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OITE > ABOS Spine > Flashcards

ABOS Spine Flashcards

1
Q

Where are sympathetic ganglia in cervical spine

A

C6 where middle cervical ganglia is, medial boarder of longus colli muscles

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2
Q

How is hypogastric plexus injuried

A

Anterior approach, retrograde ejaculation

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3
Q

Where do afferent nerve fibers arise

A

Medial branch nerves originating from next two cephalad levels; L3-4 facet joint innervated by L2 and L3 medial branches

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4
Q

Where does Artery of Adamkiewicz arise

A

left side b/w T8 and L1

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5
Q

What does neural tube become

A

from primative streak, becomes spinal cord (failure to closue anencephaly and spina bifida)

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6
Q

What does neural crest become

A

forms dorsal to neural tube
peripheral NS, pia mater, spinal ganglia, sympathetic trunk

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7
Q

What does notocord become

A

ventral to neural tube
vertebral bodies and intervertebral discs
NP from notocord, annulus from sclerotomal cells (resegmentation)

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8
Q

Smallest and largest pedicles

A

T4 smallest, L1 smallest in lumbar spine
T12 largest

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9
Q

What is concerning change in signals for SEPS and MEP

A

50% amplitude or 10% increase in latency

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10
Q

What is EMG concerning for breached pedicles

A

<8mA

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11
Q

What nerve can be injured with anterior cervical exposure up to C2

A

hypoglossal

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12
Q

Landmarks for anterior approach

A

Angle of mandible C1-C2
Hyoid bone C3-4
Thyroid cartilage C4-5
Cartoid tubercle C6

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13
Q

Anterolateral approach to thoracic spine

A

2 levels caudal for vertebral body exposed
Segmental arteries at risk midbody b/w intervertebral disks
Diaphragm can be taken down, medial risk of phrenic nerve
Lumbar plexus runs through posterior 2/3rd

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14
Q

Where is superior hypogastric plexus

A

on L5 body - retrograde ejaculation
A diagram of the back of a human body

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15
Q

Anterior approach to spine

A

transperitoneal, retroperitoneal
ureters, round ligament, iliac vessels, hypogastric plexus
sympathetic trunk medial to border of psoas, lateral to psoas is ilioinguinal nerve and farther lateral is GFN

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16
Q

Anterior cord syndrome findings

A

lower extremities more affected than upper, loss of motor and p&T
Flexion/compression injuries
Worst prognosis of all incomplete SCI

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17
Q

Brown-Sequard syndrome

A

hemitransection, excellent prognosis, 99% ambulatory at final follow up

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18
Q

Central cord syndrome

A

hyperextension injury in elderly
upper extremity and hands
Good prognosis if <50
Lower extremity recovers first, then bowel/bladder, upper then hands
typically regain ability to walk, hand may remain spastic
surgical decompression only if persistent cord compression

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19
Q

When to decompress for incomplete spinal cord injury

A

decompress when hit neurologic plateau or worsen, may recover 1-2 levels

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20
Q

Function level depending on cord injry level

A

C4- puffer, C5 hand controls, C6 manual wheel chair, C7 manual wheel chair with independent transfers

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21
Q

Causes of occipitocervical instability

A

Traumatic
Acquired: Downs, bony dysplasia, soft-tissue laxity, RA, Mucco
Requires instability of alar, tectorial membrane and alanto-occipital joint capsules

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22
Q

How to diagnosis occipitocervical instability

A

CT scan occipital condyle-C1 interval <1.5mm

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23
Q

Occipital condyle fracture

A

cervical orthosis, sugery only if neuro deficits

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24
Q

Powers ratio

A

Basion to posterior arch/anterior arch to opisthion
1 normal; >1 or <1 concern for anterior or posterior dislocation

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25
Q

Types of C1 fractures

A

Posterior arch, Jefferson (posterior and anterior arches)
lateral mass
Ligamentous disruptions

