Spine (2008-2019)

Question 1

1. 4 features of Brown-Sequard Syndrome (2010, 2012)

Answer 1

• Ipsilateral voluntary motor loss
• Unilateral UMN findings
• Ipsilateral vibration loss
• Contra-lateral pain/temperature loss

Question 2

2. List 3 features of central cord syndrome. (2011, 2014)

Answer 2

JAAOS 2009 - Central Cord

• Upper extremities are more severely affected than lower
• Distal more than Proximal
• Sacral Sparing
• Bowel and bladder only in severe cases

Question 3

3. List 3 factors that would help you diagnose an incomplete spinal cord injury? (2015)

Answer 3

JAAOS - Thoracolumbar Spine Trauma: I. Evaluation and Classification

• Sensory function below the level of the injury
• Voluntary motor control below the level of the injury
• Sacral Sparing

Question 4

4. List 3 examination features suggestive of sacral sparing. (2013)

Answer 4

From ASIA worksheet:

• Presence of intact perianal sensation (light touch and pin prick)
• Presence of voluntary anal sphincter contraction
• Presence of deep anal sensation (to deep pressure) on digital rectal exam

Question 5

5. Formula for pelvic incidence (2012)

Answer 5

• Pelvic incidence = pelvic tilt + sacral slope

Question 6

6. ASIA score question. List the 11 myotomes and corresponding muscle groups. (Variations - 2011, 2012, 2013, 2014, 2016)

Answer 6

Question 7

7. 3 ways to do posterior C1-2 fusion (2012)

Answer 7

• Trans-articular Screws (Magerl)
• Sub-laminar wires
• Lateral Mass Screw Fixation

 

Question 8

8. What are two important considerations to take into account for placing C1-C2 trans-articular screws. (2011)

Answer 8

JAAOS - Posterior fixation of the cervical spine

• Location of vertebral artery
• Avoid Bicortical Screws because:
  
  • Location of internal carotid (anteromedial)
  • Hypoglossal nerve
• Limitations in head position/body habitus
  
  • Maintain reduction, severe thoracic kyphosis, ability to get trajectory
• Hypoplastic C2 pars (variable individual anatomy)
• Reducible C1-C2 articulation

Question 9

9. List 3 spine conditions that enhance with gadolinium enhanced MRI (2012, 2013, 2014)

Answer 9

JAAOS - MRI in the Spine

• Scar tissue enhances (including granulation tissue, i.e. TB)
• Infection
• Tumors
• ** Chronic disks are dark.

Question 10

Rubrospinal tracts in the spinal cord carry: (these were long answers; look up your spinal cord anatomy.)

1. Autonomic
2. Voluntary Motor Control
3. Flexor Muscles
4. Loss of muscle tone and involuntary muscle movements
5. Sexual Function

Answer 10

ANSWER: C

2013 

TRICK: Easier to RUB one out with better flexor muscle tone. (CD)

Question 11

11.All of the following regarding spinal tracts true except:

1. Anterior corticospinal tracts carry less motor than lateral corticospinal tracts
2. Lateral corticospinal tracts are called pyramidal tracts
3. Lateral corticospinal tracts arranged so that cervical spine is more central than sacral spine
4. Posterior sensation tracts arranged so that the cervical spine ascending tracts are more central than sacral spine

Answer 11

ANSWER: D

2010, 2013, 2015 (variants)

Question 12

12.A patient sustains a gunshot wound to the right side of the neck. He develops a Brown-Sequard syndrome. Which of the following is true regarding his neurologic deficits?

1. Loss of motor function to right upper and lower extremities, ipsilateral loss of pain and temperature
2. Loss of motor function to right upper and lower extremities, contralateral loss of vibration and position sense
3. Loss of motor function to right upper and lower extremities, contralateral loss of pain and temperature sensation
4. Loss of motor function to right upper and lower extremities, contralateral loss of pain and vibration

Answer 12

 ANSWER: C

2014, 2015

Question 13

13.Given a sagittal MRI showing cervical stenosis and myelomalacia. Patient had fall and presents with neck pain. No neuro deficits described. What is the most likely physical exam finding

1. UE > LE weakness, distal > proximal
2. LE > UE weakness, distal > proximal
3. UE > LE weakness, proximal > distal
4. LE > UE weakness, proximal > distal

Answer 13

ANSWER: A

2008, 2015

JAAOS 2009 - Central Cord Syndrome

• Upper extremities affected more than lower extremities
• Hands most affected
• Urinary retention, bowel and sexual dysfunction in most severe cases

Question 14

14.Injury to what causes of retrograde ejaculation

1. Inferior hypergastic plexus
2. Superior hypogastric plexus
3. Inferior hypogastric plexus
4. Superior hypergastric plexus

Answer 14

ANSWER - B

2009, 2013,  2014

Retrograde Ejaculation After Anterior Lumbar Interbody Fusion: Transperitoneal Versus Retroperitoneal Exposure. Sasso, Burkus and LeHuec. Spine. 2003

• Damage to the superior hypogastric plexus during exposure of the anterior lumbosacral spine can denervate this bladder neck sphincter, resulting in retrograde ejaculation.

Question 15

15. Regarding anterior approach to T-spine, which is false?
16. Aorta blocks visualization of high to mid-T-spine on left
17. Liver blocks visualization of lower T-spine on right
18. Resect T11 rib head to access T11-12 disc space
19. Resect a rib 1-2 levels above the area of interest during approach

Answer 15

ANSWER - C

2010,  2014

• Anterior transthoracic thoracic spine approach – resect rib 2 levels above (see pic)
• Anterior Transabdominal thoracic spine – resect T10 rib for approach

Combo AO, JAAOS, Hoppenfeld’s:

• Right sided for T2-T9 (aorta and heart on left)
• Left sided for T10-L2 avoids liver on right

Question 16

16.Regarding the anterior approach to the cervical spine, all of the following are true EXCEPT?

