Section 7 Flashcards
A 52-year-old retired golfer presents to the emergency department with severe abdominal pain. He states that the pain started a few days ago and was initially a dull backache. However, the pain has become unbearable. He describes the pain as a shooting pain that radiates from the back to the umbilicus, passing around the right side of the abdomen. He has otherwise been well and has no significant past medical history. His examination reveals a soft abdomen with audible bowel sounds. A sensory examination reveals reduced sensation in the right T10 dermatome. Which of the following additional signs is consistent with the underlying diagnosis?
1. Right iliac fossa pain of flexion and internal rotation of the right thigh
2. Upward umbilical movement on abdominal wall contraction
3. Weakness of hip flexion
4. Pelvis tilt to left while standing on his right leg
2. Upward umbilical movement on abdominal wall contraction
- This patient has presented with radicular pain in the right T10 dermatome. The patient’s examination reveals reduced sensation of ipsilateral T 10 dermatome indicating the presence of spinal nerve compression. His golfing history and reduced sensation in the ipsilateral dermatome are consistent with T10 radiculopathy, possibly due to thoracic vertebral disc herniation.
- The compression of the spinal nerve will lead to paralysis of the muscle innervated by the involver nerve. Paralysis of abdominal muscle will lead to abnormal movement of the umbilicus on the contraction of the abdominal wall.
- This sign is also known as the Beevor’s sign, which is an upward movement of umbilicus when the patient is asked to get up from a supine position. This is due to a paralysis of lower abdominal wall muscles.
- The testing of abdominal wall muscles is recommended when suspecting thoracic discogenic pain syndrome. Right iliac fossa pain of flexion of the hip is seen in appendicitis which is an important differential. Eruption f a rash is seen in the dermatomal shingles. Trendelenburg sign is seen with the involvement of the superior gluteal nerve and subsequent pelvic instability.
A 67-year-old female patient came to the emergency department with a history of unconsciousness two weeks ago, which reversed after a few hours following treatment. The initial CT scan of the brain was normal. Since then, she has been behaving oddly, complaining about the darkness in the room, not recognizing her family members, stumbling during walking, and making excuses for her behavior. An MRI brain was done, and it showed a bilateral occipital infarct. What is the probable diagnosis?
1. Riddoch syndrome
2. Anton syndrome
3. Balint syndrome
4. Gerstmann syndrome
2. Anton syndrome
- Anton syndrome is also known as visual anosognosia. Here, the patient shows telltale signs of blindness but denies it.
- In Anton syndrome, the patient often takes the help of confabulation in the process of denial.
- It occurs due to damage to the bilateral primary visual cortex. The main cause of Anton syndrome is posterior cerebral artery stroke.
- Riddoch syndrome or Riddoch phenomenon describes a subtype of visual disturbance due to occipital lobe lesion. The affected patient solely can distinguish non-static objects in his or her blind field. Balint syndrome is composed of three major components of optic ataxia, ocular apraxia, and simultanagnosia. It might occur due to posterior parietal lobe lesions. Gerstmann syndrome is composed of four distinct parts, including the disturbance in the ability of writing, making mathematical calculations, finger identification, and making significant distinctions.
A 54-year-old female presents to the trauma bay with an acute spinal cord injury. After initial resuscitation and stabilization of the patient, the provider begins a thorough review of her past medical history. Which of the following has the most significant impact on increasing her risk for decreasing bone mineral density in the long term?
1. A fracture from a ground-level fall after 50 years of age
2. Early menopause
3. Bodyweight under 158 pounds
4. Hispanic race
2. Early menopause
- The risk factors for osteoporosis in at-risk populations remain the same when considering the spinal cord injury (SCI)-induced osteoporosis patient subgroup.
- Early menopause is a known significant risk factor for osteoporosis. Other risk factors for osteoporosis include increasing age, bodyweight under 128 pounds, smoking, family history of osteoporosis, white or Asian race, low levels of physical activity, and a personal history of a fracture from a ground-level fall or minor trauma after the age of forty.
- After an acute SCI patient is stabilized, multi-professional care must begin as soon as possible. It includes, but is not limited to, referring to a provider specializing in managing patients with bone mineral density deficiency.
- The initial two weeks after injury is the most vulnerable clinical period for rapid bone mineral density losses.
A 16-year-old boy presents with bilateral sensorineural hearing loss and unsteady gait. His MRI brain revealed features of bilateral tumors arising within the internal auditory canal and compressing upon the cerebellum. His brother also had a history of being operated on for a posterior fossa tumor. What gene is implicated in the condition seen in the patient?
1. Neurofibromin
2. Merlin
3. VHL gene
4. Rb gene
2. Merlin
- Bilateral vestibular schwannomas are diagnostic of NF2.
- NF-2 is known as Merlin and acts as a tumor suppressor. Decreased production or function results in an increased likelihood of tumors of the central and peripheral nervous systems.
- Half of the patients with NF-2 have a de nova mutation in the merlin gene.
- Neurofibromin is implicated for Neurofibromatosis type 1. VHL is associated with hemangioblastomas.
A female infant is born to a healthy mother via vaginal delivery. The initial exam shows a 3 cm x 5 cm cystic mass on the infant’s back. On careful evaluation, a skin and bone defect is the provisional diagnosis. The mother has a past history of delivery of a child with similar pathology 1 year ago. What is the estimated risk of the recurrence of similar pathology in a future pregnancy?
1. 1%
2. 3%
3. 10%
4. 15%
3. 10%
- The clinical presentation in the child is highly suggestive of a spinal dysraphism.
- This is the second occurrence of the entity following the delivery of the child to the mother.
- The estimated recurrence risk after two such pregnancies is approximately 10%.
- The empirical recurrence risk after one affected pregnancy is approximately 3%.
