Section 1 Flashcards
An 81-year-old female presents with complaints of gradual, painless bilateral vision loss and a visual glare. On physical examination, there is a marked decrease in visual acuity and upon ophthalmoscopy, there is an increased opacity in the pathological structure. The structure causing the symptoms refracts light. Which structure of the eye refracts light?
1. Lens
2. Iris
3. Retina
4. Conjunctiva
1. Lens
- The patient is presenting with symptoms of cataracts. Senile- cataracts present with gradual vision loss and increases in the opacity of the lens.
- The light travels through the iris which controls the amount of light entering the eye. It does this by changing the diameter of the pupil.
- The lens lies behind the iris and in front of the vitreous body. It is a biconvex structure allowing it to refract light onto the retina. Increasing the thickness of the lens can decrease the focus of the light onto the retina, decreasing the visual acuity.
- After the light is refracted by the lens, it is focused onto the retina. The retina then stimulates the optic nerve which sends information to the brain.
A 59-year-old female presents to the office complaining of left hip pain and aching in the anterior thigh. Further workup ruled out vascular etiology and determined that the pain was radicular in nature. Based on the complaints and physical exam, it is determined that the levels involved contribute to the innervation of the muscles superficial to the lateral femoral cutaneous artery after it has branched from the deep femoral artery. What lumbar spinal levels are most likely to be found to be stenotic on further imaging?
1. L2-L4
2. L2-L3
3. L5-S2
4. L4-S1
1. L2-L4
- The muscles that overly the lateral femoral circumflex artery are the rectus femoris and the sartorius, which are both innervated by the femoral nerve.
- L2-L4 are the levels that make up the femoral nerve.
- L2-L3 are the levels that make up the lateral femoral cutaneous nerve, which does not supply any musculature.
- L5-S2 are the levels that make up the inferior gluteal nerve, which supplies the gluteus maximus. L4-S1 are the levels that make up the superior gluteal nerve, which supplies the hip abductors.
A 58-year-old male who sustained traumatic fractures to the upper cervical spine following a motor vehicle accident. After a detailed evaluation of the fracture characteristics and imaging studies, you recommend posterior instrumentation and fusion from the occiput to C2. The patient asks you how would this affect his range of motion. You should inform him that he would probably experience which one of the following?
1. A decrease in cervical spine rotation of 50%.
2. A decrease in cervical spine flexion-extension of 50%.
3. Decrease of cervical spine rotation of 50% and a decrease of cervical spine flexion-extension of 50%.
4. Decrease of cervical spine rotation of 50% and a decrease of cervical spine flexion-extension of 10%.
3. Decrease of cervical spine rotation of 50% and a decrease of cervical spine flexion-extension of 50%.
- The occipito-axial joint (occiput-C1) provides about 50% of cervical spine flexion-extension, the patient can anticipate the loss of this plane of motion.
- The atlantoaxial joint (C1-C2) provides about 50% of cervical spine rotation, the patient can anticipate the loss of this plane of motion.
- The occipito-axial joint (occiput-C1) provides about 50% of cervical spine flexion-extension, and the atlantoaxial joint (C1- C2) provides about 50% of cervical spine rotation.
- The patient can anticipate a loss of half the motion in both of these planes upon fusion from the occiput to C2.
A 35-year-old male was involved in a high-speed motor vehicle accident with significant damage to the car and prolonged extrication. After standard ATLS protocol and stabilization, the tertiary survey identifies a fracture that extends through the entire vertebral body of L1. The vertebral body of T12 appears to be translated anteriorly to L1 as well. The patient is neurologically intact and only complains of back pain. No other injuries are identified. What is the best definitive management in a patient who sustains this type of fracture, as described by Denis?
1. Observation
2. Physical therapy
3. TLSO brace
4. Open reduction, instrumented fusion
4. Open reduction, instrumented fusion
- The patient has sustained a fracture-dislocation type injury, as described by the Denis classification.
- This is an injury to all three columns and is highly unstable. This patient requires urgent open reduction and instrumented fusion to correct the dislocation.
- There is no role for physical therapy as the definitive management, as this patient requires urgent open reduction and instrumented fusion to correct the dislocation. A TLSO brace may be appropriate for stable fractures described by the Denis classification including Compression and some Burst fractures. However, in this inherently unstable fracture-dislocation, this patient requires urgent open reduction and instrumented fusion to correct the dislocation.
A 54-year-old female presents to the ED complaining of an asymmetrical face, slurring of her words, and drooling during breakfast this morning. The patient is suspected of suffering a stroke and during the neurologic examination, the patient complains that she can not feel the left side of her face. Which of the following is responsible for her not being able to feel the left side of her face?
1. A lesion of the right nucleus cuneatus
2. A lesion of the left medial lemniscus
3. A lesion of the right ascending ventral trigeminothalamic tract
4. A lesion of the right medial lemniscus
3. A lesion of the right ascending ventral trigeminothalamic tract
- The ventral trigeminothalamic tract (VTTT) carries sensory information from both the spinal trigeminal nucleus (pain and temperature) and the chief sensory nucleus (2-point discrimination, conscious proprioception, vibration, and fine touch).
- Sensory information from the face enters the brain stem at the pons and continues to the spinal trigeminal nucleus (pain and temperature sensation) or chief sensory nucleus (2-point discrimination, conscious proprioception, vibration, and fine touch sensation) where the fibers synapse with second-order cell bodies. The specific type of sensation will determine which nucleus the fibers go to, e.g., information about pain will go to the spinal trigeminal nucleus.
- The ventral trigeminothalamic tract (VTTT) carries pain and temperature sensation (originating from the face) from the contralateral spinal trigeminal nucleus to the ventral posteromedial nucleus (VPM). From the VPM, fibers continue to the sensory cortex. Therefore, a lesion of the ascending VTTT will result in contralateral loss of these nerve functions. In this case, a lesion of the right ascending VTTT will result in loss of pain and temperature sensation from the opposite (left) side of the face.
- After synapsing in the spinal trigeminal nucleus or chief sensory nucleus, second-order sensory fibers cross over the midline of the brain stem as the ventral trigeminothalamic tract (VTTT) and ascend to the ventral posteromedial nucleus.
The anatomy of the optic nerve is thought to play a role in both the development of papilledema and the response to optic nerve sheath fenestration (ONSF). Which of the following is a proposed mechanism for the variable response to ONSF based on anatomic variations of the optic nerve?
1. Closure of the fenestration site causing a reaccumulation of perioptic cerebrospinal fluid (CSF)
2. Variations in the anatomic configuration of the vascular supply of the optic nerve and extraocular muscles
3. The variable architecture of the subarachnoid space of the optic nerve in its different segments
4. The variable meshwork and organization of the orbital septae
3. The variable architecture of the subarachnoid space of the optic nerve in its different segments
- In addition to the anatomy of the subarachnoid space, variable or increased compliance of the optic nerve sheath at the insertion to the posterior globe is thought to contribute to the development of optic disc edema and choroidal folds in the syndrome of acquired hyperopia and choroidal folds. While it has not been robustly studied as a mechanism for altered CSF dynamics in pseudotumor cerebri syndrome, it may also play a role in the development of papilledema in the setting of intracranial pressure (ICP) elevation and warrants further investigation
- The subarachnoid trabeculae, septa, and pillars of the subarachnoid space of the optic nerve tend to be more tightly packed as one approaches the globe. This could lead to a sort of ball valve effect, trapping fluid within the subarachnoid space, leading to the accumulation of substances within the CSF that could be toxic to the optic nerves and contribute to the development and severity of papilledema.
