Spine Flashcards
Features of Brown Sequard
ipsilateral loss of MVP: motor, vibration, proprioception<div>contralateral loss of pain/temp</div><div>unilateral UMN signs, possible B/B dysfxn</div>
Features of Central Cord Syndrome
affects UE>LE<div>affects distal>proximal</div><div>sacral sparing</div>
Features of Incomplete SCI
Sensory function below injury level<div>Voluntary Motor function below injury level</div><div>Sacral Sparing</div>
Features of Sacral Sparing
Sensory<div> Intact perianal (light touch/pinprick)</div><div> Deep anal pressure (DRE)</div><div>Motor</div><div> Voluntary Anal Sphicter Contraction</div>
“Power’s Ratio?”
<u>Basion-Posterior C1 arch</u><div>Opisthion-Anterior C1 arch</div><div><br></br></div><div>Normal 0.7-1.0</div>
X-ray features of instability of C-spine injury
C0-C1<div> Harris rule of 12s (BDI>12mm, BAI>12mm)</div><div> Powers ratio >1.0, <0.7</div><div>C1-C2</div><div> ADI >3.5mm</div><div> PADI <14mm</div><div>Subaxial</div><div> Anterolisthesis>3mm</div><div> Angulation>11 deg</div><div> Mvmt on Flex/ext</div><div> Facet d/l - bilateral</div><div> Flexion teardrop</div>
Negative Prognostic Factors for Type 2 Odontoid Fractures
Pt factors: Age>50, delay in tx> 4 days<div>Fracture Pattern</div><div> Post displacement >5mm</div><div> Re-displacement > 2mm</div><div> Fracture Gap >1mm</div><div> Angulation > 10 deg</div><div> Comminution</div>
Considerations for C1-C2 transart fixation
(Magerl Technique: inferomedial quadrant of C2 lateral mass with neutral med/lat and 45 deg cephalad)<div>C2 nerve root</div><div>Vertebral Artery, hypoplastic C2 Pars</div><div>Reducibility of C1-C2</div><div>Avoid bicortical screws</div>
Carotid Sheath Contents
Internal Jugular Vein<div>Carotid Artery</div><div>Vagus nerve</div>
Anterior Approach to C-spine (Smith Robinson)
“-Incision: transverse from midline to SCM<div>-Vertical Platysma dissection</div><div>-Dissect through<b>Precervical</b>fascia (SCM laterally, strap mm medially)</div><div>-Palpate carotid artery and open <b>pretracheal fascia</b>(retract carotid sheath laterally, trachea/esophagus medially) - note that recurrent laryngeal lives here; may need to ligate thyroid arteries</div><div>-identify longus coli mmm midline and incise <b>prevertebral fascia</b>(note <i>sympathetic chain</i> on lateral aspect of longus coli)</div><div><br></br></div>”
Features of instability in TL fractures?
TLICS<div>-fracture morphology (translation/rotation and distraction worst)</div><div>-neuro compromise</div><div>-PLC damage (leads to longterm kyphosis)</div><div>>4 = OR</div><div>4 = unclear</div><div><4 = non-op</div>
Functional Expectation for C4 to C8 SCIs?
<ul> <li>C4 - wheelchair mobility with sip and puff controls, usually don’t need ventilator</li> <li>C5 - power wheelchair with hand controls. May even be able to use manual wheelchairs with grip enhancements with tremendous energy usage</li> <li>C6 - manual wheelchair with grip enhancements, most prefer power wheelchair, sometimes transfers with a slider</li> <li>C7 - most ADLs/IADLs independently or with very minimal assistance. <b>Manual wheelchair can be used (RC 2018),</b> troubles with uneven surfaces</li> <li>C8 - total independence</li></ul>
Landmarks for an L3 pedicle screw?
-Inferolateral aspect of L2-L3 facet<div>-Junction of middle 1/3rd of TP and through mamillary process</div><div>-Junction of middle 1/3rd of TP and line through centre of facet</div>
RFs for progression of developmental spondy
CPX: female, dysplastic (>isthmic), pre-peak height velocity<div>Radiographic</div><div> dysplastic/deficient facet/pars/post elements</div><div> Slip angle > 45</div><div> Slip >50%</div><div></div>
Causes of Spondylolisthesis?