A 31-year-old man with a past medical history significant for spinal fusion of his L2-L4 vertebra secondary to a traumatic fracture following a motor vehicle collision presents to the office for further evaluation of his chronic back pain. He was diagnosed with spinal stenosis five years ago. His car accident occurred four years ago but has been getting worse over the last year. He was recently evaluated for depression by his primary care provider, but the assessment was negative for depression. He complains of a dull ache in his back that is constant. He denies any numbness, burning, or shooting pains in his back. The severity of his pain is 7/10. He states his low back is tender to even light pressure, where even tight-fitting clothing can cause him pain. He has been on chronic opioid therapy since the accident, requiring 60 morphine equivalents daily. Acetaminophen and NSAIDs do not help with his pain. He denies any bowel or bladder incontinence. However, he constantly worries about his pain and how it will get worse. What aspect of this patient’s pain is most consistent with a centralized process to his pain?
1. Dull nature of the pain
2. Allodynia
3. Chronic opioid dependence
4. Pain catastrophizing
2. Allodynia
- Pain being experienced from non-painful stimuli is allodynia this is a centralized process. When assessing pain it is important to be cognizant of signs of centralized pain.
- This patient is also experiencing mildly painful stimuli experienced as severe pain (hyperalgesia). This is also an important clinical sign on the assessment for centralized pain.
- Centralized pain is a maladaptive form of pain where a lower threshold is needed to experience pain. Worsening pain over time may be a sign of his pain becoming centralized. It is important to the aspect of pain assessment if the pain has gotten worse over time.
- Another reason for the worsening of this patient’s pain over time is tolerance to his chronic opioids. It is important to determine during your pain assessment if the patient has required recent changes to his pain management.
A 17-year-old female is brought to the hospital following a motor vehicle collision. While determining her motor score, she is found to have abnormal flexor posturing. Fifteen minutes later, she develops extensor posturing involving both her upper and lower limbs. What is the most likely pathological basis for the characteristic posturings observed in the patient following the traumatic brain injury?
1. Uncal herniation
2. Subfalcine herniation
3. Transtentorial central herniation
4. Tonsillar herniation
3. Transtentorial central herniation
- Central herniation of the brain can lead to abnormal flexor or extensor posturing.
- Abnormal posturing occurs in transtentorial herniation. Injury sparing the rubrospinal tract causes flexion of the upper limbs with an extension of the lower limbs. Further herniation with the involvement between the red nucleus and the vestibulospinal tract causes extensor posturing of both the upper and lower limbs.
- Once there is the involvement of the medulla, there will be no motor response. The patient will also exhibit abnormal respiration.
- Tonsillar herniation leads to respiratory arrest due to the involvement of the medullary respiratory centers.
A 40-year-old male presents to the emergency department after being involved in a motor vehicle collision. He escaped unscathed but complained of lower back pain since the event. His examination reveals no focal neurological deficit. An X-ray of the spine is performed. The X-ray shows an anterior translation of the L5 vertebrae over the S1 vertebrae. The distance of displacement is approximately 50% of the vertebral body length. Which of the following clinical findings is consistent with the radiological investigations in this patient?
1. Back pain on spine extension
2. Severe pain on light touch
3. A popliteal angle of 20 degrees
4. Back pain on spine flexion
1. Back pain on spine extension
- This patient has been involved in a motor vehicle collision. He complains of lower back pain but has no focal neurological deficit. The spine X-ray shows the anterior displacement of L5 vertebrae making the likely diagnosis of traumatic lumbar spondylolisthesis.
- Patients may complain of lower back pain or may present with symptoms of cauda equina compression. Back pain on extension of the spine often elicits pain. Extension of the spine places strain on the affected region and leads to a reproduction of pain.
- Single-leg hyperextension repeated extension and resisted back extension when prone are some of the maneuvers that can elicit back pain in individuals with spondylolisthesis. There may also be the tightness of hamstrings associated with back pain.
- No single examination finding is sensitive or specific for spondylolisthesis, and signs should be correlated with radiological evidence. Flexion of the spine usually does not cause pain. Tenderness on light touch indicates a more superficial process, such as spinous process apophysitis. The tightness of hamstrings and a popliteal angle greater than 50 degrees may be seen in individuals with higher-grade spondylolisthesis.
A 17-year-old male diver presents for follow up in the spine clinic. The patient had a fatigue fracture noted between the L4-5 and L5-S1 facet joints on the right side, a year ago. The patient and family want to know if his injury is getting better or worse. Which of the following modalities best assesses the extent of cortical disruption and is best for assessment of healing with regards to this injury?
1. Plain film
2. Computed tomography
3. Magnetic resonance imaging
4. Bone scan
2. Computed tomography
- CT scan is the best modality for determining fracture size and extent and is the most appropriate modality for follow-up assessment of healing.
- CT has the downside of additional radiation exposure, which is particularly concerning in the pediatric and adolescent population.
- Bone scan is the best modality for detecting early pars defect.
- Similar to a bone scan, MRI can be useful for early detection of acute lesions by the presence of bone marrow edema on T2 weighted sequences.
A 35-year-old woman presents to the clinic for a follow-up of epilepsy. She is taking three antiepileptic medications and still has frequent focal seizures several times a week. This has been affecting her quality of life and professional career. Which of the following is the next best investigation to help plan possible surgical treatment in this patient?
1. FDOPA PET scan
2. FDG PET scan
3. Amyloid PET scan
4. FDG SPECT scan
2. FDG PET scan
- FDG PET scan is instrumental in the presurgical workup of medically refractory epilepsy.
- FDG PET and not SPECT can localize or lateralize the seizure onset zone (SOZ).
- FDG PET scan changes are also predictive of the severity of disease and changes in glucose metabolism postoperatively are associated with a better prognosis.
- FDOPA PET scan does not currently have a clear role in the presurgical workup of epilepsy. C11 methionine, a different amino acid PET scan, has been used successfully in delineating the SOZ in tuberous sclerosis patients.
A 48-year-old woman undergoes transsphenoidal hypophysectomy. Her surgeon had not gone through her CT scans thoroughly before the surgery. Postoperatively, the patient’s vision is diminished on the right side. Presence of which anatomical variation is most likely to have caused this complication?
