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Millers > Spine: TL > Flashcards

Spine: TL Flashcards

1
Q

Name the muscle/action to test for each nerve
L1
L3/4
L4/5
L5
S1

A

L1 - hip flexors
L3/4 - knee extension
L4/5 - ankle DF (foot drop)
L5 - EHL
S1 - PF

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2
Q

Motor grading 0-5

A

0 nothing
1 flicker
2 full ROM no gravity
3 full ROM w/ gravity
4 resistance but asymmetric
5 full strength against full resistance

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3
Q

Sensation for each nerve level
L1
L4
L5
S1
S2-5

A

L1 - inguinal crease
L4 - lateral thigh, medial shin
L5 - lateral calf, 1st dorsal webspace
S1 - posterior calf, plantar foot
S2-5 - perianal

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4
Q

Reflexes per level
L4
S1
S2-5

A

L4 - patella
S1 - Achilles
S2-5 - bulbocav

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5
Q

What pathology would you get an oblique XR for

A

Spondylolysis - scottie dog
Somewhat controversial because 80% pars issues will get picked up on the lateral alone

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6
Q

What is a SPECT scan? What pathology consider for?

A

Bone scan + CT
Pars stress frx
Isthmic spondy
If bright on the scan, think might have ability to heal on own

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7
Q

What is the difference between EMG and NCS

A

EMG: are the muscle electrical changes
ie is the muscle seeing some amount of deinnervation
ie a normal EMG doesn’t mean there isn’t radiculopathy, means the changes aren’t severe enough to cause muscle changes

NCS: shock -> record distal readings through the nerve
Better peripheral nerve stuff (carpal tunnel)

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8
Q

Name most common levels for degenerative L spine changes

A

L4/5 > L5/1 > L3/4

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9
Q

How does disc disease look on MRI

A

T2 loses intensity (dark disc disease) - loss of water
Lose GAGs - lose H2O

ie OA will show disc heigh loss and less bright T2 disc

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10
Q

Discogenic back pain
- What positions aggravate
- Treat

A

Worse w/ sitting, lumbar flexion
NON OP -> treat the disc (interbody fusion, lumbar disk replacement [lol])

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11
Q

Nerve that causes facet pain
Aggravating position

A

Medial br dorsal rami and sinuvertebral nerve
Extension - loading the facets

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12
Q

Traversing or exiting root compressed? (ie L4/5 disc, which nerve)
Posterolateral / lateral recess
Central
Foraminal / far lateral

A

PL/lat rec/central: traversing (L5)

Foraminal / far lateral : exiting (L4)

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13
Q

Treat disc herniation + recurrent herniation

A

NON OP
If op, do not fuse unless instability
Diskectomy - technique won’t matter

Recurrent: another diskectomy before fusing

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14
Q

Approach for far lateral disc herniation

A

Wiltse approach - not a midline incision
Between the paraspinals (multifidus, longissimus)

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15
Q

Spinal stenosis
- 4 anatomic causes
- Exam

A

Causes:
- Central disc
- Facet arthropathy / lig flav hypertrophy from the back
- Spondylosis (think bilateral, unilateral possible)
- Congenital = short pedicles (think achondroplasia)

Exam = neurogenic claudication
- Shopping cart sign (seeking lumbar flexion)
- Buttock/post thigh pain
- Pain walking DOWN hill (vs up)
- Standing pain
- Flexion increases canal volume = relief
*Check C spine for tandem stenosis

Test to differentiate vascular = ABIs

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16
Q

SPORT trial findings for management of spinal stenosis

A

4 yr fu, surg > non op
Both op and nonop improved from baseline

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17
Q

Define spondylolysis vs listhesis
Position that makes sx worse

A

Lysis - pars defect present (breaks in sup/inf facts)
Listhesis - split through it

Prognosis - if lysis w/o listhesis at skeletal maturity, will not go on to slip

Extension worse

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18
Q

Treat lysis/listhesis

A

NON OP - break from sports
- Nonunion common

Repair (preserves motion)
- No slip!
- Gr 1/2 (<50%) if failed conservative mgmt, progressive, or neuro involvement

Fusion
- Dysplasia bc high rates of progression / deformity (LS kyphosis)
- High grade slips (>3+ levels) may need mutli level fusion
- Reduction is controversial

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19
Q

How should you fuse adult isthmic spondy w/ foraminal stenosis that failed nonop

A

Interbody fusion = better fusion rate for isthmic spondy

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20
Q

If there is a degen spondy that has a slip <5mm and does not move on flex ex, how treat after fail non op

A

Decompression alone
Contrary to your gut which is fusion!

