Multiple trauma

5

Anklylosing spondylitis trauma

What must you do?

CT scan of spine

Often skip fractures

6

Fieldig Classification of AARD

Type I:

Unilateral facet subluxation with intact transverse ligament

Type II:

Unilateral facet subluxation with 3-5mm of anterior displacement (injured TL)

Type III:

Bilateral anterior facet displacement of >5mm

High risk of neuro compromise

Type IV:

Posterior displacement of Atlas (C1)

7

Safe zone for halo application (anterior pins)?

Lateral 1/3 of eyebrow, below the equator (site D in figure)

Avoids supraorbital and supratrochlear nerves

8

In facet dislocation, what must you do after successful reduction and why?

MRI - to look for disc herniation

9

What age does the secondary ossification center of the dens fuse with the rest of C2?

~12 years

10

Normal range of kyphosis in mid-thorcic spine (T5-12)

20-50 degrees

11

Power's Ratio

Basion to posterior arch/Opisthion to anterior arch

Normal is 1

Abnormal: occipito-atlantal instability

12

Three types of Diastematomyelia?

1. boney

2. fibrous

3. cartilaginous

13

Why do you have to use a paediatric spinal board for paediatrics?  What age do you have to use it until?

To compensate for large head

Paediatric boards have an occipital cutout to compensate for this

Use until 8 years

14

Name 6 surgical options for degenerative spondy:

Laminoplasty

Laminectomy no fusion

Laminectomy UNinstrumented fusion

Laminectomy + instrumented fusion

(all of the above ± PLIF/ALIF/TLIF)

Dynamic stabilization (see pic)

Lumbar interspinous spacers (prevents extension)

 

15

Treatment algorithm for AARD

Acute

  • Soft collar, anti-inflammatories, exercise program

Acute >1 week

  • Head halter traction and bracing

Subluxation > 1month

  • halo traction and bracing

Subluation > 3 months, late diagnosis or neuro deficits

  • Posterior C1-2 fusion

16

If a patient presents with a cervical rotational deformity what injury should you think of?

Unilateral facet dislocation

17

Disc herniations at the following levels with affect which nerve root?

1.C2-C3
2.C7-T1
3.T4-T5
4.L2-L3
5.L5-S1 

 

 

1 - C3
2 - C8
3 - T4
4 - L3
5 - S1

18

Interpret:

 

a) ADI < 3 mm

b) ADI between 3 and 5 mm

c) ADI > 5 mm

 

 

a) Normal

b) Transverse Ligament Rupture

c) Transverse Ligament and Alar Ligaments Ruptured

19

Most common locations for pseudoarthrosis in adult spinal deformity?

L5-S1

Thoracolumbar junction

(so any junctional area)

20

 

Why is discography not so good?

 

It causes accelerated disc degeneration and loss of height.

21

What are the components of TLICS and what score means surgery?

  1. Morphology
  2. Neurologic injury
  3. Status of PLC

 

5 or more get OR

22

 

What type of vertebral malformation is most likely to cause a progressive congenital scoliosis?

 

Unsegmented bar with a contralateral hemivertebrae

 

Tx. is PSIF with resection of vertebrea

23

Components of PLC?

Supraspinous ligament

Interspinous ligament

Facet capsule

Ligamentum flavum

24

Complications of vertebroplasty/kyphoplasty

Cement extravasation

Cement Embolism

new fracture

neurologic compromise

25

How to improve outcomes (arthrodesis) in fusion for spondy?

Pedicle screws

Interbody fusion

Non-smokers (major risk for pseudoarthrosis)

26

 

Rate of tandem stenosis for patients with lumbar or cervical stenosis?

 

20%, so image other area if symptoms aren't clear

27

5 conditions resulting in Atlanto Axial Instability?

  1. Downs
  2. RA
  3. Dens Fracture
  4. Atlas Fracture
  5. Transverse Ligament Rupture

28

Outcomes of SPORT trial with respect to degenerative scoli

Surgical intervention > non surgical at 2 years and 4 years

No difference in surgical method used

Patients with predominantly leg pain did the best

29

Pelvic incidence

Pelvic tilt

Sacral slope

Which are position dependent?

Pelvic tilt and sacral slope are position dependent

pelvic incidence does not change after skeletal maturity

30

 

What is abnormal structure in congenital muscular torticullis?

 

Tight SCM

31

 

Most common nerve injury with myelopathy decompression?

 

C5 palst

 

Treatment is observation

32

 

With OPLL and myelopathy, what guides your choice of appraoch?

 

1) If kyphotic = Have to go ANTERIOR and do corpectomy/OPLL resection

**** Risk of dural tear

 

2) If lordotic = Can go posterior and do laminoplasty or laminectomy/fusion without OPLL resection

33

Risk factors for pseudoarthrosis of anterior single rod technique
 

Smoking

Weight >70kg

Thoracic hyperkyphosis >40 degrees

34

Risks of Low back pain

Obesity

Smoker

Male

Lifting

Vibration

Prolonged Sitting

Job dissatisfaction

35

 

Two surgical options for a curve > 50 in a Juvenile patient?

 

  1. Growing rods, VEPTR
  2. Anterior and Posterior fusion (have to do both sides to avoid crankshaft phenomenon)

36

Physical exam findings of diastematomyelia:

 

a) 4 local findings

 

b) 5 associated conditions

  1. hairy patch
  2. skin dimple
  3. Subcutaneous mass
  4. teratoma

 

  1. scoliosis
  2. tethered cord
  3. cavus foot
  4. claw toes
  5. clubfoot

37

Describe Chamberlains line

Line from dorsal margin of hard palate->posterior edge of the foramen magnum

abnormal if tip of dens > 5 mm proximal Chamberlain's line

normal distance from tip of dens to basion of occiput is 4-5 mm

this line is often hard to visualize on standard radiographs

38

 

What is the success rate of nerve root injections for lumbar herniations?

 

50%

39

Describe peltic tilt:

Angle formed between

1. Line parallel to side of radiograph

2. Line from center of femoral head to the center of the S1 endplate

40

Isthmic spondy (and spondy in general) is associated with what change in pelvic incidence?

Increased

THINK: higher incidence allows it to slip easier

41

indications for hemivertebrectomy

  • Hemivertebrae (failure of formation) with progressive curve causing truncal imbalance and oblique takeoff
  • Patients less than 4-5 years
  • Curve less than 40 degrees

42

Main finding of:

Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. - Wood 2003

 

Operative treatment of patients with a stable thoracolumbar burst fracture and normal findings on the neurological examination provided no major long-term advantage compared with nonoperative treatment.

43

Which of the following shows increased production when adisc herniates?

  • osteoprotegrin (OPG)
  • interleukin-1 beta
  • receptor activator of nuclear factor-kB ligand (RANKL)
  • parathyroid hormone (PTH)

All of them.

44

 

5 spinal conditions that can result in Juvenile Scoliosis?

 

  1. syringomyelia
  2. arnold-chiari
  3. tethered cord
  4. spinal dysraphism
  5. tumor

45

 

What percentage of Juvenile Scoliosis patients have an abnormal MRI?

 

18-25%

46

Define Sacral slope

Angle formed between:

1. horizontal line parallel to the bottom of radiograph

2. Line parallel to the S1 endplate

47

Name 6 syndromes/diseases assocated with basilar invagination

Klippel-Feil

Osteogenesis imperfecta

Morquio syndrome

achondroplasia

spondyloepiphyseal dysplasia

occipitocervical synostosis

48

Describe cervicomedullary angle

Angle formed between:

line along ventral surface of medulla

line along upper cervical cord

less than 135 suggests impending neurologic compromise

 

49

What is the relationship between:

  1. sacral slope
  2. pelvic incidence
  3. pelvic tilt

pelvic incidence = pelvic tilt + sacral slope

50

Outcomes of SPORT trial regarding herniated nucleus pulposus?