1. Pneumatisation of pterygoid base
2. Sphenoethmoidal cell
3. Poorly pneumatised sphenoid
4. Sellar type of pneumatisation
2. Sphenoethmoidal cell
- Sphenoethmoidal cell/Onodi cell is a posteriormost ethmoid cell pneumatising into the sphenoid sinus.
- It lies superolateral to the sphenoid sinus close to the internal carotid artery and optic nerve.
- It is identified as a cell superior to the ipsilateral sphenoid sinus, separated by a horizontal septation.
- Careful identification of this anatomical variant is vital as optic nerve may be exposed in this air cell.
A 78-year-old man is being evaluated in the ICU. He was admitted two days ago for severe meningoencephalitis. The patient is not able to maintain a seated or lying position and is not a candidate for the Omaya reservoir. Which of the following is the most appropriate method for intrathecal antimicrobial therapy in this patient?
1. Lumbar puncture
2. Cervical approach CSF retrieval
3. Thoracic approach CSF retrieval
4. External ventricular device for CSF retrieval
2. Cervical approach CSF retrieval
- One of the alternatives that you can evaluate when trying to start intrathecal therapies when lumbar puncture and ventricular access are contraindicated is suboccipital puncture access.
- Thoracic CSF retrieval is not recommended due to the anatomy of the spine in this segment. Suboccipital anatomy makes for a more direct and safe approach when considering intrathecal therapies.
- Also when positioning is an issue, as well as the cooperation of the patient, is null, the suboccipital puncture can give you control over the procedure and makes it safer for the patient.
- Omaya reservoir is a possible approach but is a more invasive procedure.
A 42-year-old man is brought to the emergency following a motor vehicle collision. Neurological examination revealed more weakness in his bilateral upper limbs compared to that of his lower limbs. He also has a weak gag reflex. Which of the following is the most likely pathogenesis for such a characteristic neurological presentation in the patient?
1. Central cord syndrome
2. Traumatic syrinx
3. Cruciate paralysis
4. Spinal epidural hematoma
3. Cruciate paralysis
- The patient has characteristic clinical features of cruciate paralysis.
- This characteristically occurs due to injury at the cervicomedullary region.
- The corticospinal fibers of the upper limbs decussate in the rostral pyramids compared to that of the lower limbs which decussate more caudally.
- There is characteristic involvement of the lower cranial nerves as well in sharp contrast to that of the central cord syndrome.
A patient develops acute left hemiplegia involving the face more than the arm and leg. The suck and grasp reflexes and speech are preserved. Which cerebral vessel is involved?
1. Anterior cerebral artery
2. Vertebrobasilar artery
3. Middle cerebral artery
4. Posterior cerebral artery
3. Middle cerebral artery
- Anterior cerebral artery strokes often affect the leg more than the arm or face.
- Middle cerebral artery strokes often affect the face and upper extremity. Speech is mostly a left hemisphere function.
- Posterior cerebral artery strokes present with visual field defects.
- Vertebrobasilar artery strokes are variable in presentation but often have crossed signs.
A 79-year-old male with a past medical history of atrial fibrillation, arterial hypertension, and diabetes mellitus type 2 presents to the emergency room after suffering a ground-level fall yesterday night at a dinner party. The patient is neurologically stable with a blood pressure of 160/85 mmHg. However, he is complaining of headaches and the inability to hold objects with his right upper extremity. The head computed tomographic scan shows a large left acute subdural hematoma with a 1.2 cm shift of midline structures. A craniotomy is performed for hematoma evacuation. Sutures were removed the following week. Six weeks later, the patient returns to the emergency room with headaches, low-grade fever scalp swelling near the proximal margin of the wound. He has a normal neurological exam. Which of the following disorders would be of most significant concern?
1. Hydrocephalus
2. Recurrent subdural hematoma
3. Stroke
4. Osteomyelitis
4. Osteomyelitis
- A craniotomy is performed to drain intracranial hematomas. Osteomyelitis of the bone flap can occur and is usually associated with wound infection and subdural empyema. It occurs several weeks after a craniotomy.
- Complications of a craniotomy include seizures, stroke, coma, lethargy, hydrocephalus, wound infection, osteomyelitis, and air embolism.
- Once the craniotomy concludes, the bone is reattached in position with plates and screws. Pristine hemostasis should be obtained before closing the scalp.
- When the patient is under general anesthesia, effective communication between providers minimizes complications and unexpected events.
An 80-year-old male involved in a motor vehicle collision with a positive loss of consciousness was ambulatory on the scene. He has no other past medical history. Computed tomography cervical spine reveals a C2 vertebral body fracture with 2 mm of posterior displacement. He is neurologically intact but hemodynamically unstable. Which of the following is the next best course of treatment?
1. Emergent surgery for fracture stabilization
2. Emergent surgery for neurogenic shock
3. Rigid collar fixation
4. Immediate MRI of the cervical spine
3. Rigid collar fixation
- Type III odontoid fractures are usually considered stable and do not require emergent surgery.
- Odontoid fractures with dens displacement greater than 5 mm are considered surgical.
- Rigid fixation is the standard of care for type III fractures that have minimal to no displacement.
- MRI is warranted to evaluate the ligamentous complex however rigid fixation is priority.
A 16-year-old patient sustains a severe head injury following a motor vehicle collision. His intracranial pressure (ICP) has been monitored by an external ventricular drain (EVD) placement. Despite keeping the patient intubated and sedated in mechanical ventilation, his ICP is persistently above 20 mm Hg. His serum electrolytes are normal, and serum osmolality is 330 mOsm/kg. The treating clinician plans to start medical therapy to manage his refractory cerebral edema. Which of the following is the most rational approach to managing the patient?
1. Hypertonic saline
2. Mannitol
3. Urea
4. Glycerol
1. Hypertonic saline
- The use of hypertonic saline in the management of intracranial hypertension has shown to be of rapid onset, sustained as well as long-lasting effects with collateral improvement in cerebral perfusion as well.
- 3% hypertonic saline with a loading dose of 5 ml/kg and a maintenance dose of 2 ml/kg every six hours has shown to be highly efficacious as well as safe in managing refractory intracranial hypertension. A target serum sodium while administering 3% saline is 150 to 155 mEq/L, which roughly corresponds to a serum osmolality of 320 to 340 mOsm/kg.
