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OSR CHAP 1 SPINE Flashcards

1
Q

What two changes occur in the vascular supply to the disk with aging?

A

Vessels begin disappearing after the age of 10 & Endplates ossify

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2
Q

What is the source of nutrients to the disk?

A

Diffusion through endplates

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3
Q

What two external factors decrease endplate permeability?

A
  1. Smoking; 2. Vibration
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4
Q

What factors increase permeability?

A

Exercise

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5
Q

How does aging affect the disk’s collagen content?

A

Decreased collagen content

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6
Q

How does aging affect the disk’s fibril diameter?

A

Increased fibril diameter and variability

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7
Q

How does aging affect the disk’s noncollagenous protein?

A

Increased noncollagenous protein

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8
Q

How does aging affect the disk’s pH?

A

Decreased pH

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9
Q

Magnetic resonance imaging (MRI): what are the rates of false-positive (asymptomatic) findings for patients 40 years old, and >60 years old?

A
  1. 40 years old: 60%; 3. >60 years old: 90%
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10
Q

What is the function of the anterior column and the posterior column?

A
  1. Anterior column: support; 2. Posterior column: tension band
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11
Q

An anteriorly placed graft is loaded in which two directions and unloaded in which two directions?

A
  1. Loaded in compression, flexion; 2. Unloaded in extension, traction
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12
Q

What effect does an anterior plate have on the axis of rotation?

A

Moves axis of rotation anteriorly

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13
Q

… on the graft in extension?

A

Loads graft in extension

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14
Q

… on the graft in flexion?

A

Unloads graft in flexion

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15
Q

What is the definition of terminal bending?

A

Moments at ends of a long construct

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16
Q

How can terminal bending be prevented?

A

With intermediate fixation points

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17
Q

How much lumbar torsional resistance is provided by facets, disk, and ligaments?

A
  1. Facets: 40%; 2. Disk: 40%; 3. Ligaments: 20%
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18
Q

After a flexion-distraction injury, what is the status of the anterior longitudinal ligament (ALL) and the posterior longitudinal ligament (PLL disrupted)?

A
  1. ALL intact; 2. PLL out
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19
Q

Which approach is biomechanically superior in this situation?

A

Posteriorly based fusions are superior to anteriorly based fusions

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20
Q

How are the cervical spine facets oriented in the sagittal plane?

A

Cervical: 45 degrees in the sagittal plane

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21
Q

Compare with thoracic and lumbar facet orientation.

A
  1. Thoracic: vertical in sagittal plane (essentially in the coronal plane); 2. Lumbar: sagittally aligned
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22
Q

The sinuvertebral nerve originates from which structure?

A

Sympathetic chain

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23
Q

What structures and elements does it supply?

A
  1. Supplies structures within the spinal canal; 2. Supplies posterior elements
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24
Q

What other neurologic structure also innervates the posterior elements?

A

Primary dorsal ramus also contributes to innervation

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25
Q

Pattern of innervation example: the L3 nerve root innervates which facets?

A

L3 innervates the L3-4 facets

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26
Q

At which level is the pedicle diameter the smallest?

A

T5

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27
Q

What is the furcal nerve? What is its clinical significance?

A
  1. Peripheral nerve often originating from L4 nerve root; 2. Can result in variable L4 dermatomal distribution
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28
Q

Infection versus malignancy: which generally destroys the disk?

A
  1. Infection destroys the disk early; 2. Malignancy usually skips the disk
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29
Q

Compare with the effect of tuberculosis on the disk.

A

Tb skips the disk early, but may involve the disk late

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30
Q

What are the earliest plain radiographic findings of infection?

A

Disk space narrowing at 7 to 10 days

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31
Q

What is the natural history of disk space infection?

A

Spontaneous arthrodesis

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32
Q

What are the two usual treatment for osteomyelitis?

A

Intravenous antibiotics Brace

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33
Q

What are the three operative indications?

A
  1. Failure of conservative treatment; 2. Progressive neurologic deficit; 3. Instability (e.g., fracture)
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34
Q

What are the two negative prognostic factors for infection?

A
  1. Increased age; 2. More cephalad involvement
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35
Q

What is the MRI appearance of malignancy on T1 and T2 sequences?

A
  1. T1: low; 2. T2: high
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36
Q

What three tumors classically involve the posterior elements?

A
  1. ABC (aneurysmal bone cyst); 2. Osteoid osteoma/osteoblastoma; 3. Osteochondroma
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37
Q

Cervical spondylosis is most common at which two levels?

A
  1. C5–6; 2. C6–7
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38
Q

Degenerative cervical spondylolisthesis is most common at which two levels?

A
  1. C3–4; 2. C4–5
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39
Q

What are the most common levels of cervical trauma in the young?

A

C4 to C7

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40
Q

What are the most common levels of cervical trauma in the elderly?

A

C1, C2

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41
Q

What is Spurling’s test? What is its clinical significance?

A
  1. Rotation, lateral bend, vertical compression of neck; 2. To identify cervical radiculopathy
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42
Q

What arm position classically relieves the symptoms of cervical radiculopathy?

A

Symptoms improve with the arm overhead

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43
Q

What is the ideal therapy regimen for radiculopathy? What percentage of patients improve?

A

Isometric exercises 75% improve

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44
Q

What is the finger escape test? What is its clinical significance?

A
  1. Spontaneous small finger abduction secondary to weak intrinsics; 2. Indicative of myelopathy
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45
Q

In what two ways does cervical myelopathy generally progress?

A
  1. Long quiescent periods; 2. Stepwise deterioration
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46
Q

What is Lhermittes sign?

A

Lightning sensation in arms with neck flexion

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47
Q

What does the C4 nerve root innervate?

A

Scapular muscles

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48
Q

What three roots correspond to reflexes within the upper extremities?

A
  1. C5: biceps; 2. C6: brachioradialis; 3. C7: triceps
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49
Q

What is the significance of a hypoactive brachioradialis (BR) reflex?

A

Hypoactive BR reflex = lower motor neuron involvement (radiculopathy)

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50
Q

What is the significance of an inverted radial reflex (IRR)?

A
  1. IRR: hypoactive BR reflex + concurrent finger flexion; 2. Upper motor neuron involvement (myelopathy)
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51
Q

What is Power’s ratio used for? What is its critical value?

A
  1. Anterior atlanto-occipital (AO) dissociation; 2. BC/AO >1: abnormal
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52
Q

What is the definition of Torg’s ratio? What is its clinical significance?

A
  1. Canal width divided by vertebral body width; 2. For the identification of congenital stenosis
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53
Q

Compare normal and critical values of Torg’s ratio?

A
  1. Normal is 1.0; 2. Critical value is <0.8
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54
Q

What three arteries contribute to the spinal cord blood supply?

A
  1. Anterior spinal artery (two thirds from vertebral artery); 2. Two dorsal spinal arteries (one third from posterior inferior cerebellar artery [PICA])
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55
Q

The watershed area of the cervical spinal cord is at which levels?

A

C5 to C7

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56
Q

What are the two classic symptoms of calcified disk disease in a child?

A
  1. Neck pain; 2. Torticollis
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57
Q

What is the treatment of choice?

A

Observation

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58
Q

What is the prognosis?

A

Likely to go on to spontaneous resolution

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59
Q

What is the most common reason for a missed cervical spine injury?

A

Inadequate visualization of involved levels

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60
Q

At which two levels are injuries most often missed?

A
  1. Cervicothoracic junction; 2. Atlantooccipital junction
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61
Q

In an awake, alert patient without neck symptoms, what is required for C-spine clearance?

A
  1. Clinical exam only; 2. No films required
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62
Q

Compare with a patient with neck pain or neurologic deficits.

A

Three views of cervical spine with or without computed tomography (CT)

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63
Q

What is the normal atlantodens interval (ADI) in adults and in children?

A
  1. Adults: <4.0 mm
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64
Q

What are the normal and unstable values of a lateral mass overhang on an open mouth view? What is its clinical significance?