Surgical intervnetion > nonoperative,

although both groups did well

51

Define instability on flexion-extension x-rays as it pertains to lumbar spine spondy

4mm of translation or 10 degrees of angulation of motion compared with adjacent motion segment

52

When do the basilar synchondrosis and secondary ossification centers fuse?

Basilar synchondrosis: age 6

Secondary ossification center: appears at 3, fuses at age 12

53

2 deformities associated with Klippel Feil?

1. Scoliosis

2. Sprengels

54

6 presenting symptoms in patients with DISH

Dysphagis and stridor

Hoarseness

Sleep apnea

Difficulty with intubation

Cervical myelopathy

Spinal Fracture

55

What is defined as instability on flex-ex radiographs?

Instability: >3.5mm of motion between flexion and extension views

56

 

Two common complications following Postero Decompression and instrumented fusion for degenerative spondylolisthesis?

 

1. Pseudoarthrosis (5-30%)

 

2. Adjacent level disease (2.5% per year)

57

4 clinical findings associated wiht Scheuermann's

Hyperlordosis

Spondylolsis

Scoliosis

Pulmonary compromise in curves >100 degrees

58

 

For revision anterior cervical approach with previon RLN injury what do you do?

 

Go from the same side to avoid bilateral injury

59

Technique for posterior reduction of facet dislocations?

1. Can only do after disc is dealt with if present

 

2. Can burr tops of superior facets

 

3. Put lateral mass screws in and then use these to reduce

 

4. Fuse one level above and below

60

Scheuermann's kyphosis.

What's the outcome of non-op curves (by size)

 

>75 degrees: severe pain that affects ADLs

61

What percentage of RA patients have atlantoaxial instability?

50-80%

SO CHECK FOR IT - especially in oral exam

62

Indications & Contraindications for vertebroplasty/kyphoplasty

See pic

New studies show that it may be beneficial, at least in the short term, for vertebral compression fractures

63

Injury to what nerve structure causes retrograde ejaculation?

Superior hypogastric plexus

(retroperitoneal approach to spine)

64

What disorder causes a passively correctable chin-on-chest deformity?

Dropped head syndrome

vs. AS (non-correctable chin on chest)

Caused by cervical paraspinal weakness

65

 

What is more likely to present with dysphagia: OPLL, DISH or Ank Spon?

 

DISH

66

4 dangers of Smith-Robinson Anterior approach to C-spine

Recurrent laryngeal nerve

Sympathetic chain

Carotid sheath

Post-operative hematoma

67

 

Best phase on MRI to look for foraminal stenosis and what to look for?

 

T2

 

Look for loss of perineural fat

68

 

What is the treatment for low grade isthmic spondylolistheis that is painful and fails 6 months of physio?

 

12 weeks of TLSO

69

Hypoglossal (CN 12) injury during ACDF - tongues deviates which way?

towards side of injury

70

Indications for MRI in scoliosis workup (7)

Atypical curve pattern (left thoracic curve, short angular curve, apical kyphosis) 

Signs of syndromic or neural axis pathology

  • Cavus feet
  • Signs of dysraphism
  • Asymmetric abdominal reflexes
  • neurologic symptoms or pain
  • Signs of Marfan's/Down's/Lysosomal storage disease

Rapid progression

Excessive kyphosis

Structural abnormalities

Child 20 degrees

All patients with congenital scoliosis

71

Collagen type in nucleus pulposus

Type II

It's like articular cartilage

72

What is a Hangman's fracture?

Traumatic anterior spondylolisthesis due to bilateral fracture of pars interarticularis

73

Halo application principles in adults (location, pins, tightness)

4 pins

  • 2 anterior pins over lateral 1/3 of eyebrow below equator
  • 2 posterior pins opposite of anterior ones

8 inch pounds of torque

74

Best treatment of this fracture?

Fracture separation of lateral mass

2 level posterior spinal instrumented fusion (PSIF)

75

 

If a patient has a hypoglossal nerve injury after anterior approach, what side will their tongue deviate towards?

 

Towards the affected side

76

4 complications with lumbar disc herniation surgery

Dural tear

Recurrent HNP

Discitis

Vascular catastrophy

77

What is the most common neurologic finding after cervical laminoplasty?

C5 palsy

NOT recurrent laryngel nerve palsy: you're not going anterior for a laminoplasty

78

What is the treatment for syringomyelia?

1. Cevical dempression without fusion initially once it becomes symptomatic

 

2. Instrumented fusion 3-6 months later

79

In adults, what is the first line of treatment in spondylolysis with no neuro symptoms?

Observe

80

Difference between Type 2 and Type 2A Levine/Edwards?

Levine/Edwards is Hangman's fractures

2 = > 3mm displacement, disc is compromised

Treat with traction then Halo vest.

 

2 A --> Horizontal fracture

NO TRACTION

Reduce with extension then Halo vest.

81

C-spine myelopathy.  Indications for anterior only, posterior only and anterior + posterior decompression ± fusion

Name 1 absolute contraindication to posterior only decompression

Anterior only (ACDF): gold standard for 1-2 level disease

Posterior only: <13 degrees kyphosis

  • Some say <10 degrees but definitely <13 degrees

Anterior + Posterior: rigid kyphosis >10 degrees and multilevel disease (>2 levels)

Kyphosis >13 degrees is an absolute contraindication to any posteriorly only decompression

 

82

Changes during normal aging of IV discs

Changes are like that of articular cartilage

Decrease in:

  • Collagen II (changes to fibrocartilage)
  • nutritional support
  • water content
  • Absolute number of cells
  • Proteoglycans
  • pH

Increase in:

  • Collagen I
  • Keratin sulfate : chondroitin sulfate ratio
  • Lactate
  • Degradative enzyme activity

No change in:

absolute quantity of collagen

83

Subaxial insatbility is present in what percent of RA patients?

20%

84

 

How long do you have to culture acid fast bacili?

 

Up to 10 weeks

85

Do osteoblastoma respond to NSAIDs?

No

86

When do you brace in scoliosis for:

Congenital

Infantile

Juvenile

AIS

Congenital:

May brace supple compensatory curves

Infantile:

Cobb >20 (consider, but many resolve spontaneously)

Cobb >30 for sure

Juvenile:

Cobb >20

Adoelscent:

Cobb >25

87

Findings associated with Scheuermann's kyphosis

Anterior wedging across 3 consecutive vertebra

Disc narrowing

Endplate irregularities

Schmorl's nodes

  • Herniation of disc into vertebral endplate

Scoliosis

Compensatory hyperlordosis

Important to look for spondylylysis

88

What level does the aorta bifurcate?

L4

89

4 differences between DISH & AS spine

DISH:

right thoracic often in isolation (protective pulsatile aorta)

nonmarginal osteophytes

preservation of disc space

Flowing candle wax (vs. squared off bamboo spine of AS)

Non HLA-B27 association

 

90

 

What shoulde you rule out with muscualr torticullis with no palpable SCM mass?

 

Klippel feil

AARD (atlanto-axial rotatory deformity)

91

3 Indications for PLIF in spondylolisthesis

Severe slip

Neurologic compromise

Saggital imbalance

92

Name 5 mimickers of lumbar radiculopathy

93

Major technical factor in improving fusion rates in posterior spinal fusion?

pedicle screws

94

 

Differential for myelopathy? (5)

 

  1. Stroke
  2. B12 deficiency
  3. Movement disorder
  4. ALS
  5. MS

95

What type of sub-cervical spinal trauma almost always gets posterior instrumented fusion 2 levels in each direction?

Thoracolumbar Fracture Dislocation

 

Commonly occurs at junction (T10-L2)

96

What cobb angles will puts the patient at risk of cardiopulmonary decline and mortality?

Cardiopulmonary decline:

Thoracic curves >60 degrees affect pulmonary function tests

Thoracic curves >90 degrees affect mortality

97

 

What are three signs of segemental spinal instability (specifically lumbar)?

