Neurospine Flashcards
A 15 year old boy presents with neck pain. He is neurologically intact. A CT of the cervical spine reveals an osteolytic lesion with multiple fluid-filled cavities involving the body of C4. What is the most likely diagnosis?
A. Ewings sarcoma
B. Aneurysmal bone cyst
C. Osteosarcoma
D. Eosinophilic granuloma
E. Fibrous dysplasia
B. Aneurysmal bone cyst
The most likely diagnosis is an aneurysmal bone cyst (ABC), ABCs present commonly in children and radiographically appear as an osteolytic lesion with multiple fluid-filled cysts. They are considered benign tumors. Primary malignant tumors of the bone indude osteosarcoma and Ewings sarcoma. Osteosarcoma have both a lytic and blastic component on xrays and are typically referred to having a ‘sunburst appearance’. Ewing’s sarcoma is the second most common primary bone tumor in children. Radiographically, they demonstrate diffuse destruction of bone and are associated with a periosteal reaction which produces an “onionskin” appearance on xray.
A 19 year old male presents with tussive headaches located at me posterior base of the skull. NeuroIogic examination reveals weakness of the hands bilaterally with hypesthesia. MR of the brain and cervical spine are shown in the figures. What Is the BEST initial management strategy for this presentation?
A. Posterior cervical decompression
B. Posterior fossa decompression
C. Syringo-subarachnoid shunt
D. Ventriculoperitoneal shunt
E. Anterior transoral odontoid resection
B. Posterior fossa decompression
Suboccipital or posterior fossa decompression has long been used as part of the surgical treatment for synngomyelia related to Chiari I malformation.
In approximately 50% of patients with Chiari I malformation and up to 90% of those with spinal cord symptoms an associated syrinx is present. Posterior fossa decompression in patients with Chiari I malformation and syringomyelia is an effective and safe initial treatment.
Anterior transoral odontoid resection, placement of a syringosubarachnoid shunt and posterior cervical decompression are typically reserved for patients if further abnormalities of the craniocervical junction exist or standard decompressive techniques fail or cannot be applied. Ventriculoperitoneal shunt placement is
A 26 year old male presents after motor vehicle crash with absent right and partially preserved left lower extremity motor function (more than half of left leg muscles have less than antigravity strength). Sensation to pain and temperature Is markedly diminished In the left leg. Proprioception is markedly diminished in the right leg.
Neuro-imaging studies are obtained and depicted in Figures 1 and 2. Which spinal cord syndrome BEST describes the injury:
A. Cauda equina
B. Brown-Sequard
C. Anterior spinal
D. Central cord
B. Brown-Sequard
The spinal cord injury described would be best described as a Brown-Sequard syndrome. Classically, the history and physical examination reveal ipsilateral loss of proprioception and vibratory sensation, ipsilateral motor paralysis, and contralateral loss of pain and temperature sensation inferior to the lesion. This pattern reflects a functional hemisection of the spinal cord. The central cord syndrome is characterized by disproportionately greater motor deficit in the upper extremities than in the legs. Buming upper extremity dysesthesias are also common in central cord injuries. Central cord injuries are commonly seen with forced nedc extension in the presence of underlying cervical stenosis. Anterior cord injuries are associated with ventral compressive pathology and have historically been attributed to ischemia in the anterior spinal artery
A 27 year old sustains a Type II odontoid fracture. He is complaining of upper cervical pain, but his neurologic exam is normal. Which of the following factors would increase his risk for non-union?
A. Age less than 30 years
B. Comminution of the dens
C. Anterior displacement of 3 mm
D. Basilar Skull fracture
E. Vertebral artery injury
B. Comminution of the dens
Odontoid fractures represent approximately 15% of all cervical spine fractures. A type 2 odontoid fracture is through the base of the neck of the odontoid, and is usually considered unstable. The treatment options indude rigid immobilization or surgical stabilization/fusion. The factors predicting nonunion with immobilization alone are displacement of more than 4 to 6 mm, advancing age (possibly >50 years old), posteriorly displaced fractures, and patients with neurologic deficits. Surgical treatment is indicated if displacement is >6mm, previous nonunion, or instability of the fracture site while in rigid immobilization.
