Cervical Degenerative Disk Disease and Cervical Myelopathy Flashcards
Cervical spinal spondylosis usually implies a more widespread age-related degenerative condition of the cervical spine including various combinations of which of the following?
● A. Congenital cervical spinal stenosis (the shallow cervical canal) and degeneration of the intervertebral disk producing a focal stenosis due to a cervical bar which can be due to an osteophytic spur or protrusion of intervertebral disk material
● B. Hypertrophy of lamina, dura, articular facets, and ligaments (ligamentum flavum, PLL, OPLL, ossification of ligamentum flavum) plus subluxation due to disk and facet joint degeneration
● C. Altered mobility and telescoping of the spine due to loss of height of VBs and disks, which is also called as shingling of laminae
● D. Alteration of normal lordosis curvature including excessive lordosis or kyphosis
● E. All of the above
E. All of the above
In case of myelopathy, the histological findings are degeneration of the central gray matter at the level of compression, degeneration of the posterior column above the lesion, and demyelination of the lateral columns especially corticospinal tracts (anterior spinal tracts are relatively spared). Following are included in the pathogenesis of cervical myelopathy except?
● A. Direct cord compression between osteophytic bars and hypertrophy or infolding of the ligamentum flavum especially if superimposed on congenital narrowing or cervical subluxations
● B. Ischemia due to compression of the vascular structures
● C. Repeated local cord trauma by normal movements in the presence of protruded disks and/or osteophytic bars
● D. Compression due to hypertrophy of the anterior longitudinal ligament
D. Compression due to hypertrophy of the anterior longitudinal ligament
Cervical spondylosis is the most common cause of myelopathy in patients more than 55 years of age, and cervical spondylotic myelopathy (CSM) is rare in patients less than 40 years of age. CSM develops in almost all patients with more than or equal to 30% narrowing of cross-sectional area of the cervical
spinal canal. Clinical problems that can occur with cervical spondylosis include myeloradiculopathy which includes radiculopathy and myelopathy and the second one is pain and paresthesias in the head, neck, and shoulders with little or no suggestion of radiculopathy nor abnormal physical findings. Which of the following statements regarding individual symptoms of CSM is correct?
● A. The earliest motor findings are typically weakness in the triceps and hand intrinsics with wasting of the hand muscles and slow stiff opening and closing of the fist. Clumsiness with fine motor skills (writing, buttoning buttons) is common. There is often proximal weakness of lower extremities
(mild to moderate iliopsoas weakness in 54%) and spasticity of the lower extremities
● B. Sensory disturbance may be minimal and when it occurs it is like glove distribution sensory loss in the hands. A sensory level may occur a number of levels below the area of cord compression. Lower extremity often exhibits loss of vibratory sense (in 82% cases) and occasionally has reduced pin prick
sensations (9%)
● C. In 72 to 87% of cases, reflexes are hyperactive at a varying distance below the level of stenosis and clonus, Babinski, or Hoffmann’s sign may be present. Dynamic Hoffmann’s sign may be more sensitive while inverted radial reflex is said to be pathognomonic of CSM
● D. Urinary urgency and frequency are common in CSM, while urinary incontinence is rare. Anal sphincter disturbances are uncommon
● E. All of the above
E. All of the above
Which of the following are included in the cervical spondylotic myelopathic syndromes?
● A. Transverse lesion syndrome: Most frequent syndrome, possibly an end stage of the disease process
● B. Motor system syndrome: Mixture of lower motor neuron findings in the upper extremity and upper motor neuron finding in the lower extremities which can mimic ALS
● C. Central cord syndrome: Motor and sensory involvement producing greater deficit in the upper extremities than the lower extremities results in the so-called numb-clumsy hand syndrome. Lhermitte’s sign may be more common in this group
● D. Brown-Sequard syndrome: Upper motor neuron weakness ipsilateral to the side of greater narrowing while contralateral impairment of pain, temperature, and joint position sense
● E. Brachialgia and cord syndrome: Primarily radiculopathy
with lesser association with long tract involvement
● F. All of the above
F. All of the above
According to the modified Japanese Orthopedic Association Scale, severe spondylotic myelopathy implies Benzel mJOA grade of how much?
