Surgery UE

Question 0

Boyle’s Law

Answer 0

Inverse relationship between pressure and volume. explains movement of air during inspiration and expiration (high volume, low pressure=gas in)

Question 1

Describe the motion of a single rib during inspiration and expiration (include Boyle’s Law)

Answer 1

“Bucket Handle Action” because the ribs are “hinged” anteriorly and posteriorly and the curved portion is free to move.
Boyle’s Law: Explains movement of air during inspiration (high volume, low pressure=gas in) and expiration

Question 2

What joints are involved in the motion of ribs

Answer 2

1. Costovertebral (CV)
2. Costotransverse (CT) rib articulates with the transverse processes of the corresponding vertebra. Anterior rib articulation cranially superior articulation caudally.
3. Sternocostal. Articulation with the sternum ribs 1-7

Question 3

Costovertebral (CV)

Answer 3

The 6th rib articulates with the 6th and 5th vertebral bodies

Question 4

Costotransverse (CT)

Answer 4

Rib articulates with the transverse processes of the corresponding vertebra
anterior rib articulation cranially, superior articulation caudally

Question 5

Sternocostal Joint

Answer 5

Articulation with the sternum, ribs 1-7

Question 6

What muscles are involved during inspiration

Answer 6

Quiet: diaphragm, scalene, external intercostals

Forced: Serratus posterior superior and inferior, levator cocostae, SCM, Lats, iliocostalis thoracis and cervicis, pec major and minor, SA, QL

Question 7

What muscles are involved during Expiration

Answer 7

Quiet: Passive due to relaxation of diaphragm and elastic recoil of thorax and lungs

Forced: 4 Abdominals, Transverses thoracis, internal intercostales

Question 8

Observe the orientation of the facet joint of the thoracic spine
Describe the possible/theoretical motions of the thoracic spine based on its facet orientation

Answer 8

Facet joints become progressively more vertical
Motion occur in all 3 planes: Not much in thoracic spine during physical assessment because the rib cage restricts some motion
Flex/Ext ROM increases from upper to lower throacic.
Axial Rotation decrease from upper to lower segments due to the facet joint orientation.
Lateral SB does not systematically change very much from the upper to lower thoracic spine

Question 9

Define Kyphosis

Answer 9

Kyphosis is the curvature that is concave on the anterior side (or convex posteriorly) of the spine

Question 10

What portion of the spine demonstrates a kyphotic curve

Answer 10

Normal spine at rest the thoracic spine and sacrum display kyphosis.
Kyphotic curve of the T-spine can be assessed using X-Ray
Normal kyphotic curve angle is about 40 deg
Natural curvature within the vertebral column are not fixed they change shape during movements and different postures

Question 11

How is a kyphotic curve assessed

Answer 11

X-Ray
Cobb Angle calculated from perpendicular line drawn on a standard thoracic spine radiograph
a line extends through teh superior endplate of the vertebral body which marks the beginning of the thoracic curve (T4) and the inferior endplate of the vertebral body marking the end of the thoracic curve (T12).
Normal curve 40 deg, increase as kyphosis increase

Question 12

How does increased kyphosis affect the cervical spine

Answer 12

Excessive thoracic kyphosis translates the cervical spine and head anteriorly
To compensate and maintain head position
Cervical spine may increase its lordosis curve

Question 13

How does increased kyphosis affect the loading on the thoracic and cervical spines

Answer 13

Increased kyphosis increase the external moment arm (from the throacic AOR to the line of body weight).
In static position int=ext torque (force*moment arm).
Since body weight force vector and int moment arm of the muscles are constant. increasing the ext moment arm due to kyphosis means and increased muscle force necessary. Increase the shear and compression load on T&C-Spine. Also reduce contact area b/w vertebra. pressure=force/contact area.both the potential increase in compressive force (due inc in muscle force) and decrease in contact area will dramatically increase the pressure

Question 14

Determine the axis rotation for the cervical spine

Answer 14

The sagittal plane AOR runs in the ML direction is anterior on the vertebral body
Transverse rotation, it’s longitudinal through the vertebral body.
The frontal plane AOR (AP direction) is less clear

Question 15

Is the total cross-sectional area for the anterior neck muscles the same as for the posterior neck muscles?

