Spine Flashcards

Question

Complications associated with ank spond osteotomy

Answer 1

Dural tears (secondary to dural ectasia) Transient nerve root compression Loss of correction Implant failure Postoperative instability Aortic injury ## Footnote *Note - can get 30-40 deg correction with PSO*

Answer 2

**Chin on Chest deformity - Ank Spond** * Pre-op considerations as previous * **C7-T1 cervicalthoracic osteotomy** * Contra-indicated in patients who previously did not have pain, and now have pain as this may indicate a fractre * **indications** * cervicothoracic kyphotic (chin-on-chest) deformity * goals * slight under-correction with f_inal brow-to-chin angle of 10 degrees_ * **advantage of C7-T1 osteotomy include** * vertebral artery is external to transverse foremen * larger canal diameter * mobile neural elements * requires wide decompression with removal of C7 lateral mass and portions of C7-T1 pedicles to prevent iatrogenic SCI * **instrumentation** * usually a combination of lateral mass screws, pedicle screws, and sublaminar hooks * **postoperative** * postoperative halo immobilization often required in patients with poor bone quality * **outcomes & complications** * increased risk of venous air embolus (VAE) in the sitting operative position * C8 palsy * Quadrepelegia * subluxation

Answer 3

**Fracture Associated with Ank Spond** * **Introduction** * C7-T1 common becasue of folcrum of head * often extension-type fracture that involved all three columns * may be occult so if suspicious consider _CT scan (best modality to make diagnosis)_ * high mortality rate secondary to _epidural hemorrhage_ * _75% neurologic involvement_ * neurologic symptoms often present late * **traction, orthotic or halo immobilization** * indications * stable spine fractures with no neurologic deficits * technique * low-weight traction may facilitate reduction * **spinal decompression with instrumented fusion** * _indications_ * progressive neurologic deficit * epidural hematoma with neurologic compromise * unstable fracture patterns * _Positioning_ * Fiberoptic intubation * Appropriate positioning to account for kyphosis * Neuromonitoring * Some advocate for wake up test which is more sensitive than neuromonitoring * _decompression_ * decision to go anterior or posterior depends on fracture level, presence and location of hematoma, and osteoporosis * _instrumentation_ * need to obtain long fusion construct * multiple points of fixation * fosteoporosis * long lever arms of the ankylosed spine * **do not make an effort to correct deformity** * **outcomes & complications** * progressive deformity * nonunion * hardware failure * infection

Answer 4

**DISH (Diffuse Skeletal Idiopathic Hyperostosis)** * Common disorder of unknown etiology characterized by back pain and stiffness * **Non-marginal syndesmophytes at three successive levels** * Everywhere in the spine, usually on the right * Forestier disease * Different from AS * No involvement of SI, usually older patients * **6-12%** * More common in older patients with gout and diabetes * **Sequelae** * Lumbar stenosis * Dysphagia * Cervical melopthy * Spinal cord injury resulting form even minor trauma * Increase risk of heterotopic ossication after THA * **Presentation** * Chronic back pain, stiffness * Often incidental * **Imaging** * Non-marginal syndesmophytes at three successive levels * Lateral radiographs can be helpful to differentiae from AS * DISH -anterior bone formation, preserved disc space * AS - interbody fusion * **Treatment** * Usually non-op * Surgical treatment may be indicated for certain sequelae

Answer 5

* **criteria for a positive test ** * concordant pain response * abnormal disc morphology on fluoroscopy and postdiskography CT * negative control levels in lumbar spine * **outcomes - studies show provocative discography is associated with the following** * increased incidence of lumbar disc herniations * loss of disk height * endplate changes

Answer 6

outcomes at least equal to fusion single level disease no associated facet OA

Answer 7

* **indications** * controversial * most argue **single level disc disease** with **disease-free facet joints** is the only true indication * **Contraindications** * Radiulopathy * Obesity * Stenosis * Instability * Osteoporosis * Previous lumbar fusion * Infection * Fracture

Answer 8

* **Complications** * Device migration * Vertebral body fractures * Persistent low back pain * Collapse/subsidence * **Outcomes** * showed poor results when lumbar fusion performed for discogenic pain diagnosed with a positive provacative diskography * Show to be equivocal outcomes compared to ALIF * Lower hositalizaitons * fewer complications

Answer 9

* Arthrodesis has not been found to be effective for discogenic pain * **Associated with poor outcomes of arthrodesis** * Number of previous surgery * WSIB * Low household income * Older age * Litigation * **Poor predictors of interbody fusion** * Depression * Litigation * smoking

Answer 10

* Proximal neuropathy = diabetic amyotrophy * Buttock pain radiating down * Anterior burning thigh pain associated with weakness * Associated with men \> 50 with uncontrolled DM2

Answer 11

* **Hip Arthritis** * 5-15% older 65 * People with limp are more likely to have hip pain * Can start in buttock, radiate to knee * Typically groin pain, aggrevated by activity * Will have reduced ROM on exam; OA on imaging * Can do an injection to tell the difference * **Other hip pathology** * FAI, GT bursitis, Stress fracture * Sacral insufficiency fractures, AVN * **PVD ** * Diabetes, smoking, hyperlipidemia, hypertension * Get relief with rest, but is unaffected by flexion * Pedal pulses, shiney, hairless legs, erythema * **Diabetic Amyotrophy** * Can get distal neuropathy * Proximal neuropathy = diabetic amyotrophy * Buttock pain radiating down * Anterior burning thigh pain associated with weakness * Associated with men \> 50 with uncontrolled DM2 * **Peripheral parathesias** * Peroneal nerve compression (ganlion from tib-fib joint) * Get EMG if MRI of spine is equivocal from foot drop * Usually feel a positive mass, and will have a positive tinels sign * LFCN * Irritation from obesity, diabetes, pregnancy, tight fitting pants, iatrogenic * Piriformis syndrome - from abbert muscle or overuse * Buttock pain * Aggrevated with sitting * Pain over sciatic notch * Often have positive SLR * **Infectious** * Epidural abcess (often present as neurological deficiet, fevers are second most common) * Discitis * HIV associated neuropathy, * Shingles * GBS associated neruopathy, transverse myelitis - full spine MRI to rule out higher lesion and ICU Consult * Back pain, weakness, sensory loss * Dysthesias, bowel and bladder * **Iatrogenic** * Statins = myopathy * HIV drug regimins * Thalidomide

Answer 12

* **positive predictors** for good outcome with surgery * leg pain is chief complaint * positive straight leg raise * weakness that correlates with nerve root impingement seen on MRI * married status * **negative predictor**s for good outcome with surgery * worker's compensation

Answer 13

* **Poor patient selection** * Abnormal psychometrics * Chronic pain behavior * Unreachable expectations * Incorrect diagnosis * **Wrong procedure** * Wrong level * Missed spinal stenosis * **Poor technique** * Battered root syndrome * Iatrogenic instability * Residual deformity * **Failure to achieve goal of surgery** * Pseudarthrosis * Incomplete decompression * Incomplete correction of deformity * **Progressive disease** * Recurrent disk herniation or spinal stenosis * Transition syndrome

Answer 14

wrong level Adjacent level disease

Answer 15

* persistent disabling pain lasting more than 6 weeks * failed nonoperative options (and epidural injections) * progressive and significant weakness * cauda equina syndrome

Answer 16

* **Without Gad** * pain lasting \> one month and not responding to nonoperative management or * red flags are present * infection (IV drug user, h/o of fever and chills) * tumor (h/o or cancer) * trauma (h/o car accident or fall) * cauda equina syndrome (bowel/bladder changes) * **With gad** * scar will light up

Answer 17

* **wide pedicle-to-pedicle decompression** * indications * persistent pain for _3-6 months_ that has failed to improve with nonoperative management * progressive neurologic deficit (weakness or bowel/bladder) * outcomes * improved pain and function with surgical treatment * _most common caused of failed surgery is recurrence of disease above or below decompressed level_ * _comorbid conditions are strongest predictor of clinical outcomes_ after decompression for lumbar spinal stenosis * **wide pedicle-to-pedicle decompression with instrumented fusion** * indications * presence of segmental instability (isthmic spondylolithesis, degenerative spondylolithesis, degenerative scoliosis) * surgical instability created by complete laminectomy and/or removal of \> 50% of facets * instrumentation is controversial * circumferential fusion (with PLIF or TLIF) is accepted but no studies showing its superiority

Answer 18

* Complications increase with age, blood loss, and levels fused * Major complication * wound infection (10%) * pneumonia (5%) * renal failure (5%) * neurologic deficits (2%) * Minor complication * UTI (34%) * anemia requiring transfusion (27%) * confusion (27%) * dural tear * failure for symptoms to improve

Answer 19

* during minimally invasive surgery may not be able to repair it - can keep them bed rest for 48 hours and monitor * **How to see a tear** * ****white pulsitile fluid * loss of dural turgor * bleeding from previous clean site * suction with paddy to control the site; use blunt tools to move nerve roots; ensure adequate hemostasis to see the tear * use the microscope or loops to see the tear better * **Direct repair - 4-0 silk suture** * _If can't get a repair can use a patch_ * fat patch * fascia * commerically available * _when you don't have to suture_ * minimally invasive surgery * no disruption of the arachnoid * anterior tear * **Commericial available, collagen matrix, hydrogels, fibrin glue or sealant (Tseal or Floseal)** * ****For all tears * **Test the repair with valsalva maneuver** * **Close the wound with multilayer watertight closure** * **Lumbar Drains** * ****tears you couldn't close * **IV antibiotics for 48 hours** * **Bed Rest** * ****48 hours, then attempt stand up test * for cervical lumbar tears they should be sitting * if continued headache continue bed rest, if continues to fail should consider revision surgery * symptomatic treatment of associated symptoms (headache, N/V, pain) * Montior closely post-op for successful wound healing and infection * **Missed leak** * ****headache, localized back pain, radiculopathy * fluctant mass with drianing would * MRI or B2 transferin assay can detect CSF

Answer 20

* Make sure you rule out other causes of pain and order appropraite imaging - Pelvis/hips, HgA1C, EMG, etc * Radiographs * _standing AP and lateral_ * nonspecific degenerative findings (disk space narrowing, osteophyte formation) * degenerative scoliosis * degenerative spondylolithesis * _flexion/extension _ * segmental instability and subtle degenerative spondylolisthesis * _myelography_ provides dynamic information such as degree of cut off when a patient goes into extension * an invasive procedure * **MRI** * central stenosis with a thecal sac \< 100mm2 * obliteration of perineural fat and compression of lateral recess or foramen * facet and ligamentum hypertrophy * MRI findings of spinal stenosis may found in asymptomatic patients * **CT myelogram** * more invasive than MRI * central and lateral neural element compression * bony anomalies * bony facet hypertrophy