“‘Wiltse’ Classification<div>Dysplastic/congenital</div><div>Isthmic</div><div>Degenerative</div><div>Traumatic</div><div>Pathologic</div><div>Iatrogenic</div>”
Indications for OR for C-spine in RA
-CPx: progressive neuro deficit, mechanical neck pain unresponsive to tx<div>-Xray: PADI<14mm (AAS), odontoid migration >5mm from McGregors line (hard palate to opisthion)</div><div>-MR: SAC<14mm, Cervicomedullary angle <135</div>
Pros and Cons of Anterior C-spine Approach
Pros<div>-easy positioning (esp in trauma)</div><div>-direct decompression (disc herniation/retropulsed bone)</div><div>-high fusion rate</div><div>-lower infection rate</div><div>-maintain segmental lordosis</div><div>Cons</div><div>-risk of dysphagia, hoarseness, esophageal perf, anterior seroma/hematoma (airway compromise)</div><div>-biomech inf to posterior-based construct</div>
Pros/Cons of Posterior C-spine Approach
Pros<div>-familiar to surgeons</div><div>-biomech robust > anterior</div><div>-direct visualization/reduction of dislocated elements</div><div>-high radiographic success</div><div>Cons</div><div>-wound infx</div><div>-risk of focal kyphosis (once injured disc collapses and settles)</div><div>-inability to decompress anterior fragments</div>
Intra-op Methods to monitor for SCI?
EMG<div>SSEP</div><div>Motor EPs</div><div>Wake-up Test</div>
Diagnosis of Ank Spon?
Modified NY Criteria (need radiographic+one clinical)<div>-Clinical</div><div> LBP/stiffness X 3/12 not relieved by rest</div><div> decreased lumbar ROM</div><div> decreased chest expansion</div><div>-Radiographic</div><div> Sacroilliits</div>
RFs for vision loss in spine surgery
-Patient factors: male, obese, smoker, PVD, preop anemia<div>-Surgical: prone position, increase OR time >6h, increase blood loss</div><div>-Anesthesia: increased CVP and PCO2</div>
RFs for neuro compromise in spine infx?
Pt factors<div>-age>60</div><div>-DM</div><div>-RA</div><div>-immunocomp</div><div>Infx factors</div><div>-epidural abscess</div><div>-C2-L1 (ie not L2-L5)</div><div>-Staph aureus</div><div>Tx factors</div><div>-delay in tx<br></br><div><br></br></div></div>
Complications assx with kyphoplasty/vertebroplasty
cement extravasation<div>new fractures</div><div>neuro complications</div><div>OM</div><div>chest pain</div>
Tumours in posterior elements of spine?
“Osteoid Osteoma<div>Osteoblastoma</div><div>Osteochondroma</div><div>ACB</div><div>‘OH, Oh, Oh, AHHH’</div>”
Spinal elements with free nerve endings?
Annulus<div>PLL</div><div>Facet joint capsule</div><div><br></br></div><div>NOT nucleus</div>
Risks of BMP In spine fusion surgery?
retrograde ejaculation<div>osteolysis</div><div>nerve irritation</div><div>seroma</div><div>massive soft tissue swelling</div><div>ectopic bone formation</div>
Collagen Types assx with intervertebral discs
Nucleus pulposus: type II<div>Annulus fibrosus: type I and II</div>
Indications for Pars Defect Repair
-L4 above (<b>do not do below)</b><div>-minimal slip</div><div>-normal disc<br></br><div>-no neuro deficits</div></div><div><br></br></div><div><br></br></div>
RFs for isthmic spondy?
Inuit<div>Spina bifida</div><div>Pars defect</div><div><br></br></div><div><b>not increased back pain</b></div>
Gad enhancement on spine OR?
Scar tissue enhances (including granulation tissue, i.e. TB)<div>Infection</div><div>Tumors</div><div><br></br></div><div><b>Chronic disks are dark</b><br></br></div>
AO Spine T/L Fracture Classification
A - Vertebral body fracture<div>B - failure of tension band (anterior or posterior)</div><div>C - Translation/dislocation</div>
Describe a Pedicle to pedicle decompression for L5-S1
“-remove SP of L5<div>-remove inferior L5 lamina to insertion of ligamentum flavum</div><div>-remove superior S1 lamine</div><div><br></br></div><div>-preserve pars interarticularis<br></br></div><div>-decompress exiting and descending nerve root</div><div><br></br></div><div><img></img><br></br></div>”
Mx of Leaking wound post-spine surgery?
