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Shay Hartman's > Paeds Spine (Complete) > Flashcards

Paeds Spine (Complete) Flashcards

1
Q

What are the unique anatomic and radiographic features of the pediatric cervical spine?

[JAAOS 2011;19:600-611]

A
  1. Synchondroses between ossification centres
  • Neurocentral synchondroses – between posterior elements and body
  • Dentocentral synchondroses – between dens and body of C2
  • Normal = smooth with subchondral sclerotic lines
  1. Increased elasticity of ligaments, capsule and endplates
  2. Wedge-shaped vertebral bodies
    * Normal = ≤3mm of anterior wedging
  3. Horizontally-oriented facet joints
  4. Virtually absent uncinate processes
  5. Pseudosubluxation of C2 on C3
  • C3 on C4 is second most common
  • Caused by horizontal nature of facets
  • Normal = spinolaminar line (Swischuk’s line) between C1-C3 should pass within 1mm of C2 spinolaminar junction
    • Reduces with neck extension
  • Abnormal >1.5mm of displacement
  1. Loss of cervical lordosis in neutral position
  2. Increased ADI
    * Normal = 3-5mm

***NOTE: pediatric spine adopts a more adult configuration by age 8

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2
Q

What are the types of spondylolisthesis (Wiltse system)?

A
  1. Dysplastic (congenital)
    * Dysplasia of the upper sacrum or neural arch (the pars is normal)
  2. Isthmic
  • A. Lytic – fatigue fracture of the pars
  • B. Elongated but intact pars (due to repeated micro fractures and healing)
  • C. Acute fracture of the pars
  1. Degenerative
  2. Traumatic (fracture other than the pars)
  3. Pathologic
  4. Iatrogenic
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3
Q

In pediatric population what are the risk factors for spondylolisthesis progression?

[AAOS comprehensive review 2, 2014]

A
  1. Adolescent growth spurt
  2. Lumbosacral kyphosis (slip angle >40)
  3. Meyerding grade >II
  4. Younger age
  5. Female
  6. Dysplastic posterior elements
  7. Dome shaped sacrum
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4
Q

What is the management of isthmic spondylolisthesis?

[JAAOS 2016;24:37-45]

A
  1. Nonoperative – first line
  2. Surgery
  • Indications (Pediatric)
    • i. Grade I and II slips with persistent symptoms despite >6 months of nonsurgical treatment
    • ii. Grade III or higher slips
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5
Q

What is the classification of idiopathic scoliosis based on age?

[OKU Spine 5]

A
  1. Age 10-18 = adolescent idiopathic scoliosis
  2. Age 4-9 = juvenile idiopathic scoliosis
  3. Age <4 = infantile idiopathic scoliosis
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6
Q

What is the most common cause of painful scoliosis in the adolescent population?

A

Osteoid osteoma

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7
Q

What are the risk factors for curve progression in AIS?

[AAOS comprehensive review 2, 2014]

A
  1. Curve magnitude
  • Thoracic curve >50° and lumbar curve >40° progress 1° per year after skeletal maturity
  • Curve >30° at peak growth velocity will likely require surgery
  1. Skeletal maturity
  • Tanner stage
    • Females with Tanner <3 have greatest risk of progression
  • Risser grade
    • Peak growth velocity is Grade 0
  • Age of menarche
    • Peak growth velocity is just before onset of menses
  • Triradiate cartilage
    • Open triradiate have the greatest risk of progression
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8
Q

What should be evaluated during the physical examination in AIS?

[AAOS comprehensive review 2, 2014]

A
  1. Shoulder height
  2. Trunk asymmetry, scapular prominence, rib prominence
  3. Leg length, pelvic tilt
  4. Signs of spinal dysraphism
    * Hairy patches, dimples, nevi, tumors over the spine
  5. Cavovarus foot (particularly unilateral)
  6. Neurological examination
  • Sensory, motor, reflexes
  • Abdominal reflexes
  1. Adam’s forward bending test
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9
Q

What radiographs should be ordered for evaluation of scoliosis?