 

  1. Degenerative scoliosis
  2. Spondylolisthesis (degenerative or isthmic)
  3. Surgical over resection
    1. > 50% of either facter
    2. Complete laminectomy

98

4 risk factors for myelopathy in OPLL

>60% spinal canal stenosis

≤6 mm of space available for the cord

increased cervical range of motion

OPLL that is laterally deviated within the spinal canal

(JAAOS 2014)

99

Is bullet removal from spinal canal more likely to improve motor outcomes in incomplete injuries in T12-L4 or from T1-T11?

T12-L4

100

Most common type of spondylolysis/listhesis in adult?

Degenerative

101

Symptomatic acute osteoporotic spinal compression fracture (within 5 days).  name the medical treatment?

Calcitonin x 4 weeks

AAOS 2010 - moderate evidence for

102

 

Who gets OPLL?

 

ASIANS, Men

103

Radiographic definition of central stenosis:

Cross sectional area less than 100cm2

or

less than 10mm AP diameter on axial CT

 

104

Where is the most common site for isthmic spondy and where is the most common location that predisposes to progression?

L5-S1 most common

L4-5 will progress

105

In Brown-Seqard syndrome what deficit is there in the contralateral limb?

Spinothalamic - pain and temperature

106

Findings in anterior cord syndrome

lower extremity affected more than upper extremity

loss:

LCT (motor)

LST (pain, temperature)

preserved:

DC (proprioception, vibratory sense)

Worst prognosis

May mimic complete cord

107

 

Where does pseudosubluxation happen and how do you verify diagnosis?

 

1) C2 on C3

 

2) Swischuks line should be wihting 1.5 mm of C2 sp and the deformity should reduce on extension xray

108

 

What is important to look for on physical exam if considering deformity correction or THA on a patient with Ank Spon?

 

Hip flexion contractures

109

In C-spine immobilization of a paediatric patient, where do you want to keep the external auditory meatus?

Keep external auditory meatus inline with the shoulders

This puts them in a slight position of extension

110

 

True or false: All congential scoliosis from vertebral malformations is progressive

 

False.

 

Depends on etiology. Things like a single unsegmented hemi vertebrae is unlikley to progress.

 

Unsegmented bars almost always progress.

111

 

What other organs do you need to image before surgery on congenital scoliosis?

 

Heart and kidneys

112

In doing a laminectomy and fusion, what is the biggest risk of adjacent level change?

Laminectomy (no fusion) at the adjacent level

113

In AARD, which side will the patient's head be tilted and rotated to?

Ipsilateral rotation and contralateral tilt of the head in relation to the lateral mass of C1

 

Opposite of Torticollis

114

Best candidate for radiosurgery for spinal tumours?

Life expectancy > 1 months, b/c effects don't come on for 3-4 weeks

115

 

How does a well repaired dural tear affect outcomes after lumbar decompression?

 

No effect

116

What is rate of overall complications with adult spine deformity correction?

10-20%

117

Most common surgical technique resulting in pseudoarthrosis in adult spinal defomrity correction?

Posterior fusion only

I think they mean no instrumentation??

118

Cord syndrome prognosis from best to worst

Brown-sequare (best)

Central cord

Posterior cord

Anterior cord (Worst)

119

 

What condition is the Wiltse appraoch best used for?

 

Far lateral lumbar disc herniation

120

What do you call a bar that crosses the spinal cord and causes a cleft in the spinal cord?

Diastematomyelia

121

T/F: helmets increase risk of c-spine injury

False

They do not increase risk of c-spine injury

122

4 conditions that pre-dispose to traumatic cervical spine trauma

  1. DISH
  2. Ank Spon
  3. Previous Fusion
  4. Connective Tissue Disorders

123

What is the most imporant radiographic finding that may predict complete neural recovery post decomrpessive surgery for atlantoaxial instability?

PADI/SAC > 13mm

124

Anterior reduction technique of facet dislocation?

1. Can only do for a unilateral facet dislocation

2. Caspar pins in proximal and distal bodies

3. Rotate upper pin towards the dislocation

 

125

2 Treatment options for synovial facet cyst

Laminectomy & decompression

  • classically 1st line treatment but high recurrence rates

Facetectomy & instrmented fusion

  • Some now consider this first line

126

Most important factor when deciding treatment of Axis fracture?

Stability of Transverse Ligament

 

If it is ruptured then do either C1-C2 or Occ - C2 fusion

127

Harris Rule of 12: Describe

If either of:

Basion-Dens interval (BDI)

or

Basion posterior axia line interval (BAI)

>12mm, its a sign of occipito-atlanto instability/dislocation

128

 

What is radiologic definition of Scheurmans?

 

Anterior wedging of > 5 degrees accross 3 continuous vertebreas

129

 

Are results for revision lumbar discectomies worse, better or the same?

 

Equivalent

130

How do vertebral compression fractures affect mortality?

Increase it x2 to matched controls

Higher in men

higher with earlier age of fracture

However, improved with cement augmentation (kyphoplasty) by 2-7 years

(JAAOS 2014)

131

Functional level of the following spinal level injuries

C4

C5

C6

C7

C4 —> Electric wheelchair with head/chin controls
C5 —> electric wheelchair with hand control
C6 —> Manual wheelchair with sliding board
C7 —> Manual Wheelchair with independent transfers

132

 

What is the radiographic sign of an unstable degenerative spondylolisthesis?

 

> 4mm translation on flex/ex

133

Where do you find free nerve endings in the spinal unit?

PLL, annulus fibrosis, facet joint

NOT in the nucleus pulposus

134

Risks of pseudoarthrosis in adult spinal deformity correction (7)

Age >55

kyphosis >20 degrees

positive sagittal balance >5cm

hip arthritis

smoking

thoracoabdominal approach

incomplete lumbopelvic fixation

135

What reflex differentiates between intracranial and intraspinal lesions?

Jaw Jerk

If positive, then it's an intracranial cause of myelopathic symptoms

136

Name 2 radiographic indices that indicate poor outcomes in Spondylolisthesis

Increased lymbosacral kyphosis

Positive sagittal balance

(not really the same)

137

HOw do you avoid junctional kyphosis post-op Scheuermann's kyphosis?

Make proper selection of levels

Avoid overcorrection

limit to 50% of original curve

138

General indications for surgery in adult spinal deformity (6)

Curve > 50 degrees

Sagittal imbalance

Curve progression

Intractable back pain or radicular pain that has failed nonop

Cardiopulmonary decline:

Cosmesis (controversial)

139

What spinal lesion causes an occipital headache worse with valsalva?

Syringomyelia

140

What part of the spinal cord is least sensitive to radiation (ie for stereotactic radiosurgery)

Thoracic spine

(JAAOS 2014)

141

Describe TLICS

Max score: 10

>4 operate

4 = dealer's choice

142

Radiographic findings of Scheuermann's kyphosis

anterior wedging across three consecutive vertebrae 

disc narrowing

endplate irregularities

Schmorl's nodes (herniation of disc into vertebral endplate)

scoliosis  

compensatory hyperlordosis

important to look for spondylolysis on lumbar films

143

 

What are the parameters for a structural minor curve according to lenke?

 

> 25 degrees and do not bend out to less than 25 degrees with lateral bend

144

Patient placed in garder wells tongs and reduced with traction for jumped facets.  Patient develop nystagmus and other stroke like symptoms. 

What is the most likely cause?

Vertebrobasilar insufficiency

145

 

Rate of pseudo arthrosis in single elvel ACDF?

 

5-10%

 

 

146

45-year-old manual laborer presents to the office with acute onset back pain that radiates to his right leg after carrying a heavy object. He also has mild non-progressive weakness with ankle dorsiflexion on that side.  What should be his initial treatment

PT and NSAIDs should be first line

147

Most common cause of sudden death in RA spine?

Basilar invagination

148

Patient presents with pain and neuro symptoms.

Plan?