1. Omohyoid transection improves access to the lower C spine
2. The parasympathetic trunk is at risk
3. Sub-platysmal fascial dissection improves exposure
4. The recurrent laryngeal nerve runs in the tracheoesophageal groove

Answer 16

ANSWER - B 

2014

• OKU Spine 4
  
  • Course of recurrent laryngeal nerve
    
    • Branch of the vagus nerve
    • Right –> arises anterior to subclavian artery, curves behing it, ascends to side of trachea
    • Left –> loops under arch of aorta
    • At C7 the nerve lies deep within the esophagotracheal groove on the left, but anterior and lateral to it on the right
• Operative Techniques - Anterior approach to the cervical spine (p4507-4510)
  
  • “blunt dissection with scissors undermines the edges of the platysma
  • Allows for greater mobilization of the soft tissues, which is helpful in accessing the multiple disc levels
  • Dividing the omohyoid will allow for a more extensile cephalad-caudal exposure and less tension on the wound for easier placement of plates and screws

Question 17

17.Contents of the carotid sheath include the carotid artery, internal jugular vein, and what other structure?

1. Vagus nerve
2. phrenic nerve
3. Vagus and phrenic nerve
4. Vagus and sympathetic

Answer 17

ANSWER: A

2011

Hoppenfeld:

• The carotid sheath enclosing the common carotid artery, vein and vagus nerve can now be exposed

Question 18

18.How do you calculate the Power’s ratio where B=basion, A=anterior arch of atlas, O=opisthion, C=posterior arch of atlas

1. BA/CO
2. BC/AO
3. AC/BO
4. AB/CO

Answer 18

ANSWER: B

2013, 2016

Question 19

19. Can do PLIF/TLIF in all of the following except
20. Pseudoarthoris
21. Spondylolisthesis
22. Infection

Answer 19

ANSWER: C

2012

JAAOS 2008 - Posterior Lumbar Interbody Fusion

Question 20

20. All of the following associations are right except? REPEAT
21. Foot Dorsiflexion - L4
22. Sensation over patella L2
23. Hamstring reflex L5-S1
24. Hip abductors – L5

Answer 20

ANSWER: B

2012

• L3 provides sensation over patella

Question 21

21. Which of the following is associated with an increased risk of complications with halo treatment?
22. Re-tightening the screws at an appropriate interval
23. Placing the ring 2cm above the pinna
24. Placing the ring closer to the skull
25. Using 6 pins instead of 4

Answer 21

ANSWER: B

2011, 2014

JAAOS - The Halo Fixator

• More lateral pin insertion risks penetration of the thin temporal bone.
• More medial positioning risks injury to the supraorbital and supra- trochlear nerves.

Question 22

22. Spinal associations; all of the following are true EXCEPT:
23. Isthmic spondylolisthesis and spina bifida occulta
24. Isthmic spondylolisthesis and pars abnormality
25. Folate and neural tube defects (worded exactly like this)
26. Degenerative spondylolisthesis and spondylosis

Answer 22

Answer: D

Miller’s 8th edition:

• A: Spina bifida occulta, thoracic hyperkyphosis, and Scheuermann disease have been associated with spondylolisthesis
• B: basically the definition of isthmic spondy
• C: Neural tube defect dx in utero with increased level of alpha-fetoprotein
  
  • Related to folate deficiency in utero

Question 23

23. With regards to proteoglycans, all of the following are true except
24. Proteoglycans are hydrophilic
25. Proteoglycans are hydrophobic
26. Proteoglycans are sulfated
27. Proteoglycans are bound to a protein core

Answer 23

ANSWER: B

2012

AAOS Core Review 2:

• Proteoglycans can trap water in the ECM by their negative charge, regulating matrix hydration

Question 24

24. During the posterior approach to the spine, the thecal sac can be retracted?
25. Above the level of the conus
26. Below the level of the conus
27. Below T12
28. Never

Answer 24

ANSWER: B

2014

Question 25

25. All of the following are correct landmarks for inserting an L3 pedicle screw EXCEPT?
26. Inferolateral aspect of L2-3 facet joint
27. Inferolateral aspect of L3-4 facet joint
28. Junction of the middle third of transverse process and a line through the center of the facet joint
29. Junction of the middle third of transverse process and a line through the mammillary process and pars

Answer 25

ANSWER: B (old answer C)

2014

• B would be an L4 pedicle screw
• AO Surgical Reference - Pedicle Screws
  
  • “the entry point of the pedicle screw is defined as the confluence of any of the four lines”
  • Pars interarticularis
  • Mammillary process
  • Lateral border of the superior articular facet
  • Mid transverse process

Question 26

26. Patient with complete spinal cord injury; C7 spinal level. What is most likely to still be working?
27. Wrist flexion, finger flexion, brachioradialis reflex, radial sensation
28. Wrist flexion, finger extension, triceps reflex, absent medial forearm sensation
29. Wrist extension, finger abduction, biceps reflex, medial forearm sensation
30. Wrist extension, finger flexion, triceps reflex, radial sensation

Answer 26

ANSWER: B

2015

• MABCN emerges from medial cord C8-T1
• Wrist Flexion (C7), Wrist Extension (C7)
• BR reflex (C6), triceps reflex (C7), Biceps reflex (C5)
• Radial nerve – C5-T1
• C8 – Finger flexion

Question 27

27. Benefit to cross-links in spine instrumentation:
28. Increased resistance to flexion/extension
29. Increased resistance to lateral bend
30. Increased resistance to torsion
31. Increased fusion rate

Answer 27

ANSWER: C

2011, 2015

• Brodke (Spine 2001) Segmental Pedicle Screw Fixation or Cross-Links in Multilevel Lumbar Constructs: A Biomechanical Analysis
  
  • “There were no significant changes in flexion/extension stiffness with the addition of either the cross-links or segmental pedicle screws. In Lateral bending, although no significant difference was measureable because of the cross-links…”
  • “There was a progressive increase in torsional stiffness of three-level constructs with one and two cross-links”

Question 28

28. All of the following are associated with spinopelvic alignment, except:
29. Isthmic spondylolisthesis is associated with decreased pelvic incidence
30. Pelvic tilt does not change with position
31. Pelvic incidence is a constant variable that does not change after skeletal maturity

Answer 28

ANSWER: A / B

2015

JAAOS 2009 Adult Isthmic Spondy/OKU Spine 4

• Pelvic Incidence –> correlated with HIGH PI
• Hanson (Spine 1976)
  
  • “pelvic incidence >68.5o correlates strongly with the degree of slip
• Huber L (Spine 2004)
  
