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Spine > Pediatric Spine > Flashcards

Pediatric Spine Flashcards

1
Q

Spondylolysis

A

fracture of the pars interarticularis

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2
Q

Epidemiology of spondylolysis

A
  • seen in 6-7% of athletes and up to 50% in certain athletes (gymnasts, weightlifters, etc)
  • higher incidence in Native Americans
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3
Q

Spondylolysis level in children is typically…

A

pars of L5 and anterolisthesis of L5 relative to S1

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4
Q

Pars stress reaction

A

sclerosis of the pars without complete bone disruption

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5
Q

Mechanism of spondylolysis is usually…

A

activity related and occurs from repetitive hyperextension.

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6
Q

Risk of progression of spondylolysis to spondylolisthesis

A

15%

**the larger the slip, the more likely it is to progress

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7
Q

Spondyloptosis

A

100% translation of one vertebra over the next caudal level

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8
Q

Myerding Classification

A 
Describes classes of spondylolistesis slip GRADE
Grade I: < 25% slip
Grade 2: 25-50%
Grade 3: 50-75%
Grade 4: 75-100%
Grade 5: Spondyloptosis
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9
Q

Symptoms of spondylolysis/spondylolisthesis

A
  • low back pain
  • buttock pain
  • hamstring tightness (most common) and knee contracture
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10
Q

Exam for spondylolysis/listhesis

A
  • heart shaped buttocks due to sacral prominence
  • flattened lumbar lordosis
  • palpable step off
  • limited lumbar flexion/extension
  • measure popliteal angle to evaluate for hamstring tightness
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11
Q

Pars stress reaction will show up as…

A

sclerosis on xrays and CT.

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12
Q

Indications to obtain MRI for spondylolysis

A
  • negative xrays with high suspicion
  • very acute presentation
  • any neuro deficits
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13
Q

The most important determinant for determining non-union and pain of spondylolisthesis is…

A

slip angle.

Slip angle > 45-50 degrees is associated with greater progression, instability.

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14
Q

Indications for non-op tx of spondylolysis/listhesis

A

-asymtomatic patient (regardless of slip grade)

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15
Q

Non-operative treatment for spondylolysis/listhesis

A
  • PT and activity restriction (most improve)
  • bracing (usually TLSO) for 6-12 weeks (for acute pars stress reaction/spondylolysis or for low grade spondylolysis/listhesis that has not improved with PT)
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16
Q

Indications for pars interarticularis repair for spondylolysis

A
  • L1 to L4 isthmic defect that fails non-op management
  • multiple pars defects

(preserves motion, unlike fusion)

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17
Q

Indications for L5-S1 posterolateral fusion +/- ALIF for spondylolysis/listhesis

A
  • L5 spondylolysis that has failed non-op

- low grade spondylolisthesis (I/II) that has failed non-op, is progressive, has neuro deficits

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18
Q

Indications for L4-S1 posterolateral fusion +/- ALIF for spondylolysis/listhesis

A
  • high grade spondylolisthesis (III, VI, V)

- reduction is controversial

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19
Q

Technique for repairing pars defect

A

screw fixation, tension wiring or screw/sublaminar hook technique

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20
Q

Cons of reduction for high grade spondylolisthesis

A
  • L5 is most common nerve root injury
  • sexual dysfunction
  • catastrophic neuro injury
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21
Q

Adolescent idiopathic scoliosis is…

A

idiopathic scoliosis in children 10-18 years. Most have a family history.

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22
Q

The most common curve type in AIS is…

A

right thoracic curve.

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23
Q

Curves greater than 30 degrees are move common in…

A

females.

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24
Q

Left thoracic curves in AIS are rare and indicate…

A

need for an MRI to rule out cyst or syrinx.

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25
Q

The neurocentral synchondrosis is…

A

a cartilaginous plate that forms between the centrum and posterior neural arches.

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26
Q

Order of closure of the NCS is…

A

cervical then lumbar then thoracic.

27
Q

In adults, if adolescent scoliosis is left untreated, there is…

A

increased incidence of acute and chronic pain.

28
Q

Curves greater than 90 degrees are associated with…

A

cardiopulmonary dysfunction, early death, pain and decreased self image.

29
Q

Risk factors for curve progression

A
  1. curve > 25 before skeletal maturity
  2. thoracic curve > 50 after skeletal maturity
  3. lumbar curve > 40 after skeletal maturity
  4. < 12 years old
  5. Tanner < 3
  6. Risser 0 (correlates with greatest velocity of growth)
  7. thoracic curves
  8. double curves
30
Q

The best predictor of curve progression is…

A

peak growth velocity. In females, occurs just before menarche.

Most closely correlates with the Tanner-Whitehouse method.

31
Q

Scoliosis is defined as…

A

Cobb angle > 10.