Answer 21

* Age 40-50 * C5/6 \> C6/7 most common * levels that have the most extension * Risk factors * driving * smoking * lifting * **Natural aging process of the spine includes spodylosis** * _disc degeneration_ * disc dessication, loss of disc height, disc bulging, and possible disc hernaition * _joint degeneration_ * uncinate spurring and facet arthrosis * _ligamentous changes_ * ligamentum flavum thickening and infolding secodary to loss of disc height * _deformity_ * kyphosis secondary to loss of disc height with resulting transfer of load to the facet and uncovertebral joints, leading to further uncinate spurring and facet arthrosis * **Nerve root compression (radiculopathy) caused by** * _foraminal spondylotic changes_ * secondary to chondrosseous spurs of facet and uncovertebral joints * _posterolateral disc herniation_ * between posterior edge of uncinate and lateral edge of PL * usually affects the nerve root below (C6/7 disease will affect the C7 nerve root) * **Central cord compression (myelopathy)** * occurs with canal diameter is \< 13mm (normal is 17mm) * worse during neck extension whe central cord is pinched between * degenerative disc (anterior) * hypertrophic facets and infolded ligamentum (posterior) * in asians can be caused by ossification of the posterior longitudinal ligament

Answer 22

* **pedicle/nerve root mismatch** * cervical spine C6 nerve root travels under C5 pedicle (mismatch) * lumbar spine L5 nerve root travels under L5 pedicle (match) * extra C8 nerve root (no C8 pedicle) allows transition * **horizontal (cervical) vs. vertical (lumbar) anatomy of nerve root** * because of vertical anatomy of lumbar nerve root a paracentral and foraminal disc will affect different nerve roots * because of horizontal anatomy of cervical nerve root a central and foraminal disc will affect the same nerve root

Answer 23

* **History** * Take a complete and ample history * Characterize the pain * occipital headache (common) * discogenic pain * may present with insidious onset of neck pain that is worse with vertebral motion * pain in neck, shoulder, or arms * Associated neurologic deficiets * paresthesias in neck, shoulder, or arms (often global and nondermatomal) * weakness or clumsiness in the upper extremity * Constitutional symptoms * Bowel/bladder/parathesias * IV drug use, PMhx * **Physical exam** * Examine - cervical spine for alignment * Palpate - step-off * ROM * _Spurling Test positive_ * simultaneous extension, rotation, lateral bend, and vertical compression reproduces symptoms in ipsilateral arm * _shoulder abduction relieves symptoms_ * shoulder abduction (lifting arm above head) often relieves symptoms * Differentiates between cervical and shoulder pathology * ASIA - common and testable exam findings * **Radiographs - AP, lateral, oblique, flex-ex** * common degenerative radiographic findings include * degenerative changes of uncovertebral and facet joints * osteophyte formation * disc space narrowing * endplate sclerosis * decreased sagittal diameter (cord compression occurs with canal diameter is \< 13mm) * changes often do not correlate with symptoms * 70% of patients by 70 yrs of age will have degenerative changes seen on plain xrays * _lateral radiograph_ * important to look for sagittal alignment and size of spinal canal * _oblique radiograph_ * important to look for foraminal stenosis which often caused by uncovertebral joint arthrosis * _flexion and extension views_ * important to look for angular or translational instability * look for compensatory subluxation above or below the spondylotic/stiff segment * **MRI** * T2 axial imaging is the modality of choice and gives needed information on the status of the soft tissues. It may show * disc degeneration and herniation * foraminal stenosis * spinal cord changes (myelomalacia) * has high rate of false positive (28% greater than 40 will have findings of HNP or foraminal stenosis) * **CT** * gives useful information on bony anatomy including osteophyte formation that is compression the neural elements * important preoperative planning tool to plan instrumentation * study of choice to evaluate for postoperative pseudoarthosis * **CT myelography** * indications * largely replaced by MRI * useful in patients who can not have an MRI due to pacemaker etc * useful in patients with prior surgery and hardware causing artifact on MRI * technique * intrathecal injection of contrast given via C1-C2 puncture and allowed to diffuse caudally * lumbar puncture and allowed to diffuse proximally by putting patient in trendelenburg position. * **Discography** * controversial and rarely indicated in cervical spondylosis * approach is similar to that used with ACDF * risks include esophageal puncture and disc infection * Nerve conduction studies * high false negative rate * may be useful to distinguish peripheral from central process (ALS) *

Answer 24

* **Non-operative** * There are several options, nothing will alter the natural course of the disease * _PT_ * _Hard versus soft collar immobilization_ - bad if immobilized for too long * _Cervical root injection_ - complications * Cervical manipulation or traction - no evidence * **Operative** * Indications * Radicular pain non-responsive to treatment * Progressive neurological deficit * Option to go anterior or posterior * **Anterior Cervical Discectomy and Fusion (ACDF)** * techniques * preferred technique and most common * uses Smith-Robinson anterior approach * anterior plating functions to increase fusion rates and preserve position of interbody cage or strut graft * corpectomy and strut graft may be required for multilevel spondylosis * single level ACDF is not a contraindication for return to play for athletes * complications (see below) * **Posterior foraminotomy** * indications * foraminal soft disc herniation causing single level radiculopathy * **Cervical Disc Replacement** * indications * single level disease with minimal arthrosis of the facets * studies show equivalence to ACDF * effect on adjacent level disease is controversial

Answer 25

* **post-op hematoma** * ****can cause airway comprimise and needs to be urgently decompressed on the ward * **pseudoarthrosis** * 5 to 10% for single level fusions, 30% for multilevel fusions * if asymptomatic observe * if symptomatic treat with either posterior cervical fusion or repeat anterior decompression and plating if patient has symptoms of radiculopathy * improved fusion rates but increased complications with posterior fusion * **recurrent laryngeal nerve injury (1%)** * laryngeal nerve follows aberrant pathway on the right * although theoretically the nerve is at greater risk of injury with a right sided approach, there is no evidence to support a greater incidence of nerve injury with a right sided approach. * if you see it, watch over time * if not improved over 6 weeks than ENT consult to scope patient and inject teflon * **hypoglossal nerve injury** * a recognized complication after surgery in the upper cervical spine with an anterior approach * tongue will deviate to side of injury * **esphogeal rupture/dysphagia** * dysphagia, choking, aspiration, pain * ****barium swallow and upper endoscopy * Keep NPO, broad spectrum antibiotics, consult thoracic surgery * **vertebral artery injury** (can be fatal) * alert anesthetist, gain control of the bleed * can hemmorhage without control * call vascular for direct repair * ligation and endovascular procedures are associated with infarct * **Horner's syndrome** * characterized by ptosis, anhydrosis, miosis, enophthalmos and loss of ciliospinal reflex on the affected side of the face * caused by injury to sympathetic chain, which sits on the lateral border of the logus colli muscle at C6 * **adjacent segment disease**

Answer 26

if you see it, watch over time if not improved over 6 weeks than ENT consult to scope patient and inject teflon

Answer 27

* if asymptomatic observe * if symptomatic treat with either posterior cervical fusion or repeat anterior decompression and plating if patient has symptoms of radiculopathy * improved fusion rates but increased complications with posterior fusion

Answer 28

* **Anterior** * _advantages****_ * Direct removal of anterior pathology without neural retraction * Bone graft restores height and provides indirect foraminal decompression * Fusion prevents recurrent neural compression * Muscle-sparing approach * Disadvantages * Fusion-related issues Autograft harvest morbidity Nonunion * Plate complications * May accelerate adjacent segment degeneration * **Posterior** * _Advantages_ * Avoids fusion * Can be done with minimally invasive techniques * _Disadvantages___ * Symptoms may recur at the surgical segment * Removal of anterior pathology would require neural retraction

Answer 29

* **History** * Axial neck pain, occipital headache * Nondermatomal numbness, tingling, burning * L-hermitte's sign * Upper extremity - weakness and decreased dexterity * Lower extremity - gait instability and weakness * Bowel and bladder - rare * Fever, chills, constitutional symptoms * PMHx, vocation, smoker, WSIB * **Physical Exam** * Assess spine for obvious deformity, pain step-off * Full ASIA with reflexes, UMN and rectal exam * _Motor - weakness U\>L_ * Finger escape - small finger abducts with finger extension due to intrinsic weakness * Grip and release - can't make fist 20 times in 10 seconds * _Sensory_ * Pinprick * Vibratory - severe cases * _Upper Motor Neuron_ * Hyperreflexia * Inverted radial reflex - tapping brachioradialis producses ipsilateral finger flexion * Hoffmann's * Clonus (\> 3) * Babinski * _Gait and balance_ * Toe-heel walk is difficult * Positive Romberg * **Radiographs** * general radiographic findings include * degenerative changes of uncovertebral and facet joints * osteophyte formation * disc space narrowing * endplate sclerosis * lateral radiograph * decreased sagittal diameter (cord compression occurs with _canal diameter is \< 13mm)_ * a _Pavlov ratio of less than 0.8_ suggest a congenitally narrow spinal canal * local kyphosis angle * oblique radiograph * important to look for foraminal stenosis which often caused by uncovertebral joint arthrosis * flexion and extension views * important to look for angular or translational instability * look for compensatory subluxation above or below the spondylotic/stiff segment * **MRI** * MRI is study of choice to evaluate degree of spinal cord and nerve root compression * _effacement of CSF indicates functional stenosis_ * spinal cord signal changes * seen as bright signal on T2 images (myelomalacia) * signal changes on T1-weighted images correlate with a poorer prognosis following surgical decompression * compression ratio of \< 0.4 carries poor prognosis * _CR = smallest AP diameter of cord / largest transverse diameter of cord_ * has high rate of false positive (28% greater than 40 will have findings of HNP or foraminal stenosis) * **CT without contrast** * can provide complementary information with an MRI and is more useful to evaluate OPLL and osteophytes * **CT myelography** * more invasive than an MRI but gives excellent information regarding degrees of spinal cord compression * particularly useful in patients that can not have an MRI (pacemaker) or has artifact (local hardware) * contrast given via C1-C2 puncture and allowed to diffuse caudally or given via a lumbar puncture and allowed to diffuse proximally by putting patient in trendelenburg position. * **Nerve conduction studies** * high false negative rate * may be useful to distinguish peripheral from central process (ALS)

Answer 30

canal diameter is \< 13mm) a Pavlov ratio of less than 0.8

Answer 31

compression ratio of \< 0.4 carries poor prognosis CR = smallest AP diameter of cord / largest transverse diameter of cord

Answer 32

* **Anterior** * _Advantages_ * 1. Direct decompression * 2. Stabilization with arthrodesis * 3. Correction of deformity * 4. Axial lengthening of spinal column * 5. Good axial pain relief * _Disadvantage_ * 1. Technically demanding * 2. Graft complications * 3. Need for postoperative bracing * 4. Loss of motion * 5. Adjacent segment degeneration * **Posterior approach** * _Advantages_ * 1. Less loss of motion * 2. Not as technically demanding * 3. Less bracing needed * 4. Avoids graft complication * _Disadvantages___ * 1. Indirect decompression * 2. Preoperative kyphosis and/or instability * limitations * 3. Inconsistent axial pain results * 4. Late instability