  • PI is significantly greater in subjects with spondylolisthesis
  • Severity of listhesis correlates with PI
• The mean standing pelvic tilt was −2.1° ± 7.4°, with a range of −15.2° – 15.3°. Mean supine pelvic tilt was 4.1° ± 5.5°, with a range of −9.7° – 17.9°. Mean pelvic tilt in the flexed seated position was −1.8° ± 14.1°, with a range of −31.8° – 29.1°, Fig 3

Question 29

29. What is not associated with cervicomedullary syndrome:
30. Hypotension
31. Facial numbness
32. LE > UE symptoms
33. Complete or incomplete paralysis is possible

Answer 29

ANSWER: C

2015

• The Cervical Spine (p. 188)
  
  • The essential clinical features are respiratory insufficiency or arrest, hypotension, varying degrees of tetraparesis, sensory changes from C1-C4 and sensory loss over the face in the onion skin or Dejerine pattern
  • The spinal trigeminal nucleus (STN) is the longest cranial nerve nucleus, extending caudally from the medulla to the upper cervical segment of the spinal cord.1–3) The STN has somatotopic arrangement, the central area represented rostrally, and the lateral face caudally.1–3) Therefore, upper cervical lesion has a potential to cause dysesthesia of face sparing the central area, which is called onion-skin pattern.1–3)
  • Arm > Leg weakness
  • More severe involvement the more rostral the injury

Question 30

30. Regarding MRI with gadolinium, all of the following are TRUE except?
    a. Epidural abscess rim enhances
    b. Discitis enhances on T2
    c. Epidural fibrosis does not enhance
    d. Recurrent disc material does not enhance

Answer 30

ANSWER: C

2008, 2010, 2015 (variants)

JAAOS 2009 - MRI of the Spine

• “Contrast enhancement is used to distinguish scar tissue, which enhances on MRI scans, from fragments of disk tissue in the epidural space that, lacking capillaries, do not enhance”

Question 31

31. There is a patient that sustained a fall and now has radicular arm pain and neck pain. Given an xray showing 25% vertebral body translation indicative of a C4/5 unilateral jumped facet. What would you find on physical exam?
32. Supraclavicular numbness
33. Weakness of elbow flexion with lateral shoulder numbness
34. Supraclavicular numbness + something else
35. Hand weakness

Answer 31

ANSWER: B

2016

• C5 radiculopathy –> ASIA Score
• Unilateral jumped facets present with unilateral radiculopathy, corresponds to lower level (because that is the level where the nerve root is exiting; C5 root exists straight out at C4/5)

Question 32

32. Regarding spinal infection, all true, EXCEPT: 
33. CRP and ESR decreasing are effective signs that medical management is working
34. Most have an elevated WBC
35. Greater than half are staph aureus

Answer 32

ANSWER: B

2016

• Carraggee (JBJS 1997) Pyogenic Vertebral Osteomyelitis
• CRP and ESR are almost always elevated
• Leukocytosis in < 45%

Question 33

33. Where to put screws in occiput for strongest construct
34. Midline because of thickest bone
35. Inferior to nucchal line
36. Laterally
37. Medially and laterally

 

Answer 33

ANSWER: A

2008

• JAAOS 2011 - Posterior fixation of the upper cervical spine
  
  • Occipital plate can be applied midline, where the thick midline keel provides the greatest resistance to pullout
  • Lateral fixation may be better to resist lateral bending, while midline fixation is better suited to resist axial rotation
  • Thickest occipital portion is midline on the superior nuchal line
  • At external occipital protuberance
  • Screws are inserted below the superior nuchal line to avoid intracranial venous sinus

Question 34

34. Which would not alter your approach for a C-spine myelopathic patient
35. Previous incision
36. Sagittal alignment
37. Location of compression
38. Presence of radiculopathy

Answer 34

ANSWER: D

2008

• Previous incision important with ACDF
• Cannot do posterior only approach if spine is kyphotic
• Ideally like to approach from the side of the compression

Question 35

35. Size of lumbar central canal is largest in which position
36. Flexion
37. Extension
38. Supine
39. Standing

Answer 35

ANSWER: A

2008, 2010

Question 36

36. Use of stiffer instrumentation for spinal fusion results in which of the following in the fusion mass:
37. lower modulus of elasticity
38. decreased volume density of bone
39. lower load to failure
40. increased vascularity
41. higher pseudarthrosis rate

Answer 36

ANSWER: D

2008

Yasumitsu - Vascularization of the Fusion Mass in a Posterolateral Intertransverse Process Fusion - Spine 1998

• Rigid Posterior Spinal Instrumentation
• • More rigid constructs allow for a Stronger Fusion Mass to Form
• • There is a risk of stress shielding with more Rigid constructs = Stress shielding of Peri-Fusion Mass bones
• • Bone Mineral density is HIGH at the fusion mass level, but decreases with increasing distance from fusion level
• • Fusion mass is vascularized with more stability

Question 37

37. Which of the following structures contain free nerve endings:
38. PLL, Annulus, Facet joint capsule
39. Joint capsule, Annulus
40. Annulus fibrosis and Nucleus pulposis
41. Annulus, Nucleus, PLL, joint capsule

Answer 37

ANSWER: A

2008

• Annulus does not have nerve fibres, but if degenerative it gets them
• Jackson (JBJS 1966)
  
  • Pacini endings concentrated around facet joint capsules and ventrolateral surface of the annlus fibrosus, free nerve endings found in the ALL and PLL, none found in nucleus pulposis

Question 38

38. List 4 dysplastic features in a developmental spondylolisthesis that predicts the risk for progression. (2013)

Answer 38

JAAOS 2006 - Spondylolisthesis in Children and Adolescents

• Dysplastic Features predictive of getting spondy:
  
  • Maloriented or hypoplastic facets
  • Sacral deficiency
  • Poorly developed pars
• Risk factors for progressive slip once you have it:
  
  • Dysplastic vs isthmic spondylolisthesis (32 vs 4%)
  • Diagnosis before growth spurt
  • Girls
  • Presentation with >50% slip
  • Bilateral defects
  • Slip angle >50°

Question 39

39. Name three clinical findings in Ankylosing Spondylitis (other than SI joint). (2014)

Answer 39

JAAOS Orthopedic Management of Ank Spond

• Modified New York Diagnostic Criteria:
  
  • Low Back pain lasting greater than 3 months (improved by exercise)
  • Limited lumbar spine ROM
  • Decreased chest expansion

Systemic manifestations (Orthobullets/Miller’s)