Answer 15

The posterior neck muscles (extensor) have a considerably larger cross-sectional area (greater force production)

Question 16

Are the lever arms for the anterior neck muscles similar to that of the posterior neck muscles

Answer 16

In general posterior muscles also have a larger lever arm than the anterior muscles. The posterior neck muscles (extensor) therefore can generate more muscle torque (t=force*lever arm)

Question 17

What implications does this have for whiplash injury?

Answer 17

Whiplash injuries refer to injrueis resulting from neck hyperflexion adn hyperextension
difficult to prevent from musclar perspective
Cervial spine and associated musculature is desinged to counter gravity (by ext the head and neck to keep the mass of teh head over the BOS)
Anterior neck muscle not well-designed to resist a rapid posterior acceleration of the head
Injury more likely to occur during neck hyper-extension (ROM)
Could result to injury to both anterior (muscle strain)and posterior structures (fracture of the facet joint)

Question 18

Coupled-motions of the lower cervical spine? Why? (VBI)

Answer 18

Rotation and SB are to the SAME side regardless of cervical flexion or extension
Coupled motions of the lower cervical spine are primarily due to the orientation of the facet joint (more superior anterior relative to posterior)

Question 19

Osteokinematic Motion of the cervical spine during VBI test

Answer 19

Extension plus ipsilateral rotation and SB of the C-spine

Question 20

What potentially occurs to the right vertebral artery

right artery is the ipsilateral artery. right rotation is performed

Answer 20

Position is very similar to the position of the Spurling’s Test. Any bony spurring/osteophyte formation in the lower cervical spine may compress or irritate the artery, thereby cause occlusion of the artery on the right (ipsilateral) side.
Excessive rotation of C1-C2 can also lead to ipsilateral “kinking” effect (imagine bending a garden hose to shut off water flow)
Possible when there is disruption to alar ligament, leading to joint instability

Question 21

What potentially occurs to the Left vertebral artery (left artery is contralateral artery: rotation is performed to the right)

Answer 21

Rotational motion of the C1-C2 the artery on the contralateral side is bent around the C1-C2 kinking the artery and reducing the blood flow to the brain.

Question 22

Conclusion about VBI

Answer 22

Purposefully occluding blood flow on the ocntralateral side
Positive
1. Ipsilateral bone spurring
2. Kinking on the ipsilateral artery in teh upper cervical spine with excessive rotation due to the joint instability and/or disruption of the alar ligament

Question 23

Identify the muscle of the anterior and posterior cervical spine

Answer 23

Anterior: SCM, Longus Capitis, Longus Colli, Scalene Anterior, Scalene Medius, Scalenes Posterior

Posterior: SCM,Trapezius, Spenius Capitis/Cervicis, Spinalis Capitis, Semispinalis Capitis/Cervicis, Longissimus Capitis/Cervicis

Question 24

Articulating facets of C1 with occiput in relation to cardinal planes

Answer 24

The articulating facets of the C1 are concave and lie in the transverse plane tilted slightly posterior and medial. They tend to cradle the occiput and allow some flexion/extension (nodding) and minimal Sidebending and rotation

Question 25

Name of variation in C2 morphology of Spinous Processes. Do spinal nerves exit superior or inferior to the vertebral body with the same name?

Answer 25

The spinous process are typically bifid with the C2 spinous process being the first palpable spinous process. The nerve exit superior to the vertebra for which they are named in the cervical spine. True for C1-C7 the C8 nerve root exits inferior to C7 and from that level on the nerve exit inferior to the vertebrae for which they are named

Question 26

What vertebrae does the dens osseous structure belong?

Answer 26

Dens is part of the C2 vertebra

Question 27

What is the purpose of the transverse ligament and danger of a rupture?

Answer 27

The transverse ligament holds the dens against the anterior arch of the atlas. Rupture of this ligament can lead to impingement on the spinal cord as C1 may glide anteriorly unchecked. The spinal cord would then be pinched between the dens and the posterior arch of the atlas. Vertebral artery may also be compromised. Function of the transverse ligament should be understood and translated to the clinical tests such as the Sharp-Purser Test

Question 28

Nerve Trough

Answer 28

The nerve troughs are more anterior than most people think

Question 29

Most cranial vertebral body of the cervical spine

Answer 29

The most superior vertebral body belongs to the axis. The atals consists only of a body-less ring

Question 30

Transverse ligament location and attachments

Answer 30

The attachment site for both ends is the posterior aspect of the anterior arch of C1

Question 31

Alar ligament location and attachments

Answer 31

The alar ligament runs from the lateral aspect of the odontoid process (dens) to the margins of the foramen magnum