A
  1. Normal = 0 mm overhang; 2. Unstable = >6.9 mm; 3. Relevant for Jefferson fracture
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65
Q

What are the two White/Panjabi instability criteria for subaxial C-spine on flexion-extension films?

A
  1. Sagittal translation >3.5 mm or 20%; 2. Sagittal rotation >20 degrees
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66
Q

… on resting films?

A
  1. Sagittal translation >3.5 mm or 20%; 2. Relative sagittal angulation >11 degrees
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67
Q

On a pediatric lateral C-spine film, what is the normal C2 retropharyngeal space? Retrotracheal space?

A
  1. <14 mm retrotracheal
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68
Q

What level is most commonly involved in pseudosubluxation? What is its significance?

A
  1. C2 on C3; 2. May be a normal finding in children
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69
Q

What is the key radiographic landmark when evaluating for pseudosubluxation?

A

Check spinolaminar line

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70
Q

What percentage of space is occupied by the cord? What makes up the remainder?

A
  1. 33% cord; 2. 33% dens; 3. 33% empty (cerebrospinal fluid [CSF], fat); Steele’s rule of thirds
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71
Q

What percentage of head rotation occurs at C1–2?

A

0.5

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72
Q

The arterial arcade around the odontoid process is supplied by which two vessels?

A
  1. Vertebral artery; 2. External carotid artery
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73
Q

What are the anterior landmarks for levels C3, C4, C5, and C6?

A
  1. C3: hyoid; 2. C4, C5: thyroid
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74
Q

The carotid tubercle is at which level?

A

C6

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75
Q

What is the C7-T1 landmark?

A

Sternal notch

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76
Q

With an anterior cervical discectomy and fusion (ACDF), what is the first muscle encountered? What is the innervation?

A
  1. Platysma; 2. Facial nerve (cranial nerve [CN] VII)
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77
Q

With an ACDF, the interval for dissection lies between what two anatomical areas?

A
  1. Carotid sheath; 2. Trachea
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78
Q

What are the four contents of the carotid sheath?

A
  1. Internal carotid artery (ICA); 2. Common carotid artery (CCA); 3. Internal jugular vein (IJV); 4. CN X vagus
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79
Q

What artery lies at the proximal extent of exposure? What is to be done with it?

A
  1. Superior thyroid artery; 2. It may be sacrificed
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80
Q

Where is the omohyoid muscle encountered? How should it be retracted?

A
  1. Encountered on the medial side of the carotid sheath within pretracheal tissue; 2. Retract medially, may divide if necessary
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81
Q

What are the origin, insertion, innervation, and function of the omohyoid muscle?

A
  1. Origin: scapula; 2. Insertion: hyoid bone; 3. Innervation: ansa cervicalis (C1 to C3); 4. Function: depress hyoid bone and larynx
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82
Q

More proximal approaches put which nerve at risk? What is its clinical significance?

A
  1. Superior laryngeal nerve; 2. Responsible for high note phonation
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83
Q

Classically, there is increased recurrent laryngeal nerve risk with which approach? Why?

A
  1. Right-sided approach; 2. More variable on right (left goes around the aortic arch)
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84
Q

In which interval does the recurrent laryngeal nerve ascend?

A

Tracheoesophageal interval

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85
Q

What do recent data indicate about the side of approach and recurrent laryngeal nerve injury rate?

A

Right- and left-sided approaches have equivalent injury rates

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86
Q

What approach places the thoracic duct at risk? What is the treatment if the duct is injured?

A
  1. Left-sided approach; 2. If injured, ligate proximally and distally
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87
Q

Horner’s syndrome is a risk at which level? Why?

A
  1. C7-T1; 2. Because of the inferior cervical ganglion
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88
Q

Vocal cord paralysis may also occur by which other mechanism? How can this be prevented?

A
  1. Compression of larynx between retractor and endotracheal (ET) tube; 2. Prevention: deflate ET tube after retractors are placed, allow tube to re-centralize
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89
Q

What does “SLAC Line” refer to?

A

The five capital letters in the acronym refer to the following structures (anterior to posterior):; 1. Sympathetic chain; 2. Longus coli; 3. Artery (vertebral); 4. cervical nerve root; 5. Lateral mass

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90
Q

What is the preferred proximal cervical approach for a singer?

A

Anterior retropharyngeal approach

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91
Q

What is the key posterior triangle for the posterior approach?

A

Suboccipital triangle

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92
Q

What two structures does this triangle contain?

A
  1. Vertebral artery; 2. C1 nerve
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93
Q

What is the most superficial structure?

A

Greater occipital nerve (C2)

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94
Q

What is the size of the safe zone relative to the C1 spinous process?

A

1.5 to 2 cm lateral from C1 spinous process to vertebral artery

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95
Q

With a posterior approach, which way should the nerve root be retracted?

A

Elevate root superiorly

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96
Q

What nerve root is at the highest risk for traction injury? Why?

A
  1. C5 at highest risk; 2. Straightest take-off
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97
Q

What is the best way to approach ossification of the posterior longitudinal ligament (OPLL)? What is the preferred surgical technique for decompression?

A
  1. Posterior; 2. Laminoplasty
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98
Q

What preoperative sagittal plane requirement is necessary for laminoplasty success?

A

Cervical lordosis

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99
Q

What is the principal complication of laminoplasty?

A

Decreased cervical range of motion (ROM) by 50 to 62%

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100
Q

The lateral mass includes which two structures?

A
  1. Pedicle; 2. Ipsilateral lamina
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101
Q

For a one-level ACDF, compare outcomes associated with allograft versus autograft use.

A

Equivalent outcomes

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102
Q

What two clinical conditions are the exceptions?

A
  1. Multiple levels; 2. Smokers
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103
Q

In performing a multiple-level ACDF, what should one consider preoperatively?

A
  1. Strut graft; 2. Plate; 3. Adjunct posterior fusion
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104
Q

For smokers, is allograft or autograft preferred for one level? What about for two levels?

A
  1. One level: always autograft; 2. Two levels: autograft strut
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105
Q

A posterior approach should generally be included with anterior surgeries in excess of ________.

A

Two corpectomies

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106
Q

What are reported ACDF pseudarthrosis rates for one level?

A

0.12

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107
Q

What are reported ACDF pseudarthrosis rates for multiple levels?

A

0.3

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108
Q

What is the significance of the Hillibrand study?

A

25% of ACDF patients required an additional procedure within 10 years for adjacent-level disease

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109
Q

What is the principal factor in determining adjacent-level degeneration?

A

Preoperative adjacent-level status

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110
Q

What is the treatment if the lateral femoral cutaneous nerve (LFCN) is cut with graft harvest?

A

Allow it to retract into the pelvis

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111
Q

What percentage of patients develop long-term pain at the graft site?

A

0.25

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112
Q

For the elderly patient, is an ACDF or a posterior approach generally better tolerated?

A

Posterior approach

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113
Q

Increased risk of dysphagia and respiratory compromise occur with which four factors?

A
  1. Increased number of levels; 2. Increased operative time; 3. Increased blood loss; 4. More proximal level of surgery
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114
Q

What complication is unique to an posterior approach?

A

Air embolism

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115
Q

When performing a multilevel posterior laminectomy, what else should one do? Why?

A
  1. Instrumented fusion; 2. To prevent postoperative kyphosis
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116
Q

What is the order of relative frequency of the three rheumatoid-related disorders within the cervical spine?

A
  1. 1: C1–2 instability; 2. 2: basilar invagination; 3. 3: subaxial subluxation
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117
Q

What are the criteria for atlantoaxial instability in the adult and in the child?

A
  1. Adult: >3 mm motion; 2. Child: >4 mm motion
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118
Q

What is the significance if >7 mm motion is seen at C1–2?

A
  1. Alar ligaments also disrupted; 2. Contraindication to elective orthopaedic surgery
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119
Q

A posterior atlanto-dens interval (PADI) smaller than ________ is an indication for surgery.