[AAOS comprehensive review 2, 2014]

A
  1. Full length standing 36 inch AP and lateral of entire spine
    * Look for spondylolisthesis
  2. Bending films are reserved for surgical planning
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10
Q

When should MRI be considered in evaluation of scoliosis?

[OKU Spine 5] [AAOS comprehensive review 2, 2014]

A
  1. Age <10
  2. Males
  3. Abnormal curve pattern
    * Left thoracic or right lumbar curve
  4. Rapid curve progression
  5. Abnormal neurological exam
  6. Apical thoracic kyphosis
  7. Persistent neck pain and headache
  8. Preoperative planning to evaluate for dural ectasia in patients with neurofibromatosis, Ehlers-Danlos and Marfans
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11
Q

What is the classification system for adolescent idiopathic scoliosis?

[AOfoundation]

A

Lenke classification

  • Requires upright AP and lateral and supine left and right bending
  • 4 steps
    • STEP 1 – divide spine into 3 regions
      • Proximal thoracic – Apex at T3, T4 or T5
      • Main thoracic – Apex between T6 and the T11-T12 disc
      • Thoracolumbar/Lumbar – T/L apex between T12 and L1, and lumbar apex between the L1-L2 disc and L4
    • STEP 2 – determine the major and minor curves
      • Curve with largest Cobb angle is the major curve
      • Other curves are minor
    • STEP 3 – determine if minor curves are structural or nonstructural
      • Curve is structural if:
        • Residual curve >25° in coronal plane on the bending film
        • Kyphosis >20 in sagittal plane (regardless of coronal flexibility)
    • STEP 4 – based on above information determine the curve type
      • For LENKE 4 – Main Thoracic OR TL/L can be the Major Curve
    • STEP 5 – determine lumbar and sagittal modifiers
      • Lumbar modifier – draw the CSVL and compare to lumbar apical vertebra
        • A = line is between pedicles of apical vertebra
        • B = line touches pedicle
        • C = line does not touch vertebra or pedicle
      • Sagittal modifier – assess kyphosis from T5-T12
        • ‘-‘ (hypo) = kyphosis <10
        • ‘N’ (Normal) = kyphosis 10-40
        • ‘+’ (hyper) = kyphosis >40
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12
Q

What are the radiographic parameters to be evaluated during surgical planning in AIS?

[Scoliosis Research Society]

A
  1. Cobb angle
    * Superior endplate of the upper end vertebra, to the inferior endplate of the lower end vertebra
  2. End vertebra
  • Define the ends of a curve in a frontal or sagittal projection
    • Cephalad EV – first vertebra from apex whose superior surface is tilted maximally toward the concavity of the curve
    • Caudal EV – first vertebra from apex whose inferior surface is tilted maximally toward the concavity of the curve
  1. Neutral vertebra
    * Vertebra without axial rotation
  2. Stable vertebra
    * Thoracic or lumbar vertebra cephalad to a lumbar scoliosis that is most closely bisected by CSVL assuming the pelvis is level
  3. Apical vertebra
    * Vertebra most deviated laterally from the CSVL
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13
Q

When is bracing indicated for AIS?

[JAAOS 2016;24:555-564]

A
  1. Curves 20-40° and Risser 0-1
  2. Curves 30-45° and Risser 2-3 should also be considered for bracing
  3. Curves >25 during growth [SRS Guidelines]
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14
Q

What are the bracing options in AIS?

A
  1. Curve apex above T7 = Milwaukee CTLSO [Orthobullets]
  2. Curve apex below T7 = Boston TLSO [Orthobullets]
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15
Q

What are the technical points in bracing prescription for AIS?