Question 32

If cranium and move it into left SB. Which alar becomes taut? Explain the kinematics created by the Alar ligament during this movement

Answer 32

As the occiput LEFT sidebends, the RIGHT superior Alar ligament becomes taut. LEFT side bend results in the alar ligament pulling C2 into LEFT rotation of the vertebral body, resulting in C1 positioned in a RELATIVE right rotation on C2

Question 33

Following which is True

Answer 33

1. Right SB of the occiput creates tension in the superior left Alar ligament 2. The transverse ligament attaches to the anterior arch of the atlas at both ends 3. Right SB of the occiput results in the right rotation of C1 on C2. FLASE

Question 34

Difference between the T4 and coso-transverse joint and the T10 costo-transverse joint

Answer 34

The costo-transverse joints become progressively more weight-bearing as you move caudally through the thoracic spine. The upper costo-transverse joints are ligamentous type whereas the lower joints are synovial type of joints. Thus the lower costo-transverse joints have more mobility than the upper costo-transverse joint

Question 35

Rule of 3

Answer 35

Clinical rule that attempts to generalize the orientation of the thoracic spinous processes. There are certainly deviation as can be appreciated by observing the wide variability of several cadavers. Upper 3 thoracic vertebra (T1-T3) have SP that project direcly posterior and therefore the tip of SP in the same place as TP of that same vertebra T4-T6 SP project slightly downward and therefore the tip of SP is in the plane that is halfway between its own TP and that of the TP of the caudal vertebrae T7-T9 have SP that project moderately downward and therefore the tip of the SP is in a plane with TP of the caudal vertebra T10-T12 have SP that project from a position similar to T9 and rapidly regress until T12 is more like T1 (own plane)

Question 36

Muscles attach to the 1st rib

Answer 36

Anterior and middle scalene muscles attach to the first rib

Question 37

What structures are immediately adjacent to the first rib

Answer 37

Brachial plexus, subclavian artery and subclavian vein (pass between anterior adn middle scalene on way to axilla).

Question 38

Conditions sensitive to 1st rib spatial relationship

Answer 38

Elevated first rib and/or scalene muscle tightness can be a potential cause of thoracic outlet syndrome. Other causes include cervical rib Thoracic outlet syndrome refers to the neuro vascular symptoms produce in the upper extremity due to compression of the brachial plexus and/or subclavian artery.

Question 39

Scoliosis Anatomy

Answer 39

Deformity of the vertebral column characterized by abnormal curvatures in all 3 planes most notably in the coronal and transverse. Occurs most commonly in the thoracic region but may affect other regions

Question 40

Scoliosis Demographics

Answer 40

Typically described by the location direction and number of fixed coronal curvatures within the vertebral column. The most common pattern of scoliosis consists of a single lateral curve with an apex in the T7-T9 region. There may also be secondary or compensatory curves most often in thoracolumbar or lumbar regions. Direction of the primary curve is defined by the side of convexity of the lateral deformity (right thoracic apex indicates teh most lateral point of the curve is in the thoracic spine with the convex side in the right half of the body).

Question 41

Types of Scoliosis

Answer 41

Functional Structural Idiopathic Adolescent

Question 42

Functional Scoliosis

Answer 42

Corrected by an active shift in posture

Question 43

Structural Scoliosis

Answer 43

Fixed deformity that can't be corrected fully by an active shift in posture 80% Idiopathic with no mechanical cause, no apparent biologic cause Congenital scoliosis is caused by a failure in vertebral formation or segmentation it may be associated with several neuromuscular diease like cerebral palsy, muscular dystrophy or generalized disease like Marfan's syndrome Infantile, Juvenile, Adolescent

Question 44

Idiopathic Adolescent Scoliosis

Answer 44

Most common type | progressive affects adolescent females about 4x as much as males

Question 45

Adolescent Idiopathic Scoliosis | Natural History

Answer 45

Once descovered curve must be evaled for progression lateral forces in anterior spine have to be counteracted by the musculo-ligamentous structure in the posterior spine. when this fails curve progression can increase during periods of growth progression is most likely to occur during the rapid adolescent growth

Question 46

Peak Height Velocity

Answer 46

Adolescent Idiopathic Scoliosis Chagnes in a pt height measurements over time and is reported to be about 8cm/yr for girls (11-13yr). and 9.5 cm/yr for boys (13-15)

Question 47

Certain factors have been found to be related to higher risk of curve progression for Idiopathic Adolescent Scoliosis