- The occurrence of side effects such as central pontine myelinolysis and acute tubular necrosis with hypertonic saline is minimal in patients with serum osmolality of above 320 mOsm/kg and normal serum sodium values. A serum sodium level of 155 mEq/L (and osmolality of 320 mOsm/kg) is generally considered to be the safe upper limit for the administration of mannitol.
- Urea and glycerol have low efficacy in managing cerebral edema. Mannitol use leads to a high occurrence of rebound cerebral edema, renal failure, and electrolyte imbalance. Both hypertonic saline, as well as mannitol, have comparable all- cause mortality rates.
A 32-year-old female patient presents to the hospital with left-sided eye pain and diplopia for the past three days. Her past medical history is suggestive of loss of pregnancy in the first trimester one year ago. On examination, her blood pressure is 140/90 mmHg, and heart rate is 88 bpm. Examination of her eyes reveals equal-sized pupils that are reactive to light and no proptosis. However, the left-sided eye is found to have deviated downward and outward, and it is unable to move laterally. Furthermore, there is hyperesthesia of the upper face on the left side. What is the most likely diagnosis?
1. Acute angle-closure glaucoma
2. Cavernous sinus thrombosis
3. Mucor mycosis
4. Epidural hematoma
2. Cavernous sinus thrombosis
- The diagnosis of antiphospholipid syndrome (APLS) includes clinical and laboratory criteria. Obstetric medical history is an important element of the history if APLS is suspected. Arterial and venous thrombosis are typical manifestations of APLS.
- The most common sites of venous and arterial thrombosis are the lower limbs and the cerebral arterial circulation, respectively, but thrombosis can occur in any organ.
- This patient has a history of pregnancy loss and now presents with features indicative of cavernous sinus thrombosis, which is likely to be secondary to the prothrombotic state caused by APLS.
- Acute angle-closure glaucoma usually does not present with the constellation of neurological findings described in this case.
A 28-year-old female presents with sudden onset right low back pain radiating to the right buttock, right posterior thigh, calf, and ankle. Symptoms started after she bent down to pick a heavy box at work. She reports severe pain that affects her sleep and ability to work and perform activities of daily living. Physical therapy seems to aggravate the pain. Examination shows intact strength and sensation and symmetric 2+ deep tendon reflexes. The straight leg raise test was positive on the right. She denies and bladder-bowel problems or saddle anesthesia. MRI of the lumbar spine was done and showed an L5-S1 Right paracentral disc herniation impinging the Right S1 nerve root. What would be the next best step in management?
1. Consider spine surgery consultation for lumbar discectomy.
2. Consider a trial of lumbar epidural steroid injection.
3. Consider a lumbar sympathetic nerve block.
4. No other treatment is indicated at this time
2. Consider a trial of lumbar epidural steroid injection.
- The patient’s presentation is most consistent with lumbar radiculopathy secondary to L5-S1 dis herniation. She experienced sudden onset right low back pain radiating to the Right L5-S1 dermatome with concordant MRI findings.
- Since the patient’s pain failed to improve with physical therapy and seems to significantly impair her function and quality of life, further treatment would be indicated.
- Her neurological examination is normal with no motor or sensory deficits. Therefore, the next best step would be a trial of lumbar epidural steroid injection.
- Surgical consultation should be considered sooner if any neurologic deficit is present.
A 69-year-old man is brought to the emergency department after sustaining a ground-level fall. He is complaining of neck pain. Neurological examination is unremarkable. X-rays of the cervical spine demonstrate marginal syndesmophytes and kyphosis but no acute fracture. A cervical CT scan demonstrates a nondisplaced fracture through C5-6 disc space into the posterior bony elements of C5. Which of the following is the best initial treatment for this patient?
1. Halo vest for 6 weeks
2. Hard collar for 6 weeks
3. Posterior fusion and instrumentation C4-C7
4. Posterior fusion and instrumentation C3-T1
4. Posterior fusion and instrumentation C3-T1
- This patient has ankylosing spondylitis and is prone to cervical spine fractures from low energy trauma.
- Due to the long lever arm of the fused spine, fixation constructs should be long with multiple levels above and below the fracture to allow for less stress on the construct.
- Whether or not to go anterior and posterior is still debated in the literature. However, there is a higher rate with anterior fixation alone.
- The conservative treatment of these fractures in a collar will require neuromonitoring as they are at high risk of developing neurologic deterioration.
A 25-year-old woman is brought to the emergency department (ED) with a brief sensory loss on the right side of the face and mild incoordination of the right upper extremity. Her examination done in the ED shows no residual deficits. The MRI indicates no infarct, but stenosis of the high-grade right-middle cerebral artery is found on the magnetic resonance angiography (MRA). The stenosis along with extensive hypertrophy and collateralization in the lenticulostriate vessels is confirmed on an angiogram. Her vitals shows blood pressure of 135/65mmHg, and her labs indicate a low-density lipoprotein of 109 mg/dL (reference range 100 mg/dL) and total cholesterol of 234 mg/dL (reference range 200 mg/dL). Which of the following is the most effective intervention for stroke prevention in this patient?
1. High-dose statin therapy
2. Aspirin
3. Endovascular stenting of the right-middle cerebral artery (MCA)
4. Surgical bypass of the right MCA
4. Surgical bypass of the right MCA
- The sign and symptoms, along with the angiographic findings in this patient, are suggestive of Moyamoya disease (MMD).
- Moyamoya disease (MMD) is an isolated chronic, usually bilateral, vasculopathy of undetermined etiology characterized by progressive narrowing of the terminal intracranial portion of the internal carotid artery (ICA) and circle of Willis.
- Surgical revascularization is the only main treatment for MMD with deteriorating cerebral hemodynamics to improve the cerebral blood flow and prevent further strokes.
- Main indications for surgical revascularization are apparent cerebral ischemia, reduced regional cerebral blood flow, and decreased cerebral vascular reserve in perfusion studies. However, every case is evaluated separately as decisive factors may vary from case to case. Surgery is more beneficial for children since the pediatric form of MMD is usually rapidly progressive.