[JAAOS 2016;24:555-564]

A
  1. Brace should be worn 16-18 hours per day
  2. The goal is in brace correction of 30-70%
  3. Followup should be every 4 months during peak height velocity then every 6 months
  4. Nighttime bracing can be used towards the end of treatment
  5. Bracing can be discontinued when the patient reaches skeletal maturity and curve has not progressed >50°
  • In females, bracing can be discontinued when:
    • Risser sign 4 to 5
    • Postmenarche for >2 years
    • Minimal height increase over 6 months
  • In males, bracing can be discontinued when:
    • Risser 5
    • No evidence of height increase over 6 months
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16
Q

What is the number needed to treat (NNT) with bracing to prevent one surgery in AIS?

[JAAOS 2016;24:555-564]

A

NNT = 3

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17
Q

What were the results of the BRAIST trial (Bracing in Adolescent Idiopathic Scoliosis Trial)?

[JAAOS 2016;24:555-564]

A
  1. Study stopped early due to clear evidence of bracing effectiveness
  2. Bracing group (Boston-type TLSO) showed 72% of patients had curves <50 compared to non-braced group which had 48% of patients with curves <50
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18
Q

When is surgery indicated for adolescent idiopathic scoliosis?

[OKU Spine 5] [AAOS comprehensive review 2, 2014]

A
  1. Thoracic curve >50°
  2. Lumbar curve >45°
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19
Q

What are the goals of surgical management of AIS?

[JAAOS 2013;21:519-528]

A
  1. Maintain coronal and sagittal alignment
  2. Produce level shoulders
  3. Correct deformity
  4. Save motion segments
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20
Q

What are the considerations in surgical management of AIS?

A
  1. Approach
  • Posterior instrumentation and fusion is the mainstay
  • Anterior releases can be considered for large curves (>70°) and stiff curves
  • Anterior discectomy and fusion can be considered for skeletally immature (open triradiate and Risser 0) to prevent crankshaft phenomenon
  1. Implant
    * Segmental pedicle screw instrumentation is the standard
  2. Selecting fusion levels [JAAOS 2013;21:519-528]
  • Include all Lenke structural curves
  • Include lumbar nonstructural curves >45° on standing PA radiographs
  • Nonstructural curves can achieve up to 70% spontaneous correction without instrumentation
  • Upper instrumented vertebra
    • Structural proximal thoracic curve = T2
    • Nonstructural proximal thoracic curve:
      • Use T2-3-4 rule
        • Assess height of left shoulder = “if high go high, if low go low”
        • T2 for preoperative left shoulder elevation
        • T3 for preoperative level shoulders
        • T4 for preoperative left shoulder depression
      • Exception is Lenke 5 = upper end vertebra (don’t end at apex of kyphosis)
  • Lower instrumented vertebra
    • Simplified = go to stable vertebrae
    • Generally, avoid lumbar fusion, leaving three mobile disks below the LIV if possible
    • Nonstructural thoracolumbar/lumbar curves guided by lumbar modifiers
      • Lumbar modifier A = the LIV is the vertebra touching the CSVL
      • Lumbar modifier B + C = the thoracolumbar stable vertebra is selected as the LIV
    • Structural thoracolumbar/lumbar curves = distal end vertebra
      • Rarely below L3
      • Can go one level above the distal end vertebra if it crosses midline and adequately derotates on convex bending radiograph
        4. Neuromonitoring
  • EMG, MEP, SSEP
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21
Q

What is the definition of early onset scoliosis?

A
  1. Onset <10 years of age
  • Juvenile scoliosis = 4-10
  • Infantile scoliosis = <4
22
Q

What are the etiologies of early onset scoliosis?

A
  1. Congenital/Structural/Thoracogenic
  2. Neuromuscular
  3. Syndromic
  4. Idiopathic
23
Q

What are the causes of congenital scoliosis?