32
Q

Indications to obtain MRI in scoliosis

A
  1. atypical curve (left thoracic, short angular)
  2. rapid progression
  3. excessive kyphosis
  4. structural abnormalities
  5. neuro sx
  6. foot deformities
  7. asymmetric abdominal reflexes
33
Q

Indications for observation alone with scoliosis

A

-cobb angle < 25

34
Q

Indications for bracing for scoliosis

A
  • cobb angle 25-45
  • only effective for flexible deformity in skeletally immature patient (Risser 0,1,2)

**goal is to stop progression, not correct deformity

35
Q

Posterior spinal fusion is indicated for scoliosis for…

A

cobb angle > 45

36
Q

Anterior/posterior spinal fusion is indicated for scoliosis for…

A 
larger curves >75
young age (in order to prevent crankshaft phenomenon)
37
Q

Need to wear brace for…

A

at least 12 hours per day to slow progression.

38
Q

Curves with apex about T7 need the…

A

CTO brace

39
Q

Bracing success is defined as….

A

< 5 dergrees curve progression

40
Q

In scoliosis, resistance to screw pullout increases by…

A

undertapping by 1 mm.

41
Q

A neurologic event during monitoring is defined as…

A

a drop in amplitude of > 50%.

42
Q

If neuro injury occurs intra-operatively, consider…

A
  1. check for technical problems
  2. check BP and elevate if low
  3. Check Hb and transfuse if low
  4. Lessen/reverse correction
  5. administer wake up test
  6. remove instrumentation
43
Q

Pseudoarthrosis following scoliosis surgery presents as….

A

late pain, deformity progression and HW failure.

44
Q

The most common organism for delayed infection after fusion for scoliosis is…

A

P acnes.

45
Q

The crankshaft phenomnenon is….

A

a rotational deformity of the spine created by continued anterior spinal growth in the setting of a posterior spinal fusion.

46
Q

SMA (superior mesenteric artery) syndrome

A

compression of the 3rd part of teh duodenom between the SMA and aorta. Presents with sx of bowel obstruction. Sagittal kyphosis is a risk factor.

47
Q

Skeletal maturity is defined as…

A

Risser stage 4, < 1 cm change in height over 2 visits 6 months apart or 2 years postmenarchal.

48
Q

The most common complication from a pedicle subtracting osteotomy is…

A

pseudoarthrosis.

49
Q

Juvenile idiopathic scoliosis is defined as…

A

idiopathic scoliosis in children 4-10 years of age.

50
Q

In JIS, there is a high incidence of neural axis abnormalities (up to 25%), including…

A
  • syringomyelia (cyst w/i the spinal cord)
  • Chiari syndrome (cerebellar tonsil protrudes through skull base and blocks CSF flow)
  • tethered cord
  • dysraphism
  • tumor
51
Q

JIS has high risk of progression…

A

50% require bracing, 50% require surgery

52
Q

A forward bending sitting test can…

A

eliminate leg length inequality as a cause of scoliosis.

53
Q

Abnormal abdominal reflexes are associated with…

A

presence of a syrinx.

54
Q

For JIS, MRI is indicated in…

A

children less than 10 years with a curve > 20.

55
Q

Indications for non-fusion procedures in JIS (growing rods, VEPTR)

A

-curves > 50 degrees in small children with significant growth remaining

56
Q

Infantile idiopathic scoliosis presents in…

A

a patient that is 3 years old or less. More commonly in males.

57
Q

The most common curve for infantile idiopathic scoliosis is…

A

left thoracic (unlike JIS and AIS).

58
Q

Conditions associated with infantile idiopathic scoliosis

A
  1. plagiocephaly (skull flattening)
  2. neural axis abnormalities (20% will be affected)
  3. thoracic insufficiency syndrome (pulm function impairment associated with curves > 60 degrees and cardiopulmonary function associated w/ curves > 90)
59
Q

Prognosis of infantile idiopathic scoliosis

A
  • most resolve spontaneously

- if still progressing by age 5, more than 50% will have curve > 70 degrees

60
Q

Mehta predictors of progression of infantile idiopathic scoliosis

A
  1. Cobb angle > 20
  2. RVAD (difference of 2 rib-vertebrae angles) > 20
  3. rib-vertebral overlap
61
Q

Indications for observation in infantile idiopathic scoliosis

A
  1. Cobb angle < 30
  2. RVAD < 20

90% spontaneously resolve

62
Q

Indications for derotational casting (Mehta)

A
  1. flexible curves
  2. cobb > 30
  3. RVAD > 20
63
Q

Indications for growing rods for infantile idiopathic scoliosis

A

cobb > 50
failed mehta casting or bracing

**delay fusion until as close to skeletal maturity as possible to avoid pulmonary compromise

Spine (2 decks)

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