L4-S1 posterior instrumented fusion with anterior column support

149

What is an absolute contraindication to C1-2 transarticular screws?

Aberrent vertebral artery

150

Indications for surgery in Atlantoaxial instability: (3)

ADI >10mm (even if no neuro deficits)

SAC/PADI less than 14 (in RA)

Progressive myelopathy

151

Describe pedicle screw start points in T/L spine

T-spine

  • midpoint of Transverse process and lateral pars
  • (note: midpoint in height, but you can also follow the superior aspect down to get to the same point - see image)

Mid T spine

  • Junction of midpoint of transverse process and lateral 1/3 of superior articular process

Distal T

  • Junction of transverse process and lateral pars

Lumbar

  • Junction of midpoint of transverse process and 2mm lateral to pars (lateral aspect of facet joint / mamillary process / lateral pars)

152

 

Treatment for recurrant lyrangeal nerve injury with anterior approach?

 

Observe for 6 weeks, if no better consult ENT.

153

What is the best type of MRI to look for spondylodiskitis?

 

T1 with gad and fat suppression

 

154

How do you measure kyphosis at the C-spine level?

C2-7 kyphotic level

Local kyphotic level

155

Describe Meyerdeng classification

I: <25%

II: 25-50%

III: 50-75%

IV: 75-100%

V: spondyloptosis

156

Adult spondylolishtesis at L5-S1.  What is the nerve root that is involved?

L5

It affects the exiting nerve root as it causes foraminal stenosis

157

What is a hangman's fracture?

Bilateral fracture of pars of Axis allowing for anterolisthesis of C2 on C3

158

What are 5 indications for MRI in scoliosis?

  1. Abnormal curve (think Lenke)
  2. Neurologic deficit
  3. Infantile or Juvenile onset
  4. Male patient with large curve
  5. Thoracic kyphosis > 30 degrees

159

3 techniques for C1-2 fusion

C1 Lateral mass + C2 pedicle/pars/translaminar (Harms)

C1-2 Transarticular (Magerl)

Sublaminar wiring (Brooks, Gallie)

 

160

Describe McRae's line

defines the opening of the foramen magnum

the tip of the dens may protrude slightly above this line, but if the dens is below this line then impaction is not present

161

On x-ray, criteria for absolute and relative cervical stenosis:

Lateral xray:

Absolute: canal diameter less than 10mm

Relative: canal diameter 10-13mm

Normal canal diameter is 17mm

Torg-Pavlov ratio (canal:vertebral body width)

Normal is 1

Doesn't work for athletes

162

Halo application principles in paeds (location, pins, tightness, vest)

Generally: more pins, less torque

Pins

  • 6-8 pins
  • Anterior pins: must be lateral enough to avoid frontal sinuses, supratrochlear & supraorbital nerves
  • Posterior pins: anterior enough to avoid temporalis muscle

Torque

  • 2-4 inch pounds of torque, or "finger tight"

Brace

  • Less than 2 years: Minerva
  • >2 years: custom

±CT scan to:

  • avoid cranial sutures
  • avoid thin skull regions
  • limit complications

163

6 dangers in retroperitoneal approach to lumbar spine?

Sympathetic chain: lateral aspect of vertebral body

Genitofemoral nerve: anterior surface of psoas muscle attached to fascia

Segmental lumbar arteries & veins: Branches from aorta

Aorta: Bifurcates at L4

Ureter: lies between psoas fascia and peritoneum

Superior hypogastric plexus: Injury leads to retrograde ejaculation

164

Name as many syndromes/causes of dural ectasia (there are 9 on this list)

Dural ectasia: ballooning or widening of the dural sac which can result in posterior vertebral scalloping and is associated with herniation of nerve root sleeves

  • Marfan syndrome: dural ectasia has been observed in 60-90% of patients; in these patients, the dilatation of the dural sac is almost always in the lumbar region
  • neurofibromatosis type 1
  • Ehlers-Danlos syndrome
  • ankylosing spondylitis
  • osteogenesis imperfecta
  • trauma
  • post surgery
  • tumours
  • scoliosis

165

What is the natural history of OPLL

What percentage of patients get myelopathy

Most will get radiological progression of OPLL

Only half experience worsening clinical symptoms

166

 

Contraindications for RTS with cervical stenosis (3)

 

1) Loss of CSF around Cord or any cord deformity

 

2) Multiple episodes of transient quadraparesis

 

3) Bilateral symptoms

167

Most powerful LOCATION for an osteotomy in AS

Lumbar spine

168

What are the three ligaments of the C1-C2 ligamentous complaex?

Alar Ligaments

 

Apical Ligaments

 

Transverse Ligament

169

 

Three findings associated with Ankylosing Spondylitis?

 

  1. sacroiliitis
  2. uveitis
  3. HLA-B27 +

(Bamboo spine)

170

 

What do you need to look for on physical exam of a CP kid for consideration of scoliosis surgery?

 

hip or knee contractures

171

What is the most important thing to look for in physical exam for AAI?

Myelopathy

172

What is the name of the classification system of Spondylolysis? Describe it

Wiltse-Newman

I: dysplastic

II: Isthmic

  • a: pars fatigue
  • b: pars elongation due to multiple healed stress fracture
  • c: acute

III: degenerative: pars instability without a pars fracture

IV: traumatic

V: Neoplastic

173

Which side do you approach from when using retroperitoneal approach to spine? Why?

Left: Aorta is more resistant to injury

174

What finding on radiology suggests an occipital condyle is unstable?

Avulsion fractures of alar ligaments.

This is a type 3 injury.

Other types are stable and only need c-collar.

175

 

Three characteristics of a pathologic scoliosis curve?

 

  1. painful
  2. rigid
  3. less severe than other types of scoliosis

176

 

Who gets Charcot spine and how do you treat it?

 

Patients with a spinal cord injury (i.e. with neurologic damage)

 

It causes instability so the primary treatment is posterolateral instrumented fusion +/- TLIF at level of Charcot disk

177

Mortality rate of halo in patients aged >79?

21%

Avoid it in this population

178

What level of the Thoracic or Lumbar spine has smalles pedicle length and diameter?

T4

179

 

Name 7 reasons for obtaining an MRI with a patient who presents with scoliosis (older)?

  1. atypical curve
  2. rapid progression
  3. increased kyphosis
  4. structural abnormality
  5. neurologic symptoms or pain
  6. deformity of foot
  7. assymetric abdominal reflexes

180

4 techniques for pars repair

Screw

tension wiring

Screw + hooks

U rod

181

Risks of type II odontoid fracture nonunion: (8)

>6mm displacement

Posterior displacement >5mm

Further posterior displacement after application of a Halo vest >2mm

Angulation > 10 degrees

comminuted fracture

Fracture gap >1mm

Age >50

Delay in treatment >4 days

*Highest rate of nonunion comes from posteriorly displaced an angulated Type II fractures

182

IN stereotactic radiosurgery, why is the planning treatment volume (PTV) less than the clinical target volume?

To account fro any errors in targeting

(area to be treated with radiation is 2-3mm less than the CTV)

183

What tract is the mainly affected in central cord syndrome?

Lateral Corticospinal

 

UE is more medial so more affected.

184

 

Three differences between osteoblastoma and osteoid osteoma of the spine?

 

1. OO more likely to respond to NSAIDs

2. OB usually bigger (> 1.5 cm)

3. OB more likely to have neural involvement

 

185

 

Two surgical options for a symptomatic thoracic disc?

 

1) Anterior/ Transthoracic (can use VATs)

 

2) Costotransverectomy (Lateral)

186

Name 1 poor and 5 good prognostic indicators for surgery to treat lumbar disc herniation

Positive predictors of good outcome with surgery

  • Leg pain is chief complaint
  • Positive SLR
  • Weakness that correlates with nerve root impingement on MRI
  • Married
  • Age >41

Negative predictors of outcome

  • Worker's compensation

187

Contraindications to Smith-Peterson Osteotomy?