[OKU Spine 5]

A
  1. Failure of vertebral body formation
  • Hemivertebra (unilateral formation failure)
    • Fully segmented, partially segmented, unsegmented
      • Segmented if normal disc present
    • Incarcerated or nonincarcerated
      • Incarcerated = within the curve
        • Pedicle of hemivertebra is inline with adjacent pedicles
        • Adjacent vertebral bodies conform in their shape
        • Less disruption of spinal curvature
      • Nonincarcerated = outside of the curve
        • Pedicle of hemivertebra is outside the line of adjacent pedicles
        • Typically fully segmented
        • More disruption of spinal curvature (adjacent vertebrae do not accommondate)
  • Wedge vertebra (unilateral partial formation failure)
    2. Failure of vertebral body segmentation
  • Block vertebra
  • Unilateral bars
  • Unilateral bars with contralateral hemivertebra
  1. Multiple congenital rib fusions (thoracogenic)
24
Q

What is the rate of congenital scoliosis progression based on the type of anomaly (which has the best/worst prognosis)?

[AAOS comprehensive review 2, 2014]

A
  1. Block vertebra <2°/year
  2. Wedge vertebra <2°/year
  3. Hemivertebra 2-5°/year
  4. Unilateral bar 5-6°/year
  5. Unilateral bar with contralateral hemivertebra 5-10°
25
Q

What associated systemic abnormalities occur in patients with vertebral anomalies?

A
  1. Cardiac
  2. Urogenital
  3. Pulmonary
  4. Limb
  5. Spinal cord
26
Q

What is the work up of congenital scoliosis?

[Burrow]

A
  1. Echocardiogram
  2. Renal US
  3. MRI spine
  4. C-spine radiographs
27
Q

What is the management of congenital scoliosis?

[JAAOS 2004;12:266-275]

A
  1. Nonoperative
  • Bracing not indicated
    • Does not affect progression and can cause chest wall deformity
  • Bracing can be considered for compensatory curves above and below
  1. Operative
  • Indications
    • Curve progression
    • Anomaly has a predicted high rate of progression
  • Any spinal cord anomaly must be referred to neurosurgery prior to proceeding with deformity correction
28
Q

What are the surgical options for congenital scoliosis?

[JAAOS 2004;12:266-275]

A
  1. In situ fusion
  • Indication:
    • Unilateral bar +/- contralateral hemivertebra
      • Prior to major deformity
  • PIF +/- anterior discectomy and fusion
    • Prevents crankshaft
  1. Convex hemiepiphysiodesis
  • Indications:
    • Unilateral hemivertebra
    • Age <5
    • Curve <40
  1. Hemivertebra excision
  • Indication:
    • Hemivertebra where in situ fusion or hemiepiphysiodesis would not result in adequate spinal balance
  • Ideal age is 2
  • Age <5, curve >40
  1. Correction and fusion with instrumentation
  • Indication:
    • Older children with flexible segments above and below the congenital deformity
  1. Reconstructive osteotomies and instrumentation
  • Indication:
    • Severe rigid deformity
  1. Growing rods
  • Indication:
    • Maximize spine growth in young children
29
Q

What are the causes of neuromuscular scoliosis?

[OKU Spine 5]

A
  1. Scoliosis Research Classification
    * 2 types = neuropathic and myopathic
  2. Common causes
  • Neurologic
    • Freidrich’s Ataxia, CP, CMT, myelomeningocele, polio, SMA, syringomyelia
  • Myopathic
    • Becker/Duchenne MD, congenital myotonia, arthrogryposis
30
Q

What is the typical neuromuscular scoliosis pattern?

[OKU Spine 5]

A
  1. Long, C-shaped curve
  2. Pelvic obliquity
  3. Kyphosis
31
Q

What fusion levels are typically used for neuromuscular scoliosis?

A

T2-pelvis

32
Q

What syndromes are commonly associated with scoliosis?

[OKU Spine 5]

A
  1. Down syndrome
  2. Marfan and Ehlers-Danlos
  3. Neurofibromatosis
  4. OI
  5. Klippel-Feil
  6. VACTERL
33
Q

What is the natural history of early onset idiopathic scoliosis?

[JAAOS 2006;14:101-112]

A

Spontaneous resolution occurs in a large number of patients

  • Particularly, in infantile idiopathic scoliosis
34
Q

What are the indicators of curve progression in early onset idiopathic scoliosis?