- The subarachnoid trabeculae, septa, and pillars vary in their density as well as their arrangement depending upon their location within the different portions of the optic nerve. This variability may play a role in the CSF dynamics between the subarachnoid space of the optic nerve and the suprasellar cistern that connects it to the intracranial space and may contribute to the pathophysiology of papilledema and the sometimes variable response seen to ONSF
- The closure of the durotomy site after fenestration is presumed if there is a recurrence of optic disc edema after surgery. However, incomplete fenestration can occur based on the anatomy of the subarachnoid space if a window is not excised from the sheath, and only slits or holes are created in the sheath.
A 10-year-old female complains of low back pain for the last three weeks. She does gymnastics in high school since childhood. The pain is located in the lower back, non-radiating, and exacerbates with activity. What is the most likely diagnosis?
1. Vertebral fracture
2. Spondylolysis
3. Muscular strain
4. Disc herniation
2. Spondylolysis
- Injury of the pars interarticularis is one of the most common identifiable causes of ongoing low back pain in adolescent athletes.
- Divers, rowers, gymnasts, weight lifters, wrestlers, and throwing track and field athletes have higher rates.
- The most frequently presenting complaint is low back pain, either localized or diffuse. The pain is usually exacerbated by trunk hyperextension or rotation exercises.
- There is no acute trauma for vertebra fracture diagnosis. Muscle strain can be possible, but it should relieve with painkillers and rest within a few weeks. Disc herniation usually provokes leg pain and sciatica.
A 75-year-old man presents to the emergency department due to persistent left-sided numbness that started about an hour ago. Significant medical history includes type 2 diabetes mellitus, essential hypertension, prostate cancer, cataracts, and two prior myocardial infarctions five and eight years ago. He has smoked two packs of cigarettes daily for the past 40 years. He takes metformin, atorvastatin, lisinopril, tamsulosin, and undergoes radiation therapy every two weeks. He has been compliant with his medications and follow-up visits. His vital signs are temperature 38 C (100.4 F), blood pressure 140/85 mmHg, respiratory rate 12/minute, and 92% oxygen saturation on room air. The patient is alert and oriented to person, place, and time. He can draw a clock fully with the time. The neurologic exam is significant for decreased sensation to crude touch, pinprick, and fine touch in his left face, arm, and leg. No visual field defects are noted. Strength is 5/5 throughout, and reflexes are 1+ bilaterally in his upper and lower extremities. Cardiac examination demonstrates a 1/6 systolic murmur at the right upper sternal border, and pulmonary examination demonstrates increased inspiratory and expiratory effort with bilateral expiratory wheezes in all lung fields. Chest x-ray shows a flattened diaphragm and expanded lung fields bilaterally. Head CT scan is negative. Based on this patient’s presentation, what is the most likely location of the brain lesion?
1. Right parietal lobe and middle cerebral artery
2. Left internal capsule and lenticulostriate artery
3. Right pons and perforating pontine arteries
4. Right thalamus and the thalamoperforating arteries
4. Right thalamus and the thalamoperforating arteries
- The anatomic distribution of lacunar syndromes and infarctions is most commonly the basal ganglia, the pons, and the subcortical white matter structures.
- These anatomical sites correspond to lesions at the lenticulostriate arteries, the anterior choroidal artery, thalamoperforating arteries, paramedian branches of the basilar artery, and the recurrent artery of Heubner from the anterior cerebral artery.
- In a pure sensory stroke, the patient presents with unilateral numbness of the face, arm, and leg without cortical signs or motor deficits. All sensory modalities will be impaired.
- A lesion of the contralateral thalamus, supplied by the thalamoperforating arteries, is the most common cause of a pure sensory stroke.
A 22-year-old lacrosse player presents to his primary care provider for a yearly physical. During his visit, he expresses concern over the recent attention that concussions have received in the media. He mentions that he has had several previous concussions and is worried that he may have returned to play too quickly. What is the most appropriate response when he asks about the appropriate amount of time to recover from a concussion?
1. If a concussion is diagnosed, he may return to play as soon as his coach permits
2. It does not matter whether or not a concussion is diagnosed. He must sit out at least two weeks
3. Neuropsychological tests have shown abnormalities in concussed athletes up to 5 weeks following injury. Therefore, it is possible that at least a month may be required before return to play
4. If he does not have any symptoms immediately following a rapid acceleration-deceleration impact to the head, he may return to play immediately
3. Neuropsychological tests have shown abnormalities in concussed athletes up to 5 weeks following injury. Therefore, it is possible that at least a month may be required before return to play
- There have been increasing efforts in organized team sports to decrease the number of concussions by creating stricter penalties for intentional blows to the head in addition to “return to play” guidelines.
- Unfortunately, there is limited evidence-based data as to the best method of monitoring an athlete’s neurological dysfunction following a concussion, and there is not a consensus on when return to play is appropriate.
- Most recommendations focus solely on the resolution of symptoms before allowing for a return to play and various neuropsychological tests have shown abnormalities in concussed athletes up to 5 weeks following injury.
- Therefore, it is possible that at least a month may be required before return to play as re-injury is much more likely to occur in the period immediately following a traumatic brain imaging.
A patient presented to your clinic for treatment of a low-flow indirect carotid cavernous fistula. You are performing the exposure for a direct cannulation of the superior ophthalmic vein. You have made your superior sulcus incision and opened the orbicularis oculi and orbital septum. You are unable to identify the superior ophthalmic vein, even after tracing back the supraorbital vein. What is the next best operative step?
1. Discontinue the operation. I will not be possible to cannulate the superior ophthalmic vein in this scenario
2. Perform a lateral orbitotomy to expose the superior ophthalmic vein in the lateral orbital wall
3. Continue aggressive dissection within the orbital fat pad to identify the superior ophthalmic vein
4. Make an additional eyebrow incision to facilitate an orbitofrontal bone flap. The superior ophthalmic vein will be identified running immediately under the superior rectus muscle
4. Make an additional eyebrow incision to facilitate an orbitofrontal bone flap. The superior ophthalmic vein will be identified running immediately under the superior rectus muscle
- If the superior ophthalmic vein is not hypertrophied, it may not be readily identified within the initial dissection. To broaden the exposure, an eyebrow incision is commonly used to facilitate an orbitofrontal bone flap (through a small burr hole in the orbital rim). Aborting the procedure after the initial exposure is premature.
- The superior ophthalmic vein is reliably identified within the superomedial aspect of the periorbital zone, immediately deep to the superior rectus muscle. This is a critical landmark used during surgical cutdown to the vein.
- A lateral orbitotomy has been described as one method of broadening the exposure to facilitate identification of the superior ophthalmic vein. However, it is used to expose the vessel as it exits the superior orbital fissure and not within the lateral orbital wall.