-r/o infection: CBC, ESR, CRP, swab for C/S<div>-r/o CSF: B-2 transferrin assay</div>
Treatment of persistent dural tear?
-repeat OR with wide exposure (may need to fuse if exposure destaiblizes spine)<div>-attempt primary repair</div><div>-dural graft: autograft (paraspinal fascia) or synthetic graft</div><div>-lumbar drain proximal to dural tear intradural</div><div>-ABx while drain is in (4-5 days)</div><div>-clamp drain prior to removal and get pt to valsalva</div>
Prognosis of Incomplete SCI?
B-S: best, 99% ambulatory at f/u<div>CCS: good, although <i>full</i>fxnal recovery is rare (have persistent clumsy hands)</div><div>ACS: worst 10% chance of motor recovery</div><div><ul> <li>Anterior Cord:</li> <ul> <li>Injury to anterior 1/3 of spinal cord</li> <li>Usually a hyperflexion moment</li> <li>Disruption of the anterior spinal artery</li> <li>Complete motor and sensory loss with sparing of the dorsal columns</li> <ul> <li>No pain/temp/crude touch</li> <li>Preserved proprioception/vibraton/2 pnt discrimination - dorsal column intact</li> <li>L/E > U/E (opposite of central cord – U/E > L/E)</li> </ul> <li>Worst prognosis of them all (only ~16% will show improvement)</li> </ul></ul></div>
Treatment for large spinal tumour (met)
-steroids if neuro compromise (can mess up biopsy for lymphoma)<div>-pre-op embolization for RCC/thyroid</div><div>-approach: transpedicular and transfacet if spinal cord</div><div>-surgical goals:</div><div>(1) debulk/curretage tumour, pack with cement</div><div>(2) decompress neural elements</div><div>(3) stabilize</div><div><b>-post-op rads (never pre-op given wound risk) - RC 2018;</b>and chemo</div>
Bleeding control for spinal tumours intra-op
fibrant seleant (spray tisseal)<div>bone cement</div><div>epi-soaked guaze</div><div>bone wax</div><div>get the tumour out</div><div>embolize in angio suite</div>
where is stenosis with spondylolytic spondy?
-foraminal (not central)<div><div>-The posterior elements of L5 stay with the sacrum, where as the body moves forward (anterolithesis). The body isn’t connected to the posterior elements any more.</div></div>
MR findings of TB?
Presence of paraspinal or intraspinal abscesses on T2/FS T1<div>Disc space is preserved (avascular, TB is aerobic)</div><div>Sub-ligamentous abscesses classic<br></br></div>
Biopsy of TB- send for?
PCR - fast (hours) and accurate<div>AFB - acid fast bacilli - up to 10 weeks growth</div>
Medical Mx of TB?
RIPE X 12 months<div>Rifampin</div><div>Isoniazid</div><div>Pyrazinamide</div><div>Ethambutol</div><div><br></br></div>
ASIA Grading?
A: complete<div>B: sensory incomplete - no motor, some sensation</div><div>C: motor incomplete - <50% of myotomes have >3 power</div><div>D: motor incomplete - >50% of myotomes have >3 power</div><div>E: normal</div>
Med mx of SCI
<div>Early: ICU monitoring,MAP>85, Early tracheostomy, bradyarrhythmias, VTE</div>
<div>Longterm: urosepsis, autonomic dysreflexia, ulcer prevention, MDD</div>
Peri-op Rheum Meds Mx?
<div>NSAIDS = d/c 1/52 before surgery</div>
<div>MTX = continue</div>
<div><b>DMARDS = d/c 2/52 before, start 2/52 after</b></div>
<div><br></br></div>
Risks with Ank Spon OR?
Pre-op: intubation, positioning<div>Intra-op:</div><div>-resp issues (dont take down diaphragm)</div><div>-Blood loss</div><div>-epidural hematoma</div><div>-dural tears</div>
Compression of neural elements in spinal stenosis?
intervertebral disc collapse<div>facet hypertrophy</div><div>ligamentum flavum thickens</div><div>synovial cysts form</div>
Indications for fusion while decompressing for spinal stenosis?
