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Ortho- Spine > Dr. Lehman > Flashcards

Dr. Lehman Flashcards

1
Q

General Surgical Indications

A
  1. Persistent, recurrent arm or leg pain that is non-responsive to conservative treatment for 3 months
  2. static neurological deficit associated with significant radicular pain
  3. progressive, functional neurological deficit
  4. Confirmatory imaging studies consistent with clinical findings
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2
Q

Cervical Myelopathy- definition

A

“cervical spinal cord disease”- pts with spinal cord compression
most common cause of cord dysfunction
NOT A RADIOGRAPHIC DIAGNOSIS
constellation of symptoms and findings
Caused by many issues- should always be screening for it

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3
Q

Cervical Myelopathy- Clinical Presentation

A
  1. balance/gait abnormalities
  2. coordination/dexterity loss (buttons, dropping things, handwriting)
  3. spasticity/sensory changes (diffuse numbness)
  4. Bladder/bowel dysfunction
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4
Q

Cervical Myelopathy: imaging

A

MRI is most important- if suspicious, expedient imaging and referral!
look for white signal in spinal cord –> “sick spinal cord syndrome” (signal will never go away)
IF SICK SPINAL CORD SYNDROME (spinal cord signal on MRI), DO NOT DO CERVICAL TRACTION

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5
Q

Surgical Indications: Cervical Myelopathy

A
  1. symptoms and findings of myelopathy

2. imagining showing cord compression

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6
Q

Cervical Myelopathy Symptoms

A
  1. weakness UE > LE
  2. decreased dexterity
  3. ataxia
  4. sensory changes (numbness, burning, tingling)
  5. spasticity
  6. urinary retention
  7. Hyperreflexia (hoffman’s sign, clonus, babinski, inverted radial reflex)
  8. axial neck pain
  9. occipital headaches
  10. changes/deterioration in gait - “bumping into walls”
  • often found in combination with radiculopathy
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7
Q

Cervical Myelopathy Red Flag

A

LE pain worse than UE pain (corticospinal tracts)

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8
Q

Waddell’s Signs

A

3/5 correlates with crazy:

  1. superficial tenderness
  2. simulation
  3. overreaction
  4. regional disturbances
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9
Q

Cervical Myelopathy: Physical exam findings

A

Motor: UE > LE (LE weakness is concerning), finger escape sign, grip and release
Sensory: pinprick and vibratory changes (global deficits are bad)
UMN: hyperreflexia, inverted radial reflex, hoffman’s, clonus, babinski
Gait and balance: inability for heel-to-toe and rhomberg

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10
Q

Cervical Myelopathy: Imaging findings

A

Radiographs: spondylosis, decreased canal diameter, kyphosis, flex/ext instability
MRI: effacement of CSF (functional stenosis, myelomalacia on T2
Poor Prognosis if found on MRI….
T1 changes
compression ratio

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11
Q

Cervical Myelopathy: Etiology

A
  1. Degenerative (cervical spondylitic myelopathy)
  2. congenital
  3. OPLL
  4. Epidural abscess, tumor, osteo, kyphosis
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12
Q

Cervical Myelopathy: natural history

A

stepwise deterioration followed by periods of stability

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13
Q

Cervical Myelopathy: classification

A
  1. Nurick
  2. Ranway
  3. Japanese (JOA)
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14
Q

Conus Medullaris v Cauda Equina Syndrome

A

Cauda Equina: compression of terminal nerves, radicular symptoms
Conus medullaris: compression of terminal SC, myelopathic symptoms

overlapping symptoms
CES = bowel and bladder, saddle anesthesia
early decompression necessary!! (still poor prognosis)

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15
Q

Cervical Spine Traumas: what imaging to get

A

NOT: flex/ext films
DO: MRI (PL complex), soft tissue swelling (careful with crying kids)

*~1/3 of cervical injuries require imaging

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16
Q

Cervical Surgeries: Anterior approaches

A
  1. Anterior cervical discectomy and fusion (ACDF)
  2. Anterior cervical corpectomy and fusion (ACCF)
  3. Cervical disc arthroplasty
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17
Q

Cervical surgeries: posterior approaches

A
  1. Laminectomy +/- Fusion
  2. Laminoplasty (vertebra held together with bolts)
  3. Laminoforaminotomy
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18
Q

Cervical Disc Herniations: most common, classifications

A

most common: C6/7 – C7 nerve root

Classification: Central, posterolateral, foraminal

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19
Q

Cervical Disc Herniations: Physical exam Dx

A

Physical exam:
+ Spurlings
+ shoulder ABD

Dx = symptoms + imaging + exam ALL match

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20
Q

Cervical neuroanatomy: where do nerves exit in relation to pedicles? What HNP/involved segment causes issues to what nerve?