A

14 mm

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120
Q

What are the expected surgical outcomes if PADI is 10 to 14 mm or <10 mm?

A
  1. 10 to 14 mm: can expect neurologic improvement postoperatively; 2. <10 mm: stabilize; improvement unlikely
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121
Q

What is the critical PADI value in flexed position?

A

Surgery indicated if <6 mm in flexion

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122
Q

What are the two additional operative indications at C1–2?

A
  1. > 10 mm motion; 2. Myelopathy
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123
Q

What four surgical options are appropriate if C1–2 subluxation is reducible?

A
  1. Gallie technique; 2. Brooks technique; 3. Transarticular screws; 4. Harms technique
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124
Q

What three surgical options are appropriate if subluxation is irreducible? What is the key step to all three?

A
  1. Posterior decompression with occiput-C2 fusion; 2. Posterior decompression with C1–2 transarticular screws; 3. Harms technique; Key step with all interventions: decompression!
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125
Q

What is the expected long-term consequence without surgery for instability?

A

On average, patients die within 8 years

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126
Q

What are the three criteria that indicate that surgery is less likely to be successful? What is the Ranawat category?

A
  1. Objective weakness; 2. Upper motor neuron (UMN) signs; 3. Nonambulatory
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127
Q

Upon which two factors is the Nurick classification of myelopathy based?

A
  1. Gait; 2. Ambulatory function
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128
Q

What anatomic line lies at the base of the foramen magnum? What is its clinical significance?

A
  1. McRae’s line across the base of the foramen magnum; 2. Odontoid should always be below this line (if not, then invagination is present)
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129
Q

What is the most important operative indication for invagination?

A

Neurologic compromise

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130
Q

… Migration in excess of?

A

> 5 mm

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131
Q

… Cervicomedullary angle (CMA)?

A

<135 degrees

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132
Q

… Ranawat measurement?

A

<13 mm

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133
Q

… McRae’s line?

A

Odontoid proximal to McRae’s line

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134
Q

What two surgical options are appropriate for basilar invagination?

A
  1. Occiput to C2 fusion; 2. Transoral odontoid resection
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135
Q

What are the only two current indications for a transoral approach?

A
  1. Cranial nerve deficits (brainstem compromise); 2. Solid posterior C1–2 fusion with persistent anterior cord compromise
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136
Q

What are the two classic symptoms of atlantoaxial arthritis? What is the treatment?

A
  1. Headache; 2. Rotational pain; 3. Treatment: posterior C1–2 fusion
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137
Q

What are the criteria for instability: (________ mm, ________ degrees)?

A
  1. > 3.5 mm or 20% translation; 2. >11 degrees (static film); 3. >20 degrees (flexion-extension films)
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138
Q

Which gender is most commonly affected? What are the other three primary risk factors?

A
  1. Male; 2. History steroid use; 3. RF+; 4. Nodules
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139
Q

An increased risk of neurologic compromise exists with what two radiographic criteria?

A
  1. Subluxation >4 mm; 2. Cervical height index >2
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140
Q

What is the treatment of choice?

A

Posterior fusion and wiring

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141
Q

Where is the skull thickest?

A

External occipital protuberance

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142
Q

What structures are at risk with screws?

A

Venous sinuses

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143
Q

What is the Gallie technique?

A

Spinous process wiring with midline graft

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144
Q

How much relative resistance does the Gallie provide versus flexion, extension, and rotation?

A
  1. Good versus flexion; 2. Not good versus extension and rotation; 3. Not good versus extension and rotation
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145
Q

Gallie should not be used in what situation?

A

Posteriorly displaced odontoid fracture

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146
Q

What is the Brooks technique?

A

Posterior wiring with bilateral grafts

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147
Q

How much relative resistance does the Brooks provide versus flexion, extension, and rotation?

A
  1. Good versus flexion; 2. Better versus extension and rotation; 3. Better versus extension and rotation
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148
Q

With either the Gallie or Brooks, what must be applied postoperatively?

A

Halo vest

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149
Q

How effective are C1–2 transarticular screws against flexion, extension, and rotation?

A

Best versus flex, extension, and rotation

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150
Q

How can the vertebral artery be injured with a transarticular screw?

A

Screw too caudally directed

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151
Q

How can the occiput-C1 joint be injured?

A

Screw too cephalad

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152
Q

How can the hypoglossal nerve (CN XII) be injured?

A

Screw too long: too anterior to lateral mass

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153
Q

What are the two functions of the hypoglossal nerve?

A
  1. Innervates muscles of tongue; 2. Contributes to strap muscle innervation via ansa cervicalis; 3. Contributes to strap muscle innervation via ansa cervicalis
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154
Q

If considering transarticular screws, which study must be obtained preoperatively?

A

Preoperative thin-cut CT scan

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155
Q

What percentage of patients have anatomy that precludes C1–2 screws?

A

0.15

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156
Q

If an iatrogenic injury to one vertebral artery occurs, what is the next step?

A

Sublaminar wires and graft (Gallie/ Brooks type)

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157
Q

Vertebral artery injury may be seen in association with trauma at what location?

A

Facet joint injury

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158
Q

How can it be injured intraoperatively?

A

Lateral bone removal with burr

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159
Q

If a vertebral artery stroke occurs, what is the name of the resultant syndrome? What are its four features?

A
  1. Wallenberg syndrome; 2. Nystagmus; 3. Diplopia; 4. Dysphagia; 5. Pain, temperature loss
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160
Q

What is the path of the vertebral artery? Above C1?

A
  1. C6 foramen transversarium to C1; 2. Up and medially through arcuate foramen above C1; 3. Up and medially through arcuate foramen above C1
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161
Q

Thoracic disk disease is most common at which levels?

A

T8 to T12 (especially T11-T12)

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162
Q

What is the classic mechanism of injury resulting in thoracic disk herniation (herniated nucleus pulposus [HNP])?

A

Torsion + bend

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163
Q

An HNP is most likely to be symptomatic in what two situations?

A
  1. Scheuermann’s disease; 2. Calcified disk; 3. Calcified disk
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164
Q

What are the two indications for surgery?

A
  1. Myelopathy; 2. Pain with magnetic resonance (MR) correlation; 3. Pain with magnetic resonance (MR) correlation
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165
Q

What is the disadvantage of a posterior approach?

A

Decreased midline access from the posterior

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166
Q

For the approach, should the surgeon go over or under the rib? From right or left? Why?

A
  1. Over rib; 2. From right; 3. Avoid artery of Adamkiewicz
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167
Q

Where is the watershed area for the thoracic spinal cord?

A

Middle T-spine

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168
Q

Where does the spinal cord end?

A

L1–2

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169
Q

What are the radiographic criteria for a diagnosis of disseminated idiopathic skeletal hyperostosis (DISH, diffuse idiopathic skeletal hyperostosis)?

A

Nonmarginal syndesmophytes >3 levels

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170
Q

Is the disk generally involved?

A

DISH generally spares the disk

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171
Q

What type of syndesmophytes are seen with ankylosing spondylitis?

A

Marginal syndesmophytes

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172
Q

Are compression fractures more common in the thoracic or lumbar spines? Why?

A

Thoracic spine more common because it is kyphotic

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173
Q

A vacuum sign on x-ray implies what two characteristics of the fracture?

A
  1. Osteonecrosis; 2. Nonhealing; 3. Nonhealing
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174
Q

How can compression fracture acuity be best evaluated?

A

Short tau inversion recovery (STIR) MRI

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175
Q

What are the five risk factors (in descending significance) for a vertebral compression fracture?

A
  1. Prior compression fractures; 2. Decreased bone mineral density (BMD); 3. Family history; 4. Premature menopause; 5. Smoking
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176
Q

On standing lateral films, where should the C7 plumb line fall?

A

Through the sacrum or within 2 cm anterior to the sacrum

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177
Q

What are the five common causes of kyphotic sagittal imbalance?