- Aggressive dissection in the orbital fat pad may cause damage to vital structures and is not recommended during cutdown to the superior ophthalmic vein. If difficulty is encountered, broadening of the exposure is recommended.
A 75-year-old female presents to the emergency department who was in a motor vehicle collision and had a Hangman fracture on CT imaging without any vascular injury on angiography. She is placed in a rigid cervical collar and has no neuro-deficits. The CT demonstrates less than 11 degrees of angulation of the C2 body and greater than 3.5 mm displacement. Which of the following is the next best step in the management of this patient?
1. No further imaging and rigid cervical collar for 8-14 weeks
2. Cervical spine flexion and extension x-rays
3. MRI of the cervical spine
4. Consent for internal fixation
3. MRI of the cervical spine
- The fracture described is Frances grade III. Two factors are taken into consideration for the Francis Grading system: angulation and displacement. Angulation is measured by the degree of anterior angulation off of the posterior vertebral line drawn straight up from the C3 vertebral body.
- Displacement is measured by the amount of anterolisthesis, either greater than or less than 3.5 mm. Type 1- less than 11 degrees of angulation and less than 3.5 mm of displacement, type 2- greater than 11 degrees of angulation and less than 3.5 mm of displacement, type 3- less than 11 degrees of angulation and greater than 3.5 mm displacement, type 4- greater than 11 degrees of angulation and greater than 3.5 mm of displacement, type 5- complete disc disruption.
- Francis Grades II, IV, and V (greater than 11 degrees of angulation or complete disc distribution) are treated by internal fixation, whereas Grade I and III (displacement without angulation) may be treated conservatively.
- While greater than 90% of Hangman fractures will heal with rigid cervical collar alone, further imaging to evaluate the ligamentous structures and C2-3 disc is required before deciding on conservative treatment. Cervical spine flexion and extension x- rays, if performed, would show some mobility. However, this is a dangerous alternative and will be less diagnostic when compared to an MRI of the cervical collar. An MRI of the cervical spine is necessary to evaluate the C2-3 ligamentous structures and disc.
Following a motor vehicle accident, a 35-year-old male is agitated and has multiple cerebral contusions on CT of the head. Hemodynamic measurements show a heart rate of 85 beats/min and a mean arterial pressure (MAP) of 84 mmHg. An intracranial pressure monitor reveals a pressure of 28 mmHg. What is the most appropriate management regimen?
1. Hyperventilation to maintain a cerebral PCO2 of 25 to 30 mmHg
2. Administration of phenylephrine to increase MAP
3. Administer hypertonic saline
4. Placement of patient in Trendelenburg position
3. Administer hypertonic saline
- Cerebral perfusion pressure (CPP) is the difference between mean arterial pressure (MAP) and intracranial pressure (ICP). It should be greater than or equal to 70 mmHg. ICP should be 20 mmHg or less.
- Methods for reducing ICP include elevation of the head of the bed (reverse Trendelenburg), administration of hypertonic saline, mannitol, other diuretics, sedatives to control agitation, prevention of hypovolemia, maintenance of adequate CPP, and keeping pCO2 in the proper range.
- Hypertonic saline has been shown to be superior to mannitol in patients with hypotension severe brain trauma. The patient also will require aggressive fluids management.
- Hypercapnia causes vasodilation of the cerebral vessels, which increases intracranial volume and pressure. Hyperventilation may be used for impending herniation to acutely lower ICP. However, prolonged hyperventilation decreases perfusion secondary to the vasoconstriction that occurs in an injured, ischemic brain.
A 67-year-old female was involved in a motor vehicle accident in which she was the restrained driver of a car that rear-ended the vehicle in front of her that was stopped at a red light. She is rushed to a local trauma center where advanced imaging reveals she has sustained a flexion-distraction injury. What column serves as the axis of rotation in this type of injury, according to the Denis classification system?
1. Anterior
2. Middle
3. Posterior
4. Superior
1. Anterior
- The anterior longitudinal ligament (ALL) serves as the axis of rotation, found in the anterior column of Denis’ three-column theory. The anterior column is otherwise comprised of the anterior two-thirds of the vertebral body and annulus
- The middle column is comprised of the posterior one-third of the vertebral body and annulus, posterior vertebral wall, and the posterior longitudinal ligament (PLL). Flexion-distraction injuries do not have an axis of rotation to the middle column.
- The posterior column is comprised of all structures posterior to the PLL including the posterior bony arch and the posterior ligamentous complex (supraspinous ligament, interspinous ligament, capsule and ligamentum flavum).
- There is no superior column found in Denis’ three-column theory.
A 76-year-old female is undergoing microsurgical clipping of anterior communicating artery (ACOM) aneurysm. Intraoperatively, there is an inadvertent injury to the recurrent artery of Huebner (RAH). However, other perforators are well preserved. The postoperative CT image, however, shows hypodensities involving the caudate head, anterior limb of the internal capsule as well as putamen. What is the most likely cause of the radiological findings?
1. Diffuse vasospasm
2. Seizure
3. Rete communication of RAH with other lenticulostriate vessels from ACA and MCA
4. Injury to parent ACA vessel
3. Rete communication of RAH with other lenticulostriate vessels from ACA and MCA
- The clinical scenario depicts insult to vascular territory of RAH, medial as well as lateral lenticulostriate vessels.
- Due to the same embryological origin, RAH sometimes can form a rete like vascular communication to lenticulostriate branches from ACA as well as MCA arteries.
- During such anatomical variants, injury to RAH can have a profound effect upon the vascular territory of medial and lateral striate vessels as well.
- Diffuse vasospasm and injury to the parent ACA vessels would have resulted in hypodensities along with the distal ACA territories as well. The seizure would not lead to localized vasospasm in the caudate, internal capsule or the putaminal regions.
A 15-year-old male hockey player comes off the ice with a mild headache, feeling tired, emotional lability after receiving a hard check into the side boards. He is able to answer all 5 Maddock questions appropriately, is alert and orientated appropriately, with only three errors on balance testing. After a few minutes, his symptoms clear. Should he be allowed to return to play in this game and is he at risk for suffering a second impact syndrome?
1. Yes, he can return to play and no he is not at risk
2. No, he cannot return to play and he is not at risk
3. Yes, he can return to play and he may be at risk
4. No, he cannot return to play and he is at risk
4. No, he cannot return to play and he is at risk
- Second impact syndrome is a poorly understood and an infrequently reported complication related to receiving a second concussion before the initial one clears. They are mostly seen in male athletes between 13 and 23 years old, and the most common sport is American football. Of the cases reported, athletes younger than 20 were associated with death or permanent disability. Many of the second hits appeared minor compared to the initial contact, including some of the hits not occurring to the head.
- Concussion mechanism of injury is still incompletely understood but appear to involve axonal shear injury, metabolic and blood flow dysregulation, and neurotransmitter release on a large scale. This results in varying constellation of symptoms being reported by the athlete. Concussions can present with varying types and degrees of symptoms, and there is no one “classic” presentation. Sometimes the symptoms appear minor and mild, and sometimes there is a loss of consciousness where the athlete does not get back up on their feet.