Answer 47

``` Girl>Boys Premenarchal Younger Chronological Age Risser sign of 0 Double curve> single curve thoracic curve> lumbar curve more severe curves direct correlation has been noted between decreasing vital capacity and increasing curve severity ```

Question 48

Mechanics of Scoliosis Coupling

Answer 48

Deformity in structural scoliosis has a remarkably fixed contralateral spinal coupling pattern (lateral flexion and axial rotation) Left lateral flexion (right scolisiosis) is associated with right axial rotation Ribs are forced to follow this rotation producing a rib prominence on the convex side that becomes more evident on bending forward MORE PRONOUNCED ON ANTERIOR SPINAL COLUMN. RESULT FROM DIFFERENCES IN THE GROWTH RATE BETWEEN ANTERIOR AND POSTERIOR COLUMS

Question 49

Vertebral Deformities Scoliosis (CTO scan)

Answer 49

CT scans of the apical vertebrae reveal numerous deformities Slight torsion between teh verterbal body and the posterior structures -vertebral body is rotated toward the convex side of the curve -torque of the musculo-ligamentous on the posterior aspect of the spine (towrad convex side) results in the thickening of the convex pedicle. Pedicle on concave side is narrowed -Increase longitudinal pressure on the concave side results in decreased longitudinal growth but increased appositional bone growth. therefore the depth of the vertebral body (in anterior view) is shorter on the concave side and lengthened on the convex side (wedge angle) -Depth of the vertebral body (lateral view) is shortened on the posterior aspect and lengthened on the anterior aspect creating a lordotic bony deformation. Normal anatomy is a shortened anterior aspect to allow for a kyphotic curve in the spine -tip of the SP is pointed posterior then curves toward the convex side

Question 50

CT scan of Upper end vertebrae

Answer 50

show slight torsion between the vertebral body and the posterior components of the vertebrae. there is also a greater tilt vertebral body than the posterior structures as the ligaments and muscles attempt to correct the horizontal tilt

Question 51

Rib Deformity Scoliosis (Concave side)

Answer 51

- Concave side - crowded together while those on the convex side are spread out. - muscles and other soft tissues are also shortened and lengthened on teh concave and convex sides respectively

Question 52

Rib Deformities (Concave side)

Answer 52

- Concave side - Sharper posterior angle with torsion around the longitudinal axis. ribs on the concave side have a flattened posterior angle

Question 53

Scoliosis Evaluation

Answer 53

- Back Pain (about 32%) idiopathic scoliosis - height associated with height peak velocity. limb length (pelvic tilt and compensatory scoliosis) - Assymetry: shoulder, scapula, ribs, waistline, plumb line to gluteal crease (hypokyphotic) - Adam Test - Neuro Exam (abdominal reflex found with some intraspinal disorder)

Question 54

Non-Operative Treatment for Scoliosis

Answer 54

Observation: young pt 50 deg. Milwaukee brace eplaced. work 23hr/day more wear less curve progression

Question 55

Surgery for Scoliosis Indications

Answer 55

Increase curve in growing child severe deromity (>50deg) with asymmetry of trunk in adolescent pain uncontrolled by non-operative treatment thoracic lordosis: detrimental effect on pulmonary function and is worsened by bracing significant cosmetic deformity

Question 56

Surgery Scoliosis

Answer 56

Posterior spinal fusion and bone grafting - most common surgery - original implants Harrington rods were straight stainless steel rods connected to the cephalic and caudal regions of the spine. Major correcting force with the Harrington instrumentation is distraction these rods were connected to the spine via hooks - Contemporary implants are segmental. affortd teh surgeon greater control over psitioinng rotation of teh spine. icnreased staility of segmentatl instrumentation permits early mobilziaton with ambulation the day after surgery wihtout external support such as a body cast or brace.

Question 57

Surgery Scoliosis Techniques (posterior)

Answer 57

-Soft tissue is cleared to expose teh vertebrae to be fused from SP lamina and facet to TP Inf, sup or both facets are removed allowing for movement in teh correction regiomve some intersegmental ligamentd include Flavum Use pedicle screws that are very adustable for fine-tuning pedicles in thoracic spine are smallare and more variable that lumbar spine making this technqiue very challenging -rods bent for kyphotic curve -rods first apply to concave side to top pedicle scew. second to convex side -vertebrae are de-rotated in Transverse plane for rib hump -convex side reduced concave side distracted to address teh vertebral body tilt