A
  1. Scheuermann’s disease; 2. Ankylosing spondylitis; 3. Neurofibromatosis; 4. Traumatic (e.g., compression, burst fractures); 5. Iatrogenic (e.g., postlaminectomy, Harrington distraction instrumentation)
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178
Q

What is an SPO? What is the effect on the posterior, middle, and anterior columns?

A
  1. Resection of posterior column between the facet joints; 2. Posterior column shortened; 3. Middle column = hinge; 4. Anterior column lengthened
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179
Q

How much correction can be obtained, on average, per level?

A

10 degrees

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180
Q

What additional procedure may potentially be necessary?

A

Anterior grafting if a gap opens in anterior disk space

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181
Q

What is a PSO? What is the effect on the posterior, middle, and anterior columns?

A
  1. Wedge-shaped resection with apex anterior of vertebral body, pedicle, and posterior elements; 2. Posterior column shortened; 3. Middle column shortened; 4. Anterior column = hinge
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182
Q

How much correction can be obtained, on average, per level? Which levels are preferred?

A
  1. 30 degrees; 2. L2, L3 probably safest; 3. L2, L3 probably safest
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183
Q

In thoracolumbar compression fractures, what is the indication for surgery? Why?

A

Fractures at >3 consecutive levels Increased risk of kyphosis

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184
Q

What are the five surgical indications?

A
  1. Unstable injury (posterior ligamentous complex disrupted); 2. >50% height loss; 3. >50% canal compromise; 4. >30 degrees kyphosis; 5. Incomplete or progressive neurologic deficit
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185
Q

If a neurologic deficit is present, what is the preferred surgical approach?

A

Anteriorly to decompress, fuse

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186
Q

If posterior column involvement is present, what is the preferred surgical approach? What is the significance of a lamina fracture?

A
  1. Posteriorly to fuse; 2. Lamina fracture may entrap and compress nerve roots (go posterior)
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187
Q

What is the most common long-term complication of a thoracolumbar burst fracture?

A

Pain

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188
Q

Compare the reported outcomes of operative versus nonoperative treatment of stable burst fractures.

A

Equivalent outcomes

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189
Q

What four factors are prognostic for future back pain?

A
  1. History of back pain; 2. Smoker; 3. >30 years old; 4. Workmen’s compensation case
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190
Q

In acute low back pain, when do 50% of patients recover? When do 90% of patients recover?

A
  1. 50% recover at 1 week; 2. 90% recover at 3 months
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191
Q

In acute sciatica, when do 50% of patients recover?

A

At 1 month

192
Q

A program consisting of what two factors has been demonstrated to result in the best return to work?

A
  1. Education; 2. Aerobic conditioning
193
Q

What three Minnesota Multiphasic Personality Inventory (MMPI) findings are predictors of poor recovery?

A
  1. Hysteria; 2. Hypochondriasis; 3. Depression
194
Q

What are the aggravating positions for degenerative disk disease (DDD) and instability?

A
  1. DDD: worse with flexion; 2. Instability: worse with extension
195
Q

What are the general surgical treatment principles for DDD and instability?

A
  1. DDD: treat with interbody techniques (remove painful disk); 2. Instability: treat with instrumented posterolateral fusion
196
Q

What are the two classic symptoms of lumbar instability?

A
  1. “Catch” with extension; 2. Back pain
197
Q

What are the radiographic instability criteria at L1-L4?

A
  1. > 4 mm motion; 2. 10 degrees angulation
198
Q

… at L5-S1?

A
  1. > 6 mm motion; 2. 20 degrees angulation
199
Q

What are the five Waddell signs? What is their clinical significance?

A
  1. Tenderness; 2. Simulation; 3. Distraction; 4. Regional disturbance (stocking-glove); 5. Overreaction; *Significance: be wary if >3 positive
200
Q

How are impairment and disability defined? Which determines compensation?

A
  1. Impairment: deviation from normal function; 2. Disability: inability to perform a specific function; 3. Disability more important for compensation
201
Q

What is the proven benefit of a corset? What is its effect on motion?

A
  1. Decreased intradiskal pressure; 2. No effect on motion
202
Q

Compare Jewett versus thoracolumbar spinal orthosis (TLSO) for rotational control.

A

TLSO better

203
Q

How can L5-S1 best be immobilized?

A

TLSO with thigh extension

204
Q

Which levels are accessible in transperitoneal and retroperitoneal approaches?

A
  1. Transperitoneal: L5-S1; 2. Retroperitoneal: L1-sacrum; 3. Retroperitoneal: L1-sacrum
205
Q

Where does the aorta bifurcate? Above this level, where does it lie?

A
  1. Bifurcation at L4; 2. In the midline above bifurcation
206
Q

The inferior vena cava is on which side?

A

Right

207
Q

Where do the segmental vessels come off?

A

Mid-body level (not at level of disk)

208
Q

Are the parasympathetic or sympathetic fibers at risk at these levels? Which plexus?

A
  1. Sympathetic fibers at risk; 2. Superior hypogastric plexus
209
Q

What are the potential complications of injury to the sympathetics?

A
  1. Retrograde ejaculation; 2. Lower extremity temperature difference (chain injury)
210
Q

Where are the parasympathetic fibers? What is their reproductive effect?

A

S2–3, S3–4, usually not disturbed Control erection

211
Q

What is the preferred direction of anterior dissection? Why?

A
  1. Dissect from left to right; 2. Plexus is more adherent on right
212
Q

What is the most common level of vascular injury? How is it injured? What is the consequence?

A
  1. L4–5 most common level; 2. Injury with pituitary rongeur; 3. Most commonly leads to arteriovenous (AV) fistula, but may lead to death
213
Q

What vessel lies in the L4–5 interspace?

A

Iliolumbar vein

214
Q

… Ilioinguinal and iliohypogastric nerves?

A

Lateral border of psoas

215
Q

… Genitofemoral nerve?

A

On psoas

216
Q

… Obturator and femoral nerves?

A

Deep to psoas

217
Q

… Sympathetic chain?

A

Medial to psoas

218
Q

At what level is the genitofemoral nerve? How can it be tested?

A
  1. Near L2–3; 2. Cremasteric reflex
219
Q

What is the most common complication of total disk arthroplasty?

A

Transient radiculopathy

220
Q

The optimal lumbar pedicle screw starting point lies at the junction of what three anatomical entities?

A
  1. Transverse process; 2. Pars; 3. Superior articular facet
221
Q

Should one aim more medially or laterally as one moves caudally in the lumbar spine?

A

More medially as one heads down

222
Q

What is the No. 1 factor associated with lumbar screw pullout?

A

Osteoporosis

223
Q

What is the No. 1 risk factor for postoperative interbody cage migration?

A

Posterior approach

224
Q

What two levels have the most lumbar lordosis?

A
  1. L4-L5; 2. L5-S1
225
Q

Straight leg raise (SLR) versus femoral stretch tests identify HNPs at which levels?

A
  1. Femoral stretch: L2–3 (hip flexors), L3–4 (quads, TA [tibalis anterior]); 2. SLR: L4–5, L5–S1
226
Q

What is the most specific clinical exam for HNP? Especially true in what situation?

A
  1. Contralateral SLR; 2. Especially for axillary herniation
227
Q

What body position results in the lowest intradiskal pressure? Highest?

A
  1. Lowest: supine; 2. Highest: sitting, flexed with weights in hands
228
Q

Lumbar disk herniations occur most commonly at which location (on axial imaging)?

A

Paracentral

229
Q

How can referred pain be differentiated from lumbar radicular pain?

A

Referred pain usually above knee

230
Q

How does the orientation of the upper lumbar nerve roots differ from that of the lower roots?

A

Upper roots have more direct takeoff (less room to manipulate)

231
Q

What is the natural history motor recovery, pain resolution, and sensory deficits in HNP?

A
  1. Motor generally recovers; 2. Pain generally resolves; 3. 30% of sensory deficits persist
232
Q

Pediatric herniations arenotgenerally disk material; they consist of what?