A 73-year-old male presents to the clinic with chronic low back pain. He had undergone a lumbar facet block several times with positive results. How many levels of medial branch blocks should be done if the provider wants to block the facet joints between the third to fifth vertebras?
1. 5
2. 2
3. 3
4. 4
4. 4
- Each facet joint is innervated by two medial branches of the posterior ramus.
- One from the medial branch above, the other from the medial branch below.
- The medial branch of the posterior ramus can be blocked at the location near the origin of the transverse process.
- Medial branch block can help to reduce the pain related to facet arthropathy but may have to be done every three months.
A 16-year-old woman presents with CSF rhinorrhoea. A lumbar drain is inserted for CSF rhinorrhoea. On day 4 of admission, she developed a high-grade fever, neck pain, and photophobia. On examination, neck rigidity is present and Kernig’s sign is positive. What is the most likely pathogen responsible for this presentation?
1. Neisseria meningitidis
2. Streptococcus pneumoniae
3. Anaerobic bacteria
4. Herpes simplex virus
2. Streptococcus pneumoniae
- Meningitis is the most common complication associated with and is seen in around 25-30% of the cases.
- Early warning signs include headache, photophobia, neck rigidity, positive kernig’s sign, and altered sensorium.
- In patients with evidence of meningitis, empirical antibiotics must be started, followed by culture-based antibiotics after microbial culture and sensitivity is available.
- The most common pathogens include Streptococcus pneumoniae and Hemophilus influenzae. Polymicrobial and anaerobic infections can be observed in cases with penetrating injuries.
A 49-year-old woman is being evaluated for endoscopic transsphenoidal hypophysectomy for a pituitary tumor. A recent MRI shows suprasellar extension of the mass. Which of the following is the most appropriate approach for surgery in this patient?
1. Transclival
2. Transtuberculum
3. Transpterygoid
4. Transcribriform
2. Transtuberculum
- This question focuses on the understanding of anatomical landmarks in the sphenoid sinus and adjacent skull base. A suprasellar extension may necessitate further exposure superiorly from the sellar bone.
- Sulcus chiasmaticus, tuberculum sellae, and planum sphenoidale are arranged, inferior to superior, in relationship to the sellar prominence.
- Hence superior exposure would require a transtuberculum or a transplanum-transtuberculum approach.
- Clivus is inferior to the sellar prominence. The pterygoid process and cribriform plate are lateral and anterior to the sphenoid sinus, respectively.
A 35-year-old man is diagnosed with acute hydrocephalus due to tuberculous meningitis, and antitubercular therapy is started. He is admitted to the neurosurgery intensive care unit following external ventricular drain (EVD) placement from Kocher point and is showing clinical improvement. During the second day of admission, the patient inadvertently pulls out his EVD drain. The treating clinician immediately places a new EVD from the same point. There is clear egress of cerebrospinal fluid (CSF) in the EVD bag. What is the most appropriate next step in management?
1. Repeat CT head to ensure proper EVD placement
2. Send CSF for culture and sensitivity
3. Plan for ventriculoperitoneal (VP) shunting
4. Plan for endoscopic third ventriculostomy (ETV)
2. Send CSF for culture and sensitivity
- The accidental removal of an external ventricular drain (EVD) has a reported incidence of only 0.4 %. It is a serious adverse event with high risks for intraventricular bleeding and ventriculitis.
- The incidence of ventriculostomy-related infection ranges from 0-30%. However, the mortality from ventriculitis has been reported to be as high as 40%.
- It is critical to send the cerebrospinal fluid (CSF) for culture, initiate broad-spectrum antibiotic coverage, and modify the antibiotics based on the culture and sensitivity results.
- CSF diversion procedures such as VP shunting and endoscopic third ventriculostomy (ETV) should be performed only after ruling out microbiological evidence of ventriculitis in this patient.
A 58-year-old man presents to the clinic with clumsiness of the right hand and difficulty in walking. The physical examination reveals a positive Hoffmann sign and guttering of intermetatarsal space. MRI shows cervical spondylosis and spinal canal stenosis at two levels. Lateral flexion radiograph reveals normal minimal kyphosis, which is correctable on extension radiographs. What is the most appropriate management strategy for this patient?
1. Decompression and anterior fusion
2. Decompression and posterior fusion
3. Laminectomy and decompression
4. Conservative management
2. Decompression and posterior fusion
- The above-mentioned scenario reveals significant cervical spondylosis at two levels of the cervical spine.
- Decompression with posterior fusion is the ideal treatment of choice for this patient.
- Flexion and extension radiographs are required to assess the instability and correctable deformity.
- Decompression and laminectomy without fusion lead to poor results.
A 65-year-old man is brought by his son for sudden onset nausea, vomiting, and confusion. His son reports that his father has been diagnosed with Alzheimer disease and takes medication for it and hypercholesterolemia, arthritis, and gout. He also had treatment for basal cell carcinoma about ten years ago and uses inhalers when needed for bronchiectasis. His son also mentions that his father was taken to the hospital with similar symptoms a few months ago, but the outcome from that admission is unknown. A plain CT head reveals a heterogenous, hyperdense hemorrhagic lesion in the right frontal lobe with surrounding edema and midline shift. Considering the pathogenesis of this patient’s suspected diagnosis, what aspect of his history has most likely increased the risk of his current presentation?
1. Alzheimer disease
2. Hypercholesterolemia
3. Bronchiectasis
4. Inhaler intake
1. Alzheimer disease
- The pathogenesis of Alzheimer dementia includes the formation of plaques of amyloid protein within the brain known as cerebral amyloid angiopathy (CAA), which is also a risk factor for lobar intracerebral hemorrhage (ICH).
- CAA is due to the deposition of beta-amyloid protein in cerebral cortical blood vessels (rarely in the basal ganglia and brainstem), seen most commonly in the population above 55 years of age.