Question 58

Surgery Scoliosis Techniques (anterior)

Answer 58

-Shortening of teh convex side. advantage of this are lower risk of neurolgical injury and no disturbance of paraspinal muscles more complex and pumonary function adversely affected or diaphragm endoscopically boney fusion using autografts or allographs -older stiff pt need release anterior intervertebral soft tissue perfomring psoterior fusion -avid crankshaft: still growing child, anterior spinal fusion along with posterior fusion.

Question 59

Surgery Scoliosis Complications

Answer 59

Pseudoarthrosis | Loss of lumbar lordosis leading to back and hip pain

Question 60

Cervical Laminectomy Indications

Answer 60

- Multilevel degenerative disc disease resulting in cervical stenosis and myelopathy - Cervical Stenosis resulting from ossification of the posterior longitudinal ligament - tumor - epideral abscess

Question 61

Cervical Laminectomy Cons

Answer 61

- Postoperative axial discomfort from denervation and devascularization of the paraspinal muscles - atrophy of teh paraspinals that could potentially result in kyphosis and instability - C5 paresis is a risk

Question 62

Cervical Laminectomy Technique

Answer 62

- SP, Lamina, alteral masses exposes by elevating the paraspinal muscles - lamina cut and removed - bone spurs removed from around the spinal cord and nerve root - pedicle screw rods or plates - bone graft also inserted into facet to further fuse ten spine (complications nerve root and vertebral artery)

Question 63

Cervical Skip Laminectomy Pros

Answer 63

Tend to have better surgical outcomes than both transitional laminectomy and laminoplasty including reduced axial pain decreases incidence of paresis and decreased atrophy of the deep extensors

Question 64

Cervical Laminoplasty Cons

Answer 64

Decrease in cervical sagittal motion and postoperative axial discomfort Could cause atrophy of deep extensor muscles

Question 65

Cervical Laminoplasty Pros

Answer 65

May have less complications that the standard laminectomy and allows for the preservation of posterior elements

Question 66

Cervical Laminectomy Post-Operative Management

Answer 66

After laminectomy a drain is inserted and removed after 24-48 hours May place in soft cervical collar After skip laminectomy pt able to sit up walk on the first preoperative day while wearing Philadelphia collar. pt can wear as desired After Laminoplasty early mobilization and neck exercises are encouraged. Collar may or may not be work

Question 67

Cervical Laminectomy Outcomes/Complications

Answer 67

1. Removal of one or more dorsal elements leads to tensile forces being applied to the facet joint instead of the usual compressive forces. also decreased stiffness and increase motion has been observed 2. Instability leading to progressive kyphosis and worsening of the neurological status has bee reported 3. Possible reasons for neurological worsening: intra-operative neuro trauma, sharp angulation of dural sac at limits of decompression, DESTABILIZATION occurs with greater frequency as width of laminectomy in increased leads to flexion deformity or kyphosis 4. Prevention of destabilization: limited spinal integrity disruption, addition of a stability augmentation procedure.

Question 68

Post Laminectomy Cervical KyphosisCauses

Answer 68

Arthritic changes leading to decrease in anterior column height, loss of muscle attachments, muscle denervation or fibrosis secondary to aggressive surgical exposure and resection

Question 69

Post Laminectomy Cervical Kyphosis

Answer 69

Competence of posterior column structures particularly facet joints is essential for maintenance of lordotic posture

Question 70

Post Laminectomy Cervical Kyphosis Pathological Developments

Answer 70

Lead to progressive deformity - anterior shift of weight bearing axis (compressive overload of anterior column which may acclerate arhtitic chagnes. icnreased tension on postieor column) - cervical extensors are placed at a mechanical disadvantege - chronic tensile forces may lead to attenuation of dorsal ligamnetous structures and facet capsules - spinal cord may be pulled agaisnt the apex of teh kyphotic deformity resulting in irrriation, dysfucntion and pathological damge to the cord

Question 71

Post Laminectomy Cervical Kyphosis Symptoms

Answer 71

Neck pain, muscle fatigue (from always having to contract extensors to support the head against gravity), Radiculopathy myelopathy some cases difficulty in maintaining horzontal gaze

Question 72

Post Laminectomy Cervical Kyphosis Treatment

Answer 72

Goal is to decompress neural elements and reestablish normal vertical axis Anterior column lengthening and posterior column shortening is achieved by using grafts and or implants