A

Avulsion of ring apophysis of vertebral body

233
Q

Is there a proven benefit to epidural steroids for HNP?

A

No

234
Q

What patients are especially likely to have recurrent postoperative pain? What percentage of patients?

A
  1. Large annular defect; 2. Up to 15 to 20% have long-term backache
235
Q

What is the reported re-herniation rate? What is the imaging study of choice to identify re-herniation?

A
  1. 0.1; 2. MRI with gadolinium
236
Q

What are the three components of the treatment algorithm for postoperative infection after lumbar diskectomy? When should surgery be performed?

A
  1. MRI with gadolinium; 2. Percutaneous biopsy and culture; 3. IV antibiotics
237
Q

Better outcomes can be expected if decompression is performed within what time frame?

A

48

238
Q

Does early decompression benefit bladder function, motor recovery, or pain?

A
  1. Improves bladder and motor recovery; 2. No effect on pain resolution
239
Q

What is the principal cause of lateral recess stenosis?

A

Superior articular facet hypertrophy

240
Q

What are three causes of foraminal stenosis?

A
  1. Foraminal HNP; 2. Decreased disk height; 3. Pars defect
241
Q

In foraminal stenosis, what are the critical foraminal height and the critical posterior disk height?

A
  1. Foraminal height <4 mm
242
Q

Are tension signs present with central or lateral stenosis?

A

Not generally

243
Q

Why is hyperreflexia not seen with lumbar stenosis? What is the most common neurologic deficit on exam?

A
  1. Lower motor neuron (LMN) problem, so no hyperreflexia; 2. L5 most common root for weakness
244
Q

Is there a proven benefit to epidural steroids?

A

No consistent benefit in controlled studies

245
Q

What type of injection has most consistently demonstrated symptomatic benefit?

A

Transforaminal nerve block

246
Q

What are the three indications for fusion after decompression of stenosis?

A
  1. Degenerative spondylolisthesis; 2. Instability/iatrogenic injury; 3. Degenerative scoliosis
247
Q

Is there a proven benefit to instrumentation for stenosis? How about symptomatic relief?

A
  1. No proven benefit to instrumentation; 2. Improved symptom reliefwithoutinstrumentation
248
Q

What age group has poorer decompression outcomes? Are there other prognostic factors?

A
  1. Young patients do worse; 2. Patients with multiple comorbidities do worse
249
Q

What is the typical mechanism of extraforaminal L5 root compression? What is the ideal radiographic view to identify it?

A
  1. L5 impingement between sacral ala and L5 transverse process; 2. Ferguson’s view
250
Q

What are the six types of spondylolisthesis, and (where applicable) which level is most commonly affected by each?

A
  1. Dysplastic (L5-S1); 2. Isthmic (L5-S1); 3. Degenerative (L4-L5); 4. Traumatic; 5. Pathologic; 6. Postsurgical
251
Q

What nerve root is most commonly affected by spondylolisthesis?

A

L5

252
Q

What are the two classic radiographic features?

A
  1. Trapezoidal L5; 2. Rounded S1
253
Q

What is the normal value of sacral inclination? What is the significance of greater inclination?

A
  1. Normal inclination >30 degrees; 2. More vertical sacrum: increased risk of slip
254
Q

How is the slip angle measured? What values are considered normal?

A
  1. Lordosis at L5-S1; 2. Normal <0 (kyphotic)
255
Q

What nerve root is most commonly affected? Why are nerve root signs especially common with dysplastic spondylolisthesis?

A
  1. L5 at risk; 2. Especially common because posterior arch is intact
256
Q

Is there a proven clinical benefit to spondylolisthesis reduction?

A

No

257
Q

If a reduction is performed, when is the nerve root most likely to be injured?

A

During the last 50% of reduction

258
Q

Is there a proven benefit to decompression?

A
  1. No; 2. Fusion with or without decompression leads to good outcomes
259
Q

What is the most sensitive imaging study for identification of a pars defect?

A

Single photon emission computed tomography (SPECT) scan

260
Q

When is the listhesis thought to occur? To what grade?

A
  1. At ages 4 to 6 years; 2. Usually not to more than grade II
261
Q

Which gender is most commonly affected?

A

Female

262
Q

What effect does a unilateral pars defect have on risk of listhesis?

A

Unilateral defects generally do not result in a slip

263
Q

Ideal brace?

A

Antilordotic brace

264
Q

What are the treatment and activity restrictions for the various grades of adolescent slips?

A
  1. Grade I: contact sports OK if patient asymptomatic; 2. Grade II: no contact sports; 3. Grade III/IV: fuse L4-S1 in situ
265
Q

Is a laminectomy without fusion an option for children?

A

No!

266
Q

Pars defect repair indications: age, grade, and level?

A
  1. Young; 2. Grade I or less; 3. Above L5
267
Q

For an adult patient, which levels should be fused if the L5-S1 slip is low grade or high grade?

A
  1. Low grade: L5-S1; 2. High grade: L4-S1
268
Q

Is there a proven clinical benefit to using instrumentation with fusion? Is there another point to consider?

A
  1. No proven benefit; uninstrumented outcomes are equivalent to instrumented outcomes; 2. But instrumentation does increase fusion rates
269
Q

If instrumentation is used, which approach has the best reported outcomes?

A

Best outcomes with circumferential instrumentation

270
Q

What race and which gender are at highest risk? What age group?

A
  1. African-American female; 2. >40 years
271
Q

What radiographic feature is especially common among affected patients?

A

Transitional L5 vertebrae

272
Q

What two factors may predispose to degenerative spondylolisthesis?

A
  1. Pregnancy; 2. Diabetes mellitus
273
Q

Is there a proven benefit to fusion at the time of surgery?

A

Fusion outcomes significantly better than decompression alone

274
Q

Is there a proven benefit to instrumentation?

A

None proven

275
Q

What is the long-term effect of untreated degenerative scoliosis?

A

Increased back pain

276
Q

What are the two factors that curve flexibility depend on?

A

Curve magnitude Age

277
Q

Compare general curve progression rates >50 degrees: thoracic versus thoracolumbar versus lumbar?

A
  1. Thoracic: progresses 1 degree/year; 2. Thoracolumbar: progresses 0.5 degrees/year; 3. Lumbar: progresses 0.25 degrees/year
278
Q

Are combined or staged surgical procedures generally preferred in adults?

A

Combined preferred, because staging leads to malnutrition between stages

279
Q

If severe osteoporosis is present, what is the most secure point of fixation?

A

Lamina

280
Q

What are surgical outcomes most dependent on?

A

Final coronal and sagittal balance

281
Q

What are the three benefits to interbody device use at the caudal end of long lumbosacral fusion?

A
  1. Increased construct stiffness; 2. Decreased strain on posterior instrumentation; 3. Increased fusion rate
282
Q

What is the No. 1 complication of adult scoliosis surgery?

A

Pseudarthrosis

283
Q

What is the No. 1 medical complication?

A

Urinary tract infection

284
Q

What is the pulmonary consequence of thoracotomy in the adult?

A

Never returns to preoperative pulmonary function test (PFT) values

285
Q

What is delayed postoperative paraplegia most often due to?

A

Cord ischemia (stretch)

286
Q

What was the main problem with Harrington instrumentation?

A

Positive sagittal balance = fatback

287
Q

Pedicle subtraction osteotomy (PSO) for flatback is generally performed at which levels?

A

L2 or below

288
Q

What is a contraindication to PSO?

A

Anterior pseudarthrosis

289
Q

What are the three characteristic SMA syndrome symptoms?

A
  1. Abdominal pain; 2. Distention; 3. Persistent vomiting
290
Q

When does SMA syndrome occur? Why?

A
  1. Within 1 week postop; 2. Compression of third part of duodenum between aorta and SMA
291
Q

How can SMA be differentiated clinically and radiographically from postoperative ileus?