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26
Q

How to decide if C1 fracture or ligamentous injury needs surgery

A

Sum of lateral masses >8.1mm
ADI >3mm

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27
Q

Nonsurgial management of C1 fractures or ligaments injuries

A

If stable: cervical collar or halo

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28
Q

Surgical options of unstable c1

A

C1-2 trans-articular screw (vertebral artery caudal), C1 lateral mass and C2 pedicle screws, Occiput- C2 more severe injuries

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29
Q

Atlantoaxial instability causes

A

Adult: Downs, RA, Os Odontoideum
traumatic: type I odontoid, Atlas fracture, transverse ligament injury
Peds: JRA, Morquio’s sydrome, trauma/infection

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30
Q

How to determine AA instability

A

flexion/extension xrays
unstable if ADI >3-5mm, >10mm in RA
SAD or PADI: <14mm indication for surgery
Open mouth: sum of lateral mass > 8.1mm

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31
Q

Odontoid ossifications centers

A

Basilar around 6yo, fuses to dens around age 12

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32
Q

how are odontoid fracture type I and III typically treated

A

hard cervical collar

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33
Q

Risk factors of odontoid nonunion

A

posterior displacement >2mm (strongest), >5mm displacement, >4 day delay in treatment, >10 degrees of angulation, smoker

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34
Q

Indication of anterior odontoid screw

A

minimally displaced, anterior oblique fracture
preserves motion

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35
Q

Indication of posterior C1-C2 fusion

A

> 40 and type II and risk factors for nonunion, os odontedieum with neuro deficits and poor bone quality

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36
Q

What is a Hangman’s fracture

A

traumatic spondylolithesis of Axis (bilateral pars fracture of C2)
CT and flex/ext xrays

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37
Q

Treatment for hangmans fractures

A
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38
Q

Classification of hangmans fracture

A

Type I: (axial load and hyperextension) <3mm displacement
Type II: axial load and hyperextension with rebouund hyperflexion
Type IIA: flexion distraction
TypeIII: flexion distraction followed by hyperextension, associated facet dislocation

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39
Q

Treatment of Hangmans fractures

A

Type I rigid collar 4-6weeks
Type II: < 5mm reduction with traction the halo; >5mm surgery
Type IIA: Avoid traction, axial load and hyperextension - halo
Type III: surgical reduction and stabilization
Anterior C-3 interbody fusion, posterior C1-3 fusion, bilateral C2 pars screws

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40
Q

Axis body fractures

A

typically stable and managed with hard collar

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41
Q

Halo immobilization indications

A

Upper C spine (does not control facet fractures or dislocations wells
occipital condyle fracture, occipitocervicla dislocation, stable Atlas, type II odontoid <40, Type II and IIA hangmans
Adults 4 pins 80lbs (infected abs, if loose then replace)
Kids; 6-8 2-4lbs, before age 2 Minerva cast
CNVI most commonly injured

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42
Q

Cervical facet dislocation spectrum

A

Facet fracture (typically superior facet)
Unilateral dislocation ~25% subluxation of xray
Bilateral facet dislocation (80% spinal cord involvement)

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43
Q

Workup for facet dislocation

A

Flexion/extension xrays
Awake and alert - closed reduction
MRI first: AMS, failed reduction, neurologic deterioration, patient going to OR (need to know if disc)

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44
Q

How to reduce facet dislocation

A

reduction with tongs: >100lbs ok to use 70% bW

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45
Q

Treatment of stable facet fracture

A

Halo vs hard orthosis
need to confirm stable on flex/ext xrays
unilateral facet fracture w/o instability <40% lateral mass involvement or absolute height <1cm

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46
Q

Bilateral facet dislocation or unstable facet fracture

A

single level fusion

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47
Q

Treatment for cervical lateral mass fracture with facet seperation

A

Posterior decompression and 2 level fusion

48
Q

Subaxial cervical vertebral body fracture types

A

Compression, burst, flexion teardrop, extension tear drop

49
Q

How to assess subaxial cervical vertebral body fracture

A

MRI to assess PLC

50
Q

Which features have high risk of SCI with subaxial cervical vertebral body fractures