[JAAOS 2006;14:101-112]

A
  1. Rib-Vertebra Angle Difference (RVAD)
  • AKA Mehta angle
  • Most reliable indicator
  • RVAD = angle formed between a line perpendicular to the end plate of the apical vertebra and a line from the midpoint of the rib head to the midpoint of the rib neck
    • Concave RVA – Convex RVA = RVAD
  • RVAD >20° = high risk of curve progression
  • RVAD <20° = curve more likely to resolve
    2. Phase 2 relationship
  • Rib head overlaps the apical vertebra
  • Implies that progression is certain
  1. Cobb angle >20o
35
Q

What is the nonoperative management of early onset idiopathic scoliosis?

[JAAOS 2006;14:101-112]

A
  1. Casting
  • Cast application is usually done under anesthesia
  • Cast is changed at 6- to 12-week intervals until maximum correction is achieved
  1. Bracing follows casting
    * Milwaukee brace is preferred over a thoracolumbar orthosis because of the rib cage distortion and pulmonary function reduction
36
Q

What is the treatment algorithm for early onset idiopathic scoliosis?

[JAAOS 2006;14:101-112]

A

Perform a comprehensive history/physical examination and scoliosis radiographs

  • If absent abdominal reflexes or other neurological findings = MRI spine and neurosurgical evaluation if positive imaging findings
  • If significant nonorthopedic findings = refer to appropriate specialist
  • If Cobb angle >25° OR RVAD >20° OR positive phase 2 rib relationship = initiate casting/bracing
    • Good response to casting/bracing = annual clinical examination until skeletal maturity
    • Poor response to casting/bracing = consider surgery
      • Surgery often includes growing rods ± anterior release or other emerging techniques
37
Q

What is the radiographic definition of Scheuermann Kyphosis?

[JAAOS 2012;20:113-121]

A

Thoracic kyphosis with anterior wedging of ≥5° of at least 3 consecutive vertebral bodies

38
Q

What is the age of onset of Scheuermann Kyphosis?

[JAAOS 2012;20:113-121]

A

10-12 years of age

39
Q

What are the two forms of Scheuermann kyphosis?

[JAAOS 2012;20:113-121]

A
  1. Typical form
  • Thoracic kyphosis
  • Nonstructural hyperlordosis of the lumbar spine
  • Apex T6-T8, curve from T1-L1
  • More common
  1. Atypical form
  • Thoracolumbar kyphosis
  • Often in active, athletic periadolescent males
  • Pain relieved with rest and activity modification
  • More likely to be progressive and symptomatic
  • Apex at T/L junction, curve from T4-5 to L2-3
40
Q

What are the clinical features of Scheuermann kyphosis?

[JAAOS 2012;20:113-121]

A
  1. Thoracic hyperkyphosis with compensatory lumbar and cervical hyperlordosis
  2. Forward bending accentuates the deformity
    * Postural kyphosis will often disappear with forward bending
41
Q

What are the associated radiographic findings with Scheuermann kyphosis?

[JAAOS 2012;20:113-121]

A
  1. Narrowed disc space
  2. Irregular endplates
  3. Schmorl nodes (herniation of disc into vertebral endplate)
42
Q

What are the indications for surgery in Scheurmann’s Kyphosis?

[JAAOS 2012;20:113-121]

A
  1. Kyphosis >60° with pain not relieved by nonoperative modalities
  2. Unacceptable cosmesis
  3. Neurological deficits (rare)
  4. Cardiopulmonary deficits (rare)
    * Only in patients with kyphosis >100°
43
Q

What tests should be ordered prior to surgery in Scheurmann’s Kyphosis?

[JAAOS 2012;20:113-121]

A
  1. Hyperextension lateral radiograph with bolster at apex (assess for flexibility)
  2. MRI
    * Rule out disc herniation or other canal pathology that may result in cord compression with deformity correction
44
Q

What are the options for surgeryin Scheurmann’s Kyphosis?