A
  1. Clinically: bowel sounds present; 2. X-ray: upper gastrointestinal (GI) study
292
Q

What are the two aspects to treatment for SMA syndrome?

A
  1. Nasogastric (NG) tube; 2. Intravenous (IV) fluids/alimentation
293
Q

What grade of muscle strength indicates active muscle function against gravity?

A

3 out of 5

294
Q

What are the two ways in which the functional level of an SCI patient is determined?

A
  1. Most distal intact sensory level; 2. Most distal intact (3/5 or greater) motor level if next level is 5/5
295
Q

What is the Frankel classification used for?

A

Grades motor function below injury level (A = none to E = full)

296
Q

For what two capabilities has the ASIA (American Spine Injury Association) motor score been shown to be prognostic?

A
  1. Functional improvement potential; 2. Performance in rehabilitation
297
Q

What is the significance of the jaw jerk reflex?

A

Indicates injury proximal to the cervical spine

298
Q

What result or time frame characterizes the end of spinal shock?

A
  1. Return of bulbocavernosus reflex; 2. Or 48 hours passed since injury
299
Q

Are reflexes present in spinal shock?

A

No reflexes (UMN or LMN) are present

300
Q

Neurogenic shock is associated with injuries above which level? What is it due to?

A
  1. Injury above T5; 2. Disruption of descending sympathetics
301
Q

What are the two components of the treatment algorithm for neurogenic shock?

A
  1. 1st: fluids; 2. 2nd: pressors
302
Q

What three MRI findings are poorly prognostic for recovery after SCI?

A
  1. Hemorrhage; 2. Contusion; 3. Edema
303
Q

What two factors are positively prognostic for recovery after SCI?

A
  1. <30% displacement on radiographs
304
Q

What type of injury is most often associated with further deterioration after admission?

A

Rotational fracture dislocation

305
Q

If steroids are started within 3 hours, they should be continued for how long? What if they are started within 8 hours of injury? What if they are started more than 8 hours after injury?

A
  1. Start within 3 hours, continue for 24 hours; 2. Start within 8 hours, continue for 48 hours; 3. After 8 hours, no steroids
306
Q

Should steroids be administered with a penetrating wound?

A

No

307
Q

What roots are involved with a conus medullaris injury? What functions are lost?

A
  1. Roots S2, S3, S4; 2. Lost: bowel, bladder function only
308
Q

What anatomic levels of injury are most likely to result in conus injury? What is the differential diagnosis?

A
  1. Anatomic level of injury: T12-L1 or T11-T12; 2. Important differential: cauda equina syndrome
309
Q

Motor evoked potentials (MEPs) monitor which area of the spinal cord?

A

Anterior column only

310
Q

Somatosensory evoked potentials (SSEPs) monitor which area of the spinal cord? What is the downside?

A
  1. Dorsal column only; 2. May miss anterior column injury
311
Q

What degree of SSEP amplitude change is concerning?

A

50% drop

312
Q

What degree of SSEP latency change is concerning?

A

10% increase

313
Q

What does electromyography (EMG) monitor?

A

Nerve root irritation

314
Q

What two modalities are best during scoliosis correction? What modality is best during spondylolisthesis reduction?

A
  1. Scoliosis: SSEP, motor evoked potential (MEP); 2. Spondylolisthesis reduction: EMG
315
Q

If intraoperative SSEP changes occur during scoliosis surgery, what two steps should be taken?

A
  1. Increase blood pressure; 2. Stagnara wake-up test
316
Q

If the changes persist, then what?

A

Remove instrumentation

317
Q

What are the treatment and activity restrictions for an intraoperative dural tear? Is a drain necessary?

A
  1. Primary watertight repair; 2. 48 hours of bedrest postoperatively; 3. No drain necessary
318
Q

What are the treatment and activity restrictions for a dural tear discovered postoperatively? Should it be re-explored?

A
  1. Subarachnoid drain; 2. Bedrest; 3. Re-explore if symptoms persist 3 to 4 days
319
Q

What three symptoms are associated with dural tear?

A
  1. Nausea; 2. Headache; 3. Photophobia
320
Q

What test is used to determine if drain output is CSF?

A

CSF is b2-transferrin positive

321
Q

Should antibiotics be administered after gunshot to the spine?

A

If associated with perforated viscus, broad spectrum antibiotics for 1 week

322
Q

What are the two indications for intervention by general surgery?

A
  1. Esophageal perforation; 2. Bowel perforation
323
Q

What two conditions justify surgery to remove bullet fragments?

A
  1. Incomplete SCI; 2. Bullet fragments causing compression
324
Q

Bullet removal results in improved motor recovery below which level?

A

Motor recovery improves below T10

325
Q

When should a laminectomy be performed?

A

Only if lamina fracture present

326
Q

What two factors have been shown to predict motor recovery?

A
  1. Age; 2. Injury type
327
Q

Is there a proven benefit to early surgical intervention?

A

No

328
Q

Is there a proven benefit to decompressing stenosis not associated with fracture?

A

No

329
Q

Which incomplete SCI syndrome has the best prognosis? Which has the worst prognosis?

A
  1. Best: Brown-Séquard (ipsilateral motor/sensory loss, contralateral pain/temperature loss); 2. Worst: anterior column
330
Q

With posterior cord syndrome, what is required for successful postinjury ambulation? Why?

A

Requires intact vision for ambulation Because proprioception is absent

331
Q

The presence of which sensory quality is a good prognostic factor after SCI?

A

Pinprick sensation

332
Q

With complete SCI, is erection possible? Is ejaculation possible?

A
  1. Reflex erection possible, not psychogenic; 2. Normal ejaculation not possible
333
Q

After 1 year, how much additional recovery is expected with cervical SCI versus thoracolumbar SCI?

A
  1. Cervical: 1 additional level; 2. Thoracolumbar: 0 additional levels
334
Q

What adaptive equipment is required for a patient with an SCI level of C4?

A

C4: high back, head support

335
Q

… of C5?

A

C5: mouth-driven electric wheelchair

336
Q

… of C6?

A

C6: manual wheelchair with wrist/ hand orthoses

337
Q

… of C7?

A

C7: can live independently

338
Q

For C5 SCI patients, which tendon transfers will provide C6- or C7-type function?

A
  1. C6: BR to extensor carpi radialis brevis (ECRB) transfer; BR = brachioradialis; 2. C7: deltoid to triceps transfer
339
Q

What is the treatment of an open skull fracture? Why? If closed?

A
  1. Elevate depressed fragment if open; 2. Decrease risk of infection; 3. If closed, leave alone
340
Q

What is the anticipated recovery period after traumatic brain injury?

A

84

341
Q

What extremities are most affected by an anterior cerebellar artery (ACA) stroke? What extremities are most affected by a middle cerebellar artery (MCA) stroke?

A
  1. ACA stroke: lower extremities most affected; 2. MCA stroke: upper extremities most affected
342
Q

What is the definition of a mild concussion?

A

No loss of consciousness (LOC)

343
Q

What are the three grades of mild concussion?

A
  1. I: confusion, no amnesia; 2. II: retrograde amnesia; 3. III: amnesia after impact
344
Q

What is the recommended time period before return to play (RTP) for each grade?

A
  1. I: when patient is asymptomatic; 2. II: 1 week; 3. III: 1 month
345
Q

What is the definition of classic concussion?

A

Associated with loss of consciousness

346
Q

What circumstance justifies a postconcussion head CT?

A

LOC lasts longer than 5 minutes

347
Q

What is the recommended time period before return to play (RTP) after first classic concussion?

A

1 week to 1 month

348
Q

What is the recommended time period before RTP after second classic concussion?

A

No RTP that season

349
Q

What is the definition of diffuse axonal injury? What is the RTP recommendation?

A

LOC >6 hours No RTP

350
Q

Compare the symptoms of a burner to those of transient quadriplegia?