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21
Q

Explain the bladder findings for cauda equina

A

S2-5 nerves
Bladder becomes deinnervated - fills
Can’t squeeze because paralyzed
Then overflow incontinence
Worst recovery prognosis after decompression

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22
Q

Best study for recurrent disk herniation

A

MR w/ contrast
Differentiates scar (enhances w/ contrast) from disk material (does not enhance with contrast)

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23
Q

What amount of facet defect creates instability?

A

> 50% bilateral
100% one facet (aka fracture)

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24
Q

What is the outcome of an incidental durotomy

A

If treated appropriately in OR, outcomes are equiv

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25
Q

Presentation, imaging and trt post diskectomy diskitis

A

Pres: 3-6wks post op rapid onset LBP
MR w/ contrast
IV abx unless epidural abscess

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26
Q

How treat thoracic myelopathy from disc

A

RARE for it to be a disc in the L spine

Have to do something from the front - can’t retract the cord to do diskectomy
Therefore, if taking the entire disc, need some additional fusion

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27
Q

Most common bug osteodiskitis
Treat

A

Staph aureus
CT guided biopsy for bug -> IV abx 6wks

Surg only if abscess or instability

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28
Q

Ant vs post location for epidural abscess
Trt

A

C = ant
T/L = post

Trt = laminectomy w/ abscess washout

Beware, real life, can treat some abscess w/ abx only if not MRSA/neuro deficits/systemic illness

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29
Q

Describe pathology of spinal TB
When to operate

A

Originates in metaphysis
Spreads to adjacent vetrebra
SPARES DISKS

OR: neuro deficit, instability / progressive kyphosis

30
Q

Most common location metastatic disease: C/T/L, upper vs lower

A

T, posterior elements

31
Q

3 posterior element spine tumors

A

ABC
Osteoid osteoma <2cm
Osteoblastoma >2cm

32
Q

Spine ABC
- Imaging findings
- Young or old
- Histo
- Treat

A

Fluid filled lesions in posterior elements
Young - teens/20s
Histo: blood filled spaces without endothelial lining
Trt
- En bloc / wide resection if in amenable location -> if not, poss radiotherapy
- Curettage + bone graft (not curettage alone!)

33
Q

Spine osteoid osteoma
- Imaging findings
- Young or old
- Treat

A

Thin cut CT - nidus
Young - kids
Trt: en bloc removal
Radiotherapy controversial near cord

34
Q

Spine hemangioma
- Imaging findings
- Treat

A

Often anterior body
XR: jail bar striations
CT: polka dots
MR: fluid bright lesion

Trt: NTD

35
Q

Spine eosinophilic granuloma
- Imaging findings
- Young or old
- Treat

A

Vertebra plana
KIDS
Brace to prevent kyphosis

36
Q

Spine giant cell tumor
- Imaging findings
- Young or old
- Location
- Treat

A

Destruction of the vertebral body
40/50s
SACRUM
Cant met to LUNGS
Trt:
- Surg excision = gold standard
- High local recurrence
- No rads 2/2 malig transf potential

If someone wants non-op, can offer denosumab

37
Q

Spine multiple myeloma
- Imaging findings
- Young or old
- Labs
- Treat

A

Lytic lesions
Cold on bone scan
OLD
Labs: hyperCa, renal failure, anemia
Trt: rads w/wo chemo

38
Q

Chordoma
- Imaging findings
- Location
- Treat

A

Slow growing lytic lesion
Skull base or sacrum
Trt: surg resection + recon
- High local recurrence
- NOT radiosensitive

Dont confuse for GCT - many similarities

39
Q

What are the components of the posterior ligamentous complex

A

Post joint capsule
Interspinous lig
Supraspinous lig

40
Q

What is the difference between a compression and burst fracture?

A

Compression - anterior col only
Burst - ant and middle col

41
Q

What is vertebroplasty vs kyphoplasty

A

Vertebroplasty: pressurized cement, extravasates!!! = death

Kyphoplasty = balloon creates a cavity, put low pressure cement into the balloon, lower extrav

42
Q

What is a ligamentous vs bony Chance
What is the difference for treatment

A

3 col flexion distraction injury
Bony = posterior fracture
- In theory can brace because bones heal

Lig = PCL out
- Fuse

43
Q

What are the 3 part of a TLICS score

What is the score threshold to operate

A

Morphology: compression, burst, translation, distraction

PLC: intact, indet, disrupted

Neuro: intact, nerve root, complete, incomplete

<3 = nonop
4 = indet
>4 = op

44
Q

When do you give abx for spine GSW

A

If also abd organ injury (think transfer gut flora to CSF)

Solid organ - oral abx
Hollow organ - IV abx + tetanus

45
Q

Describe neurogenic shock + trt

A

Hypotension + bradycardia

Lose sympathetic pathway
Trt = vol resus -> pressors

46
Q

Describe ASIA classification

A

A = complete, no M/S
B = incomplete, no M, S in
C = incomplete, 1/2 M groups in, S in
D = incomplete, decreased motor strength but all working, S in
E = normal

