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>”
- Anterior Cord:
- Injury to anterior 1/3 of spinal cord
- Usually a hyperflexion moment
- Disruption of the anterior spinal artery
- Complete motor and sensory loss with sparing of the dorsal columns
- No pain/temp/crude touch
- Preserved proprioception/vibraton/2 pnt discrimination - dorsal column intact
- L/E > U/E (opposite of central cord – U/E > L/E)
- Worst prognosis of them all (only ~16% will show improvement)
- General
- Decrease life expectancy
- Increase re-hospitalization
- Cardiovascular
- Autonomic dysreflexia
- SCI above T6
- 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.
- Tx: monitor BP, sit pt upright to lower BP (meds: hydralizine, labetalol), search for noxious stimuli
- CAD risk
- Resp
- Ventilator requirement
- Pneumonia
- Prevention with chest physio and vaccination
- PE: LMHW
- Urinary
- Neurogenic bladder: leads to infections, vesicoureteral reflux, renal failure, and renal calculi
- Treatment
- Clean intermittent catheterization, supplemented by medications as needed
- chronic indwelling catheter
- Meds: anticholinergics - oxybutinin
- Botulinum toxin and sacral nerve modulators
- UTI - mortality rate of 15%
- Asymptomatic don't need tx, nor is there a need for prophylaxis
- Sexual Dysfunction
- decreased libido, impotence (up to 75%), and infertility
- Erectile dysfunction may respond to treatment with a phosphodiesterase-5 inhibitor
- GI
- 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.
- MSK
- Osteoporosis affects ~60%, with ~30% getting fractures
- The role of bisphosphonates in this setting is under investigation
- HO - up to 50%
- Early NSAIDS after SCI decreases incidence
- Contractures, Spasticity
- Treatment: Options include oral medication, intrathecal baclofen, botulinum toxin, and nerve blocks
- Refractory spasticity may require surgery
- Ulcers
- Shear, friction, poor nutrition, and changes in skin physiology below the level of the lesion also contribute to the development of pressure ulcers
- Tx: education, mobillity, frequent skin checks, pressure relieving wheelchair, devices, nutrition
- Shoulder: RC pathology, GH OA
- Neurogenic pain
- often refractory but may respond to standard analgesic therapy, antiseizure drug therapy, and/or antidepressant therapy.
- Chronic opioids should be avoided
- Neurologic deterioration
- Syringomyelia may sometimes need decompression with shunt
- Psych
- Depression 20-40%
- Suicide 5X more than general popn
- Intensive care unit with monitoring of neurologic, respiratory and cardiovascular function
- Cardiovasc
- MAP > 85 for neuroprotection (Low BP can be secondary to neurogenic or hypovolemic shock)
- Excess fluids can cause further cord swelling; must monitor fluid admin, U/O, electrolytes
- Bradycardia (C1-C4 injury): atropine or pacing
- Autonomic dysreflexia can occur early and be fatal
- Respiratory
- Respiratory failure: diaphragm weakness, ineffective cough, atelectasis, hypovent
- Signs: increased RR, rising pCO2, falling pO2
- Early Tracheostomy at 7-10 days
- Chest physio, suctioning
- Pulmonary edema
- PNA
- PE
- Pressure sores - develop within hours
- Get off spine board
- Turn q2-3 hrs
- GU: indwelling cath to prevent distension
- urosepsis
- GI: stress ulceration - tx with prophylactic PPIs X 4weeks
- Enteral or parenteral feeding early
- Heme: VTE and PE
- Psych: Major depressive disorder
- temporary loss of spinal cord function and reflex activity below the level of a spinal cord injury
- characterized by
- flaccid areflexic paralysis
- bradycardia & hypotension (due to loss of sympathetic tone)
- absent bulbocavernosus reflex
- Path: peripheral neurons temporarily unresponsive to brain stim
- Resolves in 24-48 hrs – spinal shock over when bulbocavernosus reflex is present (anal wink with glans penis/clit pressure)
- Sacral sparing – intact perianal sensation, rectal tone.