A
  1. Burner: unilateral, upper plexus; 2. Transient quadriplegia: axial load, bilateral, lasts up to 36 hours
351
Q

What four factors may predispose to the development of transient quadriplegia?

A
  1. Stenosis; 2. Instability; 3. Herniated nucleus pulposus (HNP); 4. Congenital fusions
352
Q

If a patient sustains a traumatic HNP, what is the timing for RTP?

A

May return when asymptomatic

353
Q

What are the two contraindications to return to play?

A
  1. Instability; 2. Neurologic symptoms >36 hours
354
Q

Does prior transient quadriplegia predict future injury?

A

No

355
Q

What are the two key features of spear tackler’s spine?

A
  1. Stenosis; 2. Loss of lordosis
356
Q

Once spear tackler’s spine has been diagnosed, are contact sports allowed?

A

No

357
Q

What is the most common SCI mechanism in an athlete?

A

Flexion-compression (burst)

358
Q

What is an absolute contraindication to contact sports? Example?

A
  1. Congenital anomalies of the upper cervical spine; 2. Example: os odontoideum
359
Q

What is a safe alternative to endotracheal (ET) intubation in C-spine trauma patients? Is there an exception?

A
  1. Nasotracheal intubation; 2. Exception: patients in respiratory arrest
360
Q

What is a safe alternative to ET intubation in a patient with spine trauma and facial fractures?

A

Cricothyroidotomy

361
Q

What is the recommended treatment for Jefferson fracture? What must be checked at the conclusion of treatment?

A
  1. Halo with or without traction; 2. Once treatment is completed, check C1–2 stability with flexion-extension films
362
Q

How is traumatic spondylolisthesis classified?

A
  1. I: minimally displaced; 2. II: anterior translation >3 mm, angulated; 3. IIa: increased angulaion with minimal translation; 4. III: also C2–3 facet dislocation
363
Q

Type I: What are the two criteria for acceptable reduction? What is the recommended treatment?

A
  1. <10 degrees angulation; 3. Collar for treatment
364
Q

Type II/IIa: What is the recommended treatment? What is a critical consideration in a type IIa patient?

A
  1. Treat with halo; 2. IIa: Donotapply traction!
365
Q

Type III: What are the three acceptable treatment options?

A
  1. Anterior C2–3 fusion; 2. Posterior C1 to C3 fusion; 3. Bilateral pars screws
366
Q

In odontoid fractures, what two factors increase the risk of nonunion?

A
  1. Displacement >5 mm; 2. Angulation >10 degrees
367
Q

What is a salvage option for odontoid nonunion?

A

Posterior fusion, no screws

368
Q

How should a cervical facet fracture be treated? Compare nondisplaced versus foating facet injuries.

A
  1. Nondisplaced facet fracture: collar; 2. Floating facet: open reduction with internal fixation (ORIF) with lateral mass plate
369
Q

What mechanism of injury most commonly results in facet dislocation?

A

Flexion-distraction

370
Q

How can unilateral and bilateral dislocations be distinguished radiographically?

A
  1. Unilateral <50% translation; 2. Bilateral ≥50% translation
371
Q

If a pre-reduction MRI shows herniated disk, what is the necessary treatment?

A

Must approach anteriorly to decompress and fuse if herniated disk

372
Q

What is the recommended treatment for bilateral dislocation with an HNP?

A

Approach posteriorly

373
Q

What is the treatment of a stable lateral mass fracture? What is the treatment of a unstable lateral mass fracture?

A
  1. Stable: collar; 2. Unstable: surgery
374
Q

What is the usual treatment for a subaxial compression fracture?

A

Collar

375
Q

Is halo treatment generally effective for the subaxial spine?

A

No, a halo poorly immobilizes subaxial spine

376
Q

What is the treatment for a subaxial burst fracture with nerve injury and anintactposterior element?

A

ACDF

377
Q

What is the treatment for a subaxial burst fracture with nerve injury andunstableposterior elements?

A

Anterior and posterior fusions

378
Q

Where should the anterior pin be placed?

A

Lateral one-third of brow

379
Q

What structure is at risk if an anterior pin is placed too medially?

A

Supraorbital nerve

380
Q

When applying a halo to a child, what is the key preoperative imaging study?

A

CT scan to assess skull thickness

381
Q

When applying a halo to a child, how many pins should be placed?

A

Eight

382
Q

At what torque?

A

4 pounds

383
Q

When applying a halo to an adult, how many pins should be placed and at what torque?

A

4 pins at 8 pounds

384
Q

What is the most common injury mechanism?

A

Flexion distraction

385
Q

What is the associated visceral injury? What is the treatment to avoid in patients with abdominal injuries?

A
  1. Associated with abdominal injury and ileus; 2. Avoid extension bracing
386
Q

What is the bone scan appearance of sacral insuffciency fracture?

A

H-shaped uptake

387
Q

A vertical shear pelvic fracture causes tension on which ligaments? What fracture may result?

A
  1. Tension on iliolumbar ligaments; 2. Classic x-ray finding: L5 transverse process fractures (check the pelvis!)
388
Q

What is Grisel’s syndrome?

A

Retropharyngeal bursitis preceding rotatory subluxation

389
Q

Early treatment for Grisel’s consists of?

A

Traction/bracing

390
Q

What is the general classification of rotatory subluxation?

A
  1. I: rotation, no anterior displacement; 2. II: rotation with anterior displacement 3 to 5 mm; 3. III: rotation with anterior displacement >5 mm; 4. IV: rotation with posterior displacement
391
Q

What is the imaging study of choice?

A

Dynamic CT

392
Q

What is the treatment of traumatic subluxation <1 week in duration?

A

Soft collar

393
Q

… 1 week to 1 month in duration?

A

Cervical traction

394
Q

… >1 month in duration?

A

Fusion

395
Q

What is the treatment for a late presentation?

A

C1–2 fusion

396
Q

Os odontoideum may appear radio-graphically similar to what condition?

A

Type II odontoid fracture

397
Q

What are the three surgical indications?

A
  1. Instability >10 mm; 2. SAC <13 mm (SAC = space available for the cord); 3. Neurologic deficit
398
Q

What is the procedure of choice for symptomatic os odontoideum?

A

Posterior C1–2 fusion

399
Q

Are contact sports permitted with an os odontoideum?

A

No

400
Q

What injury mechanism is generally responsible?

A

Hyperextension leading to posterior cord compression

401
Q

What imaging study is necessary for diagnosis of SCIWORA? What percentage of studies will appear normal?

A

MRI 25%

402
Q

What is the treatment of cervical SCIWORA?

A

Cervical collar

403
Q

What is a common long-term complication of paraplegia/quadriplegia?

A

Paralytic scoliosis

404
Q

Where is the apex of normal thoracic kyphosis?

A

T5 to T8

405
Q

What is the average annual spinal growth rate per segment? What is the approximate total?

A

0.07 cm per year per segment 1 cm per year total

406
Q

What is the recommended scoliometry threshold for referral for spine surgery evaluation?

A

7 degrees on Adams forward bend

407
Q

Curve progression best corresponds with which measure?

A

Peak growth velocity

408
Q

Peak growth velocity generally occurs at which Risser stage? How about menarche?

A
  1. Peak growth velocity at Risser 0; 2. Menarche occurs before Risser 1
409
Q

What are five indications for obtaining an MRI in the adolescent scoliosis patient?

A
  1. Left thoracic curve; 2. Abnormal neurologic exam, especially asymmetric abdominal reflexes; 3. Excess kyphosis (conider neurofibromatosis); 4. Onset <11 years old (think infantile, juvenile); 5. Pain
410
Q

How are stable vertebrae and neutral vertebrae defined?

A
  1. Midsacral line bisects the stable vertebrae; 2. Neutral vertebrae have no rotation and symmetric-appearing pedicles
411
Q

What is the usual sagittal alignment at the apical vertebrae with AIS?

A

Apical vertebrae usually hypokyphotic

412
Q

What are the six components of the Lenke classification for AIS?