• Anterior uveitis
• Heart disease (conduction abnormalities)
• Right bundle branch block, 3rd degree block
• Pulmonary fibrosis
• Renal amyloidosis
• Ascending aortic conditions (aortitis, stenosis, aortic regurg)
• More susceptible to Klebsiella pneumonia synovitis
• Large joint arthritis
  
  • 33% hip involvement
• Spinal kyphotic deformities (thoracic)
• Sacral iliitis
• Colitis
• Arachnoiditis
• HLA B27+

Question 40

40. What are 3 risks of vertebroplasty/kyphoplasty? (2015)

Answer 40

JAAOS 2014 - Vertebroplasty and Kyphoplasty for the treatment of osteoporotic vertebral compression fracture

• Cement leakage
• Embolization of the cement
• New fracture (adjacent vertebrae)

NEJM 2009 - A RCT of Vertebroplasty for Painful Osteoporotic Vertebral Fractures

• Cement extravasation
• Fracture
• Osteomyelitis
• Tightness in back/rib cage
• Puncture site pain
• Chest pain

Question 41

41. List 6 causes of spondylolisthesis? (2015)

Answer 41

Wiltse Classification:

• Isthmic
• Degenerative
• Traumatic
• Dysplastic
• Iatrogenic
• Pathologic

Question 42

  42. List 4 indications for surgery in rheumatoid c-spine. (2015)

Answer 42

JAAOS 2005 - Rheumatoid Arthritis in the Cervical Spine

• Progressive neuro deficit
• Unresponsive mechanical neck pain
• Radiographic risk factors for neuro injury
• PADI <14mm
• >5mm rostral migration to McGregor’s Line
• Sagittal canal diameter <14mm (SAC)
• Cervicomedullary angle <135o
• <13mm Ranawat line to occiput (most reproducible)

Question 43

43. What are 3 findings of spondylotic cervical myelopathy in the upper extremity? (2016)

Answer 43

JAAOS - 2015 - Update on diagnosis and management of Cervical Spondylotic Myelopathy

• Difficulty with fine motor tasks (buttons, keys)
• Myelopathy hand:
  
  • Loss of power of adduction and extension of ulnar two digits
  • Inability to grasp and release rapidly (<20 abnormal)
  • Finger escape sign –> ulnar two digits drift into abduction
  • Hoffman Reflex
• Inverted brachioradialis reflex (hand goes down instead of up)
• Hyper-reflexia

Question 44

44. What are 3 findings of spondylotic cervical myelopathy in the lower extremity? (2016)

Answer 44

JAAOS - 2015 - Update on diagnosis and management of Cervical Spondylotic Myelopathy

• Wide based, ataxic gait
• Difficulty with Tandem gait, Rhomberg Sign
• Clonus
• Hyper-reflexia
• (upgoing toes) Babinski

Question 45

45. List 4 risk factors for neurological deterioration in vertebral osteomyelitis (2010)

Answer 45

OKU Spine 4/JAAOS 2016 Bacterial spine infections in adults/

• Diabetes
• Rheumatoid Arthritis
• Cephaled level of infection/levels involving the cord (C-L1)
• Systemic steroids
• Age > 60
• Immunocompromised (Caragee JBJS 1997)
• Infection with S aureus (Caragee JBJS 1997)

Question 46

46. List 3 ways to monitor for a spinal cord injury when performing spinal deformity correction? (2010, 2011)

Answer 46

JAAOS 2007 - Intra-operative Neurophysiologic Monitoring During Spinal Surgery

• SSEPs - Somatosensory-evoked potentials
• Transcranial electric motor-evoked potentials
• Stagnara wake-up test
• Electromyography

Question 47

47. 53yo nurse with 2 day history of severe arm pain. She presents with upper extremity motor weakness and confusion. MR was given and showed a large posterior epidural abscess. Management?
48. Anterior decompression
49. Posterior decompression
50. IV antibiotics
51. Biopsy

Answer 47

ANSWER: B

2013

• JAAOS 2016 - Bacterial Spine Infections in Adults
• Absolute indication for drainage is worsening neurologic deficit
• Drainage of abscess in addition to medical therapy is associated with better outcomes
• “When neurologic deficit is present or developing, surgical drainage is the treatment of choice, with or without stabilization, as indicated.”
• HOWEVER, as per Lewkonia at half day in 2016 –> drainage not needed unless WORSENING neurology or definite biopsy needed or failing medical management so some argument for IV antibiotics
• This person has advanced neuro deficit and is septic

Question 48

48. Most common cause of post-op spine infection?
49. Bacteroides
50. Staph epi
51. Staph aureus
52. E coli

Answer 48

ANSWER: C

2012

JAAOS 2008 - Post-operative Spinal Wounds infection

“Staph aureus is the most common offending organism. However, an increased incidence of other bacterial agents has been reported, including S epidermiditis and more virulent bacteria, such as MRSA”

Question 49

49. Epidural abscess: most common risk of neurologic outcome. All except:
50. Staph aureus
51. Steroids
52. DM
53. T10

Answer 49

ANSWER: A

2009

JAAOS 2016 - Bacterial Spine Infections in Adults

• Diabetes
• Older age
• Rheumatoid Arthritis
• Steroids
• Infection above conus

Question 50

50. Patient has metastatic disease in multiple places with more than 6 months to live and progressive neuro symptoms. You are shown an MRI with tumor at T9 pushing on cord anteriorly. Which is wrong?
51. Costotransversectomy and corpectomy
52. Laminectomy, transpedicular decompression
53. Laminectomy and posterior decompression
54. Anterior approach and decompression

Answer 50

ANSWER: C

2013

All approaches give anterior access to spinal cord except C

Laminectomy would destabilize and result in catastrophic kyphosis - need that posterior tension band!