A 28 year old male presents to the Emergency Department with complaints of severe low back and right leg pain after injury while working as a carpenter the previous day. He denies weakness, numbness and gait or bowel/bladder disturbance. Examination reveals trace weakness of dorsi-flexion on the right associated with pain. The BEST Initial management strategy for this patient is:
A. Epidural steroid injection
B. Seven day course of bed rest
C. Lumbar discectomy
D. Nonsteroidal anti-inflammatory medications
E. Posterior lumbar interbody fusion
D. Nonsteroidal anti-inflammatory medications
This patient presents with acute low back pain and sciatica without a significant neurological deficit. There are no ‘red flags’ to indicate the need for imaging. The vast majority of patients with acute low back pain and sciatica will recover spontaneously over a four to six week time course. In the absence of a clinically significant neurological deficit, it is usually inappropriate to perform any type of surgery. Similarly, the use of invasive non-operative measures is also not advised due to their inherent expense, risk, and lack of proven efficacy in this patient population. Bedrest results in deconditioning and is not generally recommended. When used, bedrest should not be prescribed for longer than four days. The use of over the counter pain medications is recommended as a treatment modality for patients with acute low back pain and radiculopathy.
A 33 year-old man with known metastatic breast carcinoma presents with a one day history of paraparesis and bladder incontinence. Her lower extremity motor strength is 2/5 in all groups. An MRI of her thoracic spine reveals an isolated dorsal metastasis with cord compression at T9-T1O and preserved alignment. After administering steroids, the next step in her course of treatment should be:
A. Single session spinal radiosurgery
B. Spinal radiation therapy
C. T9-1O spondytectomny with instrumentation
D. No additional treatment
E. T9-10 laminectomy
E. T9-10 laminectomy
The most appropriate answer is urgent T9-T1O laminectomies and decompression of the spinal cord. This patient has suffered rapid neurological deterioration including bladder incontinence. Steroids alone do not offer definitive care for this problem. A randomized, controlled study by Patchell and colleagues reported improved outcomes in selected patients treated with surgical decompression compared to patients who were treated with radiation alone. Although spinal radiation is considered one of the primary treatments for metastatic epidural spinal cord compression, in this case (in which the patient presents with acute neurologic deficits), surgical decompression should be considered first. Spondyleclomy is unecessary in a patient with isolated dorsal compression of the spinal cord.
A 35 year old woman presents with progressive upper and lower extremity myelopathy. MR imaging reveals a well defined, contrast enhancing lesion 2 cm in diameter in her cervical spinal cord. What is the most appropriate treatment for this patient?
A. Open biopsy of the lesion followed by appropriate chemotherapy and radiotherapy
B. CT guided biopsy followed by appropriate chemotherapy and radiotherapy
C. Serial MR imaging every three months
D. Complete surgical excision of the lesion, if possible
D. Complete surgical excision of the lesion, if possible
The most common histologies for intramedullary spinal cord tumors in this age group are ependymomas and astrocytomas. Surgical intervention is warranted in patients with dinicaily progressive intramedullary spinal cord tumors. Preoperative neurologic status is the single most predictor of postoperative neurologic function
A 35-year-old man presents with a several week history of left calf weakness and urinary retention. The MRI scan of the lumbar spine is most consistent with a myxopapillary ependymoma of the conus medullaris. What is the most appropriate initial management of this patient?
A. Laminectomy and tumor resection
B. Laminectomy and biopsy
C. CT-guided biopsy
D. Spinal radiosurgery
E. Clinical observation with early repeat imaging
A. Laminectomy and tumor resection
The most appropriate initial management of this patient’s probable ependymorna is laminectomy and tumor resection. Positive prognostic factors include symptoms of less than one year. confinement of the lesion to the filum terminale without infiltration or adherence to roots of the cauda equina and gross total resection.
Either laminectomy with biopsy or CT guided biopsy would not be the most appropriate treatment options as resection is the preferred approach. Radiosurgery has not been proven effective as a primary therapy for spinal ependymomas
A 36 y/o restrained driver presented after a MVC. He complained of leg numbness and weakness. Examination revealed him to have 4-/5 strength in his proximal and 3/5 strength in his distal lower extremities and an L1 sensory level. Lumbar spine radiographs and axial CT through the level of Injury are shown in the figures. What is the BEST definitive management strategy for this type of Injury:
A. TLSO brace
B. Kyphoplasty
C. Posterior spinal fusion
D. Anterior spinal fusion
C. Posterior spinal fusion
The answer is posterior spinal fusion with distraction instrumentation followed by an anterior procedure if adequate canal clearance is not obtained. The management of flexion distraction injuries in older adults usually requires surgical intervention. Stand-alone short segment constructs have been demonstrated to have a high failure rate in the presence of significant deformity of the anterior and middle elements and therefore a longer segment posterior fusion is indicated. While an anterior approach may provide useful supplementation to a posterior approach the management of fiexion distraction injuries, it does not directly address the disruption of the posterior ligamentous complex seen with this type of injury. The results of bracing in this population are usually unpredictable as the injury is also ligamentous. Kyphoplasty is useful for painful compression fractures but has no role in the management of flexion distraction Injuries.