Anterior fusion at level of osteotomy

b/c the osteotomy hinges through the disc space

188

Anterolateral approach to lumbar spine

what crosses your field at L4-5

Iliolumbar vein

Crosses left to right as it drains into vena cava

189

Post-op degenerative spony outcomes

Better pain relief

better functional outcomes

190

 

Two indications for open debridement of pediatric diskitis?

 

1. Failure of non-op

2. Abcess pressing of thecal sac or paraspinal abscess

191

 

Three xray findings of pediatric diskitis?

 

Loff of lordosis

Disc space narrowing

Late finding of end plate erosions ( 3 weeks)

192

Burst fracture with retropulsion and > 50% collapse, TLICS score of 3, neuro intact, how do you treat?

1. Fit for TLSO

 

2. Dynamic views in TLSO

193

Removal if C-collar is allowed if patient is:

  • Alert
  • Awake
  • Not intoxicated
  • Has no neck pain, tenderness or neurologic deficits
  • Has no distracting injuries

Must fulfill ALL above criteria

194

What is the least useful exam for lumbar stenosis?

A. Physical exam

B. MRI

C. Treadmill test

D. SF-36

 

Physical exam

Often people present asyptomatic and will have a + treadmill test

195

Describe a smith peterson osteotomy.  How much correction can it give?

Posterior element osteotomy and hinging through disc

Gives 10 degrees of correction per level osteotomized

196

 

What cervical approach has the higher infection rate?

 

Posterior

197

What are the 6 primary manifestations of VACTERL?

 

1 ) Vertebral malformation

2) Anal atresia

3) Cardiac malformations

4) T-E fistula

5) Radial anomolies

6) Renal malformations

198

What Spinal Cord Tumor am I?

 

Often found on filum terminale

Histology: Rosettes

Intramedullary

Ependymoma

199

List 5 things to consider in an ank spond patient with a spine injury

More likely to have spine fractures than normal population

Low energy mechanism

High bleeding risk

High risk of epidural hematoma

More likely to be Osteoporotic

More likely to present with neuro deficit

More likely to have progressive (delayed) neuro deficit (b/c of epidural hematoma)

Always unstable (long lever arms and involved anterior and posterior columns)

Higher rate of loss of reduction

30% mortality

50% morbidity

Difficult to brace b/c of severe kyphosis

Lots of reported complications with non-op treatment such as traction and bracing

Profound medical co-morbidities (lungs especially)

200

3 indications for emergent MRI with Facet injury?

1. Altered mental status

2. Neuro decline during reduction

3. Failed closed reduction

 

Otherwise get after reduction before OR

201

Negative prognostic indicators in spinal stenosis surgery

CV comorbid conditions (most important)

Increased comorbid conditions

disorder affecting gait

depression

back pain

scoliosis

202

Damage to what nerve with anterior approach to lumbar spine causes retrograde ejaculation?

superior hypogastric plexus on L5 body

 

203

What non-fracture spinal sequelae can be fatal in AS patients?

Epidural hematoma

Get MRI if suspected

204

(3) Absolute contraindications to Halo application.  Name as many relative ones as possible (5)

Absolute:

  • Cranial fracture
  • Infection
  • Severe soft tissue injury (especially near pin sites)

Relative

  • Polytrauma
  • Severe chest trauma (b/c of vest)
  • Barrel-shaped chest
  • Obesity
  • Advanced age (this is becoming more absolute)

205

>12mm on BDI or BAI indicates what?

Anterio rC0-1 displacement

 (the classification states that it's C0 anterior on C1)

206

Two requirements for treating Chance fracture with TLSO?

 

1) Neuro intact

2) PLC Intact

 

** follow over time for progressive kyphosis

207

Factors contributing to development of sagittal imbalance in adult spinal deformity (4)

Osteoporosis

Preexisting scoliosis

Iatrogenic instability

Degenerative disc disease

208

Post-traumatic spinal pain in AS patient, what MUSt you do?

CT it

x-rays are not enough

+/- MRI

209

How do the columns fail in a Chance fracture?

 

Anterior in compression.

 

Middle, posterior in tension.

210

What sense is preserved in anterior cord syndrome?

Dorsal columns - prorioception and vibration

211

 

Large/Anterior spinal abscesses are hallmarks of what infection?

TB

212

3 x-ray findings for lumbar disc herniation

Loss of lordosis

Loss of disc height

Lumbar spondylosis (degenerative changes)

213

In congenital vertebra, name which have the most risk of scoliosis progression from highest risk to lowest risk

Unilateral bar + contralateral hemi (5-10 deg)

double hemi (4-10 deg - double of a single hemi)

Unilateral bar (5-6 deg)

Unilateral hemi (2-5 deg)

Wedge vertebra (less than 2 deg)

Block vertebra (less than 2 deg)

 

214

 

4 conditions associated with dural ectasia?

 

Marfan syndrome

Ehlers-Danlos syndrome

neurofibromatosis type I

ankylosing spondylitis

215

After pseudoarthrosis of ACDF, what is the preferred treatment?

It is associated with higher rates of what?

Posterior fusion

Higher rates of fusion & overall complications

Even though it has higher overall complications, it is still preferred treatment b/c of higher fusion rates

216

What is the main prognostic difference between flexion and extension teardrop fractures?

1. Flexion are unstable whereas extension are usually stable

 

2. Extension is usually smaller fleck and common at inferior C2 endplate

 

3. Flexion is larger piece and has posterior subluxation into canal of remaining body

217

Congenital scoli with in kid younger than 5 years old. How do you treat if failure of formation vs. failure of segmentation (describe with curve magnitude)

Failure of formation:

Age less than 5 AND

Curve less than 40: hemiepiphysiodesis

Curve > 40: excision

Failure of segmentation

In-situ fusion

218

10 Complications of OR for spinal stenosis

Major complication

  • wound infection (10%) 
  • deep surgical infections are to be treated with surgical debridement and irrigation 
  • pneumonia (5%)
  • renal failure (5%)
  • neurologic deficits (2%)

Minor complication

  • UTI (34%)
  • anemia requiring transfusion (27%)
  • confusion (27%)
  • dural tear  
  • failure for symptoms to improve

219

Combined lateral mass overhang should be:

less than 7 mm (8.1mm with radiographic magnification)

220

Incidence of L5 nerve root injury with spondy reduction

30%

NOT proportional in any way to amount/degree of reduction

221

Most common nerve injured with halo application and resultant deficit?

CN 6 (Abducens)

 

Lack of lateral eye movement

 

Usually treat with observation.

222

Operating on which side anteriorly in the cervical spine has a higher rate of recurrent laryngeal nerve palsy?

Equivalent

Classically right sided was worse but new studies show injury rates are equivalent

223

Risks of prolonged immobilization in rigid C-collar

increased risk of aspiration

Inhibitions of respiratory function

Increased risk of decubitus ulcers

Possible increase in intracranial pressure

224

Three indications for OR with lumbar disc herniations?

1) Failed conservative treatment (6 weeks)

2) Progressive or significant weakness

3) Cauda Equina

225

Powers ratio.  Interpret

>1

less than 1

>1: anterior dislcoation C0-1 (head goes anterior)

Less than 1:

Posterior atlanto-occipital dislocation (head goes posterior)

Odontoid fracture

Ring or atlas fracture

226

How do you test for CSF (ie dural tear) on swab/analysis

beta-2-transferrin

227

 

Two causes of a pathologic scoliosis?

 

Osteoid osteoma

Osteoblastoma

228

In adult spinal deformity, what is the best predictor of pre and post-operative symptoms?

Sagittal balance (ie kyphosis)

229

What are the 2 approved uses of rhBMP?

rhBMP-2 is FDA approved for:

use together with the lumbar tapered fusion device (LT Cage; Medtronic) in single-­level ALIF from L2 to ­S1 levels in degenerative disc disease.