Question 51

51. Tumor associated with Posterior spinal element
52. Mets
53. Hemangioma
54. ABC
55. GCT

Answer 51

ANSWER: C

2012

JAAOS 2012 - Benign Tumours of the Spine

Oh Oh Oh, Ahhhhh

• Osteoid osteoma
• Ostoeoblastoma
• Osteochondroma
• ABC

Question 52

52. Rheumatoid spine, all are true EXCEPT: (recall not the best.)
53. Lower cranial nerves can be affected in rheumatoid spine
54. C1 – C2 is fibrous joint and therefore forms a pannus
55. C1 - C2 collapse for both C1-C2 instability and Basilar invagination
56. C1 - C2 lateral mass collapse can cause C1C2 and sub-axial instability

Answer 52

ANSWER: B

2013

JAAOS - Rheumatoid Spine

C1-C2 is a SYNOVIAL joint which is why it forms a pannus

D isn’t great either–> lateral mass collapse usually leads to basilar invagination, not sub-axial instability

Question 53

53. The most common cause of sudden death in RA?
54. basilar invagination
55. C1-2 instability
56. subaxial instability
57. Chernobyl took care of this patient

Answer 53

ANSWER: A

2011

Paus AC (Spine 2008) High mortality rate in rheumatoid arthritis with subluxation of the cervical spine

JAAOS - Rheumatoid C-Spine

Question 54

54. Middle aged woman. Picture of a grade II – III spondylo with lots of sacral beaking but slip angle 80-90. Neuro intact but has had mild back pain for 12 years. What is the best treatment?
55. In situ fusion with bone graft with or without fixation
56. Close follow up in a 3 months with xray
57. Return to clinic for follow up once symptoms progress
58. Anterior fusion with or without fixation

Answer 54

ANSWER: C

2013

McGill agrees with C

• JAAOS 2009 - Adult Isthmic Spondylolisthesis
• No guidelines have been established for surgical intervention in adults with isthmic spondylolisthesis specific to the degree or progression of slip
• Indications for surgical stabilization in young adults and adolescents include symptomatic grade III or greater slip and progressive deformity
• Some argument for B - safer option, monitor for progression. I have chosen C because an isthmic spondy is unlikely to progress rapidly in an older patient so trigger for surgery would be development of symptoms

Question 55

55. 15 yo with grade II spondy. Failed all non-operative treatment. Fully N/V intact. What now
56. L4-S1 posterolateral fusion
57. L5 laminectomy with L5/S1 posterolateral fusion
58. Pantaloon and hip spica

Answer 55

ANSWER: A

2008, 2010

L5/S1 fusion….look up indications for extending to L4, don’t think you’d need to with lower grade spondy unless it specifies that the pedicles are insufficient

JBJS Current Concepts Review 2015:

Single level fusion associated with a 17% non-union rate

Recommend L4-S1 fusion

Question 56

56. In performing reduction of a high-grade spondylolisthesis:
57. Strain on the L5 nerve root is proportional to the amount of translational correction
58. Incidence of L5 nerve root injury is 30%
59. Risk of L5 nerve root injury is related to the degree of correction of the sacral angle

Answer 56

ALL ARE CORRECT - priya

ANSWER: B?

2015

Petraco DM (SPINE 1996) An anatomic evaluation of L5 nerve stretch in spondylolisthesis reduction

• Quoted literature number for L5 injury = 20%
• Mean nerve strain was 4% for first 50% of reduction and 10% for second half
• 71% of total L5 strain occurs in second half of reduction
• Increase in lordosis will slacken L5 nerve root with high grade slip, will tension low grade slip though

JAAOS 2006 - Spondylolisthesis in Children and Adolescents

• “Isolated radiculopathy of L5, the most common complication, has been reported in as many as 30% of patients”
• (Jess thinks A)
• Argument - Strain definitely related to translation, however, isn’t linear so hard to correlate with question

JBJS Current Concepts Review 2016 - Lumbosacral Spondylolisthesis and Spondyloptosis in Children and Young Adults

• “although nerve root injury has been reported following reduction, larger, more recent studies have demonstrated a prevalence of neurologic deficit in the range of 5-10%”
• 10% permanent deficit, 40% had full recovery

Question 57

57. Regarding spondylolisthesis, all of the following are true except:
58. Degenerative spondylolisthesis occurs most commonly at L5/S1
59. Superior articular facet contributes to lateral recess stenosis
60. Palpable gap with a degenerative spondy at L4/5 will be felt at the same level as with an isthmic spondy at L5/S1

Answer 57

ANSWER: A

2015

OKU Spine 4:

Isthmic spondy most likely to occur at L5/S1

Degenerative spondy most likely to occur at L4/5

• Step is felt at L4/5 for both:
  
  • Isthmic –> posterior elements of L5 intact, L4 body moves with L5 body forwards
  • Degenerative spondy moves through facets –> therefore step is at affected level

JAAOS Dec 2016 Lumbar spinal stenosis

• Lateral recess stenosis contributed to by facet hypertrophy and associated facet osteophytes

Question 58

58. What nerve root(s) in adult L5-S1 isthmic spondylolisthesis will be affected?
59. L5
60. L5 and S1
61. S1
62. L4 and L5

Answer 58

ANSWER: A

2014

OKU Spine 5

L5-S1 isthmic spondy is most common level

Isthmic spondy affects exiting nerve root (will stretch out over S1 lip)

Question 59

59. All of the following are associated with isthmic spondylolisthesis, except?
60. Inuit heritage
61. Elongation of the pars
62. Increased disability from back pain
63. Spina bifida occulta

Answer 59

ANSWER: C

Repeat with variance 2012, 2015

JBJS 2008

• Slip progression appears to slow with each decade and the results from a back pain questionnaire and a SF36 survey were no different from those for an age-matched general population control group

JAAOS 2009 - Spondylolisthesis

• 25-50% prevalence in Inuit population
• Low-back pain and related disability in adults with spondylolysis or spondylithesis is similar to that in the general population. Many can be asymptomatic. If do have back pain and dysfunction, similar to the general population –> no increased disability

OKU 4 Spine (p 478)

• Sub-classification of Isthmic Spondy
  
  • A - disruption of pars (stress fracture)
  • B - elongation of pars
  • C - acute fracture
• Spina bifida occulta is associated with spondylolisthesis but not clear what type - presumably it would be dysplastic
  
  • With regard to the other questions, way easier if we say it is associated as other questions have definitively wrong answers

Question 60

60. Regarding isthmic spondylolytic spondylisthesis, all of the following are true except:
61. Has been associated with a lower pelvic incidence
62. The slip grade does not tend to change in adulthood
63. Neurologic injury corresponds with the exiting nerve root
64. Can be associated with spina bifida occulta

Answer 60

ANSWER: A

2016

JAAOS 2009 Adult Isthmic Spondy/OKU Spine 4

• Pelvic Incidence –> correlated with HIGH PI

Hanson (Spine 1976)

