Spine

Question 1

Features of Brown Sequard

Answer 1

ipsilateral loss of MVP: motor, vibration, proprioception<div>contralateral loss of pain/temp</div><div>unilateral UMN signs, possible B/B dysfxn</div>

Question 2

Features of Central Cord Syndrome

Answer 2

affects UE>LE<div>affects distal>proximal</div><div>sacral sparing</div>

Question 3

Features of Incomplete SCI

Answer 3

Sensory function below injury level<div>Voluntary Motor function below injury level</div><div>Sacral Sparing</div>

Question 4

Features of Sacral Sparing

Answer 4

Sensory<div> Intact perianal (light touch/pinprick)</div><div> Deep anal pressure (DRE)</div><div>Motor</div><div> Voluntary Anal Sphicter Contraction</div>

Question 5

“Power’s Ratio?”

Answer 5

<u>Basion-Posterior C1 arch</u><div>Opisthion-Anterior C1 arch</div><div><br></br></div><div>Normal 0.7-1.0</div>

Question 6

X-ray features of instability of C-spine injury

Answer 6

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>

Question 7

Negative Prognostic Factors for Type 2 Odontoid Fractures

Answer 7

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>

Question 8

Considerations for C1-C2 transart fixation

Answer 8

(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>

Question 9

Carotid Sheath Contents

Answer 9

Internal Jugular Vein<div>Carotid Artery</div><div>Vagus nerve</div>

Question 10

Anterior Approach to C-spine (Smith Robinson)

Answer 10

“-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>”

Question 11

Features of instability in TL fractures?

Answer 11

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>

Question 12

Functional Expectation for C4 to C8 SCIs?

Answer 12

<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>

Question 13

Landmarks for an L3 pedicle screw?

Answer 13

-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>

Question 14

RFs for progression of developmental spondy

Answer 14

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>

Question 15

Causes of Spondylolisthesis?

Answer 15

“‘Wiltse’ Classification<div>Dysplastic/congenital</div><div>Isthmic</div><div>Degenerative</div><div>Traumatic</div><div>Pathologic</div><div>Iatrogenic</div>”

Question 16

Indications for OR for C-spine in RA

Answer 16

-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>

Question 17

Pros and Cons of Anterior C-spine Approach

Answer 17

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>

Question 18

Pros/Cons of Posterior C-spine Approach

Answer 18

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>

Question 19

Intra-op Methods to monitor for SCI?

Answer 19

EMG<div>SSEP</div><div>Motor EPs</div><div>Wake-up Test</div>

Question 20

Diagnosis of Ank Spon?

Answer 20

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>

Question 21

RFs for vision loss in spine surgery

Answer 21

-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>

Question 22

RFs for neuro compromise in spine infx?

Answer 22

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>

Question 23

Complications assx with kyphoplasty/vertebroplasty

Answer 23

cement extravasation<div>new fractures</div><div>neuro complications</div><div>OM</div><div>chest pain</div>

Question 24

Tumours in posterior elements of spine?

Answer 24

“Osteoid Osteoma<div>Osteoblastoma</div><div>Osteochondroma</div><div>ACB</div><div>‘OH, Oh, Oh, AHHH’</div>”

Question 25

Spinal elements with free nerve endings?

Answer 25

Annulus<div>PLL</div><div>Facet joint capsule</div><div><br></br></div><div>NOT nucleus</div>

Question 26

Risks of BMP In spine fusion surgery?

Answer 26

retrograde ejaculation<div>osteolysis</div><div>nerve irritation</div><div>seroma</div><div>massive soft tissue swelling</div><div>ectopic bone formation</div>

Question 27

Collagen Types assx with intervertebral discs

Answer 27

Nucleus pulposus: type II<div>Annulus fibrosus: type I and II</div>

Question 28

Indications for Pars Defect Repair

Answer 28

-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>

Question 29

RFs for isthmic spondy?

Answer 29

Inuit<div>Spina bifida</div><div>Pars defect</div><div><br></br></div><div><b>not increased back pain</b></div>

Question 30

Gad enhancement on spine OR?

Answer 30

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>

Question 31

AO Spine T/L Fracture Classification

Answer 31

A - Vertebral body fracture<div>B - failure of tension band (anterior or posterior)</div><div>C - Translation/dislocation</div>

Question 32

Describe a Pedicle to pedicle decompression for L5-S1

Answer 32

“-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>”

Question 33

Mx of Leaking wound post-spine surgery?

Answer 33

-r/o infection: CBC, ESR, CRP, swab for C/S<div>-r/o CSF: B-2 transferrin assay</div>

Question 34

Treatment of persistent dural tear?

Answer 34

-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>

Question 35

Prognosis of Incomplete SCI?

Answer 35

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>

Question 36

Treatment for large spinal tumour (met)

Answer 36

-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>

Question 37

Bleeding control for spinal tumours intra-op

Answer 37

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>

Question 38

where is stenosis with spondylolytic spondy?

Answer 38

-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>

Question 39

MR findings of TB?

Answer 39

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>

Question 40

Biopsy of TB- send for?