Open tibial shaft fractures treated with IM nail with 14 days

230

Radiographic signs of unstable C1 fracture

Combined lateral mass displacement of >7mm (8.1mm with radiographic magnification) on open mouth view

ADI >3mm (normal is <3mm)

  • ADI 3-5mm: TL injury, alar & apical ligaments intact
  • ADI >5mm: Injury to TL & alar ligaments ± tectorial membrane

231

Describe ranawat classification for RA C-spine

I: pain only

II: subjective weakness, hyperreflexia, dysaesthsia

IIIa: objective weakness, long tract signs, ambulatory

IIIb: objective weakness, long tract signs, non-ambulatory

232

What are two types of strut graft that can be used for an anterior decompression for spondylodiskitis?

1) tricortical autograft from Ilium, rig or fibula

 

2) Titanium mesh cage filled with autograft

233

In AIS, what curves are least and most likely to progress?

Skeletally mature:

Least: curves <45

Most: Thoracic curves >55 degrees

45-55 - don't know

Skeletally immature:

>25-30 deg will progress

234

Difference on x-ray between DISH and AS?

DISH spares the disc spaces

vs.

AS: discs will be ossified, resulting in fusion of vertebrae

See pic of AS

235

Briefly Describe a pedicle subtracting osteotomy. How much correction can you get from a PSO?

Posterior osteotomy including vertebral body

Can give 30-35 degrees of correction

236

 

How do these lesions affect disc space?

1. TB spondylodiskitis

2. Pyogenic spondylodiskitis

3. Tumor

 

1. TB spondylodiskitis = No early disk involvement

2. Pyogenic spondylodiskitis = Involves the disk space

3. Tumor = Spares the disk space

237

Where should sagittal C7 plumb line end?

posterior superior corner of S1

238

Procedure if neurologic event (as per MEPs, SSEPs) occurs intraop:

Take control of the room

Check for technical errors

Test screws

Make sure there is no anesthetic affecting readings

Check blood pressure and evaluate if low

MAP > 75-90mmHg

Check hemoglobin and transfuse as necessary

Check O2 sats >90%

Lessen/reverse correction

Administer Stagnara wake up testWake the patient up and evaluate voluntary motor function

Ask them to move their feet

Remove instrumentation if spine is stable

Call for second opinion

Give steroids

239

What is the relationship between pelvic incidence and Spondylolisthesis?

Direct linear relationship between pelvic incidence and the severity of the spondylolisthesis

240

 

Three indications for surgery according to Wai?

 

  1. unpinch a nerve
  2. instability
  3. restore a balanced spine

241

 

Two techniques to increase maximal insertional torque for pedicle screws?

 

1) under tap by 1 mm

 

2) Straightfroward trajectory parallel to superior endplate

242

Describe pedicle - nerve root match/mismatch

Pedicle - nerve root:

Mismatch: different level nerve root travels under numbered pedicle

ie: C-spine: C6 nerve root travels under C5 pedicle

Match: same level nerve root exits numbered pedicle

ieL L-spine: L5 nerve root travels under L5 pedicle

C8 nerve root allows transition b/c no C8 pedicle

 

243

Most sensitive and specific test for predicting neurologic compromise in subaxial instability?

Cervical height index

=body height/width

<2 is 100% sensitive & specific for predicting neurologic compromise

*So normally should be 2x taller than it is wide - flattened is bad

244

Contraindications to transarticular (Magerl) technique

Large, medially located vertebral artery

Hypoplastic C2 pars

Inability to obtain an anatomic reduction of C1 over C2

Substantial thoracic kyphosis that precludes the angle necessary for this approach

245

Causes of AARD (10)

Degenerative:

  • Down's syndrome
  • RA/JRA
  • Os odontoideum

Traumatic

  • Type I odontoid fracture (rare)
  • Atlas fracture
  • Transverse ligament injuries

Other:

  • Grisel's disease (retropharyngeal irritation)
  • Morquio's
  • Tumour
  • Congenital

 

246

Are uni or bilateral facet dislocations easier to reduce? 

Which are easier to maintain reduction once reduced?

Bilateral easier to reduce

Unilateral easier to maintain reduction once reduced

247

What is the incidence of neural axis abnormalities in infantile scoli?

Same as that of juvenile idiopathic

20-30%

248

What is Swischuk's line?

the Spinolaminar line drawn from C1-C3

Tests for pseudosubluxation of C-spine in paeds

normal: C2 should be within 1.5mm of spinolaminar line

249

 

Antibiotic treatment for Potts disease?

 

Isoniazid

Rifampin

Pyrazanimide

 

*** 9 - 18 months!!!

250

What is characteristic of a Type IIA Hangman's fracture?  What is indicated and contraindicated in treatment?

IIA: Horizontal fracture line

Absolute contraindications: traction

Classic treatment: ACDF

251

When is calcitonin useful for compression fractures?

Acute (, 4 days old) osteoporotic compression fractures.

Use for four weeks.

Useful for pain.

252

Where is diastematomyelia most common?

L1 - L3

253

What percent of RA patients has basilar invagination?

40%

254

 

What is Swischuks line?

 

Line from Sp of C1 to C3, the SP of C2 should be within 1.5 mm in true pseudosubluxation

255

In patients with adult scoliosis requiring long thoracolumbar fusions, what is the major advantage of extending the fusion to the sacrum as opposed to ending at L5

Improved correction and maintenance of sagittal balance

256

Describe retroperitoneal approach to L-spine

  • Oblique Incision From posterior half of 12th rib to lateral border of rectus abdominis
  • incise subcutaneous fat
  • expose aponeurosis of external oblique muscle
  • divide external oblique in line with fibers
  • divide internal oblique in line with incision and perpendicular to muscle fibers
  • divide transverus abdominis in line with skin incision
  • bluntly dissect plane between retroperitoneal fat and psoas fascia
  • retract peritoneal cavity medially
  • bring ureter medially with peritoneal cavity
  • follow surface of psoas muscle to vertebral bodies
  • tie off segmental lumbar arteries of aorta in the field of dissection
  • L4/5 disc space
  • mobilize aorta to the contralateral side
  • place needle in disc and take lateral xray to identify level
  • L5/S1 disc space
  • work between the bifurcation of aorta
  • place needle in disc and take lateral xray to identify level

257

Which side of the curve do osteoid osteomas live in?

concave side, usually at the apex

258

Acute managmement of occipito-cervical instability

NO movement of the head

Must immobilize head/neck with sandbags & tape (C-collar doesn't do much in these cases)

Mark patient with instructions not to move head

259

3 radipgrahic lines for basilar invagination:

Ranawat's line

McGregor's line

Chamberlain's line

McRae's line

260

Diagnostic criteria Scheuermann's kyphosis

>3 consecutive wedged vertebrae  > 5 degrees

Thoracic kyphosis >45 degrees

or

Thoracolumbar kyphosis > 30 degrees

261

Positive predictors for spinal stenosis surgery

good self reported health (most important)

higher income (most important)

good self reported ambulatory status

central stenosis

shorter duration of symptoms

younger

male

more expectations for function

262

T/F: helmets control rotational forces

True

263

 

Which myelopathy classification is based on physical exam findings and which is based on functional ability?

 

a) Nurick is Functional

 

b) Ranawat is based on exam

264

4 indications and 1 contraindication to pars repair

spondylolytic defects L1 through L4:

spondylolytic defects of multiple vertebral levels

low-grade but reducible spondylolisthesis at levels
cephalad to L5 with an intact vertebral disk at the level of slippage

 

Contraindicated in L5 and below

265

Is DM a risk of pseudoarthrosis of the spine after PSIF?

No

Had 91% fusion rates at 5 months, which is comparable to non-DM

(JAAOS 2014)

266

What are the different means of getting to a thoracic disc (deep approaches)?