- With diagnosing a concussion being a challenge, the ability to predict a second impact syndrome is even more difficult. It would be prudent to be cautious, especially any adolescent athlete. Current literature supports the idea of this being a complication of a younger athlete returning to play too early after sustaining a concussion. It would also be prudent to be extra vigilant when providing sideline coverage during youth contact/collision sports.
- Current guidelines recommend at least seven days, and a graded return to sport program be followed after receiving a concussion. Even if the symptoms are mild, with the right mechanism of injury, it would be prudent to watch the athlete closely and not allow a return to play until the graded return to sport protocol has been completed, and the athlete is symptom- free. Unfortunately, many athletes will hide or try to downplay their symptoms. One survey found only 1 out of 27 head injuries were reported in American college football players. All too often, athletes choose to play through the pain
A 76-year-old female presents today with progressive, severe low back pain. She has a history of osteoarthritis, type 2 diabetes, osteoporosis, hypertension, COPD, and osteoporotic compression fractures. Her last osteoporotic compression fracture was 2 years ago. She has been on alendronate since her last fracture. Pain is described as dull and achy, nine out of 10 in severity, without radiation pain. Her walking is limited due to her back pain. She denies any numbness or tingling into her lower extremities, or bowel or bladder incontinence at this time. On physical exam, there is point tenderness over her lower lumbar spine at the L4-L5 vertebral levels. Muscle strength examination of lower extremities is difficult to perform due to pain. However, plantar flexion and dorsiflexion muscle strength is 5/5 bilaterally, and lower extremity sensation is otherwise intact. Deep tendon reflexes for the L4, S1 are 2/4 bilaterally. Special tests cannot be performed to pain. Pain is elicited immediately upon the patient lying on her back. Kyphoplasty is being considered for the patient. What is the strongest contraindication for vertebral augmentation?
1. Metastatic vertebral fracture
2. Complete vertebral body collapse
3. Vertebral body fracture with a posterior cortical breach
4. Osteoporotic compression fracture
2. Complete vertebral body collapse
- A complete vertebral body collapse would be a true contraindication of vertebral augmentation. An underlying fracture of the posterior wall of the vertebra has potentially serious complications. This would include extravasation of cement, leading to catastrophic neurological damage.
- A relative contraindication to vertebral augmentation is a vertebral body fracture with a posterior cortical breach compared to a true contraindication in the case of a complete vertebral body collapse. In some studies, kyphoplasty has been completed on patients with a posterior cortical breach.
- However, the concern for kyphoplasty in patients with posterior cortical branches arises when balloon inflation is stopped when pressures are above 250 PSI. The balloon then contacts the cortical surface of the vertebral body. Posteriorly, this could lead to extravasation of the cement and neurological damage. This risk is significantly increased with a complete vertebral collapse.
- A metastatic vertebral fracture would be an indication to proceed with kyphoplasty compared to a contraindication such as the case of a complete vertebral body collapse. For any procedure, it is important to focus on the indications, contraindications, and alternatives of the procedures, as well as, post-operative expectations and follow up. In an osteoporotic compression fracture that has been unresponsive to conservative management, there is neither a contraindication or an indication to proceed with vertebroplasty. Some guidelines consider this to be a contraindication, while some expert opinion supports its use. Multiple systematic reviews of vertebral augmentation for patients with underlying cancer have been reported. In over half of these studies, patients reported significant improvement in pain. Similar scores were shown for decreases in pharmacological analgesia and disability scores.
A 64-year-old Northern Indian man with past medical history of diabetes mellitus and heterozygous MTHFR gene mutation was brought by his son to the emergency department for fever, eye discharge on the right side, painful eye movement on the right side for three days. The patient also reported a headache and vision changes on the right side for two weeks which are unusual for him. He takes only metformin 1000 mg BID and insulin shots with meals. There is no significant family history. Blood pressure is 110/65 mmHg, heart rate 105 bpm, and temperature 38.5 C. He is alert and oriented to person and place but not time, chemosis, periorbital edema and proptosis on the right eye. There is mild restriction of all extraocular movements of the right eye and mild drooping of the right eyelid. There was poor effort during strength exam. The rest of the exam is unremarkable. WBC, ESR, CRP, and D-dimer are mildly elevated. CT head is unremarkable. Lumbar puncture is done with no WBCs but mildly elevated protein of 120 mg/dL. Brain MRI shows an isointense lesion in the right cavernous sinus close to cranial nerve III with a decreased caliber of the intracavernous internal carotid artery on T1 and hypointense mass on T2. The lesion was well enhanced on T1 contrast. MR angiography shows a cavernous sinus mass and occlusion of the intracavernous carotid artery on the right side. What is the most likely diagnosis?
1. Carotid-cavernous fistula
2. Cavernous sinus tumors
3. Cavernous sinus thrombosis
4. Carotid-cavernous aneurysm
3. Cavernous sinus thrombosis
- Cavernous sinus thrombosis (CST) is the most likely diagnosis because of the history of immunosuppression due to diabetes mellitus, hypercoagulable state due to heterozygous MTHFR gene mutation and geographic situation.
- Fungal infection is the second common cause of cause of CST in a case series from Northern India with Aspergillosis for 8/18 (44.4%), mucormycosis 4/18 (22.2%), and probable fungal infection 6/18 (33.3%).
- Infectious workup including lumbar puncture, D-dimer, MRI, and MRV or CTV should be performed if there is a suspicion for CST. If there is no concern for septic thrombosis, patients may need a further hematological workup for lymphoproliferative disorders and hypercoagulable states.
- The management of CST should include antimicrobial with or without surgical drainage in the air sinuses or mastoid regions and antithrombotic therapies.
An 87-year-old male is involved in a car accident. A CT scan of the head identifies a lesion in the third ventricle suspected to be a colloid cyst. The patient also has mild hydrocephalus. He has multiple medical issues, including pulmonary hypertension, aortic valve stenosis, chronic kidney disease, hypertension, poorly controlled diabetes mellitus, and chronic obstructive pulmonary disease. The patient is very concerned about the possible risk of the sudden death of with a colloid cyst. Given his medical comorbidities, which of the following treatments has the lowest upfront surgical risk for this patient?
1. Craniotomy with a transcortical approach
2. Craniotomy with a transcallosal approach
3. Endoscopic cyst resection
4. Stereotactic cyst aspiration
4. Stereotactic cyst aspiration
- Stereotactic cyst aspiration of a colloid cyst has the lowest up- front surgical risk but the cyst is most likely to recur.
- Endoscopic cyst resection of a colloid cyst has less surgical risk than a craniotomy for colloid cyst resection but has a slightly higher colloid cyst recurrence rate.
- Craniotomy for resection of a colloid cyst has the highest up- front risk of the possible treatment options but also has the lowest colloid cyst recurrence rate.
- Asympotomatic colloid cysts can be watched with serial imaging if small in size and more centrally located in the third ventricle.