• “pelvic incidence >68.5° correlates strongly with the degree of slip

Huber L (Spine 2004)

• PI is significantly greater in subjects with spondylolisthesis
• Severity of listhesis correlates with PI

Mehta VA (Neurosurg 2012) – Implications of Spinopelvic alignment

• Nice review

Natural History:

• Beutler (Spine 2003)
  
  • 45 year long term follow up
  • 50% no slippage if none at diagnosis
  • 7-20% additional slip if slipped at diagnosis
  • Incidence of slip progression ~5% in asymptomatic adults
  • 20% if symptomatic (Floman Y Spine 2000 Progression of lumbosacral isthmic spondylolisthesis in adults)
  • Slip progression is associated with disc degeneration
  • “progression tends to be greater in adults than in adolescents, is more frequent in subjects with bilateral L4 spondylolysis and correlates with disk degeneration at the slip level”
  • Progression > 10mm occurs in <5% of subjects (Saraste H JPO 1987 Long term radiological follow-up of spondylolysis and spondylolisthesis)

Neurologic Symptoms:

• “Neurologic symptoms and signs in spondylolysis result from impingement on the exiting nerve root by hypertrophic fibrocartilaginous or bony tissue at the site of the pars defect”
• Rarely have L5 impingement between TP and sacrum in slips >20% with large TPs

Spina Bifida:

• Kumar R (Eur Spin J 2002)
  
  • Case report of 11 year of girl with grade IIB spondy + spina bifida occulta (really?)
• Albanese (JPO 1982)
  
  • Series of a single family with high prevalence of spondy (>300 relatives!!)
  • 61% had spina bifida occulta - high incidence in familial

Question 61

61. What is not an appropriate situation in which to do primary repair of a pars defect: young adult with L5-S1 isthmic spondylolysis with the following findings:
62. MRI shows normal signal in L5-S1 disc
63. MRI shows normal signal in L4-5 disc
64. L5-S1 spondylolisthesis present
65. no neuro symptoms/signs

Answer 61

ANSWER: C

2014

JAAOS 2006 Spondylosis and Spondylolisthesis in children and adolescents

In situ L5-S1 posterolateral fusion is standard for L5 isthmic defects

Repair of pars defect indicated for L1 through L4

Question 62

62. Patient presents with cervical myelopathy and upper motor neuron signs. All of the following are UMN signs except?
63. Scapulohumeral reflex
64. Jaw jerk
65. Hoffmans
66. Babinski

Answer 62

ANSWER: B

2012

Jaw Jerk tests CN V

• Tap on mandible below lips –> masseter muscles jerk mandible upwards
• Usually pretty minimal, unless hyperreflexia present
• Indicates UMN lesions but must be above spinal cord

Scapulohumeral Reflex:

• Tap spine near medial acromion
• Scapula elevates and/or arm abducts
• Indicates C1-3 compression

Question 63

63. Patient with hyperreflexia and ataxic gait. MRI shows L4/5 severe spinal stenosis. What is the next step?
64. Posterior decompression
65. MRI C+T spine
66. Fuse L4/5
67. Physio

Answer 63

ANSWER: B

2016

Question 64

64. Pt. With known lumbar spinal stenosis treated non operatively. Which exercises should he avoid?
65. hip flexor stretching
66. pelvic tilt
67. flexion exercises
68. Lumbar paraspinal extension stretching

Answer 64

ANSWER: D

2011

Position of provocation is extension

Question 65

65. Spinal stenosis. What is least useful?
66. physical exam
67. treadmill stress
68. MRI
69. SF-36

Answer 65

ANSWER: A

2008, 2011

Old groups’ rationale:

• Search Results
• Web results
• SPORT: Spine Patient Outcomes Research Trial
• Didn’t use physical exam, but used SF36
• The distance reached in the treadmill test predicts the grade of stenosis in MRI

Question 66

66. What is NOT a predictor of poor outcome after lumbar stenosis surgery?
67. Poor ambulation pre-op
68. Poor general health pre-op
69. Cardiovascular disease
70. Patient required a decompression and fusion intra-op

Answer 66

ANSWER: D

2008, 2009

Preoperative predictors for postoperative clinical outcome in lumbar spinal stenosis: systematic review (Spine 2006)

Conclusion:

“Depression, cardiovascular comorbidity, disorder influencing walking ability, and scoliosis predicted poorer subjective outcome. Better walking ability, self-rated health, higher income, less overall comorbidity, and pronounced central stenosis predicted better subjective outcome. Male gender and younger age predicted better postoperative walking ability”

Question 67

67. All of the following are true regarding a thoracic disc herniation, except:
68. Resect the T9 rib head for a T8/9 disc
69. Less common than cervical and lumbar disc degeneration
70. Should be addressed with a posterior laminectomy
71. May show calcifications on CT

Answer 67

ANSWER: C

2015

• JAAOS 2000 - Thoracic Disc Disease
• The frequency of morbidity associated with posterior laminectomy has led to the abandonment of this technique
• Calcifications very common with thoracic disc herniations; can make removal tricky

Question 68

68. What is not associated with Charcot spondyloarthropathy:
69. Equal risk with all ASIA grades
70. Associated with unrecognized low virulence surgical site infection
71. Can be stabilized with a short segment fusion

Answer 68

ANSWER: A

2015

Barrey C (Annal Phys Rehab Med 2010)

• Review of 111 cases
• Only 38% have neurologic change indicating an incomplete SCI –> only 13% have sensorimotor changes
• Interpretation: majority of cases have complete SCI
• 14% have history of infection
• Short segment fusion recommended for patients with minimal boney destruction

Question 69

69. What is advantage of dynamic plate for anterior spine- all advantages except
70. Increased fusion rate
71. Allows subsidence
72. Load shares with subsidence
73. Hasn’t been shown to make a difference

Answer 69

ANSWER: B/D

2008

JAAOS 2007 Dynamic Anterior Cervical Plates

• Rigid anterior cervical plates lead to stress shielding of the bone graft
• Dynamic plates allow load sharing (therefore subsidence)
• “it is unclear whether dynamic plates provide superior or even equivalent fusion rates to rigid plates”

Question 70

70. 5 radiographic or clinical features suggesting an unstable C spine injury (2012, 2014)