  1. laminectomy/hemilaminectomy
  2. transpedicular
  3. costotransversectomy
  4. lateral extracavitary
  5. anterior intracavitary
    1. thoracotomy
    2. VATS (video assisted thoracoscopic surgery)

267

In early onset scoliosis, what are radiologic signs for risk of progression (4)

 

Rib phase 2 (rib-apical vertebra overlap)

RVAD (Mehta angle) > 20degrees (80% progress)

Cobb angle > 20 degrees

Thoracolumbar curve

Conversely, phase 1 rib (no overlap), RVAD

RVAD

268

Which nerve roots do central, paracentral and far-lateral discs affect higher than C8 and lower than C8?

Cervical:

central and foraminal disc will affect the same nerve root

Always the exiting one

due to horizontal nerve root anatomy

Lumbar:

paracentral and far lateral affect different roots

paracentral: affects traversing nerve root

Far lateral: affects exiting nerve root

 

269

 

6 Indications for surgery with spondylodiscitis?

 

  1. intractable neck pain
  2. septicemia
  3. epidural abscess
  4. neurological compromise
  5. gross kyphotic deformity with extensive destruction
  6. failure of conservative treatment.

270

Type of pars defect in degenerative spondy

NO PARS DEFECT

This differentiates it from adult/paeds isthmic spondy

271

When will osteoid osteoma caused scoli resolve?

After resection only if performed 15-18 months of age in a child

272

Indication for bracing in Scheuermann's kyphosis

Observation alone:

  • Kyphosis less than 60 degrees and asymptomatic
  • Most patinets fall into this group

Bracing with extension type orthosis Modified milwaukee brace:

  • Kyphosis 60-80 degrees in patients Risser 3 or below & asymptomatic

273

 

How does Scheurmans differ from physiologic kyphosis?

 

> 45 degrees

can be painful

rigid

anterior vertebral wedging

274

Dangers of retroperitoneal (anterolateral) approach to spine?

Sympathetic chain

Ureter

Genitofemoral nerve

Aorta

Segemental lumbar vertebral arteries

Superior hypogastric plexus

275

Definidtion of instability on flex-ex views in degenerative spondy?

4mm translation

10 degrees of angulation

276

When is an isthmic spony most likely to progress?

in adolescence during growth spurt

277

What is a type 1 Dens fracture and what imaging should be performed in these cases?

Avulsion of tip of Dens.

 

Should do flex/ex views to check for AAI.

278

Infantile scoliosis normally is which direction?

Left thoracic

(vs AIS: right thoracic)

279

What is the only cervical dermatome with an autonomous zone?

C4 - over AC joint

280

After facet dislocation, what is an absolute indication for an anterior approach?

Herniated disc

281

Two reasons to add posterior instrumentation after doing an anterior decompression and strut graft for spondylodiskitis?

1) Severe kyphosis

 

2) If the anterior decompression was multilevel

282

5 Indications for MRI for lumbar discogenic pain

Pain > 1 month and not responding to nonoperative managmeent

Infection (IVDU, hx of fevers/chills)

Tumour: hx of cancer

Trauma

Cauda equina syndrome

283

Risk factors for OPLL

idiopathic skeletal hyperostosis

Hypoparathyroidism

hypophosphatemic rickets

hyperinsulinemia

obesity

Body mass index

insulinogenic index (serum insulin divided by serum glucose)

284

Two most common types of extradural spinal cord tumours?

Mets

 

Lymphoma

285

What lab test confirms CSF fluid?

beta-2 transferrin

286

Anterolateral approach to lumbar spine

What crosses your field at the sacral promontory (L5-S1)

Median sacral artery

287

 

What finding on radiology do you need to check for if doing an anterior cervical decompression?

 

OPLL (can result in dural tears)

288

T/F? Spony is not associated with increased risk of back pain in adulthood compared to age-matched individuals

True

NO risk of back pain in adults

289

 

What percentage of asymptomatic patients have cord compression from thoracic disc pathology?

 

29%!!

290

 

What is the typical proximal levels with scoliosis correction in CP?

 

T1 or T2

291

 

Spinal ring enhancing lesion on MR + Gad?

 

Abscess

292

Where should incision for thoracotomy be?

2 levels above where you want to go

293

 

Classic triad of Klippel Feil?

 

1. short webbed neck

2. decreased cervical ROM

3. low posterior hairline

294

Outcomes of SPORT trial regarding lumbar stenosis

surgical > nonsurgical at 2 & 4 years

 

295

What is a syrinx?

 

What is a syringomyelia?

a) Fluid filled cavity in spinal cord

 

b) Fluid filled cavity that expands and causes deficits

296

Most common site for adult isthmic spondylolysis/listhesis?

L5-S1

L4-L5 is second most common

297

 

Indications for decompression of TB spinal Abscess?

(4)

 

  1. Neuro deficit
  2. Presence of caseation
  3. Failure of 6 months non-op
  4. Progressive kyphosis or instability

298

Collagen type in annulus fibrosis

Type I

 

299

3 pathological processes associated with sacroiliitis

Ankylosing spondylitis

Reiter's syndrome (oligoarticualr arthritis, conjunctivitis, uveitis)

Joint arthritis

300

Burst fracture with retropulsed fragment and neuro injury, TLICS is 6:

 

1) How do you decompress?

2) If posterior, how many levels to instrument?

 

1) Either anterior or posterior via transpedicle decompression or indirect decompression with distraction and ligamentotaxis

 

2) One level above and below (old fashioned is three above and below)

301

 

What is favoured treatment for sympotmatic synovial facet cyst?

 

Facetectomy and instrumented fusion

 

(Lower recurrance rate than laminectomy)

302

Main problem with MRI of thoracic disc herniation?

High false + rate

303

C1-2 instability

How does treatment differ if it is redicible vs. irreducible

Irreducible:

Cannot do Magerl

Must do laminectomy and then fuse

 

304

Most likley associated injury in a chance fracture?

GI (50%)

305

Name 4 approaches to the lumbar spine:

Posterior

Wiltse

Anterior intra-peritoneal

Anterior retroperitoneal approach

306

 

2 signs on MRI to suggest significant stenosis

 

  1. effacement of CSF
  2. Myelomalacia (bright on T2)

307

 

Two conditions associated with vertebral malformations?

 

1) VACTERL

 

2) Klippel Feil

308

How much torque should be on an adult and pediatric halo pin?

a) Adult is 8 inch lbs

 

b) Pediatric is 2-4 inch lbs, you use more pins to make up for the decrease in torque

309

Difference between vertebroplasty & kyphoplasty?  Which is recommended/not recommended?

Kyphoplasty: creates a cavity in which cement can be injected into.  Recommended by AAOS (although limited evidence)

vs.

Vertebroplasty: straight injection of cement into vertebral body - no cavity (NOT recommended by AAOS)

 

310

What kind of spondy is associated with spina bifida?

Isthmic

311

 

Most common complication following Anterior/ Transthoracic approach (+/- VATs)?

 

Intercostal neuralgia

312

A patient has a compression fracture, what are 4 signs that it may be caused by a Met?

  1. Higher than T5
  2. Atypical radiographs
  3. Constitutional symptoms
  4. Young patient with no trauma history

313

 

How do you immobilize a c-spine in a patient younger than 8?

 

They have relatively large heads. Use a coard with a cut out for the head or sandbags. The auditory meatus should be in line with the shoulder.

314

 

What is an absolute indication for fusing to the pelvis with CP scoliosis?

 

Pelvic obliquity > 15 degrees

315

anterior decomrpession of OPLL has higher rates of what complication?

Dural tear

316

Describe McGregor's line

For basilar invagination

317

Timeline for treatment of cauda equina syndrome

decompression within 48 hours

shows better recovery of bladder and bowel function and motor and sensory recovery than delayed surgery >48 hours

318

 

What is cephalomedullary angle and what does it predict?

 

1. Angle between cerebrum and branstem on saggital MRI

 

2. Severity of Basilar Invagination

319

 

What nerve is most commonly injured with reduction of an isthmic spondylolisthesis?