Answer 33

* **observation, NSAIDs, therapy, and lifestyle modifications** * _indications_ * mild symptoms * patients who are not candidates for surgery * _modalities_ * medications (NSAIDS, narcotics) * immobilization (hard collar in slight flexion) * physical therapy for neck strengthening, balance, and gait training * traction and chiropractic modalities are not likely to benefit and do have some risks * _outcomes_ * improved nonoperative outcomes associated with patients with larger transverse area of the spinal cord (\>70mm2) * studies have shown ~30% improvement with immobilization * **Prospective studies show improvement in pain, neuro symptoms and function with operative treatment** * _Considerations_ * number of stenotic levels * sagittal alignment of the spine * degree of existing motion and desire to maintain * medical comorbidities (eg, dysphasia) * **Unstable spine pre-op** * Awake fiberoptic intubation, glidoscope * C-spine precautions, collar, Sandwich and flip * neuromonitoring * **Anterior Decompression and Fusion (ACDF)** * _indications_ * fixed cervical kyphosis of \> 10 degrees * \< 2 or less disc segments * pathology is anterior (OPLL, soft discs, disc osteophyte complexes * _techniques_ * uses Smith-Robinson anterior approach * anterior plating functions to increase fusion rates and preserve position of interbody cage or strut graft * corpectomy and strut graft may be required for multilevel spondylosis * if \> 2 levels * 7% to 20% rates of graft dislodgement with cervical corpectomy with associated severe complications including death reported. * _advantages_ * lower infection rate * mild postoperative pain * _complications & disadvantages_ * dysphagia * alteration in speech * pseudoarthrosis * 12% for single level fusions, 30% for multilevel fusions * treat with either posterior wiring or plating or repeat anterior decompression and plating if patient has symptoms of radiculopathy * recurrent laryngeal nerve injury (see below) * C5 palsy below (see below) * esophageal injury * airway obstruction (may be due to edema or hematoma) * vascular injury * vertebral artery injury (can be fatal) * **Laminectomy with posterior fusion** * _indications_ * multilevel compression * kyphosis of \< 10 degrees * in flexible kyphotic spine, posterior decompression and fusion may be indicated if kyphotic deformity can be corrected * _contraindications_ * fixed kyphosis of \> 10 degrees * **Laminectomy alone** * _indications_ * rarely indicated due to risk of post laminectomy kyphosis * _complications_ * progressive kyphosis * 11 to 47% incidence if laminectomy performed alone without fusion * \*\*Largest predictor of progressive kyphosis is not the number of levels but the inclusion of C7-T1 * **Laminoplasty ** * _overview & advantages_ * allows for decompression of multilevel stenotic myelopathy without compromising stability and motion (avoids postlaminectomy kyphosis) * lower complication rate than multilevel anterior decompression * a motion preserving technique * _indications_ * ossification of PLL * has less instability than a multilevel laminectomy * Kingwell - lordosis, multi-level * _technique_ * volume of canal is expanded by hinged-door laminoplasty followed by fusion * common techniques include * **open door** (hinge created unilateral at junction of lateral mass and lamina and opening on opposite side) * **French door** (hinge created bilaterally and opening created midline) * opening held open by bone, suture anchors, or special plates * _contraindications_ * cervical kyphosis \> 13 degrees * servere axial neck pain * is a relative contraindication and these patients should be fused * _complications_ * loss of motion is most common complication * associated with a higher degree of postoperative axial neck pain * postoperative radiculopathy (see C5 palsy below) * _outcomes_ * equivalent to multilevel anterior decompression and fusion * **Combined anterior and posterior surgery** * indications * multilevel stenosis in the rigid kyphotic spine * multi-level anterior cervical corpectomies * also used to treat a pseudoarthosis following ACDF * postlaminectomy kyphosis * **Anterior Diskectomy and Total Disk Replacements** * _indications_ * only indicated in single level disease due to soft disk herniation

Answer 34

* **Postoperative C5 palsy ** * _incidence _ * reported to occur in ~ _4.6% of patients_ after surgery for cervical compression myelopathy * no significant differences between patients undergoing anterior decompression and fusion and posterior laminoplasty * _mechanism_ * mechanism is controversial * in laminectomy patients it is thought to be caused by tethering of nerve root with dorsal migration of spinal cord following removal of posterior elements * _prognosis_ * patients with postoperative C5 palsy generally have a good prognosis for functional recovery, but recovery takes time * **Recurrent laryngeal nerve injury** * _approach_ * in the past it has been postulated that the RLN is more vulnerable to injury on the right due to a more aberrant pathway * **recent studies have shown there is not an increased injury rate with a right sided approach** * _treatment_ * if you have a postoperative RLN palsy, watch over time * if not improved over 6 weeks than ENT consult to scope patient and inject teflon * if you are performing revision anterior cervical surgery, and there is an any suspicion of a RLN from the first operation, obtain ENT consult to establish prior injury * if patient has prior RLN nerve perform revision surgery on the same as the prior injury/approach to prevent a bilateral RLN injury

Answer 35

* fixed cervical kyphosis of \> 10 degrees * \< 2 or less disc segments * pathology is anterior (OPLL, soft discs, disc osteophyte complexes

Answer 36

* dysphagia * alteration in speech * pseudoarthrosis * 12% for single level fusions, 30% for multilevel fusions * treat with either posterior wiring or plating or repeat anterior decompression and plating if patient has symptoms of radiculopathy * recurrent laryngeal nerve injury (see below) * C5 palsy below (see below) * esophageal injury * airway obstruction (may be due to edema or hematoma) * vascular injury * vertebral artery injury (can be fatal)

Answer 37

\*\*Largest predictor of progressive kyphosis is not the number of levels but the inclusion of C7-T1

Answer 38

* Lordosis * multiple levels - preserves motion; outcomes are as good as ACDF * Contraindications * \>13 deg kyphosis * axial neck pain - indication for fusion

Answer 39

* **atlantoaxial subluxation** (most common form of instability) * Due to movement and disruption of the ligaments supporting this joint * Erosion of the odontoid can be posterior (C1), anterior (transverse), superior * Can leave to subluxation in anterior, anterolateral, rotatory * **basilar invagination** * Usually results following atlantoaxial subluxation * Can lead to sudden death from depression on brainstem and respiratory center * Can lead to compression on the anterior vertebral artery leading to TIA or neuro deficiets * **subaxial subluxation** * Leads to a characteristic staircase deformity with anterior instability and kyphosis

Answer 40

* Symptoms and physcial exam findings similar to cervical myelopathy * **History** * Can be asymptomatic * neck pain * neck stiffness * occipital headaches * gradual onset of weakness and loss of sensation * Can have a feeling of anterior instatiblity, or hear a clicking as the atlanto-axial joint reduces (Sharp-purser test) * bowel, bladder, constitutional * Meds for RA, previous treatment, other PMHx * **Physical exam** * hyperreflexia * upper and lower extremity weakness * ataxia (gait instability and loss of hand dexterity) * Ranawat classificatoin of neurologic impairment * 1 - parasthesia, pain * 2 - subjective weakness, UMN * 3 - objective weakness, UMN * a - ambulatory * b - non ambulatory * **Radiographs** * Indications * Cervical symptoms \> 6 months * neurological signs * procedure and no imaging 2 years * rapid deterioration in function * rapid deterioration of carpal and tarsal bones * flexion-extension xrays * always obtain before elective surgery * see subtopic for radiographic lines and measurements * **CT scan** * useful to better delineate bony anatomy and for surgical planning * **MRI** * study of choice to evaluate degree of spinal cord * compression and identify myelomalacia

Answer 41

Cervical symptoms \> 6 months neurological signs procedure and no imaging 2 years rapid deterioration in function rapid deterioration of carpal and tarsal bones

Answer 42

* progressive neurological deficit * pain refractory to medication * radiographic risk factors for neurological injury * PADI \< 14mm with AAI * odontoid migration \> 5mm above magregor's line * Canal diameter \< 14mm in SAS * AAI or cord stenosis * cervicomedullary angle 135

Answer 43

* **Introduction** * present in 50-80% of patients with RA * most common to have anterior subluxation of C1 on C2 (can have lateral and posterior) * **Mechanism** * caused by pannus formation between dens and ring of C1 that leads to the destruction of transverse ligament and dens * **Radiographs** * controlled flexion-extension views to determine ADI and SAC/PADI * _ADI (atlanto-dens interval)_ * instability defined as **\> 3.5 mm of motion** between flexion and extension views * instability alone is not an indication for surgery * \> 7 mm - alar ligament * **\> 10 mm motion of associated with increased risk of neurologic injury** and an indication for surgery * _PADI / SAC_ (posterior atlanto-dens interval and space available for cord describe same thing) * **\< 14 mm associated with increased risk of neurologic injury and is an indication for surgery** * \> 13mm is the most important radiographic finding that may predict complete neural recovery after decompressive surgery * **nonoperative** * indicated in stable atlantoaxial subluxation * **posterior C1-C2 fusion** * _indications_ * ADI \> 10 mm (on flex-ex views) * SAC / PADI \< 14 mm * progressive instability or pain refractory to non-operative treatment * myelopathy * progressive neurologic deficits * _technique_ * Can use posterior wiring (Magerl) or pedicle screws if the joint is reducible * **adding transarticular screws eliminated need for halo immobilization** (obtain preoperative CT to identify location of vertebral arteries) * Better if the joint is not reducible * **occiput-C2 fusion** * _indications_ * atlantoaxial subluxation is combined with basilar invagination * resection of C1 posterior arch required for complete decompression * leads to indirect decompression of anterior cord compression by pannus * may be required if atlantoaxial subluxation is not reducible * **odontoidectomy** * _indications_ * rarely indicated * used as a secondary procedure when there is residual anterior cord compression due to panus formation that fails to resolves with time following a posterior spinal fusion * pannus often resolves following posterior fusion alone due to decrease in instability

Answer 44

\> 13mm is the most important radiographic finding that may predict complete neural recovery after decompressive surgery

Answer 45

* **Introduction** * also known as superior migration of odontoid (SMO) * tip of dens migrates above foramen magnum * present in 40% * often seen in combination with fixed atlantoaxial subluxation * **Mechanism** * cranial migration of dens from erosion and bone loss between occiput and C1&C2 * **Radiographs** * _Ranawat C1-C2 index_ * center of C2 pedicle to a line connecting the anterior and posterior C1 arches * normal measurement in men is 17 mm, whereas in women it is 15 mm * **distance of \< 13 mm** is consistent with impaction * most reproducible measurement * _McGregor's line_ * line drawn from the posterior edge of the hard palate to the caudal posterior occiput curve * cranial settling is present when the **tip of dens is more than 4.5 mm** above this line * can be difficult when there is dens erosion * _Chamberlain's line_ * line from dorsal margin of hard palate-\>posterior edge of the foramen magnum * abnormal if **tip of dens \> 5 mm proximal** Chamberlain's line * normal distance from tip of dens to basion of occiput is 4-5 mm * this line is often hard to visualize on standard radiographs * **McRae's line** * defines the opening of the foramen magnum * the tip of the dens may protrude slightly above this line (confounded if the dens has erroded) * **C2 to occiput fusion** * indications * progressive cranial migration (\> 5 mm) * neurologic compromise * **transoral or anterior retropharyngeal odontoid resection** * _indications_ * brain stem compromise