Answer 70

• Harris Rule of 12’s
• Power’s Ratio
• Vertical Displacement >2mm between occiput and C1
• ADI > 3.5mm
• PADI < 14mm
• Combined C1 lateral mass displacement > 6.9mm
• Anterolisthesis >3mm
• 11° angulation
• Flexion tear drop
• Translation on flex/ex films
• Bilateral facet fracture or dislocation

Question 71

71. What are the most important predictors of instability in a thoracolumbar fracture (3 points)? (2015)

Answer 71

TLICS:

• Fracture morphology (translation/rotation and distraction are worst)
• Neurologic Injury
• Damage to posterior ligamentous complex

Question 72

72. List 5 negative prognostic factors for Type 2 odontoid fractures (2010, 2011, 2016)

Answer 72

JAAOS 2010 - Odontoid Fractures

• Posterior displacement > 5mm
• Fracture gap > 1mm
• 4-day delay to start of treatment
• Loss of position > 2mm (re-displacement)

OrthoBullets:

• > 6mm displacement
• Age > 50 years (some references 40, some 65)
• Comminution
• Angulation > 10°
• Delay in Treatment

Question 73

73. CT of upper C spine showing possible C0-C1 dissociation. All of the following except:
74. Shows altantooccipital dissociation
75. Powers ratio > 1
76. Increased distance between dens and basion
77. Basion dens interval decreased.

Answer 73

ANSWER: D

2008

JAAOS 2014 - Upper Cervical Spine Trauma

Increased BDI and BAI

Question 74

 

74. You are shown a lateral C-spine x-ray. There is no obvious fracture except slight impaction of anterosuperior cortex of C5 vertebral body. There is 25% anterolisthesis of C4 on 5. What is true about this injury?
75. Unilateral facet fracture-dislocation
76. Bilateral perched facets
77. Flexion teardrop fracture
78. It is likely just a cervical strain

Answer 74

ANSWER - A

2008, 2012, 2014

Fractures and Dislocations of the Cervical Spine. Beatson. 1963. JBJS. 45B (1):21-35 :

• Radiographs were then taken after various manoeuvres and the following facts emerged:
  
  • It was impossible to produce a forward slip of the body of the fourth cervical vertebra on that of the fifth of more than half the anteroposterior depth of the body if the dislocation of the inter-facetal joint was confined to one side.
  • It was impossible to produce a forward slip of the body of the fourth cervical vertebra on the fifth of less than half the anteroposterior depth of the body if the inter-facetal dislocation was bilateral.”
  • “lf this shows that one vertebral body has dislocated forward on that next below it by less than half the anteroposterior depth of the vertebral body, there is a unilateral facet dislocation.”
  • “Forward dislocation of a vertebral body on that next below it by more than half the anteroposterior depth of the body indicates dislocation of both facet”

Question 75

75. All of the following are true about a lumbar burst fracture, except
76. It is usually the inferior endplate that is retropulsed
77. Facet joints can be diastased
78. Pedicles widened on AP
79. Lamina often involved

Answer 75

ANSWER: A

2013, 2015

Atlas SW (Am J Roentgenol 1986) The radiographic characterization of burst fractures of the spine

• Characteristic Features of a Burst:
  
  • Posterior element fractures (fracture of necessity of the lamina)
  • Vertical sagittal plane fracture through body
  • Increased inter-pedicular distance
  • Anterior wedging of the vertebral body with loss of height
  • Retropulsion (SUPERIOR endplate retropulsed)
• Indicators of Potential Instability:
  
  • Translation of one vertebra on another
  • Loss of greater than 50% height
  • Fracture through posterior elements
  • Increased inter-pedicular distance
  • Greater than 25% loss of vertebral body height

Question 76

76. Burst fracture; all of the following except?
77. Anterior vertebral body is disrupted
78. Posterior vertebral body is disrupted
79. Lamina are fractured
80. There is a linear correlation with the amount of retropulsion and neurological injury

Answer 76

ANSWER: D

2012

Neurologic injury is dependent on size of canal and level of injury in association with degree of retropulsion

Question 77

77. One month following an L1 burst fracture with 60% canal stenosis, a patient presents with new onset numbness and weakness to both legs. What is the optimal treatment?
78. L1 laminectomy
79. T12-L2 posterior fusion
80. Thoracoabdominal approach with L1 corpectomy and anterior column reconstruction
81. Observation

Answer 77

ANSWER - C

 2008, 2014

Thoracolumbar Spine Trauma II. Principles of Management. J Am Acad Orthop Surg 1995;3:353-360.

• In cases of significant canal com- promise and incomplete or complete neurologic injury, we prefer anterior decompression by means of vertebral corpectomy and autologous iliac-crest strut grafting, followed by posterior compression instrumentation with the use of hooks or transpedicular screws.

Thoughts:

• Can’t do short posterior fusion at thoracolumbar function (T11-L2)
• Bracing obviously a bad idea
• Laminectomy at L1 –> destabilize already kyphotic junction area and this is conus level so may not decompress

Question 78

78. Thoracolumbar burst fracture with significant canal compromises treated non-operatively. What happens to canal afterwards.
79. Canal stays the same
80. Canal increases in size
81. Canal decreases in size
82. Lateral recess stenosis

Answer 78

ANSWER: B

2011

JBJS 2003:

• RCT 47 patients with non-op bursts
• Changed from 34% canal compromise to 19% at 44 months

CORR 1996:

• 6 patients
• 55% to 20% at final follow up

Question 79

79. What is the most likely functional expectation of a quadriplegic with motor function intact to C7?
80. Fully independent transfers
81. Regular use of a manual wheelchair
82. Electric wheelchair
83. Ambulatory

Answer 79

ANSWER: B (old answer A; not FULLY independent w/C7 level)

2014, 2016

Bruns AS (Spine 2001) Establishing prognosis and maximizing functional outcomes after spinal cord injury

• C7 patients gain functional strength in the triceps. The ability to forcefully extend the elbow allows the patient to lift their body weight.
• These patients can roll over, sit up in bed, and move about in the sitting position. Motivated patients can also transfer independently.
• Some assistance may still be required for toileting and dressing activities, particularly for the lower extremities. Eating can be done independently except for cutting.
• Independent wheelchair propulsion is possible for long distances on smooth surfaces.