 

L5

320

 

Where is the most common extrapulmonary site for TB?

 

Thoracic Spine

321

Normal BDI/BAI?

less than 12mm

>12mm indicates atlanto-occipital dissociation

322

 

In Infantile Scoliosis what degrees of curve are associated with a) pulmonary insufficiency and b) cardio pulmonary insufficiency?

 

a) 60

 

b) 90

323

Nerves at risk with medial Halo pins?

Supraorbital

Supratrochlear

324

What percentage of vertebral compression fractures come to clinical attention?

Less than 30%

325

 

4 positive predictors of success in lumbar discectomy and 1 negative predictor

 

Positive: Leg pain, + SLR, Weakness that corresponds with MRI, Married

 

Negative: Workmans Comp.

326

Pedicles angulate more               as you move distal.

medial

327

What part of ATLS do you change for a patient with AS?

May skip C-collar

Do not "correct" their deformity to fit them into a collar

This will cause more damage

328

What Spinal Cord Tumor am I?

 

Common

Associated with NF 2

Histology: meningothelic whorls

Meningioma

329

 

Three conditions common for RA involving the c-spine?

 

  1. Atlanto-Axial istability
  2. Basilar Invagination
  3. Sub-Axial Subluxation

330

 

What does a fluid sign on MR suggest with a vertebral body lesion?

 

Osteoporotic vertebral compression fracture

331

What Spinal Cord Tumor am I?

 

Very common

Associated with NF 2

Forms at dorsal nerve root

S-100 +

 

Schwanoma

332

4 angles or clnical tests for AS

Schober test

Chin-brow angle

Occiput to wall angle

Gaze angle

333

What are Waddells signs?

  1. Over-reaction
  2. Simulation (reaction to simulated test)
  3. Distraction (neg. SLR when distracted)
  4. Regional (non-dermotermal)
  5. Tenderness (to light touch)

334

How much correction can you get with a vertebral column resection?

45 degrees

335

 

What spinal condition shows sparing of the right thoracic area?

 

DISH

336

What must you do before operating on a c-spine?

CT scan to look for course of vertebral artery

337

Name the following vertebral levels and landmarks

C2-3

C3

C4-5

C6

C7

T3

T8

T10

L4

S1

C2-3: Mandible

C3: Hyoid

C4-5: thyroid

C6: Cricoid

C7: vertberal prominence

T3: Spine of scapula

T8: nipples

T10: xiphoid

L4: bifurcation of aorta

S1: Bifurcation of iliacs

338

3 pediatric causes of AAI?

  1. Morquios
  2. JRA
  3. Rotatory AA subluxation

339

Spondy incidence in Inuit

high!

Not rare

 

340

Describe pelvic incidence:

Pelvic Incidence = pelvic tilt + sacral slope

Angle formed by:

1. a line from the center of the femoral head to the middle of the S1 end plate

2. a line perpendicular to the S1 endplate

341

 

5 signs of UMN injury:

 

  1. increased reflexes
  2. inverted radial reflex
  3. Positive hoffmans
  4. Positive babinsky
  5. Sustained CLonus (more than 3 beats)

342

PADI/SAC: less than what amount is associated with risk of neurologic injury and an indication for surgery?

less than 14mm

>17 is normal

14-17mm is grey zone

343

Poor prognostic indicators for spinal stenosis

cardiovascular comorbidity

Disordered walking condition

Scoliosis

Depression

 

344

Three indications for surgery with spondylodiskitis?

1) Refractory to medical amagement

 

2) Neurologic deficits

 

3) Progressive kyphosis or gross instability

345

If you have an anterior fusion, what kind of spinal osteotomy can you do?

Pedicle subtracting osteotomy

b/c it does not hinge on the disc, but the vertebral body instead

346

Whar is the most reproducible measure of basilar invagination on xray?

Ranawat Index

(shoulde be > 14 mm)

Measure from center of C2 pedicle to a line connecting the anterior and posterior C1 arches

normal measurement in men is 17 mm, whereas in women it is 15 mm

distance of

most reproducible measurement

Also: cervicomedullary angle on MRI

347

What are 4 factors supporting pseudosubluxation in paediatric C-spine?

Reduction of subluation with neck extension

Spinolaminar line within 1.5mm of C2

No hx of exam findings of significant trauma

Absence of anterior soft-tissue swelling

348

What Spinal Cord Tumor am I?

 

Found at cervicothoracic junction in kids

Histology: Fusiform

Intramedullary

Astrocytoma

349

Treatment of spine fracture in ank spond?

Long PSIF construct

350

What abdominal pathology can cause paresthesias along medial aspect of knee that may be confused with L3 sensory symptoms?

PSOAS Abcess

351

 

What is Spear Tacklers Spine?

 

Cervical stenosis due to multiple microtrauma caused by bad tackling technique.

No RTS.

352

Management of cauda equina syndrome

Decompression

Classic: wide laminectomy + discectomy.  "pedicle to pedicle decompression"

However, no comparative studies for wide decompression and discectomy vs. microdiscectomy

353

What is the organization of the cauda equina?

describe location of Sacral and lumbar roots

Motor and sensory fibers

Sacral roots central to lumbar

Motor fibers anterior, sensory dorsal

354

 

What is the indication for pars repair?

 

Spondylolysis at L4 or above with no listhesis.

Fails bracing.

 

If at L5 you have to fuse .

355

Mortality rate of patients over 79 treated with Halo?

21%

356

Which side do you approach from during an anterior/transthoracic appraoch to the spine?  Why?

Left side

Aorta is more resiliant to injury

Avoids liver

357

How many occipital screws are optimal in an occiput - C2 fusion?

6

358

First line of treatment for adult spondylolisthesis?

Nonoperative observation

NOT TLSO, although it may be beneficial

This was an orthobullets question

359

Describe Smith-Robinson Approach

Incision

make transverse skin crease incision at appropriate level

extend obliquely from the midline to the posterior border of the SCN

Superficial Dissection

incise fascia over platysma

spit platysma with finger

identify anterior border of SCM

incise fascia and retract SCM lateral

identify and retract strap muscles medially (sternohyoid and sternothyroid)

identify the carotid pulse and retract carotid sheath lateral

cut through pretrachial fascia

localize superior and inferior thyroid arteries and tie off if necessary

Deep dissection

split longus colli muscles and anterior longitudinal ligament

be aware of sympathetic chain that lies on longus colli lateral to vertebral body

subperiostally disect to expose anterior surface of vertebral body

retract longus colli muscles and ALL laterally

identify level with needle in disc space and lateral xray

360

How is treatment of Type 2 Dens fractures different in the elderly?

They can't tolerate Halo so lower threshold to fuse.

 

In the young can do Halo if no risk factors for non-union. Benefit is preservation of ROM.

361

What orientation are a) Thoracic and b) Lumbar facets (largest dimension)?

a) coronal

 

b) saggital

362

 

How do you decide betwwen Occiput --> C2 and C1 --< C2 posterior fusion in treatment of AAI?

 

Either the presence of significant basilar invagination or if C2 is not reducible suggests you should do occ. --> C2 fusion

363

What percentage of SCI patients have major depressive disorder?

11%

364

Why do Down's get occipitalcervical instability and how is it treated?

1) Hypoplastic occipital condyles

 

2) Occiput --> C2 fusion if symptomatic

365

 

What is the finger escape sign suggest?

 

Myelopathy

 

(due to intrinsic weakness)

366

Indication for surgery in Scheuermanns kyphosis

Kyphosis >75 degrees that is rigid in a skeletally mature patient

Neurologic deficit

Spinal cord compression

Severe pain in adults

367

Name 5 complications with anterior approach to the cervical spine

Postoperative C5 palsy  incidence   

Recurrent laryngeal nerve injury

Hardware failure and migration

Postlaminectomy kyphosisPostoperative axial neck pain

Vertebral artery injury

Esophageal Injury

Dysphagia & alteration in speech