Answer 46

* **Introduction** * present in 20% with RA * often occurs at multiple levels * often combined with upper c-spine instability * lower spine involvement more common with * steroid use * males * seropositive RA * nodules present * **Mechanism** * soft tissue instability of facet joints and Luschka joints * **Radiographs** * subaxial subluxatoin of \> 4mm or \> 20% of body indicates cord compression * cervical height index (body heigh/width) \< 2.0 is almost 100% sensitive and specific for predicting neurologic compromise * **posterior fusion and wiring** * indications * \> 4mm subaxial subluxation AND intractable pain and neurologic symptoms * _Need to extend this to all levels invovled as RA is a progressive disease_

Answer 47

* **High rates of complications in general** * _Infection_ * _High mortality rates_ * _Failure to improve symptoms_ * outcome less reliable in Ranawat Grade IIIB * _Pseudoarthrosis_ * 10-20% pseudoarthrosis rate * decreased by extension to occiput * _Adjacent level degeneration_

Answer 48

**Adult Degenerative Spondylolisthesis** * **Pathoanatomy** * degenerative cascade involves * disc degeneration * settling of the motion segment * buckling of ligamentum flavum * microinstability which leads to further degeneration * eventual macroinstability and anterolithesis * **Neurologic symptoms** * _central and lateral recess stenosis_ * **a degenerative slip at L4/5 will affect the descending L5 nerve root in the lateral recess** * caused by slippage, hypertrophy of ligamentum flavum, and encrouchment into the spinal canal of osteophytes from facet arthrosis * _foraminal stenosis_ * **a degenerative slip at L4/5 will affect the L4 nerve root as it is compressed in the foramen** * vertical foraminal stenosis (loss of height of foramen) caused by * loss of disk height * osteophytes from posterolateral corner of vertebral body pushing the nerve root up against the inferior surface of the pedicle * anteroposterior foraminal stenosis (loss of anterior to posterior area) caused by * degenerative changes of the superior articular facet and posterior vertebral body

Answer 49

* **Take a complete and ample history** * mechanical/axial back pain * neurogenic claudication * defined as buttock and leg pain/discomfort caused by upright walking * relieved by sitting * not relieved by standing in one place (as is vascular claudication) * may be unilateral or bilateral * same symptoms found with spinal stenosis * cauda equina syndrome (bowel, bladder, saddle parathesias) * PMHx, B-Sx * **Physical exam** * **L4 nerve root involvment** (compressed in foramen with L4/5 DS) * _weakness to quadriceps_ * best seen with sit to stand exam manuever * _weakness to ankle dorsiflexion_ (cross over with L5) * best seen with heel-walk exam manuever * decreased _patellar reflex_ * **L5 nerve root involvement** * _weakness to ankle dorsiflexion_ (cross over with L4) * best seen with heel-walk exam manuever * _weakness to EHL_ * provactive walking test * have patient walk prolonged distance until onset of buttock and leg pain * have patient stop but remain standing upright * if pain resolves this is consistent with vascular claudication * have patient sit * if pain resolves this is consistent with neurogenic claudication (DS) * **Radiographs - lumbar AP, lateral neutral/WB, lateral flexion, lateral extension** * slip evident on lateral xray - myerding grade * flexion-extension studies * _instability defined as 4 mm of translation or 10° of angulation of motion compared to adjacent motion segment_ * **MRI** * best study to evaluate impingement of neural elements * T2 weighted sagittal and axials best to look for spinal stenosis * **CT myelogram** * helpful in patients in which a MRI is contraindicated (pacemaker)

Answer 50

* 4 mm of translation * 10° of angulation

Answer 51

* **instability** (\>4mm translation, \>10 deg motion on flex-ex) * will improve fusion * Other benefits: * improve saggital alignement * indirect decompression

Answer 52

**Adult Degenerative Spondylolisthesis** * **Nonoperative** * physical therapy and NSAIDS * _indications_ * most patients can be treated non-operatively * _modalities include_ * activity restriction * NSAIDS * PT - core strengthening * **epidural steroid injections** * _indications_ * second line of treatment if non-invasive methods fail * **TLIF for DS is cost effective** * $42,854 at 2-year follow-up, per QALY * \<50 000 per QALY is considered cost effective (THA is used as a gold standard) * **Lumbar decompression alone** * Renewed interest in recent years * Advocates will say there is less morbidity than with fusion * Studies show that outcomes are better with fusion * **lumbar wide decompression with instrumented fusion** * **Age should not be a detourant, good outcomes have been reported** * _indications_ * persistent and incapacitating pain that has _failed 6 mos. of non-operative_ management and epidural steroid injections * progressive motor deficit * cauda equina syndrome * Risk of pseudoarthrosis (36%) without instrumentation does not appear to affect outcomes * _However, instrumentation is the standard of care_ * **Anterior Lumbar Interbody Fusion (ALIF) or PLIF** * _indications_ * reserved for revision cases with pseudoarthrosis * Consider PLIF for unstable spine * _Benefits_ * Enhance fusion rate * Improve saggital alignment and disc height * Indirect decompression of nerve roots * **MIS-TLIF** * May be beneficial in elderly patients with poor bone quality where blood loss and poor bone quality may be an issue * Some studies have shown good outcomes, but there have been few complications with traditional methods * May be more cost-effective with shorter hospital stay and sooner return to work

Answer 53

* 70% of patients treated surgically had improvement, 20% patients treated non-operatively had improvement * No difference in outcomes regarding how patients were fused * Iliac bone graft is associated with higher blood loss, longer surgery and no improvement in fusion or reduction in complications * Good outcomes with ALIF, but no direct comparision * PLIF is better than PLF alone for patients with an unstable lumbar spine (4mm translation, \>10 deg motion) * Less success with lateral IF * Considerations for interbody fusion * high risk of non- union and in the presence of local kyphosis * high-grade slip * symptomatic instability with sagittally oriented facet joints * joint effusion on MRI * tall intervertebral disk

Answer 54

* **Dural Tear** * _Intra-op_ * Watertight closure * 6-0 nonabsorbable suture * Commercial sealant * 48 hours bed rest with progressive mobilization * Post-op can develop psuedomeningocele * Headache, subcutaneous fluid collection * CT myelogram to assess lesion * **Pseudoarthrosis** * ****36% with no instrumentation * improved with instrumentation * growing support for TLIF which may also increase fusion rates and decrease risk of progression * **Surgical Infection** * Acutely don't need to take the hardware out * try to treat with abx and take it out once you get a fusion * Chronically; get a CT and if there is a fusion you can take the hardware out

Answer 55

Pain at the level of the defect History of back pain as an adolescent Absence of other pathology Absence of secondary gain Pathological motion on dynamic radiographs

Answer 56

* **pros** * may increase chance of union by more complete discectomy and endplate preparation * allows improved restoration of disc height * **cons** * retrograde ejaculation and sexual dysfunction * persistent radiculopathy due to inadequate indirect foraminal decompression * persistent low back pain may be caused by nociceptive pain fibers in pars defect that are not removed in an anterior procedure alone

Answer 57

* Defined as spondylolisthesis in an adult caused by a defect in the pars interarticularis (spondylolysis) * spondylolysis is seen in **4-6% of population** * increased prevalence in sports that involve repetitive hyperextension (gymnasts, weightlifters, football linemen) * **location** * _82% occur at L5/S1_ * 11% occurs L4/5 (11%) * due to forces in the lumbar spine being greatest at these levels and the facet being more coronal * **Pathophysiology** * _foraminal stenosis_ * adult isthmic spondylolisthesis at L5/S1 often leads to radicular symptoms caused by compression of the exiting L5 nerve root in the L5-S1 foramen (but not by posterior elements as occurs with degenerative) * compression can be caused by * hypertrophic fibrous repair tissue of the pars defect * uncinate spur formation of the posterior L5 body * bulging of the L5/S1 disc * _lateral recess stenosis_ * caused by facet arthrosis and hypertrophic ligamentum flavum * _central stenosis_ * rare due to fact that these slips are usually only Grade I or II * Also rare because the disease process is usually bilateral * The posterior elements remain posterior so there is no compression that you would get with a degenerative or congential pathology * **Prognosis** * relatively few patients (5%) with spondylolysis with develop spondylolisthesis * \>10mm occurs in \<5% patients * slip progression more common in _females_ * Progression more common in _adults_ than adolescents * More in _bilateral_ * _L4/5_ at higher risk * _Disk degeneration_ is associated with risk of slip

Answer 58

* female * adult (vs adolsecent) * L4/5 * bilateral pars defect * disc degeneration ## Footnote * \>10mm occurs in 5% of adults* * These are also the same factors that increase the chance of the slip being symptomatic*

Answer 59

* **History** * axial back pain * most common presentation * pain usually has a long history with periodic episodes that vary in intensity and duration * Pain can be from the slip or degeneration around the slip - disc, facets * Pain from the isthmic fracture * Pain at the level of the defect * History of back pain as an adolescent * Absence of other pathology * Absence of secondary gain * Pathological motion on dynamic radiographs * leg pain - common presentation * usually a L5 radiculopathy usually caused by foraminal stenosis at the L5-S1 level * Neurogenic symptoms and cauda equina are rare * neurogenic claudication * caused by spinal stenosis * characterized by buttock and leg pain worse with walking * **Physical exam** * Examine - gait, lumbar lordosis * Feel * Stepoff is almost always at L4/5 * ROM * Tight hamstrings * Full neuro exam * L5 radiculopathy * ankle dorsiflexion and EHL weakness

Answer 60

* **AP** * deformity in coronal plane * **lateral** * will see spondylolisthesis and pars defect * _Note dysplastic features of L5_ * Horizonal facets * Trapezoidal body * Sacral beaking/doming * Deficient inferior articular process * Note degenerative features - OA, disc space narrowing * **flexion-extension** * instability defined as _4 mm of translation or 10° of angulation of motion_ compared to adjacent motion segment * **measurements** * _Myerding slip_ and _slip angle_ are most important * Slip angle measures the degree of kyphosis * _pelvic incidence_ * pelvic incidence = pelvic tilt + sacral slope * a line is drawn from the center of the S1 endplate to the center of the femoral head * a second line is drawn perpendicular to a line drawn along the S1 endplate, intersecting the point in the center of the S1 endplate * the angle between these two lines is the pelvic incidence (see angle X in figure above) * **correlates with severity of disease** * _pelvic tilt_ * sacral slope = pelvic incidence - pelvic tilt * a line is drawn from the center of the S1 endplate to the center of the femoral head * a second vertical line (parallel with side margin of radiograph) line is drawn intersecting the center of the femoral head * the angle between these two lines is the pelvic tilt (see angle Z in figure above) * _sacral slope_ * pelvic tilt = pelvic incidence - sacral slope * a line is drawn parallel to the S1 endplate * a second horizontal line (parallel to the inferior margin of the radiograph) is drawn * the angle between these two lines is the sacral slope (see angle Y in the figure above) * **Correlations with slip** * Loss of disc height * Lumbar index * Pelvic incidence \> 68.5 * **CT** * Good to look at the boney anatomy pre-op * Can help identify healed fractures for those treated non-op * **MRI or CT myelography** * T2 parasagittal images are best study to evaluate for foraminal stenosis and compression of neural elements * **SPECT is more senstive than MRI or bone scan**