-iatrogenic resection of facet<div>-pars defect</div><div>-radiographic instability</div><div>-spondylolisthesis</div><div>-degen scoli</div>
EMG and NCV for Radiculopathy?
EMG can distinguish peripheral nerve compression vs radiculopathy based on muscle groupings<div><br></br></div><div>NCV is normal in radiculopathy (but abnormal in nerve compression)</div>
Treatment for Chordoma
Surgical resection<div>(Radiation if positive margins or unresectable)</div>
Longterm Complications of SCI? Not a RC Q
“<div> <div> <div> <ul> <li>General</li> <ul> <li>Decrease life expectancy</li> <li>Increase re-hospitalization</li> </ul> <li>Cardiovascular</li> <ul> <li>Autonomic dysreflexia </li> <ul> <li>SCI above T6</li> <li>Exaggerated sympathetic response characterized by headache, diaphoresis, and increased blood pressure that occurs with noxious stimuli such as pain from bladder distension, constipation, or pressure sores. </li> <li>Tx: monitor BP, sit pt upright to lower BP (meds: hydralizine, labetalol), search for noxious stimuli</li> </ul> <li>CAD risk</li> </ul> <li>Resp</li> <ul> <li>Ventilator requirement</li> <li>Pneumonia</li> <ul> <li>Prevention with chest physio and vaccination</li> </ul> </ul> <ul> <li>PE: LMHW</li> </ul> </ul> <ul> <li>Urinary</li> <ul> <li>Neurogenic bladder: leads to infections, vesicoureteral reflux, renal failure, and renal calculi</li> <ul> <li>Treatment</li> <ul> <li>Clean intermittent catheterization, supplemented by medications as needed</li> <li>chronic indwelling catheter</li> <li>Meds: anticholinergics - oxybutinin</li> <li>Botulinum toxin and sacral nerve modulators</li> </ul> </ul> </ul> <ul> <li>UTI - mortality rate of 15%</li> <ul> <li>Asymptomatic don’t need tx, nor is there a need for prophylaxis</li> </ul> </ul> </ul> <ul> <li>Sexual Dysfunction</li> <ul> <li>decreased libido, impotence (up to 75%), and infertility</li> <li>Erectile dysfunction may respond to treatment with a phosphodiesterase-5 inhibitor</li> </ul> <li>GI</li> <ul> <li>Bowel dysfunction usually requires treatment with a bowel evacuation protocol and a multidimensional approach. A regular diet that includes adequate fiber is an important part of management. </li> </ul> <li>MSK</li> <ul> <li>Osteoporosis affects ~60%, with ~30% getting fractures</li> <ul> <li>The role of bisphosphonates in this setting is under investigation</li> </ul> <li>HO - up to 50%</li> <ul> <li>Early NSAIDS after SCI decreases incidence</li> </ul> <li>Contractures, Spasticity</li> <ul> <li>Treatment: Options include oral medication, intrathecalbaclofen, botulinum toxin, and nerve blocks</li> <li>Refractory spasticity may require surgery</li> </ul> <li>Ulcers</li> <ul> <li>Shear, friction, poor nutrition, and changes in skin physiology below the level of the lesion also contribute to the development of pressure ulcers</li> <li>Tx: education, mobillity, frequent skin checks, pressure relieving wheelchair, devices, nutrition</li> </ul> <li>Shoulder: RC pathology, GH OA</li> </ul> <li>Neurogenic pain</li> <ul> <li>often refractory but may respond to standard analgesic therapy, antiseizure drug therapy,and/orantidepressant therapy. </li> <li>Chronic opioids should be avoided</li> </ul> <li>Neurologic deterioration</li> <ul> <li>Syringomyelia may sometimes need decompression with shunt</li> </ul> <li>Psych</li> <ul> <li>Depression 20-40% </li> <li>Suicide 5X more than general popn</li> </ul> </ul> <div></div> </div> </div></div>”
Initial Med Mx of SCI?