A

tear drop, disruption of posterior cortex, PLC injury

51
Q

Nonoperative treatment of subaxial cervical vertebral body fractures

A

Hard collar, mild compression but stable (PLC intact), anterior tear drop

52
Q

Surgical treatment of subaxial cervical vertebral body fractures

A

Anterior surgery - best within 24 hours
Compression fx with 11 degrees of angulation or 25% height loss
Unstable burst with cord compression
Unstable flexion tear drop with cord compression
Minimal injury to posterior elements
Posterior surgery if significant injury to posterior elements

53
Q

extension tear drop fracture of cervical spine

A

avulsion of anteroinferior corner of vertebral body from forced hyperextension
hard collar

54
Q

Cervical spinous process fracture

A

Clay-Shoveler fracture
Avulsion of spinous process fracture
Nonop

55
Q

Closed cervical traction

A

pin placement: 1cm above pinna, in line with external auditory meatus below equator of skull
Too anterior: extension and superficial temporal artery at risk
Too posterior: flexion

56
Q

TLICS Scoring

A

4 indeterminate, 5 surgery
compression 1, burst +1, translation/rotational 3, distraction 4
Nerve: intact 0, nerve root 2, Complete cord/CM 2, incomplete cord 3, CE 3
PLC: intact 0, suspected interminate 2, injured 3

57
Q

Thoracolumbar burst fracture treatmetn

A

if PLC intact and neuro intact - nonop TLSO controversial
posterior stablization w/o decompression: PLC, progressive kyphosis
W/ decompression and fusion: neurodeficits, TLCs >5
translational always 3 column

58
Q

Flexion-distraction thoracic trauma

A

Chance fracture; high rate of GI injuries
MRI PLC stability
TLSO: stabile PLC, bony chance, neuro intact
Decompression stabilization possible corpectemy: neuro deficits, PLC damage

59
Q

Thoracolumbar fracture dislocation

A

typically at the junction, posterior facet dislocation
MRI pLC stability
Posterior open reduction and fusion

60
Q

Osteoporotic vertebral compression fracture

A

hx of 2+ VCf greatest risk factor for more
Observation and bracing even in >30 degrees kyphosis or > 50% height loss
<5d: calcitonin for pain or bisphosponates
Kyphoplasty 6 weeks of refractory pain

61
Q

hold long do fusion constructs need to be in thoracic spine

A

short segment pedicle screw rod constructs for most thoracolumbar fractures

62
Q

Most common site of cervcal disc herniation

A

C5-C6, posterior lateral
ACDF if failed 3 months with radic sypmptoms

63
Q

Indication of poor prognosis on imaging with myelopathy

A

Myelomalacia on T2 (bright)

64
Q

What compression ratio (Torgs) is indicative of poor prognosis with myelopathy

A

<0.4

65
Q

Basilar invagination measurements

A

Ranawat <13mm
>5mm migration with McGregor’s or Chamberlains
MRI cervicomedullary angle <135

66
Q

Causes of subaxial subluxation in RA

A

more common with steroids, males, seropositive RA and nodules
Pannus formation at facet and Luschka

67
Q

Subaxial subluxation in RA measurements

A

Subluxation of >4mm or 20% indicates cord compression
cervicle height index (body height/width) <2.0 is 100% sensitive for predicting neurologic compromise

68
Q

Ranawat classificaiton

A

I: pain, neuro intact
II: dysesthesias, UNM signs, normal strength
IIIA: objective weakness
IIIB: nonambulatory (do not operate)

69
Q

Surgical indications in RA

A

Ranawat IIIA, II, IIIB, myelopathy
meet indication for AA, BI or SS

70
Q

Elective surgery precaution in patient with RA

A

instability if >4mm motion

71
Q

Treatment for OPLL

A

Asians, decompression if myelopathic symptoms

72
Q

Adjacent segment disease risk after ACDF

A

25% at 10 years
c5-6 high risk
Smoking strongest patient factor

73
Q

Outcomes of cervicle disk replacement

A

equivalent to fusion for neurologic improvement and patient reported outcomes for 1 and 2 level disease
superior reoperation rates