Answer 61

Loss of disc height Lumbar index \< 75 Pelvic incidence \> 68.5

Answer 62

PI = PT + SS ## Footnote *Pelvic incidence correlates to severity of disease*

Answer 63

**Adult isthmic spony (L5/S1)** * **oral medications, lifestyle modifications, therapy** * _indications_ * most patients can be treated nonoperatively * _techniques_ * Flexion based program is better than extension based * But evidence is more supportive of surgery than PT * activity restriction * NSAID * role of injections unclear * bracing may be beneficial especially in the acute phase * **L5-S1 decompression and instrumented fusion +/- reduction** * _indications_ * L5-S1 low-grade spondylolisthesis with persistent and incapacitating pain that has failed 6 months of nonoperative management (most common) * \<50% slip * progressive neurologic deficit * slip progression * cauda equina syndrome * _Decompression_ * usually involves Gil laminectomy and foraminal decompression * removal of loose lamina and scared pars defect allows decompression of nerve root * a Gill decompression is destabilizing and should be combined with fusion * _Instrumentation_ * Improves fusion rates * Higher rates of neuro complications associated with screw misplacement * _interbody fusion (PLIF/TLIF)_ commonly performed * posterior lumbar interbody fusion (PLIF) involves insertion of device medial to facets * transforaminal lumbar interbody fusion (TLIF) requires facetectomy and more lateralized and transforaminal approach to the disc space * Cons - increased blood loss and longer hospital stay * _Reduction_ * improved sagittal balance with reduction * risk of stretch injury to L5 nerve root with reduction * Catastrophic events and 360 fusion has improved with neuromonitoring * **L4-S1 decompression and instrumented fusion +/- reduction** * _indications_ * L5-S1 high-grade spondylolithesis with persistent and incapacitating pain that has failed 6 months of nonoperative management * \>50% slip * Outcomes of \> 50% slip have a higher risk of the following * Pseudoarthrosis * Progression of slip * Neurological damage * Implant failure * **ALIF/PLIT/TLIF** * _indications_ * can be used successfully to treat low-grade isthmic spondylolisthesis even when radicular symptoms are present * cannot be used to treat high grade isthmic spondylolisthesis due to translational and angular deformity * _Benefits_ * Improved fusion rates * Indirect decompression * _outcomes_ * studies have shown good to excellent results in 87-94% at 2 years * ALIF alone comparable to PLF * PLIF has better saggital alignment with matienence of reduction * Does not translate to improved functional outcomes * TLIF has been shown to increase fusion and decrease disability scores * Complications of PLIF/TLIF * Injury to nerve root * Incident durotomy * Migration of implant * Epidural bleeding

Answer 64

Pseudoarthrosis Progression of slip Neurological damage Implant failure

Answer 65

* studies have shown good to excellent results in 87-94% at 2 years * ALIF alone comparable to PLF * PLIF has better saggital alignment with matienence of reduction * Does not translate to improved functional outcomes * TLIF has been shown to increase fusion and decrease disability scores * Complications of PLIF/TLIF * Injury to nerve root * Incident durotomy * Migration of implant * Epidural bleeding

Answer 66

congenital stenosis \< 60% OA increased ROM \<6mm available for cord lateral deviation of OPLL

Answer 67

* male * positive rheumatoid factor * increased CRP * subcutaneous nodules * aggressive/progressive distal disease

Answer 68

* ligamentum flavum * interspinous ligament * supraspinous ligament * facet capsules

Answer 69

* **Lateral view** * Basion Dens Interval (BDI) \<12mm * Anterior spinolaminar line \< 1mm * Drawn from opisthion to C1 arch, should pass C1/C2 * ADI \< 3mm * Posterior cortex of atlas should be parallel to anterior cortex of axis * SAC \> 13mm * **Open mouth** * Joint articulations should be \<2mm * Combine overhang \< 7mm

Answer 70

* **Type I** * comminuted fracture cause by axial load (3% of fractures) * cervical orthoses * **Type II** * involve extension of basilar skull fracture into condyle (22%) * cervical orthoses * **Type III - avulsion fracture (75%)** * have a clinical suspicion for occipitocervical dissociation * if associated with dissociation treat wtih occipitocervical fusion

Answer 71

**Craniocervical dissociation** * severe injury and patients rarely survive * most patients die of brainstem destruction * identified in 19% fatal cervical injuries * in patients that survive very high risk of neurologic injury * mechanism can be either translation or distraction * **Classification** * Type I - anterior dislocation (most) * Type II - longitudinal dislocation * Type III - posterior dislocation * **Harbourview Classification - use this; base on stability** * _Stage 1 - stable_ * MRI evidence of craniocervical osseoligamentous injury, \<2 mm displacement with traction test * collar for comfort * _Stage 2 - unstable with stress view_ * Most dangerous because can be unclear * MRI evidence of craniocervical osseoligamentous injury, \>2 mm displacement with traction test * _Stage 3 - grossly unstable_ * Craniocervical malalignment of .2 mm on static radiography * **Stress view** * ****Garden-wells tongs * start with 5 lbs; monitor for distraction between OA or AA joints * Also make sure to screen people for blunt cerebrovascular injuries * **occipitocervical fusion - posterior segmental stabilization with fusion from Occiput to C2 (minimum)** * most modern constructs are modular occipital plates that rigidly lock to screw/rod contructs of the subaxial cervical spine * the thickest portion of the occiput is located 5 cm lateral to the external occipital protuberance * the major dural venous sinuses are located just below the external occipital protuberance and are at risk of penetrative injury during occipitocervical fusion

Answer 72

* low sensitivity to detecting injury (57%) * **Powers ratio** * used to diagnosis occipitocervical dislocation * technique * Powers ratio = C-D/A-B * C-D: distance from basion to posterior arch * A-B: distance from anterior arch to opisthion * significance * ratio ~ 1 is normal * if \> 1.0 concern for anterior dislocation * ratio \< 1.0 raises concern for * posterior atlanto-occipital dislocation * odontiod fractures * ring of atlas fractures * **BDI - basin dens interval, BAI - basin axis interval** * Should be \< 12mm * _Harris lines rule of 12_, both should be \< 12mm

Answer 73

* **tectorial membrane (most dorsal layer)** * connects the posterior body of the axis to the anterior foramen magnum and is the cephalad continuation of the PLL * **cruciate ligaments (middle layer)** * _transverse ligament_ is the strongest component * connects the posterior odontoid to the anterior atlas arch, inserting laterally on bony tubercles. * **odontoid ligaments including alar and apical ligaments (most ventral layer)** * _paired alar ligaments_ * connect the odontoid to the occipital condyles * relatively strong * _apical ligament_ * runs vertically between the odontoid and foramen magnum. * not very strong

Answer 74

* **Radiographs** * lateral radiographs * _atlantodens interval (ADI)_ * \< 3 mm = normal in adult (\< 5mm normal in child) * 3-5 mm = injury to transverse ligament with intact alar and apical ligaments * \> 5 mm = injury to transverse, alar ligament, and tectorial membrane * open-mouth odontoid * open-mouth odontoid view important to identify atlas fractures * _sum of lateral mass displacement_ * if sum of lateral mass displacement is \> 8.1 mm then a transverse ligament rupture is assured and the injury pattern is considered unstable * traditional thinking based on anatomic studies was that a sum of lateral mass displacement of \> 6.9 inferred a transverse ligament rupture. But new studies that consider radiographic magnification argue that a transverse ligament rupture should not be inferred unless the lateral mass displacement is \> 8.1mm. * **MRI** * more sensitive at detecting injury to transverse ligament * **CT** * effective at identifying bony fracture patterns such as a Jefferson fx

Answer 75

* **Jefferson Fracture** * bilateral fractures of anterior and posterior arch resulting from axial load * **lateral mass fracture** * **lamina fracture** * **Transverse ligament injuries** * Type I - intersubstance tear of transverse ligament * Type II - bony avulsion of transverse ligament

Answer 76

* **halo immobilization for 6-12 weeks (minerva, somi)** * _indications_ (most atlas fractures) (90% union rates with external immobilization - levigne) * intact transverse ligament (\< 7mm spread of lateral masses) * bony avulsion of transverse ligament (Type II) * _technique_ * some injuries may require initial traction * _Risk_ * __can lead to distraciton of injury which can risk cock-robin deformity * treated with complex osteotomy * risk of pseudoarthrosis * painful malunion * treat with C1-C2 fusion * **posterior fusion** * _indications_ * midsubstance rupture of transverse ligament (Type I) with widely displaced lateral masses (\> 7mm) * _Options_ * Don't say these * __C1-C2 * C1 alone if ammenable * **occiput-C2 if C1 comminuted** * Historically treatment with transverse ligament disruption was treat with occiput-C1 fusion - don't say this on your oral * Now some will fix C1 alone to try to preserve mobility

Answer 77

* **C1 lateral mass screws / C2 pedicle screw construct - Harms** * C1 lateral mass screws * distance from ICA is 2mm * C2 pedicle screws - still VA s at risk * option to use pars or crossed interlaminar screws; more difficult * Pros * more compatable and can be adjusted as per anatomy * less disection * **C1-2 transarticular screw placement - Magerl** * is the most stable form of fixation and obviates need for postoperative halo immobilization * Contraindicaitons * large/medial VA (CT angio) * nonanatomic reduction C1/C2 * hypoplastic C2 pars * substatial thoracic kyphosis * Optimal screw length is 34mm * **C1-2 wiring techniques** * also used but are considered less stable and are usually treated with postoperative halo immobilization. Wiring techniques include * _Brooke's technique_ * _Gallie's technique_

Answer 78

* Traumatic anterior spondylolithesis of the axis due to bilateral fracture of pars interarticularis * MVA is most common cause * **Mechanism is** * hyperextension (leads to fracture of pars) * secondary flexion (tears PLL and disc allowing subluxation) * **Associated injuries** * 30% have concomitant c-spine fx

Answer 79

* **Type I** * Injury (extension and axial loading) * \< 3mm horizontal displacement * No angulation * C2/3 disc remains intact * stable fx pattern * Rigid cervical collar 10 weeks * **Type IA** * Injury * Atypical, unstable * Fracutre threw one bars and out threw body * Side-side bending * Rigid collar 10 weeks * Unpredictable, follow closely * **Type II** * _Injury_ (with flexion) * \> 3mm of horizontal displacement * Significant angulation * Vertical fracture line * unstable fracture pattern * Get MRI to discern from TIIA * If \< 5mm displacement than reduction with traction then halo immobilization for 6-12 weeks * assess closely; if you get distraction the injury is a IIA; this you can also use if you don't have access to MRI * If \> 5mm displacement consider surgery or prolonged traction. * Usually heal despite displacment (autofuse C2 on C3). * **Type IIA** * _Injury_ * Distraction injury * No horizontal displacement * Horizontal fracture line * Significant angulation * Will have injury to disc; unstable in traction * Avoid Traction in Type IIA * Reduction with hyperextension then halo immobilization for 6-12 weeks. * **Type III** * Injury * Type I fracture with associated bilateral C2-3 facet dislocation * Rare injury pattern * Surgical reduction of facet dislocation followed by stabilization required.