A 38 year old man presents with severe left leg pain. The pain came on spontaneously and he cannot remember any antecedent trauma or illness. The pain is severe and has prevented him from working as a carpenter since its onset two weeks ago. His examination Is notable for a positive straight leg raising test on the left and paresthesias in the S1 distribution on the left. The remainder of his physical and neurologal examination is normal. An MRI was ordered by his primary care physician, and it reveals a left sided herniated disc. The next appropriate management strategy for this patient is:
A. Posterior lumbar interbody fusion
B. Minimally incisional endoscopic discectomy
C. Analgesics and Physical Therapy
D. Percutaneous Chymopapain injection
E. Traditional open discectomy
C. Analgesics and Physical Therapy
Because of the absence of dinical “red flags”, the patient is not a candidate for any surgical procedure in the absence of significant neurological deflcits unless his symptoms persist for at least six weeks. Conservative (i.e. non-operative) management should be employed at this point in time.
A 42-year-old woman is referred with biopsy proven chordoma within the L3 vertebral body. MRI does not show any ventral epidural extension or involvement of the peddes or posterior elements, The BEST management option for this patient Is:
A. L3 spondylectomy and L2-4 fusion
B. DebuIking of tumor and L2-4 fusion
C. L3 corpectomy and fusion plus chemotherapy
D. Radiation therapy alone
E. L3 corpectorny and fusion plus radiation therapy
A. L3 spondylectomy and L2-4 fusion
Chordomas are the most common primary malignant tumor of the spine. Although considered not to possess significant metastatic potential, such lesions are locally aggressive, leading to neurologic compromise and lytic destruction of bone. En bloc resection has afforded patients the greatest chance of local control and disease-free survival. A spondylectomy is the most widely accepted approach, consisting of resection of the posterior elements, pedicles and vertebral body. Such radical resections may be assooated with significant surgical morbidity.
Chordomas are generally considered to be resistant to radiation therapy and chemotherapy. However, recent advances in photon and proton radiation therapy and use of monoclonal antibodies may provide improved outcomes for poor surgical candidates and for tumors that recur after surgery
A 43 year old man with a 3 month history of numbness and tingling in bilateral lower extremities, diffioulty ambulating, and weakness in both hands and arms undergoes MR imaging of his cervical spine revealing a homogeneously enhancing intramedullary spinal cord tumor. The tumor diffusely and symmetrically enlarges the involved portion of the spinal cord without cyst formation. At surgery, intraoperative frozen section yields ependymoma. The MOST appropriate treatment strategy is:
A. Attempted gross total resection
B. Biopsy and external beam radiation
C. Tumor debulking and duraplasty
D. Subtotal resection and radiotherapy
A. Attempted gross total resection
In cases of intramedullary ependymoma, a plane usually occurs between the spinal cord and tumor These tumors tend to expand symmetrically within the spinal cord and may be approached via a dorsal midline myelotomy. Spinal ependymomas are often reddish brown, enhancing the surgeon’s ability to distinguish normal from neoplastic tissue. They may be totally excised in the majority of cases. often with limited neurological morbidity. Therefore, debulking the tumor and/or referring the patient for radiotherapy are less appropriate choices. After gross total resection, patients should not undergo postoperative radiotherapy but should instead be followed with serial imaging. However, it may be appropriate to administer radiotherapy to those patients where total resection was not possible. The best predictor of functional outcome after spinal ependymoma resection is the patient’s preoperative neurologic status.
A 45 year old gentleman is seen in the PACU after undergoing an anterior cervical discectomy and fusion with plating at C6-7. He is noted to have a constricted pupil and ptosis. What is the most likely explanation of this condition?
A. Recurrent laryngeal nerve injury
B. Over distraction of the disc space
C. Vertebral artery injury
D. Stretch injury of the sympathetic trunk
E. Myastenia gravis exacerbation
D. Stretch injury of the sympathetic trunk
The most likely explanation is a stretch injury of the sympathetic trunk causing a Horner’s syndrome.
Hornets syndrome results from an Interruption of the sympathetic nerve supply to the eye, and Is
characlenzed by the thad of miosis (constrked pupil), partial plosis, and loss of hemifacial sweating
(anhidrosis).