A

8 nerve roots in cervical spine
All (except 8th) exit ABOVE pedicle of corresponding vertebral level
Affected nerve root = lower of the involved segment (C5/6 HNP = C6 nerve root affected)

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21
Q

Lumbar neuroanatomy: where do nerves exit in relation to pedicles? What HNP/involved segment causes issues to what nerve?

A

lumbar nerves exit BELOW pedicle of corresponding vertebral level
Affected nerve root = lower of the involved segment (L4/5 HNP = L5 nerve root affected)
*exception = far lateral disc herniation, then above nerve root is affected (L4/5 far lateral HNP = L4 involvement)

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22
Q

Cervical Spine HNP Operative indications

A
  1. neuro deficit

2. 6-12 weeks failed conservative tx (80% resolve with conservative tx)

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23
Q

C-Spine HNP surgical options

A

Central and PL ACDF
Laminoforaminotomy (cannot perform above C5)

Note: HNP can cause cervical myelopathy

24
Q

Cervical Stenosis: measurements

A

Relative stenosis: 13mm
absolue stenosis: 10mm
*can cause cervical myelopathy

25
Q

Cervical Radiculopathy: Useful imaging

A
  1. Plain X-Rays
  2. MRI
  3. CT Scan
26
Q

Cervical Radiculopathy: Plain X-Rays

A

important in initial screening test in eval of C-spine symptoms
valuable information: presence of deformity, instability, congenital anomolies, neuplasms
Different views for different advantages

27
Q

Cervical Radiculopathy: advantage of lateral plain X-Ray

A
  1. disc height
  2. osteophytes
  3. alignment
  4. facet joints
28
Q

Cervical Radiculopathy: advantage of AP plain X-Ray

A
  1. uncinate processes
  2. uncovertebral joints
  3. disc spaces
29
Q

Cervical Radiculopathy: advantage of oblique plain X-Ray

A
  1. foramina
  2. pedicles
  3. articular masses
  4. apophyseal joints
30
Q

Cervical Radiculopathy: advantage of flex/ext plain X-Ray

A

subluxation

31
Q

Cervical Radiculopathy: advantage of MRI (T1 v T2)

A

most common + accurate for HNP or stenosis
T1: HNP, calcified ligaments, bone-spurs, masses
T2: myelographic view

32
Q

Cervical Radiculopathy: Disadvantage of MRI

A
  1. limited ability to distinguish “hard discs” from ossified posterior longitudinal ligament
  2. limited imaging of neuroforamina
33
Q

Cervical Radiculopathy: Electrodiagnosis

A

EMG and NCS

  • role = assist in difficult diagnostic situations and rule out peripheral neuropathies
  • dependent on ability to detect motor changes occurring as a result of nerve compression
  • sensory nerve AP remains normal if compression occurs proximal to dorsal root ganglion (abnormalities may be noted 3wks post injury)
  • Findings: Fibrillation potentials, + sharp waves, polyphase potentials
34
Q

Cervical Radiculopathy: Treatment options

A
  1. Nonoperative: activity modification, pharma, epidural steroids, PT
  2. Operative: Cervical discectomy with fusion (anterior or posterior)
35
Q

Cervical Radiculopathy: Non-Operative Treatment

A

Soft collar for maximum 2 weeks (dec. inflammation)
Traction (unproved)
Medications
PT

36
Q

Cervical Radiculopathy: Pharmacological Treatment

A
  1. Narcotics (acute)
  2. muscle relaxants (no shown benefit)
  3. NSAIDS
  4. Oral corticosteroids (medrol dose pack, anecdotal evidence)
  5. neurontin/lyrica
37
Q