A 12-year-old previously healthy boy is brought to the emergency department (ED) after he was struck on his right side by a motor vehicle while he was running across the street. His upper body was thrown forward, and he bumped his left forehead on the pavement. He was alert and oriented when the paramedics arrived at the scene. They immobilized his entire spine using a pediatric backboard and cervical spine collar before transport. In the ED, he is anxious but fully oriented. He reports pain in his head, abdomen, and legs. His vital signs include a temperature of 37.6 C, heart rate of 89 beats/min, respiratory rate of 19 breaths/min, blood pressure of 100/70 mmHg, and pulse oximetry of 99% (room air). On physical examination, the boy’s airway is clear, he is breathing spontaneously with normal respiratory effort, and his pulses and perfusion are normal. A superficial abrasion over his left forehead is noted. His abdomen is soft and non-distended, but it is tender to palpation in the right upper quadrant. He displays no peritoneal signs. There is tenderness to palpation over his right thigh with swelling and bruising. Imaging is performed which shows a hepatic contusion and a non-displaced skull fracture on the left side. What additional finding in this patient would confirm the diagnosis of Waddell triad?
1. Left tibia fracture
2. Right femur fracture
3. Right humerus fracture
4. Spinal injury
2. Right femur fracture
- Waddell triad consists of three distinct features seen in pediatric pedestrian patients with blunt force trauma, usually secondary to direct impact by a motor vehicle. They include ipsilateral femur fracture, ipsilateral intrathoracic or intraabdominal injury, and contralateral head injury.
- In this case, the patient was struck on his right side causing right side intraabdominal injury of the liver, left side head injury and would also have a right-sided femur fracture as the third sign of the triad.
- Whenever children pedestrians are involved in a motor vehicle accident, it is important not to assume that they have only one organ injury. Further investigation should be done to identify other affected organs.
- Patients who have Waddell triad should be treated as significantly injured and high risk for bleeding and shock.
A 14-year-old male presents with a 9 cm, highly vascular mass centered in the posterior nasal cavity and sphenopalatine foramen invading the infratemporal fossa (ITF), middle cranial fossa, and cavernous sinus. Staged surgical resection is being planned. Which of the following is the best imaging modality to evaluate this patient’s vascular anatomy for preoperative planning?
1. CT angiography (CTA)
2. MR angiography (MRA)
3. Angiography
4. Doppler ultrasound
3. Angiography
- Angiography allows selection and superselection of distal external and internal carotid artery branches to more accurately identify the vascular supply of the tumor.
- Angiography can be performed in conjunction with embolization and minimizes bleeding during surgery.
- Angiography also shows tumor vascularity, the proximity of the internal carotid artery, cerebral circulation, and collateral vasculature.
- MRA and CTA can be used to assess the anatomy of giant nasopharyngeal angiofibroma but angiography has the benefit of allowing for preoperative embolization of the tumor, making angiography the imaging modality to evaluate this patient’s vascular anatomy for preoperative planning. Doppler ultrasound does not offer significant benefit for determining the vascular supply of nasopharyngeal angiofibroma.
A 65-year-old female presents with blurred vision. During the interview, she admits that she also has had episodes of feeling the “room spinning,” especially when she turns her head. Two days ago, she had an episode of suddenly feeling weak and subsequently dropped to the floor. Which of the following statements is the most appropriate pertaining to the neurological event observed in the patient?
1. Dysarthria may develop
2. Balance problems are very rare
3. Fifty percent of transient ischemic attacks and strokes occur in the vertebrobasilar system
4. Hemiparesis is the most common symptom
1. Dysarthria may develop
- Twenty-five percent of transient ischemic attacks and strokes occur in the posterior circulation. Other symptoms associated with vertebrobasilar insufficiency (VBI) may include gait disturbances, diplopia, visual loss, dysesthesias, headaches, nausea, vomiting, and poor coordination. It is important to distinguish VBI from more benign causes that may appear similarly such as benign paroxysmal positional vertigo. The head thrust test may be done to differentiate between peripheral vertigo and central, as well as the appearance of brainstem signs and cranial nerve abnormalities.
- The posterior circulation supplies the pons, midbrain, medulla, occipital lobe, cerebellum, and part of the thalamus.
- Consequently, there is a wide variety of symptoms depending on which structures are affected and the extent of the ischemia.
- VBI is caused by narrowing of the arteries and progressive hypoperfusion or inadequate blood supply. Smaller arteries are prone to closing off from thrombotic changes.
A 27-year old male presents to the emergency department with a penetrating injury. He states that he was at work on a construction site when a sharp object fell on him and led to a penetrating injury on his back. MRI of the spinal cord is immediately done and reveals a cut in the spinal cord on the left side at the level of T9. Which of the following statement regarding the effect of his injury is true?
1. He will not be able to move his legs at all
2. He will not be able to move his right hand and right leg properly
3. He will not be able to move his left leg properly
4. He will not be able to move his left leg and left arm properly
3. He will not be able to move his left leg properly
- In the spinal cord, the corticospinal tract supplies the ipsilateral muscles. Therefore, any damage in the tract will lead to damage in the muscles on the same side.
- At each level of the spinal cord, roots arise and eventually form nerves that innervated different muscles. At the level of T9, the nerves to the arms have already left the spinal cord, however, those that supply the legs are yet to arise.
- Ipsilateral damage in the corticospinal tract in the spinal cord will lead to an ipsilateral deficit in the muscles. Therefore, damage to the left corticospinal tract will lead to weakness or even paralysis of the left arm and leg depending on the level of the lesion
- While the corticospinal tract within the spinal cord supplies ipsilateral muscles as decussation occurs at the level of the brainstem, other tracts such as the spinothalamic decussate within the spinal cord, so damage to that tract will lead to the contralateral effect. It is essential to understand those anatomical differences to identify lesions ion the nervous system.
An adult patient presents with the worst headache of her life. A noncontrast CT of the head is negative. A lumbar puncture produces four bloody tubes, each with RBC counts greater than 100,000/mm3. What is the next step in management?
1. Repeat a noncontrast head CT the next day
2. Perform a CT angiogram
3. Perform a head CT with contrast
4. Administer mannitol
2. Perform a CT angiogram
- A noncontrast head CT in the context of a nontraumatic, bloody tap will be positive in the vast majority of patients with subarachnoid hemorrhage. However, a normal CT does not mean a bloody tap can be ignored.
- Unlike a traumatic tap, the blood cell count does not diminish from the first to the fourth tube. Xanthochromia is the yellow appearance of cerebrospinal fluid caused by the degradation of heme to bilirubin confirming a hemorrhage.
- CT or MR angiography is needed to detect vascular pathology that might account for the lumbar puncture findings of subarachnoid hemorrhage.
- Initial management consists of preventing vasospasm, blood pressure control, fluid management, anticonvulsant therapy, pain control, and many neurosurgeons recommend early surgery.
- **
A 19-year-old male is thrown off his motorbike and brought to the emergency department for evaluation. He has a decreased level of consciousness and is moaning and complaining of pain on the left side of his neck. His vital signs are temperature 99.6 F, heart rate 82 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 120/84 mm Hg. He is alert and awake and following simple commands. His examination reveals bilateral equal and reactive pupils. There is a clear fluid coming out of the left ear. He also has a nosebleed and a large scalp laceration. The remainder of the examination is unremarkable. Which of the following is the most rational approach to confirm the diagnosis of CSF leak suspected in the patient?