<ul> <li>Intensive care unit with monitoring of neurologic, respiratory and cardiovascular function</li> <li>Cardiovasc</li> <ul> <li>MAP > 85 for neuroprotection (Low BP can be secondary to neurogenic or hypovolemic shock)</li> <li>Excess fluids can cause further cord swelling; must monitor fluid admin, U/O, electrolytes</li> <li>Bradycardia (C1-C4 injury): atropine or pacing</li> <li>Autonomic dysreflexia can occur early and be fatal</li> </ul> <li>Respiratory</li> <ul> <li>Respiratory failure: diaphragm weakness, ineffective cough, atelectasis, hypovent</li> <ul> <li>Signs: increased RR, rising pCO2, falling pO2</li> <li>Early Tracheostomy at 7-10 days</li> <li>Chest physio, suctioning</li> </ul> <li>Pulmonary edema</li> <li>PNA</li> <li>PE</li> </ul> <li>Pressure sores - develop within hours</li> <ul> <li>Get off spine board</li> <li>Turn q2-3 hrs</li> </ul> <li>GU: indwelling cath to prevent distension</li> <ul> <li>urosepsis</li> </ul> <li>GI: stress ulceration - tx with prophylactic PPIs X 4weeks</li> <ul> <li>Enteral or parenteral feeding early</li> </ul> <li>Heme: VTE and PE</li> <li>Psych: Major depressive disorder</li></ul>
Spinal shock: what is it? whats the importance?
<ul> <li>temporary lossof spinal cord function and reflex activity below the level of a spinal cord injury</li> <ul> <li>characterized by</li> <ul> <li>flaccid areflexic paralysis</li> <li>bradycardia & hypotension(due to loss of sympathetic tone)</li> <li>absent bulbocavernosus reflex</li> </ul> </ul> <ul> <li>Path: peripheral neurons temporarily unresponsive to brain stim</li> <li>Resolves in 24-48 hrs – spinal shock over when bulbocavernosus reflex is present (anal wink with glans penis/clit pressure)</li> <li>Sacral sparing – intact perianal sensation, rectal tone.</li> <ul> <li>Partial structural continuity of white matter long tracts</li> </ul> <ul> <li>Potential for more recovery after spinal shock ends</li> </ul></ul><li>Importance: Cannot fully assess degree of injury until this resolves</li><ul><ul> </ul> </ul></ul>
Features of Anterior Cord Syndrome? Not a RC Q
<ul> <li>Anterior Cord:</li> <ul> <li>Injury to anterior 1/3 of spinal cord</li> <li>Usually a hyperflexion moment</li> <li>Disruption of the anterior spinal artery</li> <li>Complete motor and sensory loss with sparing of the dorsal columns</li> <ul> <li>No pain/temp/crude touch</li> <li>Preserved proprioception/vibraton/2 pnt discrimination - dorsal column intact</li> <li><b>L/E > U/E</b> (opposite of central cord – U/E > L/E)</li> </ul> <li><b>Worst prognosis of them all</b> (only ~16% will show improvement)</li> </ul></ul>
Clearance of C-spine
<div>Awake Patients:</div>
No distracting injuries<div>No neurologic injury</div><div>Not obtunded/substances on board <div></div> <div>Obtunded patient:</div> High resolution CT with 1mm cuts</div><div>Read as normal by neuroradiologist</div><div>MRI not useful over 72 hours (over calls soft tissue)</div>
Occipital Condyle fracture - classification/treatment? not a rc q.
“<div>Classification:</div> <ul> <li>Type 1 - comminuted fracture without displacement</li> <li>Type 2 - entire condyle detached/extension of basilar skull fracture</li> <li>Type 3 - alar ligament avulsion</li> <ul> <li>Associated with Occipitoatlantal dislocation</li> <li>Bilateral injuries more significant instability</li> </ul> </ul> <div>Treatment:</div> <ul> <li>Stable –> rigid orthosis</li> <li>Unstable –> halo</li> <ul> <li>If reduced, should be reduced</li> </ul></ul><div><img></img><br></br></div>”
Classification and Tx for Hangman fracture?