- The apolipoprotein E (ApoE) genotype is thought to impact the pathophysiology of CAA but is not a sensitive test to diagnose the disease. CAA increases the risk of lobar ICH significantly, and imaging often reveals hemorrhages of varying ages, which may be seen as heterogeneously attenuating lesions.
- Low cholesterol, when associated with hypercoagulable states or hypertension, can be a risk factor for ICH.
A patient presents to the clinic with a complaint of back pain. He gives a history of a fall from stairs one week ago. Now he has developed stiffness in the lumbosacral region and numbness in the feet. The attending clinician advises MRI of the lumbosacral region. The attending clinicians should keep in mind that surgical intervention for the initial management of such patients should be considered if a patient is found to have which of the following?
1. Severe pain
2. Lower extremity motor deficit
3. Symptoms that have lasted less than 3 months
4. Difficulty completing activities of daily living
2. Lower extremity motor deficit
- While even severe pain may be expected to improve with multimodal nonoperative treatment, the presence of motor deficits is less amenable to conservative management.
- As motor deficits resulting from direct nerve root compression by a lumbosacral disc injury may result in permanent weakness and the resulting disability, surgery should be considered as an early treatment option when evaluating a patient with lumbosacral disc injury and associated focal weakness.
- Without formal adherence to nonoperative treatment such as oral NSAIDs, physical therapy and epidural injections, the duration of symptoms alone is not an indication to proceed with surgery prolonged pain does not have the potential for permanent disability seen with motor deficits.
- In the absence of motor deficits, physical impairment is not an indication to proceed with surgical intervention initially when managing lumbosacral disc injuries. Nonoperative treatment such as oral NSAIDs, physical therapy, and epidural injections should be trialed with the expectation that they may improve functional status.
A 1-year old boy is brought to the clinic due to an abnormal midline forehead bony ridge. There is no family history of a similar disease. The developmental milestones are normal for his age. A 3D computed tomographic scan shows frontal bones with a triangular shape, hypotelorism, anterior displacement of the coronal sutures, widening of the posterior parietal regions, pterional constriction, and flattening of the supraorbital ridges with lateral orbital hypoplasia. What is the most appropriate management strategy for this patient?
1. Conservative management
2. Head helmet therapy
3. Endoscopic surgery
4. Open surgery
4. Open surgery
- Early operative treatment is recommended to provide the best possibility for the brain to expand and produce a normal configuration of the skull. Surgery goals are to remove the bony ridge of the metopic suture, advance both orbits and the frontal bones, achieve a rounder forehead contour, and prevent the psychosocial impact and neurodevelopmental delay.
- Operative treatment can be endoscopic or open. This child is already one year of age. Endoscopic technique is best used before 3 to 4 months of age due to the skull’s pliability. Thus, open surgery is recommended.
- In those cases where cranial reconstruction is required, a bifrontal craniotomy is performed to reconstruct the anterior cranial vault, including the lateral portions of the sphenoid wings to allow brain expansion.
- If the deformity is minimal or there is only a bony ridge without hypotelorism, a more conservative approach can be used; however, the child should be followed for a minimum of 12 months of age to assess and corroborate adequate cranial growth. Clinical evaluations and family discussions regarding neuropsychological development are engaged. A head helmet is used on the patient on the fifth postoperative day after endoscopic surgery. It is used for the next 10–12 months to directed cranial growth by allowing cranial expansion in recessed areas of the skull.
A 76-year-old woman with a history of achondroplasia presents to the clinic with weakness and pain in the lower back and intermittently in the legs for the past 5 months. A nerve conduction study with needle electromyography is ordered. Which of the following sets of findings is most likely to be seen in this patient?
1. SNAP amplitudes are normal, CMAP amplitudes normal, and abnormal spontaneous potentials on needle EMG
2. SNAP amplitudes are normal, CMAP amplitudes increased and abnormal spontaneous potentials on needle EMG
3. SNAP amplitudes are increased, CMAP amplitudes normal and abnormal spontaneous potentials on needle EMG
4. SNAP amplitudes are increased, CMAP amplitudes increased and abnormal spontaneous potentials on needle EMG
1. SNAP amplitudes are normal, CMAP amplitudes normal, and abnormal spontaneous potentials on needle EMG
- The majority of the patients have normal sensory and mother nerve conduction studies. However, needle EMG is possible in cases with radiculopathy but not essential during a spinal stenosis study. If there is a significant narrowing of the vertebral formanina and root compressions in the acute setting, you may find fibrillations and positive sharp waves at different levels bilaterally.
- In a patient with spinal stenosis, motor nerve conduction studies and amplitudes are usually normal. Distal latencies should also be normal as the distal aspect of the nerve is not disturbed. However, if the disease has progressed to the point where axonal damage has occurred, you will see a decrease in amplitude of the CMAP on nerve conduction studies.
- In a patient with spinal stenosis, sensory nerve conduction studies and amplitudes are usually normal. This occurs because the sensory fibers travel through the dorsal root ganglion, which is located outside the spinal canal.
- For the needle EMG portion of the exam, it is essential to test multiple paraspinal levels bilaterally and multiple myotomes in both extremities. In spinal stenosis, often, there are findings of bilateral multilevel nerve root involvement, if there is root involvement.
A 54-year-old female with a history of low back pain for many years and frequent falls presents to her primary care office due to an increase in the back pain, which is now radiating to the right leg. Pain starts at the right buttock and goes lateral on the thigh and anterior in the leg down to the big toe. On exam, she has a positive straight leg raising on the right leg. Knee jerk and ankle jerk are normal, but she can not dorsiflex the big toe. She also has a completed foot drop. Which type of gait disturbance will she present?
1. Steppage gait
2. Waddling gait
3. Hemiparetic gait
4. Myelopatic gait
1. Steppage gait
- Steppage gait produces an initial contact with toes (foot drop). The heel is unable to strike first.
- Steppage gait is caused by ankle dorsiflexion weakness. A herniated disc at L4-L5 will compress the L5 root and create radiculopathy affecting the muscles and producing dorsiflexion of the ankle.