In the anterior cervical discectorny approach. lateral exposure of the longus cdi musdes can lead to exposure and injury of the sympathetic trunk. whh lies just anterior. This ocoirs in approximately 1% of patients undergoing this approach, and usually recovers spontaneously. The sympathetic trunk Is more commonly injured in the r cervical spine compared to the upper levels.
A 48 y/o female with a history of breast caronoma presents with severe neck pain for several days. The neck pain resolves with recumbency and worsens with movement. Her neurological examination is normal except for symmetric hyper-reflexia in all four extremities. Her primary disease Is well-controlled and she is otherwise healthy. MR imaging is shown below (Figure 1) In addition to appropriate adjuvant chemotherapy and radiation, the BEST treatment option is:
A. Occipito-cervical fusion
B. Posterior C1-2 transarticular screw fixation
C. transoral resection and posterior fusion
D. External orthosis only
A. Occipito-cervical fusion
The best option Is ocopito-cervical fusion, radiation therapy, and chemotherapy.
The patient is a 48 y/o, otherwise healthy female a C1-2 metastasis. The patients MRI demonstrates involvement of C1, C2, and the superior endplate of C3. There is no canal compromise.
Indications for surgical intervention In patients with spinal metastases include 1) the need to establish a diagnosis, 2) treatment of spinal instability, 3) decompression of the spinal canal in patients with radioresistant tumors or tumors that have progressed despite XRT, and 4) the potential for cure in patients with a single small metastasis within the vertebral body.
A 48 year old men presents with progressive complaints of hand paresthesias, loss of fine motor control, gait instability, and urinary urgency (MR imaging is shown below). She undergoes a posterior decompression via an open-door laminoplasty from C3 to C7. On post-operative day number 3, she complains of bilateral shoulder pain and demonstrates mild weakness of her right deltoid. The MOST appropflate next step in the management of this patient is:
A. Bilateral upper extremity EMG
B. Bilateral selective nerve root injections
C. Emergent surgery for laminectomy/foraminotomy
D. Administration of corticosteroids
E. Orthopedic/Physiatry consult for “frozen shoulder”
D. Administration of corticosteroids
The most appropriate initial step in the management of this patient is the administration of cortIcosteroids. Dissociated motor loss (DML) is a well known. but infrequent complication of extensive decompressive cervical procedures classically characterized by specific motor weakness of the C5 myotome, shoulder pain, and no dermatomal sensory loss. The reported incidence ranges from 2% to 20%. Although the etiology is unknown, nerve root tethering and traction injury after an acute anatomic shift of the spinal cord following the decompression is one hypothesis. Traditional management consists of conservative therapies including cervical immobilization, steroids, and analgesics Improvement typically occurs over many months.
A 54 year old male with non-small cell lung cancer (NSCLC) presents with progressive myelopathy over the past 2 months along with incontinence and an inability to ambulate over the past 48 hours. Imaging is as shown. What Is the most accurate statement regarding surgical decision making in this patient?
A. Regardless of surgery, performance status, serum calcium and albumin levels are the most important prognostic factors.
B. The presence of a spinal metastasis carries an extremely poor prognosis, therefore no surgery should be pursued.
C. Aggressive surgical decompression and reconstruion should be performed, as life expectancy in this patient is > 2 years.
D. Surgical decompression should be pursued in the face of neurologic deterioration during radiotherapy given its clear benefit relative to risk
A. Regardless of surgery, performance status, serum calcium and albumin levels are the most important prognostic factors
Metastatic NSCLC presenting with a spinal cord compression carries a relatively poor prognosis with a median survival of 8.8 months. As a result it is important to further stratify patients to determine which ones are best served with surgical decompression/stabilization.