1. Glucose content
2. Beta-2 transferrin
3. MRI of the brain
4. Beta trace protein
2. Beta-2 transferrin
- ß2-Transferrin is present only in CSF, perilymph, and vitreous humor. Agarose gel electrophoresis can be formed to detect ß2- Transferrin.
- Beta-2 transferrin testing can be performed to establish the diagnosis of CSF leak in suspected cases of traumatic brain injury.
- Beta 2 transferrin is the best test as this substance is only made in the brain. If it is located outside the brain, a CSF leak should be suspected.
- ‘Halo’ sign and the sodium content of the fluid also help to suspect CSF leak in patients with traumatic brain injury.
The husband of a 73-year-old female calls emergency medical services (EMS) after noticing slurred speech and right-sided weakness in his wife. EMS personnel evaluates the patient and suspects a possible large vessel occlusion stroke using the Los Angeles Motor Scale. The patient’s last known normal was 30 minutes ago. According to the American Heart Association and American Stroke Association ‘Severity-Based Stroke Triage Algorithm for EMS’, to which of the following facilities should the patient be transported?
1. The closest acute stroke-ready hospital 45 minutes away
2. The closest primary stroke center 55 minutes away
3. The closest comprehensive stroke center 60 minutes away
4. The closest hospital regardless of stroke center certification
3. The closest comprehensive stroke center 60 minutes away
- Eligible patients with a large vessel occlusion may benefit from mechanical thrombectomy.
- Several stroke scales can be used by emergency medical services (EMS) to help identify possible large vessel occlusions including the Los Angeles Motor Scale (LAMS), Cincinnati Prehospital Stroke Severity Scale (CSTAT), Rapid Arterial Occlusion Evaluation (RACE), and Field Assessment Stroke Triage for Emergency Destination (FAST-ED).
- The 2018 American Heart Association and American Stroke Association guidelines state, “It remains unknown whether it would be beneficial for emergency medical services to bypass a closer IV tPA-capable hospital for a thrombectomy-capable hospital.”
- The American Heart Association and American Stroke Association ‘Severity-Based Stroke Triage Algorithm for EMS’ recommends patients with suspected large vessel occlusion and last known normal within 6 hours be transported directly to nearest thrombectomy-capable stroke center or comprehensive stroke center, as long as bypass does not add more than 15 minutes to transport and does not preclude use of IV tPA.
A 39-year-old man comes into the emergency department for evaluation of a 2-day history of his “right eye- bulging,” swelling of the eyelids, and headache. The patient notes that he has had a sinus infection for the past couple of weeks that has not resolved. Vitals reveal a temperature of 100.6 F, heart rate of 112 bpm, respiratory rate of 18 bpm, and blood pressure 130/78 mmHg. Physical exam reveals exophthalmos and periorbital edema of the right eye, tenderness of the face below the eyes, and bilateral purulent discharge from the nares. The remainder of the exam is relatively benign. If his condition were allowed to persist, what other physical exam finding or symptom would be most likely expected?
1. Left hemiparesis
2. Nausea and vomiting, particularly in the morning
3. Inability to look up with the right eye
4. Inability to abduct the right eye
4. Inability to abduct the right eye
- This patient has a cavernous sinus thrombosis (CST) or the formation of a blood clot within the cavernous sinus.
- Cavernous sinus thrombosis (CST) may be either septic or aseptic in etiology. Septic causes include spreading infections from the ears, nose, sinuses, or teeth. This patient had a sinus infection, predisposing him to a CST. Aseptic causes are typically traumatic in nature.
- Cavernous sinus thrombosis may occur due to a superficial infection of the face due to the anastomosis of the pterygoid venous plexus via the inferior ophthalmic vein.
- Cavernous sinus thrombosis commonly affects the cranial nerves of the cavernous sinus, nerves III, IV, V(1), and VI. Of these, the abducent nerve is the most commonly affected, which would result in the inability of the eye to abduct.
A geriatric patient falls because of his Parkinson disease. Seven days later, he is brought to the emergency department and found to have altered mental status and weakness of his extremities. A CT of the brain reveals a subdural hematoma and transtentorial herniation. If this patient develops a cerebral infarct due to this herniation, which vessel will be compromised?
1. Anterior cerebral artery
2. Posterior cerebral artery
3. Bridging veins
4. Middle meningeal artery
2. Posterior cerebral artery
- Subdural hemorrhage is most often due to tearing of bridging veins. This can occur secondary to acute high-speed impact to the skull. The geriatric population is at higher risk due to brain atrophy.
- Herniation can occur in patients who have large hematomas. With a transtentorial herniation, a cerebral infarct occurs when the posterior cerebral artery is compressed.
- A transtentorial herniation will also cause compression of the oculomotor nerve and dilatation of the ipsilateral pupil and decreased reactivity.
- With a subfalcine herniation, the cerebral infarct occurs because of compression of the anterior cerebral artery.
A 12-year-old male presents to the emergency department with a new-onset headache and blurry vision for 6 hours. The patient denies a history of prior seizures. Past medical history includes a right-hand corrective surgery for polydactyly at eight months of age. The neurological examination reveals no abnormalities. CT head without contrast shows a mass in the suprasellar region. MRI of the brain further confirms the presence of a hypothalamic hamartoma. A rare genetic disorder is suspected. Which of the following best describes the patient’s clinical syndrome?
1. Pallister-Hall syndrome
2. Greig cephalopolysyndactyly syndrome
3. Oral-facial-digital syndrome
4. Acrocallosal syndrome
1. Pallister-Hall syndrome
- Hypothalamic hamartomas are associated with rare genetic disorders such as Pallister-Hall syndrome.
- Pallister-Hall syndrome is an autosomal dominant disorder caused by a mutation to the GLI3 gene which classically presents with hypothalamic hamartoma and polydactyly.
- Pallister-Hall syndrome is also associated with other abnormalities such as hypopituitarism, growth hormone deficiency, bifid epiglottis, and genital hypoplasia.
- Pallister-Hall syndrome is typically diagnosed in early childhood presenting with seizures, central precocious puberty due to hypothalamic hamartomas, and polydactyly.
A 67-year-old female presents with upper back pain and progressive weakness over the past 15 days. History revealed a multilevel spine surgery for vertebral compression fractures six months ago. Previous laboratory and radiological evaluations revealed the diagnosis of multiple myeloma. Computed tomography (CT) and magnetic resonance imaging (MRI) showed lytic lesions and multiple pathological fractures involving T5, T6, and T9 vertebrae along with an epidural mass compressing the spinal cord at the T5 level. On evaluation, her lower extremity strength is grade 4 bilaterally. High-dose corticosteroids and radiotherapy are performed. Three-month follow-up radiological examination revealed complete resolution of cord compression and epidural mass. One year later she presented with worsening back pain and right facial numbness. MRI revealed leptomeningeal enhancement involving the right cavernous sinus, and trigeminal nerve extending to involve the thoracolumbar spine. Cerebrospinal fluid obtained from lumbar puncture showed a large number of atypical mononuclear cells. Flow cytometry confirmed plasma cells with kappa light chain restriction. What is the most likely cause of her presentation at this time?