Cervical Radiculopathy: Manipulation during PT

A

debated efficacy
generally safe (5-10/10million complications)
short term benefits
RED FLAG: CERVICAL MYELOPATHY

38
Q

Cervical Radiculopathy: Epidural Steroids- who is it beneficial in

A

Pts with signs and symptoms of specific radicular disorder
postitive prognosis
*weight pros and cons of needle placement and anti-inflammatory effects

39
Q

Cervical Disc Replacement: description

A
  1. FDA approved
  2. same indication as fusion
  3. same approach/decompression
  4. advantages: maintains motion, avoids nonunions

*12 Level 1 studies

40
Q

Cervical Radiculopathy: Findings in exam

A
  1. spinal nerve compression
  2. follows dermatome
  3. pain distal to elbow (Except C5)
  4. +/- associated findings: motor weakness, sensory changes, loss of reflex
41
Q

Cervical Radiculopathy: C5

A
  1. Starts in neck
  2. overhead alleviates pain
    • spurlings
  4. shoulder ROM nl
42
Q

Cervical Radiculopathy: Shoulder pathology

A
  1. starts in shoulder
  2. overhead is painful
    • impingement signs
  4. localized tenderness
  5. dec. shoulder ROM
43
Q

Cervical Radiculopathy: C7

A
  1. starts in neck
  2. long finger
    • Spurlings
  4. MRI findings
44
Q

Cervical Radiculopathy: C8

A
  1. starts in wrist/hand
  2. 3-5 fingers
    • Phalen’s/Tinel’s
  4. EMG findings
45
Q

Lumbar Radiculopathy: Signs and symptoms

A
  1. dermatomal pain
  2. usually radiates below the knee
  3. +/-: motor weakness, sensory changes, loss of reflex
46
Q

Lumbar Radiculopathy: Classic Physical Findings

A
    • SLR (Esp L5 S1)

2. + Femoral Stretch test (L2, L3, L4)

47
Q

Lumbar Radiculopathy: L5-L5 HNP (pain pattern, description, aggravation)

A 
L5 nerve root! * most common lumbar HNP
Pain pattern: lateral calf, dorsum foot
Description: "shooting pain"
Numbness: great toe
Worse in sitting/driving
48
Q

Lumbar Spinal Stenosis: presentation

A
  1. 50+ yrs
  2. back and leg pain
  3. +/- radicular distribution
  4. burning/tightness in the buttocks with walking
  5. neurogenic claudication (pain with walking/standing, alleviated with flexion/sitting, “heavy” leg)
49
Q

Lumbar Spine: HNP Treatment

A
  1. PT (core strengthening)
  2. nerve root injections
  3. microdiscectomy
50
Q

Lumbar Spine HNP: indications for microdiscectomy

A
  1. failure of non-op treatment of at least 6wks
  2. intractable plain
  3. progressive weakness
  4. expect return to sport (take needs of athlete into account)
51
Q

Lumbar Disc Herniation: Natural History of Sciatica, surgical/non-surgical intervention

A
  • 38% improve after 1 month
  • 73% improve after 3 months
  • recurrence rate increased in non-op pts

*surgery is beneficial early (1yr f/u), but no significant difference with non-op at 4yr and 10yr f/u

52
Q

Indications for lumbar discectomy

A
  1. cauda equina syndrome
  2. progressive neurologic deficit
  3. significant neurologic deficit
  4. failure of nonoperative treatment
53
Q

Degenerative Lumbar Spondylolysthesis: most common area and population

A

L4-5

Females > males (5:1)

54
Q

Degenerative Lumbar Spondylolysthesis: physical exam

A
  1. loss of lumbar lordosis
  2. fixed forward posture (ask if they lean on the shopping cart)
  3. hip flexion contracture
  4. weakness in 15% pts
  5. if extreme, look for HNP
55
Q

Degenerative Lumbar Spondylolysthesis: Treatment

A

Should be treated surgically (especially if persistent neurogenic claudication)
*showed substantially greater improvement in pain and fucntion for 2yrs

Ortho- Spine (2 decks)

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