“<div><img></img><br></br></div><ul> <li>Type 1: Bilateral pars fractures</li> </ul><ol> <li>Translation < 3mm</li> <li>No angulation</li> <li>Disk and posterior ligaments intact</li> <li>1A –> elongation of C2 body</li> </ol><ul> <li>Fracture through one pars and one foramen transversarium</li> </ul> <li>Tx: Collar</li> <li>Type 2: C2-3 Disk and posterior longitudinal ligament disrupted</li> <ol> <li>>3mm translation (Reduce with traction)</li> <li>2A –> angulation with no translation</li> </ol><ul> <li>Do not traction –> reduce with hyperextension</li> </ul> <li>Tx: Reduce (then Halo (surgery if severe displacement)</li> <li>Type 3: Pars fracture with C2-3 facet dislocation</li> <ol> <li>Very unstable</li> <li>Free-floating inferior articular process</li> <li>Most common pattern to have neuro deficit</li> <li>Necessitate surgery</li> </ol><ul> <li>Cannot be reduced closed</li> <li>Techniques</li> <ul> <li>anterior C2-3 interbody fusion</li> <li>posterior C1-3 fusion</li> <li>bilateral C2 pars screw osteosynthesis</li> </ul> </ul> “
Stability to C1-C2? not a RC Q
“<div> <div> <div><img></img></div><div><img></img><br></br></div> </div></div>”
<div>RC 2008 - 3mm displaced odontoid fracture. Neuro intact. Fracture of posterior arch C1. All are possible treatments EXCEPT</div>
<ol> <li>Halo Vest</li> <li>C1-C2 posterior wiring + Bone graft</li> <li>C1-C2 trans-articular screws + Bone Graft</li> <li>C1 lateral mass screws connected to C2 pedicle screws + Bone graft</li></ol>
“B.<div><div>Can’t do posterior wires with fracture of posterior arch of C1</div></div>”
Treatment for Odontoid Fractures?
<div> <div>Os Odontoideum</div> <div>Observation</div> <div>Type I</div> <div>Cervical Orthosis</div> <div>Type IIYoung</div> <div>Halo if no risk factors for nonunion</div> <div>Surgery if risk factors for nonunion</div> <div>Type IIElderly</div> <div>Cervical Orthosis if not surgical candidates</div> <div>Surgery if surgical candidates</div> <div>Type III</div> <div>Cervical Orthosis</div> </div>
RFs for spinal epidural hematoma? not a RC Q
“<img></img>”
RC 2010, 2009 - During a retroperitoneal approach to L4/5 you see a vessel running over the vertebrae. What is it? <ol> <li>Iliolumbar</li> <li>Genitofemoral</li> <li>External iliac</li> <li>Superior hypogastric</li></ol>
A.
PJK RFs and solutions? not a RC Q
“<img></img>”
Neurogenic vs Spinal Shock
“<img></img>”
Summary of incomplete SCIs - presentation and Px?
“<div><img></img><br></br></div><ul> <li>Central Cord: (70%)</li> <ul> <li>Most common incomplete SCI, hyperextension mechanism</li> <li>Often in setting of pre-existing stenosis/elderly patients</li> <li>Features (RC EXAM)</li> <ul> <li>Usually U/E > L/E affected</li> <li>No U/E motor and sensory with proximal leg weakness ± sensory loss</li> <li>Rectal tone and sensation usually preserved (most peripheral corticospinal tract)</li> </ul> <li>2nd best prognosis</li> <ul> <li>Bowel and bladder OK</li> <li>Improved ambulatory status</li> <li>Residual U/E dysfunction not improved</li> </ul> </ul> <li>Brown-Sequard (90%):</li> <ul> <li>Hemitransection of cord: unilateral facet injury or penetrating trauma </li> <li>Features (RC EXAM)</li> <ul> <li>Ipsilateral loss of ‘MVP’: motor, vibration, proprioception</li> <li>Contralateral loss of pain/temp (lateral spinothalamic tract, 2-3 levels below level on injury)</li> <li>Unilateral UMN signs</li> <li>Possible bowel & bladder dysfunction </li> </ul> <li>Best prognosis</li> <ul> <li>Best potential for neurological improvement, ambulation and bowel and bladder function</li> <li>Hand fxn usually still shitty</li> </ul> </ul> <li>Anterior Cord (10%):</li> <ul> <li>Injury to anterior 1/3 of spinal cord</li> <li>Usually a hyperflexion moment</li> <li>Disruption of the anterior spinal artery</li> <li><b>Complete motor and sensory loss with sparing of the dorsal columns</b></li> <ul> <li>No pain/temp/crude touch</li> <li>Preserved proprioception/vibraton/2 pnt discrimination - dorsal column intact</li> <li>L/E > U/E (opposite of central cord – U/E > L/E)</li> </ul> <li>Worst prognosis of them all (only ~16% will show improvement)</li> </ul></ul>”
Approach to C2-C3 disc space
<ul> <li>Smith Robinson</li> <li>Trans Oral</li> <li>Submandibular</li> <li>Mandibular split</li></ul>
stabilizers of atlantoaxial joint?