Answer 80

* Most IIA, III * some II * C1-3 fusion * might requrie halo, especially if poor screw purchase across fracture * Include C1 if still unstable * ACDF (TIIA) C2/3 * preserves motion * more difficult approach

Answer 81

* Injury morphology * 1 - compression * +1 burst * 3 - rotation * 4 - distraction * Neurological status * 2 - nerve root * 3 - incomplete SCI * 2 - complete SCI * 3 - cauda equina * Posterior ligamentous complex * 2 - suspected * 3 - disrupted

Answer 82

* **anterior column** * anterior longitudinal ligament (ALL) * anterior 2/3 of vertebral body and annulus * **middle column** * posterior longitudinal ligament (PLL) * posterior 1/3 of vertebral body and annulus * **posterior column** * pedicles * lamina * facets * ligamentum flavum * spinous process * posterior ligament complex (PLC) * instability defined by

Answer 83

## Footnote supraspinous ligament interspinous ligament ligamentum flavum facet capsule

Answer 84

injury to the Posterior Ligament Complex (PLC) progressive kyphosis \> 30°kyphosis (controversial) \> 50% loss of vertebral body height (controversial) \> 50% canal compromise (controversial) neurological deficiet *Otherwise the best treatment is bracing for pain control*

Answer 85

* Anterior * direct decompression * better for severe comprimise of canal and comminution * better for delay to surgery * do not stabilize posterior elements * fewer segments to stabilize * better correction for deformity \>30 deg * Posterior * easier approach * better multiple medical co-mobidities or severe trauma * lower non-union * more stable fore fracture dislocation * indirect decompression * ligamentotaxis less effective after 5 days * can decompress transpedicular * try not to do a laminectomy * one level above, one below

Answer 86

* **Side of approach** * _\> T8 right (aorta and heart on the left)_ * will require lung deflation * can still go left because arteries easier to mobilize than the veins on the right * go right to avoid the heart in the thorax * * Don't go through the ribs lower than T10 * _Lat dorsi/serattus_ * _Enter the rib cage_ * ideally at the level of interest, or one level above * _intercostal_ * _rib resection - better exposure_ * Incise the rib peristeium and perietal layer together to enter the thorax * can use the rib as graft * _Costotransversectomy_ * __aim for the rib of the same vertebrae (10th rib for T9/10) or if in doubt one rib above * _Diaphragm is at T12_ * leave a 1-2cm cuff to repair to * will need to take it down to see T12, L1 * _Will have to ligate semental vessels, but the more you ligate the more you put the cord at risk_ * _Artery of Adamkawitz T4-T9_ * __if going from the left you should get a pre-op angiography * can clamp the vessels and assess evoked potentials before ligating potential vessels

Answer 87

* **Intercostal vessels** * vulnerable during * rib resection when running along undersurface of rib, and * exposure of vertebrae within chest * avoid injury by entering pleura from above the ribs * **Lungs** * avoid injury by using sharp instruments wisely when within chest * expand lungs every 30 minutes to prevent microatelectasis * **Esophagus** * avoid injury through adequate retraction of esophagus while working on spine * **Artery of Adamkiewicz** * travels on left side between T9-L2 in 60% of patients * must preserve to prevent spinal cord ischemia

Answer 88

* **Sympathetic chain** * lateral aspect of vertebral body * **Genitofemoral nerve** * anterior surface of psoas muscle attached to fascia * **Segmental arteries** * segmental lumbar arteries and veins * **aorta** * **Ureter** * lies between psoas fascia and peritoneum * attached more firmly to peritoneum * stroke to produce peristalsis to confirm

Answer 89

* pulmonary comprimise * incisional hernia * hardware failure * vessel comprimise * infection

Answer 90

* T12 diaphragm * L1 - SMA * L2 - renal * L4 - common iliac bifurcation

Answer 91

* Complications are even higher with revision surgery; always get imaging to assess proximity of anterior structures (vascular/ureters). * If doing revision get a senior collegaue or general/thoracic surgery to help * **Vessel injury** * _left iliac artery_ most common artery * \>4mm repair and be aware of compartment syndrome * _left common iliac vie_n most common vein * _Iliolumbar_ and ascending lumbar vien transverse over L5/S1 * Gain control of the room - let anaesthesia know, trendelenberg position * Pack with epinephrine soaked sponges, gain control with pressure above and below tear (no aggressive use of suction or clamps) * Can repair the vien with 5-0 nonabsorbable suture in a figure of 8 fashion * If unrepairable can litagate or control bleeding with fibrin sealant, gelfoam, surgicell, floseal * Follow closely post-op for DVT * If arterial * can use clamps above and below * should call vascular to repair * may need bypass * consider fasciotomy, monitor limb with O2 sat and pulses post-op * **Visceral** * ureter tear * occurs with mobilization of the posas * delayed CTA can show ureters pre-op * IV methylene blue pre-op * Peritoneum * Bowel * should be repaired immediately * can be worse with adhesions or if scarred from chronic inflammation around spine * Consult general surgery or urology * Pre-op bowel prep can be considered for revision surgery * Always have a good bowel regime post-op; _ilieus is a very common complication_ * **Nervous** * retrograde ejaculation - presarcal superior hypogastric plexus * increased with transperitoneal * lumbar sympathetic trunk * **Nerve root injury** * over distraction * iatrogenic disc hernation * posterior protrusion of cage * **Other** * Proximal DVT * monitor closely * DVT prophylaxis * arterial thrombosis * **_Increased risk with_** * L4/5 compared to L5/S1 * anterior osteophyte * previous surgery * diskitis * fracture

Answer 92

presarcal superior hypogastric plexus

Answer 93

\> 5 mm displacement (\>50% nonunion rate) fx comminution angulations \> 10 degrees age \> 50 years delay in treatment

Answer 94

* **observation alone** * indications * Os odontoideum * assuming no neurologic symptoms or instability * **hard cervical orthosis for 6-12 weeks** * _indications_ * Type I * Type II in elderly who are not surgical candidates * union is unlikely, however a fibrous union should provide sufficient stability except in the case of major trauma * Type III fractures * no evidence to support Halo over hard collar * **halo vest immobilization for 6-12 weeks** * _indications_ * Type II young patient with no risk factors for nonunion * _contraindications_ * elderly patients * do not tolerate halo (may lead to aspiration, pneumonia, and death) * **Operative** * _posterior C1-C2 fusion_ * indications * Type II fractures with risk factors for nonunion * Type II/III fracture nonunions * Os odontoideum with neurologic deficits or instability * Type I with atlantooccipital instability (extremely rare) * _anterior odontoid osteosynthesis_ * indications * Type II fractures with risk factors for nonunion AND * acceptable alignment and minimal displacement * oblique fracture pattern perpendicular to screw trajectory * patient body habitus must allow proper screw trajectory * outcomes * associated with higher failure rates than posterior C1-2 fusion * **transoral odontoidectomy** * indications * severe posterior displacement of dens with spinal cord compression and neurologic deficits

Answer 95

* acceptable alignment * minimal displacement * oblique fracture pattern perpendicular to screw trajectory * patient body habitus must allow proper screw trajectory * **Pro** - preserves motion segments * **Con** - higher risk of nonunion

Answer 96

* **ADI (atlanto-dens interval)** * instability defined as \> 3.5 mm of motionbetween flexion and extension views * instability alone is not an indication for surgery * \> 7 mm - alar ligament * _\> 10 mm motion of associated with increased risk of neurologic injury and an indication for surgery_ * **PADI / SAC (posterior atlanto-dens interval and space available for cord describe same thing)** * \< 14 mm associated with increased risk of neurologic injury and is an indication for surgery * \> 13mm is the most important radiographic finding that may predict complete neural recovery after decompressive surgery

Answer 97

* Usually seen in adults with a median age for pyogenic osteomyelitis is **50 to 60 years** * Pathogens include * _staph aureus_ is most common (50-65%) * staph epidermidis is second most common cause * pseudomonas seen in patients with IV drug use (and UTI) * salmonella seen in patients with sickle cell disease * gram negative infections increasing over last decade and often associated with gram negative infections of the GU and respiratory tract * **Locations** * 50-60% of cases occur in lumbar spine * 30-40% in thoracic spine * ~10% in cervical spine * **Risk factors include** * IV drug abuse * diabetes * obesity * malignancy * immunodeficiency or immunosuppressive medications * malnutrition (serum albumin * recent systemic infection (UTI, pneumonia) * trauma * smoking

Answer 98

* **Epidural abscess** * defined as a collection of pus or inflammatory granulation tissue between dura mater and surrounding adipose tissue * usually associated with vertebral osteomyelitis * present in **~18% of patients with spondylodiskitis** * **50% of patients with an epidural abscess will have neurologic symptoms** * **Pathogenesis** * _hematogenous seeding_ * generally agreed that inoculation likely occurs through hematogenous seeding (arterial or venous) of the endplates and intervertebral discs * endplates contain area of low-flow vascular anastomosis that may provide an environment suited for inoculation * involvement of one endplate leads to direct extension into intervertebral discs, followed by direct extension into the second endplate * _direct inoculation_ * can occur after penetrating trauma, open fractures, and following surgical procedure * contiguous spread from local infection * most commonly associated with retropharyngeal and retroperitoneal abscesses * **Neurologic symptoms results from** * direct infectious _involvement of neural elements_ * _compression from an epidural abscess_ * epidural abscess present in ~18% of patients with spondylodiskitis * 50% of patients with an epidural abscess will have neurologic symptoms * neural compression caused by _instability of the spine_