- Partial structural continuity of white matter long tracts
- Potential for more recovery after spinal shock ends
- Importance: Cannot fully assess degree of injury until this resolves
- Anterior Cord:
- Injury to anterior 1/3 of spinal cord
- Usually a hyperflexion moment
- Disruption of the anterior spinal artery
- Complete motor and sensory loss with sparing of the dorsal columns
- No pain/temp/crude touch
- Preserved proprioception/vibraton/2 pnt discrimination - dorsal column intact
- L/E > U/E (opposite of central cord – U/E > L/E)
- Worst prognosis of them all (only ~16% will show improvement)
- Type 1 - comminuted fracture without displacement
- Type 2 - entire condyle detached/extension of basilar skull fracture
- Type 3 - alar ligament avulsion
- Associated with Occipitoatlantal dislocation
- Bilateral injuries more significant instability
- Stable --> rigid orthosis
- Unstable --> halo
- If reduced, should be reduced
- Type 1: Bilateral pars fractures
- Translation < 3mm
- No angulation
- Disk and posterior ligaments intact
- 1A --> elongation of C2 body
- Fracture through one pars and one foramen transversarium
- >3mm translation (Reduce with traction)
- 2A --> angulation with no translation
- Do not traction --> reduce with hyperextension
- Very unstable
- Free-floating inferior articular process
- Most common pattern to have neuro deficit
- Necessitate surgery
- Cannot be reduced closed
- Techniques
- anterior C2-3 interbody fusion
- posterior C1-3 fusion
- bilateral C2 pars screw osteosynthesis
- Halo Vest
- C1-C2 posterior wiring + Bone graft
- C1-C2 trans-articular screws + Bone Graft
- C1 lateral mass screws connected to C2 pedicle screws + Bone graft
- Iliolumbar
- Genitofemoral
- External iliac
- Superior hypogastric
- Central Cord: (70%)
- Most common incomplete SCI, hyperextension mechanism
- Often in setting of pre-existing stenosis/elderly patients
- Features (RC EXAM)
- Usually U/E > L/E affected
- No U/E motor and sensory with proximal leg weakness ± sensory loss
- Rectal tone and sensation usually preserved (most peripheral corticospinal tract)
- 2nd best prognosis
- Bowel and bladder OK
- Improved ambulatory status
- Residual U/E dysfunction not improved
- Brown-Sequard (90%):
- Hemitransection of cord: unilateral facet injury or penetrating trauma
- Features (RC EXAM)
- Ipsilateral loss of 'MVP': motor, vibration, proprioception
- Contralateral loss of pain/temp (lateral spinothalamic tract, 2-3 levels below level on injury)
- Unilateral UMN signs
- Possible bowel & bladder dysfunction
- Best prognosis
- Best potential for neurological improvement, ambulation and bowel and bladder function
- Hand fxn usually still shitty
- Anterior Cord (10%):
- Injury to anterior 1/3 of spinal cord
- Usually a hyperflexion moment
- Disruption of the anterior spinal artery
- Complete motor and sensory loss with sparing of the dorsal columns
- No pain/temp/crude touch
- Preserved proprioception/vibraton/2 pnt discrimination - dorsal column intact
- L/E > U/E (opposite of central cord – U/E > L/E)
- Worst prognosis of them all (only ~16% will show improvement)
- Smith Robinson
- Trans Oral
- Submandibular
- Mandibular split
- occipital-cervical junction and atlantoaxial junction are coupled
- ligaments in spinal canal
- transverse ligament - primary stabilizer of atlantoaxial junction
- paired alar ligament
- apical ligament
- tectorial membrane
- Don’t do in comminuted fractures, osteoporotic bone, sagital plane fractures, delayed union or nonunion
- Don’t do in patients with big chests – hard to get right angle for screw
- technique
- supine
- reduce with halo traction (pre-op), extended head (intra-op), mayfield clamp, direct pressure on mouth
- approach: usually start at c5-c6 (kwire to localize) then work up to C2-c3
- take out some of C3 sup endplate
- drill towards posterior odontoid tip
- screw
- post-op brace
- Type A injuries are fractures that result in compression of the vertebra with intact tension band (inherently stable).
- 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.
- 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
- Anterior HIGH C-spine approach risk
- Hypoglossal (CN XII)
- Spinal Accessory (CN XI)
- Pharynx
- No neuro deficit
- Weakness, hyper-reflexia, altered sensation
- Paresis and long tract signs, ambulatory
- Quadriparesis, non-ambulatory - do not operate
- PADI<14
- CMA<135
- Odontoid protrusion to McCrae's line
- Odontoid protrusion >5mm prox to McGregor's like
- Ranawat method: C2 pedicle to transverse C1 <15mm in men and <13mm in women
- >4mm or 20% listhesis
- arthrogryposis
- larsen
- tibial hemimelia
- myelodysplasia
- amniotic band syndrome
- Signs & symptoms should reflect those of UNM.
- The presence of > 4 beats of clonus also suggests UMN dysfunction.
- 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).
- Proprioception dysfunction
- Due to dorsal column involvement
- Occurs in advanced disease
- Associated with a poor prognosis
- In general, the clinical features of CSM are:
- Axial neck pain and decreased ROM
- Gait instability/balance impairment (diminished proprioception due to dysfunction of posterior column)
- Diminished hand dexterity/difficulty with fine motor tasks
- Bowel/bladder dysfunction (advanced CSM)
- Inability to ambulate (advanced CSM)