[JAAOS 2012;20:113-121]

A
  1. Posterior only approach
  • Preferred approach for most patients
  • Advantages
    • Decreased blood loss
    • Shorter surgical times
    • Better correction
  • Technique
    • Pedicle screw fixation +/- Smith-Peterson osteotomies
    • Include entire length of the kyphosis with inclusion of the sagittal stable vertebra distally
  1. Anterior and posterior approach
  • Consider for large, rigid curves that do not correct with hyperextension
  • Technique
    • Anterior release with posterior instrumentation and fusion
45
Q

What is the definition of Atlantoaxial Rotatory Subluxation (AARS)?

[JAAOS 2015;23:382-392]

A

Rotation of the atlantoaxial complex that is held in a fixed position as a result of muscle spasm or a mechanical block to reduction

46
Q

What is the cause of AARS?

[JAAOS 2015;23:382-392]

A
  • Normally there is a different rate of rotation between C1 and C2 producing a natural subluxation of the C1-2 facets
    • AARS occurs when the natural subluxation is prevented from returning to normal either by muscle spasm or mechanical block
  • 2 main causes:
    • Trauma
      • Fractures, falls, bumps to head (24%)
      • Head/neck surgery (20%)
    • Inflammation
      • Infection (35%)
      • Autoimmune disorders
47
Q

What is the Fielding and Hawkins atlantoaxial rotatory subluxation classification?

[JAAOS 2015;23:382-392]

A

Type I

  • unilateral facet subluxation with intact transverse ligament
  • No displacement between the anterior arch of C1 and the dens

Type II

  • Unilateral facet subluxation with anterior displacement of 3 to 5 mm

Type III

  • Bilateral anterior facet displacement
  • Interval between the C1 arch and dens is 5 mm

Type IV

  • Atlas is displaced posteriorly
48
Q

Based on the Fieldings and Hawkins classification what is the most common type of AARS?

[JAAOS 2015;23:382-392]

A

Type I

  • Unilateral facet subluxation with an intact transverse ligament
    • No displacement occurs between the anterior arch of C1 and the dens
  • The dens acts as a pivot, with one C1-2 facet subluxating anteriorly and the other facet subluxating posteriorly
49
Q

What does the Ishii Classification system describe related to chronic AARS?

[JAAOS 2015;23:382-392]

A

Progressive facet deformity based on 3d CT

  • Grade I = no facet deformity
  • Grade II = moderate facet deformity with <20° of C1 inclination
  • Grade III = severe facet deformity with >20° of C1 inclination
50
Q

What is the presentation of AARS?

[JAAOS 2015;23:382-392]

A
  1. New, fixed torticollis
  2. Head held in classic “cock robin” position
    * Head tilted to one side and chin rotated to the side opposite the facet subluxation
  3. Pain in the neck or jaw
  4. No preexisting history of congenital muscular torticollis, significant trauma or congenital abnormality
51
Q

What investigations are warranted for evaluation of AARS?

[JAAOS 2015;23:382-392]

A
  1. C-spine radiographs
  2. Consider CBC, ESR, CRP if concern for infection or inflammatory cause
  3. CT and MRI not indicated
    * Unless strong clinical suspicion for infection, fracture or congenital abnormality
52
Q

What is the recommended treatment algorithm for management of AARS?

[JAAOS 2015;23:382-392]

A
  1. Acute presentation (<2 weeks)
  • First line = cervical collar and NSAIDs
    • Resolution of torticollis = monitor for recurrence
    • Torticollis persists after 2 weeks of treatment = cervical halter traction, NSAIDs and benzodiazepines
      • Resolution of torticollis = cervical collar for 3 months and monitor for recurrence
      • Torticollis persists after 2 weeks of treatment = skull traction, NSAIDs and benzodiazepines
        • Resolution of torticollis = halo vest immobilization for 3 months followed by cervical collar for 3 months
        • Torticollis persists after 2 weeks of treatment = C1-2 fusion
          2. Chronic presentation (>2 weeks)
  • First line = cervical halter traction, NSAIDs and benzodiazepines
    • Follow above algorithm based on response to treatment

Shay Hartman's (29 decks)

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