Answer 99

**Assessment for discitis** * **History** * Take a complete and AMPLE history * pain * pain is often severe and insidious in onset * pain is usually worse with activity and unrelenting in nature * pain that awakens patients at night should raise concern for malignancy and infection * neurologic symptoms present in 10-20% * radiculopathy * Myelopathy * fever is only present in 1/3 of patients * history of UTI, pneumonia, skin infection, of organ transplant are common * History of IV Drug use * recent travel, history of emmigration * PMHx - diabetes, obesity, immunocomprimised malnutrition, trauma, smoking * **Physical exam** * Examine (Look) * Status of the patient, evidence of IV drug use * Obvious deformity of the spine * Palpate (feel) * obvious stepoff, palpable collection * perform careful neurological exam * Rectal exam * **Management** * ESR, CRP, WBC, _blood cultures_ * __urine cultures * AP, lateral full spine * _MRI with gad_, CT * _Open biopsy if cultures neg_ * **Radiographs** * findings are usually delayed by weeks * paraspinous soft tissue swelling (loss of psoas shadow) seen if first few days * _disc space narrowing and disc destruction_ (remember disc destruction is atypical of neoplasm) seen at **7-10 days** * _endplate erosion or sclerosis_ seen at **10-21 days** * osteopenia * **CT** * usefull to show bony abnormalities, abscess formation, and extent of bony involvement * CT myelogram is contraindicated * **MRI** * _MRI with gadolinium contrast most sensitive (96%) and specific (93%) imaging modality for diagnosis of spinal osteomyelitis_ * also most specific imaging modality to differentiate from tumor * findings include * paraspinal and epidural inflammation * disc and endplate enhancement with gadolinium\*\*\* * Destroys endplate and then goes up into the body * T2-weighted hyperintensity of the disk and endplate * **Bone scan** * Technetium Tc99m bone scan are 90% sensitive but lacks specificity * combined Technetium Tc99m and gallium 67 scan is both more specific and more sensitive than Technetium Tc99m alone * indium 111 labeled scan not recommended due to poor sensitivity (17%)

Answer 100

**Discitis** * **Consult ID** * **Goals of treatment** * identify organism * Blood cultures * CT guided biposy * Open biopsy * eliminate infection * Directed antibiotics * prevent or improve neurologic deficits * maintain spinal stability * Provide adequate nutrition * **Confirm Organism** * _blood cultures_ * 33% (reports show 25%-66%) of patients with spondylodiskitis have positive blood cultures which are 85% accurate for isolating the correct organism * blood culture yield is improved by **withholding antibiotic** and **obtaining cultures when patient is febrile** * _CT guided biopsy_ * indicated in patients who do not have indications for immediate open surgery and blood cultures are negative * can provide diagnosis in 68-86% of patients * can be guided by fluoroscopy or by CT scan * **cultures should be held for 10 days and sent for:** * aerobic * anaerobic * fungal * acid-fast cultures * _open biopsy_ * indicated when tissue/organism diagnosis can not be made with noninvasive techniques * anterior, costotransversectomy, or transpedicular approach used * **bracing and long term antibiotic (6-12 weeks)** * indicated in most cases and successful in 80% * _bracing_ * helps improve pain and prevent deformity * rigid cervicothoracic orthosis or halo required for cervical osteomyelitis * _antibiotics_ * if patient is septic or critically ill that start antibiotics immediately, otherwise hold until organism identified * usually treated with **IV antibiotics until signs of improvement (~ 6 weeks) and then converted to PO antibiotics** * use broad spectrum antibiotics until organism is identified * vancomycin for pencicillin-resistent and gram-positive bacteria * third-generation cephalosporin for gram-negative coverage * new antibiotic-resistant strains of microorganisms are becoming more common and failure to diagnose can have dire consequences organisms include * MRSA (methicillin-resistent Staph aureus) * VRSA (vancomycin resistant Staph aureus) * VRE (vancomycin resistant enterococcus) * newer generation antibiotics for antibiotic resistant organisms include **linezolid** and **daptomycin** * **anterior debridement and strut grafting, +/- posterior instrumentation** * _indications_ * abcess * neurologic deficits (for any reason) * progressive deformity * gross spinal instability * persistent infection despite antibiotic (BW still elevated) * _Approach_ * Retroperitoneal * Thoracolumbar * Lateral decubitus, pad all pressure points * T2-9 right * T10-L2 left * 2 rbis above level, divide lat dorsi and serratous anterior * Intercostal vs rib resection (5th or 6th intercostal space) * Enter pleural, deflate the lung, retract esophagus, ligate intercostal vessesl * _strut graft selection_ * autogenous tricortical iliac crest, rib, or fibula strut graft have proven safe and effective in presence of acute infection * allograft being used with good results, but autogenous sources theoretically have better incorporation * a recent study showed improved deformity correction with titanium mesh cages filled with autograft (followed by posterior instrumentation) * _instrumentation_ * spinal instrumentation in presence of active infection is controversial * some advocated I&D followed by staged instrumentation * some advocate a single procedure with bone graft and instrumentation in the presence of an active infection * titanium is preferred over stainless steel * **posterior instumentation** * _Indications_ * severe kyphotic deformity * multilevel anterior construct * posterior instrumentation can be performed at same time or as a staged procedure

Answer 101

* **Anterior debridement with strut graft** * abcess * neurologic deficits (for any reason) * progressive deformity * gross spinal instability * persistent infection despite antibiotic (BW still elevated) * **Posterior instrumentation** * severe kyphotic deformity * multilevel anterior construct

Answer 102

* **Identify organism** * Blood/urine cultures * CT guided biposy * Open biopsy * **Eliminate infection** * Directed antibiotics * **prevent or improve neurologic deficits** * **maintain spinal stability** * **Provide adequate nutrition**

Answer 103

**Posterior Epidural Abcess** * adults \> _60 years of age_ * vertebral osteomyelitis and diskitis (spondylodiscitis) * _present in ~18% of patients with spondylodiskitis_ * **Neurologic deficits** * 33% of patients with an epidural abscess will have neurologic symptoms * 4-22% incidence of permanent paralysis * can be caused from direct compression or infarction of spinal cord blood flow * **Location** * usually dorsal in thoracolumbar spine * **Risk factors include** * IV drug abuse * immunodeficiency * malignancy * HIV * immunosuppressive medications * recent spinal procedure * **Outcome** * preoperative degree of neurologic deficits is most important indicator of clinical outcome * mortality ~ 5% * **History** * Take a complete and AMPLE history * Characterize the pain - pain is often severe and insidious in onset an occurs in 87% * Associated numbness, weakness; difficulty with gait or hands * Constitutional symptoms * systemic illness more profound than patients with vertebral osteomyelitis * fever present in ~50% * Bowel/bladder/parasthesias * IV drug use, PMHx, recent travel/infectious contacts * **Physical exam** * Examine - patient, deformity * Palpate - step-off * ROM/ASIA * neurologic deficits present in ~33% * may present as a radiculopathy or a myelopathy * **Management** * ESR, CRP, WBC, Blood cultures, urine cultures * WBC elevated 42% of time * ESR/CRP elevated 90% of time * AP lateral spine, MRI with gad * **Radiographs - AP/Lateral** * Often normal * **MRI is the study of choice** * MRI with gadolinium is the imaging modality of choice for diagnosis of spinal epidural abscess * shows extent of abscess, presence of vertebral osteomyelitis, and allows evaluation of neurologic compression * _gadolinium allows differentiation of pus from CSF_ * _a ring enhancing lesion_ is pathognomonic for abscess * **CT** * poor sensitivity for epidural abscess * **CT myelogram** * 90% sensitivity but invasive

Answer 104

preoperative degree of neurologic deficits is most important indicator of clinical outcome

Answer 105

**Posterior Epidural Abcess** * **Goals** * early diagnosis is most essential factor in preventing devastating outcomes * historically presence of epidural abscess has been considered a medical surgical emergency * there has been a recent trend towards nonoperative management as new studies shows nonoperative treatment effective in patients without neurologic deficit * **bracing and long term antibiotic** * indicated only patients with * no neurologic deficits * small abscess * patient capable of close clinical followup * those who are not candidates for surgery due to medical comorbidities * **surgical decompression is indicated in most patients with spinal epidural abscess.** * indications for surgery include * neurologic deficits * persistent infection * progressive deformity * gross spinal instability * technique depends on location of abscess and extent of infection (presence of spondylodiscitis) * **decompressive laminectomy** * most common form of operative treatment * indicated when abscess is posterior and there is no contiguous spondylodiscitis * _avoid wide decompression and facetectomy as it will result in spinal instability_ * **anterior debridement and strut grafting** * indications * abscess is located anteriorly * anterior vertebral body and discs are involved (presence of spondylodiscitis) * technique * see vertebral osteomyelitis treatment for technique details * **postoperative antibiotics** * indicated for 2-4 weeks if no bony involvement of infection * indicated for 6 weeks if bony involvement

Answer 106

* no neurologic deficits * small abscess * patient capable of close clinical followup * those who are not candidates for surgery due to medical comorbidities

Answer 107

* indicated for 2-4 weeks if no bony involvement of infection * indicated for 6 weeks if bony involvement

Answer 108

**Pott's disease - spinal TB** * **History** * Complete and AMPLE history * Characterize the onset of the pain, history of TB/travel/contacts/immigration * onset of symptoms of _tuberculous spondylitis is typically more insidious_ than pyogenic infection * _constitutional symptoms_ * chronic illness * malaise * night sweats * weigh loss * back pain * Bowel/bladder parasthesias * presents and appears more similar to cancer than infection * **Physical exam** * Examine (Look) * Deformity * Palpate (Feel) * Areas of pain, stepoff * ROM (Move) * Full ASIA exam * neurologic deficits (present in 10-47% of patients with Pott's Disease) * **Management** * ESR, CRP, WBC * ESR up in 25% * CXR - 66% will be abnormal * full spine XR, CT, MRI with gad * ID Consult * **Spine radiographs** * _early infection_ * shows involvement of anterior vertebral body with sparring of the disc space (this finding can differentiate from pyogenic infection) * _late infection_ * shows disk space destuction, lucency and compression of adjacent vertebral bodies, and development of severe kyphosis * **MRI with gadolinium contrast** * remains preferred imaging study for diagnosis and treatment * **Nucleur medicine studies (combination of technetium and gallium)** * shown to have highest sensitivity for detecting infection * **CT guided biopsy** * PPD (purified protein derivative of tuberculin) * positive in ~ 80% * PCR can speed up culture results * AFB take 10 weeks to grow

Answer 109

**TB - Pott's Disease** * **Diagnosis** * CT guided biopsy with cultures and staining effective at obaining diagnosis * mycobacteria (acid-fast bacill) may take 10 weeks to grow in culture * PCR allows for faster identification (95% sensitivity and 93% accuracy) * **chemotherapy is the mainstay of treatment** * treated with isoniazid, rifampin, and pyrazanamide for 9 to 18 months * ethambutol and streptomycin added for part of treatment * Follow with serial imaging for progression of kyphosis * spinal orthosis * may be used for pain control and prevention of deformity * **Radical debridement with stabilization** * unstable when all three columns are invovled * two with trauma because acute and the inflammatory tissue provides support * Begin chemotherapy 10-12 days prior * _indications_ * neurologic deficit * spinal instability or progressive kyphosis * advanced disease with caseation preventing access by antibiotics * failure of nonoperative treatment after 3 to 6 months * _advantages of surgical treatement_ * less progressive kyphosis * earlier healing * decreased sinus formation * in patients with neurologic deficits, early debridement and decompression led to improved neurologic recovery * _Anteiror approach with strut graft_ * **short segment disease with moderate kyphosis** * lateral decubitus with anterior approach * autogenous and allograft strut grafts are acceptable with good results * rib strut grafts are readily available in thoracic approach * iliac crest grafts another option with mesh * Anterior plating with one level above and one level below or rod construct * good outcomes with anterior approach alone, but if more severe or long segement might want to also go posterior * Posterior stabilization means more surgery, more difficult nursing and has been shown not to be necessary * _Posterior approach with transpedicular decompression +/- pedical subtraction osteotomy_ * **\>5cm disease with \>30 deg kyphosis** * better correction, more stable construct but technically very difficult * better correction for more chronic situation