- Treatment for steppage gait is hinged or posterior leaf spring ankle-foot-orthosis (AFO) and electrical stimulator. Sometimes surgery can reverse foot drop.
- Waddling gait or toe walking is caused by proximal muscle weakness.
A 3-year-old girl was brought to the hospital by her grandmother, who looked very concerned. The child fell from her bed in the morning and was very irritable for a couple of hours following the injury. The grandmother informed that the child held her neck “stiff” for the initial hour, after which she was fairly comfortable. There was no episode of loss of consciousness or vomiting. The general physical and neurological examination of the child was normal. The child was playful, and it was decided to obtain a CT scan of the head. The CT scan reveals no brain injury. However, there is a bilateral discontinuity on the arch of the atlas (C1), just anterior to the facet. What is the next step in management?
1. Reassurance
2. Discuss the concern for a major cervical injury with the grandmother and advise CT and MRI studies of her cervical spine
3. Skull traction, followed by surgical stabilization
4. Halo vest application
1. Reassurance
- Three ossification centers develop in the immature atlas one for the anterior ring and one for each posterior neural arch. These ossification centers appear at one year of age.
- The connection between anterior and posterior arches is composed of neurocentral synchondrosis, which fuses at 7 years of age. The posterior arch usually closes by three years of age.
- The pattern of cervical fractures in children younger than 10 years is much different from older children and adults.
- Most of the cervical spine fractures in young children occur between occiput and C2 due to large head size and relative hypermobility.
A 17-year-old boy is brought to the emergency department with head trauma after crashing in his skateboard. He has a minimally depressed frontal bone fracture that includes the anterior and posterior sinus walls. Two weeks later, the patient presents to the same hospital, and the mother explains that since the accident, his forehead has grown larger, warmer, and more tender. The patient also complains of subjective fevers, frontal headaches, and mild nausea. What is the most likely causative organism of this patient’s condition?
1. Pseudomonas aeruginosa
2. Fusobacterium
3. Streptococcus pneumoniae
4. Staphylococcus aureus
4. Staphylococcus aureus
- The condition described is a Pott’s puffy tumor which is osteomyelitis of the anterior table of the frontal sinus with a subperiosteal abscess. It is a complication of frontal sinusitis that is most commonly seen in young adults due to a more extensive network of diploic veins. The rapid diagnosis for fast treatment of this condition is crucial for optimal outcome and decreases the risk of development of complications such as intracranial extension via erosion of the posterior table of the frontal sinus. Studies have demonstrated that the best strategy for the management of Pott puffy tumors is the combination of medical and surgical treatment to prevent further complications and improve morbidity and mortality.
- Once the patient arrives and diagnosis is suspected, the patient should be admitted and started on broad-spectrum IV antibiotic, IV hydration, analgesia, and rapid coordination for imaging studies. A moth-eaten pattern of bone destruction is characteristic on imaging.
- Broad-spectrum IV antibiotics should be started as soon as the diagnosis is suspected. Coverage should be provided for the most common pathogens, including gram-positive and anaerobes. It is important to choose antibiotics that have adequate blood-brain barrier penetration for central nervous system coverage. Choices include penicillin or vancomycin, 3rd generation cephalosporin, and metronidazole. Once the culture has a final result, guide antibiotic therapy for that specific pathogen.
- While many Pott puffy tumors are polymicrobial, the most common single species are Staphylococcus aureus.
A 66-year-old man with chronic axial lower back pain for two years is undergoing basivertebral neurotomy. There was no leg pain, no bowel or bladder incontinence or retention, and no motor or sensory changes. After the procedure, the patient does well, and on a 4-week follow-up, the patient is doing well with marked improvement in function and reduced pain and opioid utilization. Which of the following findings is most likely to have been seen in this patient’s pre-procedure MRI?
1. Lumbar L4-5 spondylolisthesis
2. One-eye owl sign with pedicle destruction
3. 50% reduction of the anterior vertebral body
4. Modic changes type I or type II
4. Modic changes type I or type II
- Based on this patient’s history and exam findings, a basivertebral nerve ablation procedure is indicated, and MRI diagnostic studies usually reveal Modic Type I and/or Modic type II changes. These are related to vertebral endplate changes with inflammation, edema, disruption, and/or fissuring, as well as fibrovascular bone marrow changes and fatty bone marrow replacement.
- Basivertebral nerve (BVN) ablation targets neurotomy (nerve destruction via radiofrequency ablation) of the BVN, which is responsible for carrying nociceptive input from damaged vertebral endplates, often seen in MRI as Modic changes type I and type II.
- BVN ablation is clinically indicated to treat chronic axial low back/vertebral pain refractory to six months of conservative treatment in the setting of Modic changes (type I and type II). Modic changes are seen on MRI as fibrovascular bone marrow changes (hypointensive signal for Modic type I changes); and fatty bone marrow replacement (hyperintensive signal for Modic type II changes).
- Pedicle destruction, compression fracture, and spondylolisthesis are not structural pathologies treated by BVN neurotomy.
A 65-year-old female with a known history of multiple stable compression fractures of the spine returns to the clinic for an annual check-up. Upon review of systems, the patient admits to progressively worsening dyspnea and dizziness. Physical examination reveals worsening thoracolumbar curvature. However, motor and neurologic findings remain normal. Which of the following is the next best step in management?
1. Echocardiography
2. Spinal cord decompression
3. Pulmonary function testing
4. CT scan of the chest
3. Pulmonary function testing
- Pulmonary dysfunction can include both obstructive and restrictive pulmonary changes.
- Physical examination should include a thorough inspection of symmetry, spinal alignment, flexibility, and work of breathing.
- Studies have shown a relationship between increased Cobb angle and poor performance on pulmonary function testing.
- Dizziness in this scenario may be secondary to comprised respiratory status. Therefore pulmonary causes should be ruled out before a neurology referral.
A 25-year-old patient was involved in a motor vehicle accident and suffered a traumatic brain injury with his presenting Glasgow Coma Scale score of 6 out of 15. Upon painful stimulation over his supraorbital ridge, he elicits abnormal flexion of his upper extremities with an extension of his lower limbs. Which is the anatomical region responsible for such motor response seen in the patient?