A
  1. Main thoracic; 2. Double thoracic; 3. Double major; 4. Triple major; 5. Thoracolumbar/lumbar; 6. Thoracolumbar/lumbar-main thoracic
413
Q

What is the definition of a structural curve? Why are structural curves clinically significant?

A
  1. Structural curves do not bend out to less than 25 degrees; 2. All structural curves should be incorporated in fusion
414
Q

What three aspects make the progression of neuromuscular scoliosis unique?

A
  1. More rapid; 2. Continues after maturity; 3. Pelvic obliquity
415
Q

In general, at what age should fusion surgery be undertaken for neuromuscular scoliosis?

A

10 to 12 years

416
Q

If the apex is proximal to T7, what brace is needed?

A

Milwaukee brace

417
Q

Bracing has been prospectively shown to be effective for which population?

A

Females with 25- to 35-degree curves

418
Q

An anterior spinal fusion alone may suffice for which curve type?

A

Thoracolumbar curves

419
Q

What are the two classic advantages of an anterior fusion in this population? Is there an important caveat?

A
  1. Save levels; 2. Improve correction; 3. Caveat: pedicle screws may negate these advantages
420
Q

What are the three general indications for a combined anterior and posterior fusion?

A
  1. Curves >75 degrees; 2. Crankshaft prevention (females <13 years old); 3. Neuromuscular scoliosis
421
Q

Why are some neuromuscular conditions treated with posterior fusion alone?

A

To avoid compromising already fragile pulmonary function

422
Q

What are three examples of neuromuscular disorders treated with posterior fusion only?

A
  1. Muscular dystrophy; 2. Spinal muscular atrophy; 3. Werdnig-Hoffmann
423
Q

What should the distal extent of fusion ideally be in the adolescent idiopathic population?

A

L3 or above

424
Q

What are the two risk factors for neurologic injury?

A
  1. Excessive correction; 2. Sublaminar wires
425
Q

What is the ideal pedicle screw depth?

A

80% of vertebral body depth

426
Q

In what percentage of patients do pseudarthroses develop?

A

0.02

427
Q

How is an asymptomatic pseudarthrosis treated?

A

Observation

428
Q

If symptomatic?

A

Revision with compression instrumentation

429
Q

What graft type increases pseudarthrosis risk in adult scoliosis patients?

A

Freeze-dried allograft

430
Q

In general, what are the two surgical options for flatback correction?

A
  1. Posterior closing wedge osteotomy (at L2 or below); 2. Anterior release and fusion
431
Q

Untreated AIS patients are more likely to suffer from which two conditions as adults?

A
  1. Dyspnea; 2. Back pain
432
Q

What are treated AIS patients more likely than the general population to suffer from?

A

Back pain

433
Q

Has the magnitude of Cobb angle correction ever been associated with patient satisfaction?

A

No

434
Q

What is the preferred tool for evaluation of patient postoperative satisfaction?

A

SRS-22 has been validated as an outcome measure

435
Q

What age group is affected by infantile idiopathic scoliosis?

A

<3 years of age

436
Q

What gender is most commonly affected?

A

Male

437
Q

With which two musculoskeletal conditions is infantile scoliosis associated?

A
  1. Plagiocephaly (fat skull); 2. Congenital defects; 3. Congenital defects
438
Q

What percentage of patients have associated spinal cord disease?

A

0.2

439
Q

What is the most common curve pattern?

A

Left thoracic curve

440
Q

What is the difference between phase I and phase II? What is the clinical significance?

A
  1. Phase I: no rib/vertebral overlap; 2. Phase II: rib/vertebral overlap is present; 3. All phase II curves progress
441
Q

For phase I curves, what two conditions indicate that spontaneous resolution is likely?

A
  1. Curve <20 degrees
442
Q

Where should the RVAD be measured?

A

Curve convexity

443
Q

What does surgical treatment entail?

A

Combined anterior and posterior fusion

444
Q

Under which two conditions may a preoperative brace be of benefit?

A
  1. To delay surgery until greater maturity; 2. If RVAD is increasing
445
Q

What is the treatment if RVAD >20 degrees and if it progresses?

A
  1. If RVAD >20 degrees, then brace; 2. If progresses, then operate
446
Q

What age group is affected by juvenile idiopathic scoliosis?

A

3 to 10 years old

447
Q

What is the most common curve type?

A

Right thoracic

448
Q

How does the risk of progression compare with the risk of AIS?

A

Increased

449
Q

What are the two general treatment options?

A
  1. Growing rods (unfused); 2. Combined anterior/posterior spinal fusion
450
Q

With congenital scoliosis, the defect occurs at how many weeks of gestation?

A

4 to 6 weeks

451
Q

Patients must also be evaluated for which two conditions? Why?

A
  1. Renal anomalies (abdominal ultrasound); 2. Heart disease; 3. Because these systems develop at same point in gestation
452
Q

What are the two components of the general classification of congenital scoliosis?

A
  1. I: failure of segmentation (bar); 2. II: failure of formation (hemivertebra)
453
Q

Which type has the best prognosis? Which has the worst?

A
  1. Best: block vertebrae (bilateral failure of segmentation); 2. Worst: unilateral unsegmented bar with contralateral fully segmented hemivertebra
454
Q

What is the treatment for unilateral unsegmented bar with contralateral fully segmented hemivertebra?

A

Fuse at presentation with combined anterior/posterior procedure

455
Q

What is the treatment for other types of congenital scoliosis?

A

Await progression

456
Q

What is the classic form of treatment? What is the notable exception?

A
  1. Classically, posterior spinal fusion in situ; 2. Exception: combined anterior/posterior fusion if significant crankshaft risk
457
Q

What are the two other surgical options and their associated criteria?

A
  1. Hemivertebra excision (curve >40 degrees; especially L4, L5); 2. Anterior/posterior hemiepiphysiodesis (curve >40 degrees)
458
Q

Which type has the worst prognosis? Why?

A
  1. Failure of formation (type I); 2. Because it is most likely to result in paraplegia
459
Q

What is the surgical procedure of choice?

A

Posterior spinal fusion (because crankshaft is desirable)

460
Q

An anterior approach should also be considered with curves of which magnitude?

A

> 55 degrees

461
Q

What is the definition of diastematomyelia?

A

Longitudinal cleft in cord

462
Q

With what condition is diastematomyelia associated?

A

Cord tethering

463
Q

What is a key radiographic feature suggestive of diastematomyelia?

A

Intrapedicular widening

464
Q

What is the treatment if asymptomatic?

A

Observation

465
Q

How can sacral agenesis be differentiated from myelomeningocele?

A

Protective sensation present, but motor function still absent

466
Q

What is the classic physical exam finding?

A

Dimpling of buttocks

467
Q

What is the characteristic gait pattern of these patients?

A

Trendelenburg

468
Q

What are the two treatment options?

A

Amputation Spinal-pelvic fusion

469
Q

What are the two diagnostic criteria?

A
  1. > 45 degrees thoracic kyphosis; 2. >5 degrees anterior wedging of three sequential vertebrae
470
Q

Scheuermann’s may be associated with what three spinal conditions?

A
  1. Spondylolysis; 2. Scoliosis; 3. Schmorl’s nodes
471
Q

Which gender is most commonly affected?

A

Male

472
Q

What are the two indications for bracing?

A
  1. Kyphosis <75 degrees; 2. Skeletally immature patient
473
Q

What are the three criteria for surgical intervention?

A
  1. Skeletally mature patient; 2. Kyphosis >75 degrees; 3. Does not correct to <55 degrees (relatively inflexible curve)
474
Q

What is the surgical procedure of choice?

A

Posterior spinal fusion with or without anterior release and fusion

475
Q

What levels should be included in the fusion? What are the proximal and distal extents?

A
  1. T2 proximally; 2. One level beyond lordosis distally
476
Q

What are the two common complications of operative treatment?

A
  1. SMA syndrome; 2. Junctional kyphosis

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