74
Q

Indication for fusion with laminectomy

A

complete facet removal
pars fracture
degenerative spondy or scoliosis

75
Q

Persistent pain after disketomy

A

Perineural fibrosis

76
Q

Most common level of thoracic disc herniation

A

T9-12, even if radiculopathy dont knee to operate
Posterior approach highest rate of neurologic injury

77
Q

Wiltse Newman Classification

A

I: dysplastic congenital pars defect
II-A: isthmic pars fatigue fracture
IIB: isthmic pars elongation
IIC: isthmic pars acute fracture
III: degenerative facet instability without a pars fracture
IV: traumatic acute posterior arch fx other than pars
V: neoplastic

78
Q

How to test for spondylolithesis instability

A

flex/ext xrays
4mm translation or 10 degrees of angulation

79
Q

Initial treatment degenerative spondylolithesis

A

nonop
PLIF or TLIF failure 3-6mo
ALIF reserved for pseudoarthorosis

80
Q

What is associated with highest risk for in hospital complication with patient undergoing fusion for degen spondyl

A

Age

81
Q

Typical level of isthmic spondylolithesis

A

L5 on S1, can cause radicular symptoms of L5

82
Q

Indications for surgery in adult isthmic spondylolithesis

A

slip greater than 50% in growing children
greater than 75% in mature adolescents
Progression more than 30%
functional impairment, pain, neurosymptoms
Decompression with TLIF/PLIF if pain with 6 mo nonop treatment or indications above
Insitu if low grade

83
Q

When to do pars repair

A

no slippage, no disc disease
L1-L4 isthmic that fails nonop

84
Q

risk factors for isthmic spondy

A

repetitive hyperextension, higher sacral table index, higher pelvic incidence and sacral slope

85
Q

Risk factor for slip progression

A

higher grade slip, Myerding 2 >50% risk of progression

86
Q

clinical tests for spondy

A

hamstring tightness, back pain aggravated with extension
pain with standing single limb lumbar extension

87
Q

Indications for TLSO treatment with isthmic spondy

A

acute pars stress reaction, isthmic failure or low grade failure to improve with PT ~6 weeks
6-12 wks, brace immobilization superior to activity restriction alone for acute stress reaction

88
Q

What meets criteria for adult spine deformity

A

> 10 degree curve or >5cm sagittal imbalance on C7 plumb line
idiopathic thoracic spine
degenerative lumbar spine

89
Q

Risk of progression with adult spine deformity

A

thoracic curve 1 degree/yr, lumbar 0.5 degrees per year, thoracolumbar 0.25 degrees per year

90
Q

Surgical indications for adult spine deformity

A

Coronal curve >50 degrees, Sagittal imbalance >5cm, curve progression, severe pain unresponsive to nonsurgical management

91
Q

What degrees of curve affect pulmonary function and mortality in ASD

A

60 for pulmonary compromise, 90 for mortality

92
Q

Goals of surgery with ASD

A

Restore sagital balance SVA <5cm (most reliable predictor for resolution of clinical symptoms postop
LL within 9 degrees of PI
Pelvic tilt < 20 degrees
Solid fusion
Cement augmentation better in every way w/o complications

93
Q

How to choose fusion levels in ASD

A

Proximally to neutral horizontal vertebrae
Extend to L5 if no L5-S1 pathology
Extend to S1 if pathology: increased stability, higher rate of pseudoarthrosis
Extend to pelvis: >3 fusion level, increases stability and fusion success