1. Post radiotherapy changes
2. Infection
3. Pathological fractures
4. Meningeal myelomatosis
4. Meningeal myelomatosis
- Back pain is a common complaint of patients with multiple myeloma due to the development of new lesions or pathological fractures. The possibility of vertebral infections should also be considered. Both disease and treatment-related complications can lead to infections. Chemotherapy with high-dose corticosteroids may be a predisposing factor for vertebral infections. Radiological appearance is similar to vertebral osteomyelitis and discitis.
- Spinal cord compression can be seen in 20% of multiple myeloma cases during the disease. Neurological symptoms may also occur due to meningeal involvement. Meningeal myelomatosis is a rare finding. They can present as altered mental status, lower limb weakness, cranial nerve palsies, headache, speech disorder, or features of meningismus. Diagnosis is usually made by finding myeloma cells in cerebrospinal fluid. The median survival is one month in those who had no initial response to therapy while it is five months in those who showed remission on initial treatment.
- CT findings of meningeal myelomatosis have been reported as a peripheral markedly hyperdense mass with associated edema and mass effect. MRI shows heterogeneous to homogenous intensity on T2 of extra-axial mass and diffuse enhancement on post-contrast T1 images. Abnormal leptomeningeal enhancement along sulci and cranial nerves.
- In conclusion, meningeal myelomatosis is a rare form of multiple myeloma and is more aggressive and resistant to treatment.
A 65-year-old man with a history of depression and generalized anxiety disorder presents complaining of pain in his lumbar region. He has a history of spinal stenosis, which has undergone two previous lumbar decompression surgeries without success. Three months ago, his pain was exacerbated when he was involved in a car accident for which he is currently involved in litigation against the other driver. He reports numbness in his pubic region and says that he has had difficulty starting urination over the past day. Which of the following is the next best step in managing this case?
1. Referral for spinal cord stimulator implant
2. Emergent surgery
3. MRI
4. Prescribe ibuprofen
3. MRI
- Although this patient presents with risk factors for failed back surgery syndrome (FBSS), psychiatric comorbidity, history of failed back pain surgery, litigation, “red flag” symptoms must still be evaluated in the patient presenting with lower back pain.
- This patient’s saddle anesthesia and urinary incontinence are concerning for cauda equina syndrome and should be urgently diagnosed with an MRI and likely managed with surgery.
- Red flags should always be ruled out before addressing chronic symptoms from FBSS.
- Clinical presentations such as saddle anesthesia and urinary continence require emergent surgery. Failure to recognize this presentation can result in irreversible nerve damage.
A 48-year-old female patient in the intensive care unit recovering from brain surgery presents with multiple small lesions on her legs. She has multiple 1 mm non-blanching lesions throughout her legs, with the majority concentrated on her shins. The patient has a past medical history significant for hypertension, diabetes insipidus, and glioblastoma. She has not regained consciousness since her surgery two days ago. Her family states that the patient has had these lesions before, but they are not sure of what precipitated them in the past. The patient is currently receiving lisinopril, hydrochlorothiazide, and desmopressin. She is also receiving nitrofurantoin for a urinary tract infection she developed in the hospital. Which of the following is the most likely cause of this patient’s symptoms?
1. Desmopressin
2. Hydrochlorothiazide
3. Nitrofurantoin
4. Lisinopril
1. Desmopressin
- Desmopressin is used in patients suffering from diabetes insipidus.
- A rare side effect of desmopressin is the occurrence of thrombocytopenic purpura.
- Patients with a history of thrombocytopenic purpura in the past are more at risk for developing purpuras when on desmopressin.
- Desmopressin acts as an ADH analog in patients suffering from diabetes insipidus to help retain water in these patients.
A young girl presents to the hospital with a history of weakness of both upper and lower limbs following a trivial fall injury. An MRI of her head shows a high riding odontoid tip well above the foramen magnum and compressing upon the brain stem. Which of the following best describes the commonly accepted pathophysiology of the condition in the child?
1. Genetic abnormality
2. C1-C2 facetal joint instability
3. Embryological dysgenesis
4. Viral infection
2. C1-C2 facetal joint instability
- The above case scenario is classical for basilar invagination.
- Currently, the most logical pathological genesis of the condition is the C1-C2 facetal joint instability thereby allowing for the odontoid peg to migrate upwards into the foramen magnum.
- Studies have confirmed that C1-C2 Facetal distraction with the use of spacer and C1-C2 fusion alone reverses the pathological changes seen in the basilar invagination.
- Though previously many etiological factors were considered for the condition, facetal instability is currently the most favored one.
A 33-year-old male construction worker presents with three months of chronic diffuse low back pain, which is worse at the end of the day. Upright plain film x-rays and flexion and extension x-rays of the lumbar region are unremarkable. An MRI of the lumbar spine shows a T2 hyperintensity of the lumbar 3-4 disc space eccentric to the right in the posterolateral region. What is the most appropriate initial treatment for this patient?
1. Right lumbar 3-4 laminotomy and foraminotomy
2. Right lumbar 3-4 transforaminal corticosteroid injection
3. Non-steroidal anti-inflammatory medication
4. Continue to watch expectantly
3. Non-steroidal anti-inflammatory medication
- First line treatment for an annular disc tear is nonsteroidal anti- inflammatory medications and low-impact physical therapy.
- Annular disc tears can be symptomatic or asymptomatic.
- Chronically an annular disc tear can lead to granulation tissue accumulation which can cause nerve irritation and radiculopathy.
- A transforaminal corticosteroid injection can be considered for annular disc tear if the patient fails an adequate trial of more conservative treatment.
A 17-year-old female presents with a fever and a headache. She has no significant past medical history. Her temperature is measured to be 39 C (102.2 F) while her blood pressure is 102/74 mmHg. Physical examination shows petechiae on her legs. Neck stiffness is present as well. Lumbar puncture is performed after which appropriate antibiotics and fluids are started. The next day, she develops severe back pain, perineal anesthesia, and is unable to urinate. Magnetic resonance imaging (MRI) confirms spinal cord compression. Which of the following is the most likely cause of the spinal compression in this patient?
1. Spinal abscess
2. Epidural hematoma
3. Disc herniation
4. Tumor
2. Epidural hematoma
- Cauda equina syndrome is a known complication of lumbar puncture procedures involving direct trauma or an epidural hematoma although the most common cause overall is disk herniation.
- Medicolegal litigation is high in these syndromes due to missed diagnoses and the high degree of residual functional impairment.
- Surgical decompression within 48 hours is paramount in acute cauda equina and conus medullaris syndromes.
- Saddle anesthesia is one of the most common presenting symptoms.
A 65-year-old male with a history of stage 4 prostate cancer with multiple bony metastases presents to the emergency department after a bicycle accident complaining only of neck pain and multiple excoriations to his body. He was placed is in a rigid cervical collar upon presentation. He reports he fell over the front of his bicycle when he hit a pothole. He remembers landing on his hands and chin. He is neurologically intact. A CT is performed, and a bilateral C2 pars interarticularis fracture with disruption of the C2 to C3 disc with greater than 4 mm subluxation of C2 on C3 is noted. Which additional structure is most at risk of being injured?