Multivariate analysis of NSCLC patients has demonstrated that performance status, calcium levels, and albumin are the most significant prognostic factors for survival. Tomita et al. developed a grading system that looked at tumor histology, state of visceral disease and the presence of other bone metastasis to suggest a strategy for overall management. Depending on the patients total tumor load and other prognostic factors an argument can be made for treatment ranging from aggressive surgical resection
A 54 yo male presents with 10 years of progressive back and bilateral radicular L5 leg pain. The pain is worse when upright and refractory to conservative management. Examination reveals full strength in his distal lower extremities. Lumbar spine radiographs and MRI are shown in the figures. Flexion/extension radiographs show 4 mm of motion of L4 on L5. According to the ‘Guidelines for Management of Degenerative Lumbar Disease’, what is the BEST surgical management strategy:
A. Lumbar decompression
B. Lumbar decompression and fusion
C. Spinal cord stimulator
D. Lumbar fusion
E. Morphine pain pump
B. Lumbar decompression and fusion
According to the Guidelines, lumbar decompession and fusion is recommended for patients with lumbar stenosis and associated spondylolisthesis. Herkowitz and Kurz published a randomized controlled trial with improved outcomes for those patients randomized to fusion vs. decompression alone for lumbar stenosis with degenerative spondylolisthesis. Another randomized trial noted that the addition of segmental hardware improved fusion rates but did not appear to result in improved clinical outcomes (Fischgrund et al.,1997). The SPORT trial (Weinstein et al., 2007) also provides randomized evidence in favor of surgical management degenerative spondylolisthesis. The majority of patients treated surgically in this trial had associated stenosis at the sponlylolitic level and underwent fusion with instrumentation.
A 62 year old with known metastatic renal cell cancer presents with unbearable bad pain and lower extremity myelopathy after a fall. Her imaging is displayed in the accompanying figures, The best management strategy of this lesion would be:
A. Kyphoplasty/Vertebroplasty followed by radiotherapy
B. Stereotactic Radiosurgery
C. Conventional external beam radiotherapy
D. Laminectomy and resection of epidural disease followed by radiotherapy
E. Vertebrecomy with posterior stabilization followed by radiotherapy
E. Vertebrecomy with posterior stabilization followed by radiotherapy
The most appropriate management Includes vertebrectomy, posterior pedicle screw instrumentation, and postoperative radiotherapy. Patchell et. al demonstrated in a prospective randomized trial superior results with circumferential surgical decompression followed by radiation over conventional radiotherapy in the management of symptomatic metastatic epidural spinal cord compression (Class 1 evidence). Patients who underwent surgical intervention were not only more likely to ambulate postoperatively, but also more likely to maintain urinary continence and to achieve better pain control.
Stereotactic radiosurgery is not a good option in this case because of the presence of myelopathy and the high degree of epidural compression which would limit adequate dosing to the epidural tumor. The pathologic fracture and kyphosis will not respond to radiation alone. Vertebral augmentation may offer
A 65-year old man complains of bilateral lower extremity pain, numbness, and weakness after standing or walking for 5 minutes. A brief period of sitting or lying down results in complete relief of symptoms, after which he can walk another 5 minutes. Magnetic resonance image is shown in Figure 1. The clinical syndrome is BEST described as:
A. Neurogenic claudication
B. Diabetic peripheral neuropathy
C. Radiculopathy
D. Sciatica
E. Plexopathy
A. Neurogenic claudication
Neurogenic claudication is the symptom complex most commonly associated with lumbar spinal stenosis (illustrated in Figure 1). Patients with neurogenic daudication may be asymptomatic at rest, without neurological deficit. Symptoms typically begin when the patient stands or walks. Back fiexion typically decreases or delays the onset of symptoms. whereas back extension may exacerbate the symptoms. For this reason, patients may notice that it is easier to climb stairs than it is to descend. Neurogenic claudication must be differentiated from vascular claudication, caused by lower extremity arterial insufficiency. Patients with vascular claudication may present with diminished lower extremity pulses, non-healing sores on the lower legs or feet, and loss of hair on the calves. Pain radiating to the groin should always prompt a suspicion of degenerative hip arthritis.
A 65-year-old man presents with progressive neck pain, bilateral numb, clumsy hands, spastic gait and a present Babinski sign. Tongue fasciculations are absent, MR imaging is shown in the figure. The
MOST likely diagnosis is:
A. Combined systems degeneration
B. Parkinson’s disease
C. Amyotrophic lateral sclerosis
D. Cervical spondylotic myelopathy
E. Cerebral palsy
D. Cervical spondylotic myelopathy
Cervical spondylotic myelopathy is characterized by a combination of neck pain, numb and clumsy hands, gait disturbance, sphincter dysfunction, and impotence. Associated physical findings may include increased lower extremity muscle stretch reflexes, positive Babinski sign, and Lhermitte phenomenon, all of which are nonspecific signs of myelopathy.
The combination of decreased lower extremity reflexes and positive Babinski sign, although not absolute, should prompt a consideration of vitamin B12 deficiency (combined systems disease). Tongue fasciculations and atrophy suggest a process with bulbar involvement (for example, motor-neurone disease). Cogwheel rigidity is commonly a feature of Parkinson’s disease and combined systems degeneration. The patients MR imaging is demonstrated in the figure.