Answer 110

* Hard to diagnose, difficult to treat * **Increased with** * Trauma * ICU, multiple co-mobidities, malnutrition * Instrumentation * Microscope * Complete neuro deficit * Cognitive impairment * Posterior approach * Anterior approach carries low infection * **Risk factors** * Obesity * Diabetes * long-term steroid use * alcohol abuse * prior infection * prior spinal surgery * preoperative hospitalization \>1 week * Surgery \> 3 hours * Blood loss \> 1L * **Prevention** * Periop antibiotics are the most important thing * Release retractors, debride necrosis, don’t use drains * Negative pressure room

Answer 111

* **Superficial Wound** * Will present like any other wound with erythema, pain, redness * **Deep Infection** * Concerning with purulent drainage, increaseing pain * Fever \>39 is in the number one predictor * **Late** * Even with a well healed wound, increasing pain can be associated from infection seeded hematogenously * **Latent** * May have negative intra-op cultures if the bacteria is only on the rods * **Presentation** * For late infections, there may only be pain * Take a careful history of pain, night pain, contitutional symptoms * Rule out any neurological/bowel/bladder * Get history of old or reports * PMHx and risk factors * **Labs** * ESR and CRP are the most sensitive * **Imaging** * XR usually not helpful * MRI is the most useful but can be limited by post-inflammatory changes * _Rim enhancing fluid collection is pathognomonic for infection_

Answer 112

**Post-op Disc Infection with Rim Enhancing Lesion** * Presentation * Increasing pain * complete and AMPLE history * other infectious symptoms * MRI will show rim enhancing lesion * **Mangement** * Blood and urine cultures * Needle biopsy for cultures * **ID consult and IV abx for minimum 12 weeks** * follow blood work * change to PO when responding * **Indications for surgery** * Refractor to antibiotics * Infection in spinal canal * Neurologic deficit * Instability * **Decompression usually done anteriorly, but can be done posteriorly in the lumbar spine**

Answer 113

May not have erythema, redness Present with increasing pain ESR/CRP and MRI are usually helpful Usually respond to antibiotics alone

Answer 114

* **ESR, CRP, WBC** * **Urine and blood cultures** * **XR to look for loose hardware** * **CT pre-op to look for fusion** * **ID consult** * Will need minimum 6 weeks IV antibiotics * Follow with serial blood work * **Aggressive ID, removal of loose graft or loose hardware** * If there is not yet fusion try to retain hardware * Try and treat with antibiotics until you can get the fusion mass to heal, then remove hardware * Take deep cultures * Close with VAC * **Multi-organism infections will require repeat debridement every 48-72 hours** * Take cultures at each I&D * Alter or add abx as necessary * **Plastic surgery consult for soft tissue coverage** * **PT for early ROM and mobilization**

Answer 115

* **Group Anatomic Type/Severity of Infection** 1. Single organism (superficial or deep) 2. Multiple organism, deep 3. Multiple organism with myonecrosis * **Physiological/Host Characteristics** 1. A Normal 2. B Local or multiple systemic disease (eg, smoking) 3. C Immunocompromised (Injury Severity Score \>18)

Answer 116

* Considerations * transperitoneal has a higher risk of retrograde ejaculation (superior hypogastric plexus) * if you go from left it's easier, because easier to mobilize arteries rather than frail vessels * Common Iliac branch at L4 * Incise the rectus and transversalis * Find the arcuate line (fasica of the rectus); incise it and use it to retract the peritoneum * **Iliolumbar vessles branch** off the internal iliac and need to be **ligated for exposure to L4/5** * For exposure to L5/S1 the median sacral artery needs to be identified and ligated

Answer 117

* getting tinnitus, diplopia, nystagmus, vertigo, facial palsy * due to occlusion of the vertebral artery * Wallenberg syndrome * complete brainstem infarct * falling to side of lesion * Medial medullary syndrome * diplopia * contralateral arm and leg syndrome * Basilar artery syndrome * "locked-in"

Answer 118

* less risk of retrograde ejaculation * go from left to avoid liver and veins * Lateral decibuitus * T12 * may need to incise the diagphram, leave a cuff of tissue * attaches to the vertebrae, xiphoid and lower 6 ribs * Incise the transversalis fascia and enter behind the peritoenum * be careful of ureter, and genifemoral nerve that sits on psoas * disect the psoas off the vertebrae and ligate the segmental vessels

Answer 119

large/medial VA (CT angio) nonanatomic reduction C1/C2 hypoplastic C2 pars substatial thoracic kyphosis

Answer 120

- Decompression alone - Laminectomy and non-instrumented fusion - Decompression posterior instrumented fusion - Decompression, PIF and interbody fusion (PLIF, TLIF) - MIS decompression - MIS decompression and TLIF - Dynamic stabilization

Answer 121

1. biocompatible 2. bioremodeled 3. osteoconductive 4. osteoinductive 5. easily acquired 6. cost effective

Answer 122

* Nothing to show that PLIF is a good augment to PLF alone * Risk factors * smoking * diabetes is NOT * Augments * BMP-2 * autograft * allograft mixed with autograft * gels not supported * demineralized bone matrix not supported

Answer 123

* Injury morphology * 1 - compression * +1 burst * 3 - rotation * 4 - distraction * Neurological status * 2 - nerve root * 3 - incomplete SCI * 2 - complete SCI * 3 - cauda equina * Posterior ligamentous complex * 2 - suspected * 3 - disrupted

Answer 124

* **anterior column** * anterior longitudinal ligament (ALL) * anterior 2/3 of vertebral body and annulus * **middle column** * posterior longitudinal ligament (PLL) * posterior 1/3 of vertebral body and annulus * **posterior column** * pedicles * lamina * facets * ligamentum flavum * spinous process * posterior ligament complex (PLC) * instability defined by

Answer 125

## Footnote supraspinous ligament interspinous ligament ligamentum flavum facet capsule

Answer 126

injury to the Posterior Ligament Complex (PLC) progressive kyphosis \> 30°kyphosis (controversial) \> 50% loss of vertebral body height (controversial) \> 50% canal compromise (controversial) neurological deficiet *Otherwise the best treatment is bracing for pain control*

Answer 127

* Anterior * direct decompression * better for severe comprimise of canal and comminution * better for delay to surgery * do not stabilize posterior elements * fewer segments to stabilize * better correction for deformity \>30 deg * Posterior * easier approach * better multiple medical co-mobidities or severe trauma * lower non-union * more stable fore fracture dislocation * indirect decompression * ligamentotaxis less effective after 5 days * can decompress transpedicular * try not to do a laminectomy * one level above, one below

Answer 128

* Side of approach * \> T11 right (aorta on the left) * * Lat dorsi/serattus * End the rib cage * intercostal * rib resection - better exposure * Diaphragm is at T12 * leave a cuff to repair to

Answer 129

* **Intercostal vessels** * vulnerable during * rib resection when running along undersurface of rib, and * exposure of vertebrae within chest * avoid injury by entering pleura from above the ribs * **Lungs** * avoid injury by using sharp instruments wisely when within chest * expand lungs every 30 minutes to prevent microatelectasis * **Esophagus** * avoid injury through adequate retraction of esophagus while working on spine * **Artery of Adamkiewicz** * travels on left side between T9-L2 in 60% of patients * must preserve to prevent spinal cord ischemia

Answer 130

* **Sympathetic chain** * lateral aspect of vertebral body * **Genitofemoral nerve** * anterior surface of psoas muscle attached to fascia * **Segmental arteries** * segmental lumbar arteries and veins * **aorta** * **Ureter** * lies between psoas fascia and peritoneum * attached more firmly to peritoneum * stroke to produce peristalsis to confirm

Answer 131

* T12 diaphragm * L1 - SMA * L2 - renal * L4 - common iliac bifurcation

Answer 132

* left iliac artery most common artery * left common iliac vien most common vein * ureter tear * retrograde ejaculation - presarcal superior hypogastric plexus * lumbar sympathetic trunk * Nerve root injury * over distraction * iatrogenic disc hernation * posterior protrusion of cage * Proximal DVT * arterial thrombosis

Answer 133

presarcal superior hypogastric plexus

Answer 134

transverse diameter that is .85% of the diameter of the affected bone and a cyst wall that is ,0.5 mm thick

Answer 135

* Poor outcomes * Depression * cardiovascular comorbidity * disorder influencing walking ability * scoliosis * Good outcomes * Better walking ability * self-rated health * higher income * less overall comorbidity * pronounced central stenosis * Male gender and younger age predicted better postoperative walking ability.

Answer 136

* Posterior midline incision * Divide the fascia and come down onto the spinous processes, and remove the SP of the level of interest * Wide pedicle to pedicle decompression for cauda equira * unilateral laminectomy is better for single sided pathology and discectomy * Use loops or magnification to do a laminotomy * preserve 50% of the facets bilateraly * preserve at least 5mm of the pars * remove to the top and bottom of the facet joint and remove the liagmentum flavum * debride any osteophytes *

Answer 137

* Awake and co-operative patient * consult anesthesia for gentle sedation with benzos and airway management * supine with appropriate flouro * Application of garden-wells tongs * 1cm above the pinna at the equator of the skull * tighten until the preset spring is loaded * in line traction, starting with 10 lbs, every 20 min with repeat neuro checks and imaging * max 70 lbs although this is very controversial * Stop if: * reduction is achieved * when \> 1 cm of distraction occurs at site of injury * when neurological status of pt deteriorates * when maximum amount of weight is applied * unilateral facet * maintain traction and rotate towards dislocation * bilateral * maintain traction, palpate the stepoff, push the inferior facet anteriorly, then rotate 40 deg each way to reduce the facets

Answer 138

* Get MRI pre-op to make sure there's not a disc * Maintain spinal precautions and collar * Fiberoptic or glidoscope intubation * Sandwich and flip * Neuromonitoring * Anterior alone * unilateral * do a discectomy then fuse * can use caspar pins from the front for unilateral dislocation * cannot reduce bilateral from the front * Posterior * bilateral or unilateral with no disc * one level above and below * Anterior then posterior * anterior to do a discectomy * then put in graft and a kick-out plate * allows reduction without having to go back anteiror * posteiror to get reduction * can try unscrubbed * caspar pin distractors * intervertebral spreader

Answer 139

reduction is achieved when \> 1 cm of distraction occurs at site of injury when neurological status of pt deteriorates when maximum amount of weight is applied

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