<ul><li>occipital-cervical junction and atlantoaxial junction are <b>coupled</b></li><li>ligaments in spinal canal<br></br><ul><li>transverse ligament - <b><i>primary stabilizer</i></b> of atlantoaxial junction</li><li>paired alar ligament</li><li>apical ligament</li><li>tectorial membrane</li></ul></li></ul>
odontoid screw fixation
<ul> <li>Don’t do in comminuted fractures, osteoporotic bone, sagital plane fractures, delayed union or nonunion</li> <li>Don’t do in patients with big chests – hard to get right angle for screw</li><li><u>technique</u></li><li>supine</li><li>reduce with halo traction (pre-op), extended head (intra-op), mayfield clamp, direct pressure on mouth</li><li>approach: usually start at c5-c6 (kwire to localize) then work up to C2-c3</li><li>take out some of C3 sup endplate</li><li>drill towards posterior odontoid tip</li><li>screw</li><li>post-op brace</li></ul>
<div>Greatest independent risk factor for vert artery injury?</div>
“facet fracture<div><img></img><br></br></div>”
MR indications for jumped facet?
<div>obtunded patient and only going from the back surgically</div>
AO fracture classification
“<ul> <li>Type A injuries are fractures that result in compression of the vertebra with intact tension band (inherently stable).</li> <li>Type B injuries include failure of the posterior or anterior tension band through distraction with physical separation of the subaxial spinal elements while maintaining continuity of the alignment of the spinal axis without translation or dislocation.</li> <li>Type C includes those injuries with displacement or translation of one vertebral body relative to another in any direction; anterior, posterior, lateral translation, or vertical distraction</li> </ul> <div><img></img></div>”
anterior vs posterior approaches for TL trauma
“<img></img>”
<ul> <li>Anterior HIGH C-spine approach risk</li> </ul>
“<ul><li>Hypoglossal (CN XII)</li><li>Spinal Accessory (CN XI)</li><li>Pharynx</li></ul><div><img></img><br></br></div>”
ranawat classification for RA function?
<ul></ul>
<ol><li>No neuro deficit</li> <li>Weakness, hyper-reflexia, altered sensation</li> <li>Paresis and long tract signs, ambulatory</li> <li>Quadriparesis, non-ambulatory <b>- do not operate</b></li> </ol>
<div><div>-PADI >10mm --> improvement of Ranawat class by 1 grade</div></div>
<div>-outcome less reliable in Ranawat Grade IIIB (objectively weak with UMN signs and nonambulatory<br></br></div>
Radiographic signs for AAS, AAI, subaxial instability
“<div>Atlantoaxial Subluxation (AAS):</div> <ul> <li>PADI<14</li><li>CMA<135</li></ul><div><div>Atlantoaxial Impaction (AAI)</div> <ul> <li>Odontoid protrusion to McCrae’s line</li><li>Odontoid protrusion >5mm prox to McGregor’s like</li><li>Ranawat method: C2 pedicle to transverse C1 <15mm in men and <13mm in women</li><li><div> <div> <div><img></img></div> </div></div></li><li><div><img></img><br></br></div></li></ul><div><div>Subaxial Subluxation:</div> <ul> <li>>4mm or 20% listhesis</li></ul></div></div>”
Conditions associated with CTEV?
<ul><li>arthrogryposis</li><li>larsen</li><li>tibial hemimelia</li><li>myelodysplasia</li><li>amniotic band syndrome</li></ul>
landmarks for anterior approach to c-spine
<div> <div> <div> <div> <div>C2-3 - Corner of jaw</div><div>C3 - Hyoid bone</div><div>C4-5 - Thyroid cartilage</div><div>C6 - Cricoid cartilage, Carotid tubercle</div> </div> </div> </div></div>
lateral recess borders?