Answer 40

PCR - fast (hours) and accurate<div>AFB - acid fast bacilli - up to 10 weeks growth</div>

Question 41

Medical Mx of TB?

Answer 41

RIPE X 12 months<div>Rifampin</div><div>Isoniazid</div><div>Pyrazinamide</div><div>Ethambutol</div><div><br></br></div>

Question 42

ASIA Grading?

Answer 42

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>

Question 43

Med mx of SCI

Answer 43

<div>Early: ICU monitoring,MAP>85, Early tracheostomy, bradyarrhythmias, VTE</div>

<div>Longterm: urosepsis, autonomic dysreflexia, ulcer prevention, MDD</div>

Question 44

Peri-op Rheum Meds Mx?

Answer 44

<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>

Question 45

Risks with Ank Spon OR?

Answer 45

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>

Question 46

Compression of neural elements in spinal stenosis?

Answer 46

intervertebral disc collapse<div>facet hypertrophy</div><div>ligamentum flavum thickens</div><div>synovial cysts form</div>

Question 47

Indications for fusion while decompressing for spinal stenosis?

Answer 47

-iatrogenic resection of facet<div>-pars defect</div><div>-radiographic instability</div><div>-spondylolisthesis</div><div>-degen scoli</div>

Question 48

EMG and NCV for Radiculopathy?

Answer 48

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>

Question 49

Treatment for Chordoma

Answer 49

Surgical resection<div>(Radiation if positive margins or unresectable)</div>

Question 50

Longterm Complications of SCI? Not a RC Q

Answer 50

“<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>”

Question 51

Initial Med Mx of SCI?

Answer 51

<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>

Question 52

Spinal shock: what is it? whats the importance?

Answer 52

<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>

Question 53

Features of Anterior Cord Syndrome? Not a RC Q

Answer 53

<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>

Question 54

Clearance of C-spine

Answer 54

<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>

Question 55

Occipital Condyle fracture - classification/treatment? not a rc q.

Answer 55

“<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>”

Question 56

Classification and Tx for Hangman fracture?

Answer 56

“<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> “

Question 57

Stability to C1-C2? not a RC Q

Answer 57

“<div> <div> <div><img></img></div><div><img></img><br></br></div> </div></div>”

Question 58

<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>

Answer 58

“B.<div><div>Can’t do posterior wires with fracture of posterior arch of C1</div></div>”

Question 59

Treatment for Odontoid Fractures?

Answer 59

<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>

Question 60

RFs for spinal epidural hematoma? not a RC Q

Answer 60

“<img></img>”

Question 61

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>

Answer 61

A.

Question 62

PJK RFs and solutions? not a RC Q

Answer 62

“<img></img>”

Question 63

Neurogenic vs Spinal Shock

Answer 63

“<img></img>”

Question 64

Summary of incomplete SCIs - presentation and Px?

Answer 64

“<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>”

Question 65

Approach to C2-C3 disc space

Answer 65

<ul> <li>Smith Robinson</li> <li>Trans Oral</li> <li>Submandibular</li> <li>Mandibular split</li></ul>

Question 66

stabilizers of atlantoaxial joint?

Answer 66

<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>

Question 67

odontoid screw fixation

Answer 67

<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>

Question 68

<div>Greatest independent risk factor for vert artery injury?</div>

Answer 68

“facet fracture<div><img></img><br></br></div>”

Question 69

MR indications for jumped facet?

Answer 69

<div>obtunded patient and only going from the back surgically</div>

Question 70

AO fracture classification

Answer 70

“<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>”

Question 71

anterior vs posterior approaches for TL trauma

Answer 71

“<img></img>”

Question 72

<ul> <li>Anterior HIGH C-spine approach risk</li> </ul>

Answer 72

“<ul><li>Hypoglossal (CN XII)</li><li>Spinal Accessory (CN XI)</li><li>Pharynx</li></ul><div><img></img><br></br></div>”

Question 73

ranawat classification for RA function?

Answer 73

<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>

Question 74

Radiographic signs for AAS, AAI, subaxial instability

Answer 74

“<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>”

Question 75

Conditions associated with CTEV?

Answer 75

<ul><li>arthrogryposis</li><li>larsen</li><li>tibial hemimelia</li><li>myelodysplasia</li><li>amniotic band syndrome</li></ul>

Question 76

landmarks for anterior approach to c-spine

Answer 76

<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>

Question 77

lateral recess borders?

Answer 77

<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>

Question 78

“Autonomic dysreflexia: def’n, causes, tx”

Answer 78

<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>

Question 79

Indications and C/I for PSO

Answer 79

Indications:<div>- Need for >25^oor 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 >40^oof 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>

Question 80

What is the natural history of cervical spondylotic myelopathy? (JAAOS 2015)

Answer 80

20-60% of patients with mild CSM progress over time in absence of surgery

Question 81

What is the management of an intra-operative alert while using intra-operative neuromonitoring?

Answer 81

1. 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>

Question 82

What is a simplified treatment algorithm for the management of CSM?

Answer 82

“1. >10^origid 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>”

Question 83

“<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>”

Answer 83

“<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>”