47
Q

Brown Sequard

A

Think stab/penetrating injury
Ipsi motor, CL pain/temp

Best prog ambulation

48
Q

Central cord syndrome

A

Hyper ext inj
UE > LE involvement

49
Q

Ant cord syndrome

A

Vasc inj (+/- art Adamkiewicz)
Motor, pain, temp loss
Dorsal columns (proprioception) preserved
Worst prognosis for ambulation

50
Q

Posterior cord syndrome

A

Think late neurosyphilis
Motor intact
Lose proprioception (dorsal columns)

51
Q

What spine trauma injuries are at risk for autonomic dysreflexia? Cause and presentation

A

T5 and above

Cause: obstructed urinary cath / fecal impaction, boosting in para sports, unknown lower body fracture

Sudden hypertension (potentially catastrophic) , flushing, blurred vision

52
Q

What is the C7 plumb line

A

= SVA
Middle C7 body to posterior corner of L5/S1
Does cross the T12/L1 junction?

For sagittal balance

53
Q

Define pelvic incidence
- What is the goal PI
- What does a high PI mean?

A

PI = SS + PT
FIXED

= line from center FH and line perpendicular to sacral endplate

Goal PI = LL (within 10 deg)

High PI = more horizontal sacrum
So you have more lumbar lordosis to compensate for a horizontal sacrum

54
Q

Goals for deformity correction
LL-PI mismatch
PT
SVA target

A

LL-PI mismatch 9deg
PT < 25deg
SVA
- 0 young patients
- 0 in elderly can lead to PJK

55
Q

What kind of osteotomy is:
- Ponte / Smith Pete
- PSO / VCO

A

Ponte / Smith Pete = posterior col
*must have a flexible disc to correct through

PSO/VCO = 3 col

56
Q

What type of spondy is more common in kids/adults? What nerve is affected

A

Kids = isthmic spondy, L5/S1, exiting root L5
- Post elements stay still, rest moves forward, the central space is very open
- Isthmic more likely to progress

Adult = degen spondy, L4/5, trav root L5

57
Q

What is the defining exam characteristics to differentiate conus vs cauda

A

Conus (T11-T12, T12-L1) - isolated bowel/bladder loss, NO MOTOR

Cauda - back pain, LE motor weakness, b/b loss

58
Q

Compare/contrast Jewett vs TLSO

A

Both control flex/ext

Jewett - cheaper, better compliance

TLSO - better rotational control

59
Q

What are abscesses outside the spine associated with osteodiskitis in the C/T/L spine (may give you these as a hint to the underlying pathology)

A

C - retropharyngeal
T - paraspinal
L - psoas

60
Q

Name contents of carotid sheath - how does this protect you during ACDF approach

A

AVN - art more medial
Feel for the artery, go medial with dissection, all impt structures are protected lateral

Common carotid art
IJ
Vagus n

61
Q

Where does the recurrent laryngeal nerve recur on left vs right? Which is the “safer” side

A

L - aortic arch, lower, more consistent, “safer”

R - subclavian, higher, more variable

Injury = ipsi vocal cord paralysis

62
Q

Where is the sympathetic chain live

A

Ant to longus coli
Why don’t want retractors riding up on the longus

63
Q

How injury superior laryngeal nerve
Which patients care about

A

High ACDF approach (C2/3)
Retraction injury
Lose high phonation - matters for singers

64
Q

If you do a laryngoscope for a patient with suspected recurrent laryngeal nerve injury - what will you see

A

Vocal cords ADDucted
Normal = aBducted

65
Q

When can you do a pedicle screw in the C spine
What is the more traditional C spine posterior screw

A

C2 and C7 if you confirm no vert on pre op MRI
Otherwise C spine is lateral mass screws = up + out
- Up = avoid exiting root
- Out = avoid vert

66
Q

Where is the artery of adamkiewicz

A

L SIDE - low thoracic spine (T8-12)

67
Q

Where is the thoracic duct

A

L side T spine

68
Q

For aging disc, what happens to chondroitin vs keratin sulfate?

A

Chondroitin DOWN
Keratin UP

69
Q

What is BMP mechanism, what one is for spine

A

TGF-B that pushes stem cells to differentiate to osteoblasts
BMP2 - only for ALIF in a metal cage

70
Q

Concern for BMP complication, 2 surgeries cannot use it

A

Retrograde ejaculation (swelling compromising the inf hypogastric plexus) - no diff
CI if active or history of cancer - but doesn’t cause cancer itself
ACDF higher risk 2/2 swelling - never use
PLIF don’t use bc get HO along the insertion track

71
Q

TLIF/PLIF vs ALIF for lordosis

A

ALIF best for restoring lordosis

Millers (29 decks)

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