<b>JAAOS 2012: the area of the spine bordered by the superior articular facet posteriorly, the disk and vertebral body anteriorly, the thecal sac medially, and the pedicle laterally.</b>
“Autonomic dysreflexia: def’n, causes, tx”
<div>Autonomic dysreflexia is defined as “an increase in systolic blood pressure of at least 20% associated with a change in heart rate and accompanied by at least one of the following signs (sweating, piloerection, facial flushing), or symptoms (headache, blurred vision, stuffy nose)” due to a stimulus such as overdistended bladder or bowel impaction<br></br></div>
<br></br><div>Guidelines for treatment of autonomic dysreflexia include</div><div>1) patient immediately placed in a sitting position if the person is supine.</div><div>2) clothing or constrictive devices need to be loosened</div><div>3) troubleshoot etiologies for bladder distention or bowel impaction</div><div>4) a SBP >150 mmHg may need to be treated with nifedipine or nitrates</div><div>5) close monitoring of symptoms, blood pressure, and heart rate for at least 2 hours.</div>
Indications and C/I for PSO
Indications:<div>- Need for >25oor lordosis correction</div><div>- A stiff spine that does not achieve any correction on either supine or extension radiographs</div><div>- Previously posteriorly fused spine with very collapsed and stiff disc space</div><div>- A spine that has been circumferentially fused over multipled segments</div><div>- Both coronal and sagittal plane malalignment</div><div><br></br></div><div>Contraindications</div><div>- Inability to tolerate procedure due to co-morbidities</div><div>- Poor bone quality, at risk of failure of osteotomy closure and poor healing potential</div><div>- Open disc spaces and can be managed with combined anterior/posterior or posterior only Smith-Petersen osteotomies</div><div>- Patients who require >40oof correction may benefit from extended PSO that involves removing adjacent disc space , 2 non-adjacent PSOs or vertebral column excision</div><div>- Normal sagittal and coronal alignment</div>
What is the natural history of cervical spondylotic myelopathy? (JAAOS 2015)
20-60% of patients with mild CSM progress over time in absence of surgery
What is the management of an intra-operative alert while using intra-operative neuromonitoring?
- Intra-operative pause<div>2. Communicate with anaesthesiologist, surgeon, neuromonitoring team</div><div>3. Ensure blood pressure is adequate (MAP >80mmHg recommended)</div><div>4. Ensure oxygen saturation is adequate</div><div>5. Reverse surgical interventions until baseline achieved</div><div>6. If alert persists, perform wake up test</div>
What is a simplified treatment algorithm for the management of CSM?
“1. >10origid kyphosis<div>a. 1 or 2 levels of compression = anterior approach (ACDF/Corpectomy)</div><div>b. 3+ levels of compression = combined anterior and posterior</div><div>- Anterior corrects kyphosis and decompresses</div><div>- Posterior decompresses</div><div><br></br></div><div>2. <10<span>origid kyphosis</span></div><div><span>a. 1 or 2 levels of compression = anterior approach (ACDF/Corpectomy)</span></div><div><span>b. 3+ levels of compression = posterior approach (laminectomy + fusion OR laminoplasty)</span></div>”
“<div>Cervical myelopathy, what is the most reliable physical exam?</div><div><span>A. Loss of Proprioception</span></div><div><span>B. Neural root tension signs</span></div><div><span>C. Clonus < 4 beats</span></div><div><span>D. Hyporeflexia in the extremities</span></div>”
“<div><span>Answer: A</span></div><br></br><ul><li><div>Signs & symptoms should reflect those of UNM.</div></li><li><div>The presence of <span>> 4 beats</span> of clonus also suggests UMN dysfunction.</div></li><li><div>Neurologic compression of the cervical spinal nerve root may result in LMN findings (eg, hyporeflexia), whereas compression of the cervical spinal cord may result in UMN findings (eg, hyperreflexia).</div></li><li><div>Proprioception dysfunction</div></li><ul><li><div>Due to dorsal column involvement</div></li><li><div>Occurs in advanced disease</div></li><li><div>Associated with a poor prognosis</div></li></ul><li><div>In general, the clinical features of CSM are:</div></li><ul><li><div>Axial neck pain and decreased ROM</div></li><li><div><span>Gait instability/balance impairment (diminished proprioception due to dysfunction of posterior column)</span></div></li><li><div>Diminished hand dexterity/difficulty with fine motor tasks</div></li><li><div>Bowel/bladder dysfunction (advanced CSM)</div></li><li><div>Inability to ambulate (advanced CSM)</div></li></ul></ul>”