● A. More than or equal to 15
● B. 12 to 14
● C. Less than or equal to 11
● D. More than 9
● E. None of the above
C. Less than or equal to 11
Amyotrophic lateral sclerosis (ALS) is anterior horn motor neuron disease which can mimic motor system syndrome of cervical spondylotic myelopathy (CSM). Triad of ALS are atrophic weakness of hands and forearms, mild lower extremity spasticity, and diffuse hyperreflexia. Which of the following features can help differentiate ALS from CSM?
● A. In ALS sensory symptoms are conspicuously absent while in CSM hand numbness may occur
● B. Bulbar symptoms like dysarthria and hyperactive jaw jerk may occur in ALS but are absent in CSM
● C. ALS causes extensive weakness/muscle atrophy of hands usually with fasciculations
● D. ALS will cause LMN findings in the tongue like visible fasciculations and positive sharp waves on EMG or in the lower extremity like atrophy and fasciculations
● E. CSM or herniated cervical disk usually includes neck and shoulder pain, limitation of neck movements, sensory changes, and LMN findings restricted to one or two spinal cord segments
● F. All of the above
F. All of the above
Cervical canal stenosis is spina canal narrowing sufficient to produce spinal cord compression and thereby spinal cord symptoms. Cervical spondylotic myelopathy (CSM) is rare in patients with canal diameter more than 16 mm, and its risk is increased in patients with less than 14-mm diameter. Values
less than or equal to 10 mm are likely to be associated with myelopathy while in average patients with CSM, canal diameter is around 11.8 mm. Which of the following findings are found in CSM patients with poor outcome?
● A. Multilevel hyperintensity within the spinal cord parenchyma in T2WI
● B. Single-level T2WI hyperintensity with corresponding T1WI hypointensity
● C. Spinal cord atrophy (transverse area less than 45 mm2)
● D. Banana-shaped cord in axial images
● E. Snake eyes within the spinal cord on axial T2WI may be related to cystic necrosis of cord and is correlated with pooroutcome
● F. All of the above
F. All of the above
Nonoperative management of cervical spondylotic myelopathy includes which of the following?
● A. Prolonged immobilization with rigid cervical bracing
● B. Modified activities to eliminate high-risk activities
● C. Bed rest
● D. Anti-inflammatory medications
● E. All of the above
E. All of the above
Patients with mJOA score of more than 12 may derive significant improvement from surgery and deterioration from this point may be ominous. For degenerative cervical radiculopathy, patients do better with anterior decompression with/without fusion and cause rapid relief of pain in arm and neck
and of sensory loss within 3 to 4 months while relief of symptoms like weakness of wrist extension, elbow extension, shoulder abduction, and internal rotation may take up to how long?
● A. 9 months
● B. 6 months
● C. 3 months
● D. More than or equal to 12 months
● E. More than 18 months
D. More than or equal to 12 months
Situations where posterior approach would generally be the initial choice include which of the following?
● A. Congenital cervical stenosis
● B. Disease over more than or equal to three levels
● C. Cases of OPLL
● D. Primary posterior pathology like infolding of ligamentum flavum
● E. All of the above
E. All of the above
Hard calcified disks are commonly found in thoracic spine. Which of the following is sometimes called a hard disk in cervical spine?
● A. Shallow canal
● B. Osteophyte
● C. Lamina
● D. Hypertrophied ligamentum flavum
● E. Facet joint capsule
B. Osteophyte
The bow stringing of cervical spinal cord refers to which of the following?
● A. Kyphosis
● B. Lordosis
● C. Ossified posterior longitudinal ligament
● D. Hypertrophied ligamentum flavum
● E. Multilevel disk protrusion
A. Kyphosis
What is the earliest motor finding in cervical spondylotic myelopathy (CSM)?
● A. Weakness of triceps and hand intrinsics
● B. Proximal weakness of lower extremities
● C. Spasticity of lower limb
● D. Weakness of biceps
● E. Weak extension of elbow
A. Weakness of triceps and hand intrinsics
During degenerative cervical spine disease, which of the following is usually spared?
● A. Gray matter
● B. Posterior columns
● C. Lateral columns
● D. Corticospinal tracts
● E. Anterior spinal tracts
E. Anterior spinal tracts
What is the pathognomonic test for cervical spondylosis myelopathy?
● A. Lhermitte’s sign
● B. Hoffmann’s sign
● C. Dynamic Hoffmann sign
● D. Inverted radial reflex
● E. Babinski’s reflex
D. Inverted radial reflex