1. V2 segment of the vertebral artery
2. Superior cervical ganglion
3. V3 segment of the vertebral artery
4. Cervical segment of the internal carotid artery
1. V2 segment of the vertebral artery
- Segments of the vertebral artery include V1 - origin to C6 transverse foramen, V2 - C6-C2 transverse foramen, V3 - C2 transverse foramen to dura, V4 - intradural vertebral artery ending at basilar artery.
- The V2 segment of the vertebral artery is the structure most at risk in a Hangman fracture due to its close relationship of the C2 transverse foramen and the pars interarticularis.
- Often a fracture may extend to the transverse foramen, and thus a CT angiogram of the neck must be obtained for the evaluation of the vertebral artery.
- The superior cervical ganglion is located nearby but unlikely to be injured in a Hangman fracture. While not impossible for the V3 segment to be injured, it is more likely for the V2 segment to be injured at the level of the transverse foramen of C2. The cervical internal carotid artery is unlikely to be injured from in the setting of a Hangman’s fractures.
A mother brings her 10-year-old son to the emergency room for evaluation. He has a history of spina bifida requiring repair at birth and subsequent shunt placement. The child complains of increased pain in the legs, disturbed gait, and increased scoliosis. Which of the following clinic feature can also be associated with the neurological complication this child is experiencing?
1. Worsening bowel and bladder function
2. Hypotonia
3. Facial weakness
4. Neck rigidity
1. Worsening bowel and bladder function
- The child in this vignette is experiencing a well-known complication of spina bifida, a tethered cord.
- These patients present with pain in back and legs, increased spasticity, worsening of gait, increased scoliosis, and problems with bowel and bladder function.
- Providers should have a high index of suspicion for this complication in patients with a history of spina bifida.
- Facial weakness is not a complication of spina bifida. Neck rigidity may be seen with meningitis.
A 31-year-old woman presents to the emergency department after a motor vehicle collision. She has no acute complaints other than soreness and bruising. Her vital signs are stable. On exam, she has many superficial cuts and abrasions. Exam findings also include difficulty swallowing food, decreased right sided gag reflex, and no taste sensation on the right posterior 1/3rd of the tongue. An MRI reveals a lesion on the brainstem. Which of the following portions of the brainstem is most likely affected?
1. The superior half of the pons
2. The inferior half of the pons
3. The superior half of the medulla oblongata
4. The midbrain
3. The superior half of the medulla oblongata
- The glossopharyngeal nerve CN IX is responsible for the afferent portion of the gag reflex, taste on the posterior 1/3 of the tongue, and innervation of the stylopharyngeus muscle.
- The nucleus ambiguus is located in the superior medulla oblongata and gives rise to the sensory nerves of CN IX and is a synapse point for the motor fibers of CN IX as they descend from the cortex.
- The medulla oblongata is the lowest portion of the brainstem and has 4 cranial nerves that arise from it, CN IX-XII.
- Only one of the cranial nerve motor nuclei in the medulla oblongata is located medially, the hypoglossal nerve, cranial nerve XII.
A patient presents to the office with a three-month history of severe low back pain secondary to an osteoporotic compression fracture. The patient has been unresponsive to all conservative management. He underwent kyphoplasty but failed to have adequate pain relief longer than one month post-procedure. What is the best next step in the management of this patient?
1. Bracing
2. Facet joint injections
3. Vertebral fusion
4. Disc dissection
3. Vertebral fusion
- Spinal fusion surgery can loosely be described as the fusing two or more of a patient’s vertebral bodies together. Studies have shown patients undergoing surgery have decreased levels of pain in both short and intermediate follow-up after surgery. However, there are limited disability outcomes for patients undergoing vertebral fusion.
- There has been a recommendation for patients with low back pain greater than one year in duration and nonradicular in nature, to undergo spinal fusion as a reasonable treatment option, despite having inadequate evidence effectiveness in the long term.
- Bracing would be a potential option for the acute or subacute phase of treatment for pain control in an osteoporotic compression fracture. However, this can lead to atrophy of the core musculature with prolonged use. It also shows limited efficacy with long term use compared to a spinal fusion surgery, which has been shown to have some efficacy in the short term and intermediate follow up.
- Steroid injections into the facet joint have been shown to have limited evidence for the use. They have not been shown to be effective to treat low back pain secondary to osteoporotic compression fractures. Disc dissection surgery has not been shown to be a reasonable treatment option for osteoporotic compression fractures. There is limited evidence to be beneficial patient’s chronic low back pain.
An 8-year old child is brought to the emergency department after being struck by a car while crossing the street. He is not alert. He required immediate intubation at the scene by emergency management services. His Glasgow coma scale is 8. He appears to have a significant laceration of his scalp on the left side, but there are no skeletal fractures. The initial chest x-ray reveals a right-side pneumothorax. A chest tube was inserted. His hematocrit is 30%, and his hemoglobin is 10.6 g/dL. Heart rate is 100 bpm, blood pressure 100/60 mmHg, and respirations 20/minute. What is the next step in management?
1. CT of the head, thorax, and abdomen
2. Repeat chest x-ray
3. Repeat blood work
4. MRI of the head and neck
1. CT of the head, thorax, and abdomen
- The patient has two signs of Waddell triad and has a low hematocrit. The abdomen, especially the retroperitoneum, can be a source of significant bleeding.
- The Waddel triad includes trauma to the head, abdomen, thorax, and lower extremities with a car versus pedestrian impact. The full workup includes a whole-body CT scan, which can rapidly identify injuries to the brain (intracranial hemorrhage), chest, abdomen, and presence of any fractures. This is usually done as part of the tertiary trauma survey, which follows the secondary survey (a focused history and physical exam).
- If the patient has low hematocrit and there is no fracture, and the chest is clear, think about possible bleeding in the abdomen.
- The size of the child and the type of car can help determine injury patterns. Injury patterns will vary depending on the country and what side of the road a driver is on when a pedestrian is impacted by the vehicle. Children ages 1 to 5 years may be knocked down and dragged under the vehicle. The front bumper causes injuries to the femur, chest, abdomen, and pelvis. Children ages 3 to 11 years are prone to bumper impacts that fracture femurs and chest injuries from fenders or the hood. A child may be thrown onto the hood and hit the windshield, causing head and facial trauma. Another insult to the head occurs when the car stops abruptly, and they are thrown off the hood and onto the road striking their head again. Suspect multiple injuries with a car versus pedestrian impact. When taking a history, determine speed, the point of impact, and any safety gear worn at the time.
A 70-year-old male patient with a history of dementia presents to the spine clinic following repeated fall incidents at home. X-ray spine showed features of type III odontoid fracture. A full history cannot be obtained, and a physical exam is unreliable. What is the best imaging modality to accurately predict the acuteness of the fracture observed in the patient?
1. MRI spine
2. CT spine
3. Dynamic X-ray spine
4. USG spine
1. MRI spine
- MRI is the preferred imaging modality to determine the fracture acuity in terms of bone marrow edema.
- MRI will show T2 signal hyperintensities, mostly seen on STIR imaging, in cases of an acute fracture.
- MRI also provides the anatomic status of the spine as well as the integrity of the soft tissues, thereby enabling rational therapeutic decision-making.
- Elevation of the trabecular attenuation was the only CT spine variable showing high specificity in predicting acute fracture while comparing to MRI spine.