94
Q

When to do an anterior procedure with ASD

A

Large rigid curves >70 degrees

95
Q

Most common reason for reoperation in ASD

A

Hardware failure due to pseudoarthrosis

96
Q

Risk factors for pseudoarthrosis in ASD

A

age, kyphosis >20 degrees, >5cm positive sagittal imbalance, smoking

97
Q

What affect does smoking have with surgical treatment of ASD

A

infection, pseudoarthrosis, reoperation, lower functional outcome scores

98
Q

Osteotomies in spine surgery and degree of correction

A

SPO: 10 degree/level
PSO: for sagittal imbalance >12cm, 30-35 degrees in lumbar, 25 degrees in thoracic (good if anterior fusion unlike SPO)
Vertebral column resection: sagittal imbalance requiring correction up to 45 degrees, good for rigid thoracic spine kyphosis, severe rigid scoliosis, congenital kyphosis

99
Q

Treatment of sacral insufficiency fractures

A

WBAT walker, pain control
Sacroplasty failed nonop with Denis zone I
otherwise SI screws

100
Q

Risk factors for DISh

A

Gout, Diabetes, hyperlipidemia
bisphosphates then surgery
most common right side of thoracic spine

101
Q

Types of extra dural spine tumors

A

Mets: rad and chemo, resection if isolated lesion
Lymphoma: MTX

102
Q

Intradural intramedullary spine tumors

A

radicular pain, motor and sensory deficits
Ependymoma: resection
Astrocytoma: benign in children, resection

103
Q

Intradural extramedullary tumors of spine

A

Central cord compression and radicular symptoms
Schwannoma S100+, Antoni A/B, surgical resection, post op chemo
Meningoma: meningothelia whorls, surgical resection

104
Q

Diastematomyelia

A

congenital spine condition with fibrous, cartilaginous or osseous bar creating and longitudinal cleft in spinal cord
observation if asymptomatic, resect if sxs

105
Q

Syrinx and synringomyelia

A

fluid filled cavity in spinal cord, lesion for obstruction CSF flow
Scoliosis, Charcot’s, Klippel feil deformity
Need MRI
Decompression if symptomsO

106
Q

Osteoblastoma and osteoid osteoma treatment

A

en bloc resection

107
Q

Plasmocytoma

A

radiation, stabilization if neeed

108
Q

Markers of maturity in AIS

A

Risser 4, <1cm change in height over 2 visits 6 months apart, 2 years postmenarchal

109
Q

Klippel Feil

A

congenital cervical fusion SGM1 chrom 8
Short neck, low hairline, stiff neck, renal and cardiac problems, Sprengles deformity, Scoliosis, deafness

110
Q

Other tests for congenital scoliosis

A

renal U/s, ECHO
VACTERAL, Chiari, tether, syrinx, Klippel feil

111
Q

Risk of progression in infantile scoliosis

A

RVAD >20, Cobb>20

112
Q

Scheuermann’s Kyphosis

A

AD
Anterior wedging >5 degrees across 3 consecutive vertebrae
Bracing: 60-80 degrees if growth remaining
Fusion kyphosis >75, neuro deficits

113
Q

Atlantoaxial rotatory instability

A

C1-C2 subluxation or facet dislocation
Torticollis, Downs, RA, Trauma, infection
CT scan diagnosis
<1 week subluxation: soft collar
>1 week: halter traction and hard collar
>3m, neuro deficits, failed halo traction, C1-C2 fusion

114
Q

Congenital muscular torticollis

A

recommend U/S, MRI brain and cervical spine
Passive stretching 1 year (>90% resolution), flat facial features contralateral side
Bipolar relase or Z lengthening
Assocations: DDH, adductus, CV foot (packing disorders)

115
Q

Pediatric intervertebral disc calcificaitons

A

unknown, pain and stiffness
Observation

116
Q

Treatment of spinal TB

A

CT guided bx
Bracing AntiTB drugs
Surgery if neuro deficits or progressive kyphosis (anterior decompression/corpectomy with posterior stabilization)

117
Q

7 risk factors of antibiotic failure with epidural abscess

A

IV abx only if no neuro deficits
Neuro deficits, diabetes, CRP>155, WBC >12, Age>65, MRSA, +blood cultures

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