1. Corticospinal tract
2. Rubrospinal tract
3. Vestibulospinal tract
4. Extrapyramidal tract
2. Rubrospinal tract
- The description is typical of an abnormal flexion response equivalent to a motor score of 3.
- The rubrospinal tract is responsible for mediating flexion of upper limbs and extension of the lower limbs.
- The flexion of upper limbs indicates the location of the traumatic insult to be above the anatomic location of the rubrospinal tract.
- The vestibulospinal tract mediates the extension of both upper and lower limbs. The corticospinal tract governs voluntary motor functioning.
A 65-year-old male presents in the emergency department with the complaint of pain in the cervical region and pain in the paraspinal region after he fell from a ladder. On examination, there is an asymmetry in the neck position, tenderness over the spinous process of the axis, and positive Sudeck’s sign. Which radiological investigation will help in confirming the diagnosis?
1. Computed tomography
2. Ultrasound
3. Open mouth anteroposterior cervical plain film radiograph
4. Lateral cervical plain film radiograph in maximum flexion and extension
4. Lateral cervical plain film radiograph in maximum flexion and extension
- The patient has C1-C2 instability, also called atlantoaxial instability. Lateral flexion-extension views are a dynamic study that shows the degree of displacement between vertebrae in the sagittal plane.
- Increased motion at the C1-C2 level can lead to vertebral artery occlusion, ischemia of the brainstem and posterior fossa structures, resulting in seizures, syncope, vertigo, visual disturbances and even sudden death after minor trauma.
- Surgery is usually indicated in patients who have more than 5 mm of translation in flexion and extension X-rays.
- Open mouth anteroposterior cervical X-Ray is not the proper incidence to detect anteroposterior C1-C2 instability. It reflects mediolateral instability, and spinal cord compression is less probable to occur under these circumstances. As with CT, MRI does not reflect the degree of instability between two vertebrae.
A 28 years old male presents to the trauma bay with epistaxis and nasal deformity after a motor vehicle collision. Pt is alert and complains of severe headache and facial pain. Vital signs are HR = 110/min, BP = 116/80 mmHg, SpO2 = 99% on room air. Pt is assessed and sent for stat head and maxillofacial CT scan. Imaging reveals acute nasal bone and cribriform plate fractures. No intracranial hemorrhaging is identified. Rhinorrhea is sent to the lab and tests positive for beta two transferrin. What is the most likely management plan for this patient’s injury?
1. Conservative treatment with observation
2. Subcranial endoscopic repair
3. Open surgical repair
4. Discharge with outpatient follow up
1. Conservative treatment with observation
- Most cerebrospinal fluid leaks from cribriform plate fracture resolve spontaneously.
- While conservative treatment is usually the best choice, the patient warrants observation to ensure resolution.
- Conservative treatment is preferred for patients who present with a GCS > 8 without other significant intracranial pathology.
- If the cerebrospinal fluid leak persists for greater than 7 days, surgery should be considered due to an increased risk of morbidity and mortality.
A 32-year-old male patient was doing work in his backyard, and while cutting a branch, the electric saw jumped off the branch and made a laceration on his left arm on its lateral aspect. He controlled the bleeding with pressure but noticed that he could not dorsiflex the wrist. He went to his local emergency room, and the laceration was cleaned, but the radial nerve was found injured. The wound was closed, but the nerve was not repaired as there were no specialists in the clinic. He is referred to a neurosurgeon and a physiatrist. After four weeks, he goes to receive physical therapy. Which is the next best step in the management of this patient?
1. Start physical therapy to avoid muscle atrophy
2. Observe for 3 months for evidence of reinnervation
3. Send immediately to a neurosurgeon for nerve repair
4. Perform needle electromyography
4. Perform needle electromyography
- Electromyography (EMG) is most useful after a two week to three-week delay to permit denervation changes to occur in the affected muscles. In a complete neurapraxia lesion, needle EMG will show no motor unit action potentials (MUAPs) under voluntary control, but fibrillations are not present. In complete lesions, the appearance of fibrillations and positive sharp waves is time and length-dependent; they do not appear for a number of days after the injury. In proximal muscles, they appear after 10 days to 14 days and in distal muscles after 3 weeks to 4 weeks. The presence of MUAPs by EMG examination indicates that reinnervation is occurring.
- The EMG is more sensitive than the physical examination for detecting early reinnervation, so the return of MUAPs on needle examination in the muscle closest to the injury site is typically the first evidence of reservation.
- Neurotmesis is the complete disruption of the nerve and nerve sheath. Recovery is unlikely without surgical intervention as the nerve axons will unlikely grow. For optimal nerve regeneration, nerve stumps must be precisely aligned without tension and repaired atraumatically with minimal tissue damage and a minimal number of sutures.
- Blunt transection repairs are usually delayed for 3 weeks to 4 weeks, at which point the nonconducting fibrotic segment of both stumps is appreciable and can be adequately resected before repair. Physical therapy can assist with some improvement of wrist function using compensatory techniques, stretching, and orthotics.
A 27-year-old male patient presents to the clinic with complaints of tingling and burning pain in the right hand, which was amputated three weeks ago. He also says that his right hand feels shorter and is in a distorted and painful position. He also complains of increased pain when he goes out in the cold. Which of the following is the appropriate treatment in patients with this condition and a positive ketamine trial?
1. Phenytoin
2. Amantadine
3. Methadone
4. Nerve stimulation
2. Amantadine
- The sign and symptoms in this patient are suggestive of phantom pain. Treatment should be started when patients have phantom pain and a positive lidocaine trial.
- A patient with phantom pain and a positive ketamine trial should begin taking amantadine.
- Pharmacological techniques often are used in conjunction with other treatment options. Doses of pain medications needed often decrease when combined with other techniques but rarely are completely discontinued.
- Tricyclic antidepressants and sodium channel blockers often are used to relieve chronic pain and in an attempt to reduce phantom pains. Opioids, ketamine, calcitonin, and lidocaine may relieve pain.