AAOS Comprehensive Review page 235:

• C4 - wheelchair mobility with sip and puff controls, usually don’t need ventilator
• C5 - power wheelchair with hand controls. May even be able to use manual wheelchairs with grip enhancements with tremendous energy usage
• C6 - manual wheelchair with grip enhancements, most prefer power wheelchair, sometimes transfers with a slider
• C7 - most ADLs/IADLs independently or with very minimal assistance. Manual wheelchair can be used, troubles with uneven surfaces
• C8 - total independence

Question 80

80. Given a sagittal CT cut showing a T5 flexion distraction injury. What is the neurological injury?
81. anterior
82. complete
83. mixed UMN & Lower
84. central

Answer 80

ANSWER: B

2011

• Couldn’t find any evidence (neither could old groups) - debate between A and B
• My Logic:
• Flexion distraction in the thoracic and lumbar spine don’t have axial load to them to columns fail in TENSION. Therefore more likely to have either posterior based lesion or complete cord
• Anterior cord is compression to anterior spine
• Central cord is an extension injury
• No reason to have LMN signs in thoracic spine

Question 81

81. MRI of severe cervical flexion injury with posterior displacement of the body. What is the most likely spinal cord injury?
82. UMN
83. Anterior cord
84. Central cord
85. LMN

Answer 81

ANSWER: B

2010

Wheeless:

Flexion tear drop fractures are associated with acute anterior cervical cord syndrome

Question 82

82. Thoracolumbar fracture what is true? 
83. UMN only
84. LMN only
85. Nerves in the cauda equina recover the same as peripheral nerve injuries
86. conus end at L2-L3

Answer 82

ANSWER: D/A (Poor question)

2010

• UMN/LMN depends on where the conus is
• Some variability in end point between T12 and L3
• Jess argument: sure the conus can be a bit low, but L2/3 is pretty low in an adult. I take a thoracolumbar fracture to mean around T12/L1, where the conus really should be involved. Therefore it would cause an UMN injury. I bet this question wasn’t remembered well, though.
• Conus can have both UMN and LMN symptoms with injury

JAAOS - Cauda Equina:

• Unlike peripheral nerves that are protected by a series of successive layers of connective tissue known as the epineurium, perineurium, and endoneurium, the nerve roots of the cauda equina have only one layer, the endoneurium. In the cauda equina, the layers equivalent to the perineurium and epineurium are cerebrospinal fluid and the dura sac, respectively. This relative lack of protection leaves the nerve roots of the cauda equina particularly susceptible to traumatic injury.

Question 83

83. 3mm displaced odontoid fracture. Neuro intact. Fracture of posterior arch C1. All are possible treatments EXCEPT
84. Halo Vest
85. C1-C2 posterior wiring + Bone graft
86. C1-C2 trans-articular screws + Bone Graft
87. C1 lateral mass screws connected to C2 pedicle screws + Bone graft

Answer 83

ANSWER: B

2008

Can’t do posterior wires with fracture of posterior arch of C1

Question 84

84. All are poor prognostic indicators of recovery after whiplash injury EXCEPT:
85. Sedentary occupation
86. Radiculopathy at time of injury
87. Spondylosis preceding injury
88. Female gender

Answer 84

ANSWER: A?

2008

JAAOS 2007 - Chronic Whiplash and Whiplash Associated Disorders

• Prognostic Factors:
  
  • Initial high intensity of pain
• Controversial:
  
  • Gender, older age, litigation
• Inconclusive:
  
  • Radicular symptoms, cognitive impairment, poor concentration, prior HA, velocity change > 10km/h
• CONCLUSION –> evidence terrible

Question 85

85. What is true about hangman fractures
86. Usually associated with neuro deficit
87. Associated with C3-C4 interspinous ligament injury
88. Good union rate with conservative management
89. Usually a flexion mechanism

Answer 85

ANSWER: C

2019

• Good union rate with conservative management (can eliminate all others)
• Traumatic spondylolisthesis of axis

JAAOS 2002 Upper Cervical Spine Injuries

JAAOS 2014 Upper Cervical Spine Trauma

• Nonsurgical management results in successful healing rates approaching 95%
• Important points
  
  • Hyperextension and compression (with secondary flexion)
  • Second most common axis fracture (after odontoid)
  • Neurology uncommon
  • Neurologic injury is uncommon because the fracture fragments separate, decompressing the spinal canal.
  • Neurologic injury is uncommon in Hangman’s fractures unless the injury pattern causes narrowing of the spinal canal, generally restricted to type IA (33%) and type III (60%) injuries
  • Problem is at C2-C3 level* (NOT C1-2)
  • Levine and Starr Classification
    
    • Type I – Non-displaced (<3mm)
      
      • Collar for 12 weeks
    • Type IA – Atypical, one pars, extending to body on contralateral side
      
      • Halo, surgery if neuro deficit
    • Type II - >3mm displacement on upright film
      
      • Halo
    • Type IIA – Flexion-distraction injury - Disruption of discoligamentous complex at C2/3 – horizontal fracture line
      
      • Halo or C1-C3 fusion
      • AVOID TRACTION IN IIA***
    • Type III – dislocation of C2-3 facets, similar fracture line to type I
      
      • Need to go posterior to reduce facets C1-3 or C2-3
      • Usually heal despite displacement (autofuse C2 on C3)

Question 86

86. Regarding Charcot spine:
87. Low virulence postoperative infection
88. Indication for long-term followup for SCI patients.
89. Regardless of ASIA grade, equal risk of developing Charcot spine
90. Short posterolateral fusion is sufficient

Answer 86

ANSWER: B

2019

• Indication for long-term follow-up for SCI patients
• Charcot spinal arthropathy - 2018
  
  • CSA secondary to traumatic SCI occurs 17 years after injury on average
  • While posterior-only reconstruction has been indicated in mild cases with minimal bony involvement, the majority of CSA today is treated by circumferential arthrodesis
  • Otherwise, the majority of surgical procedures for CSA today comprise of a circumferential arthrodesis, involving a combined anterior-posterior vertebral column construct
  • ?virulence – higher suspicion for TB or purulent infections, MRSA
  • Cases have been described more often in individuals with paraplegia and neurologically complete injuries

Question 87

87. All of the following are true except:
88. Inferomedial facet of L4 will cause lateral recess stenosis affecting L5 nerve root.
89. Wiltse paramedian is the best approach for far lateral disc
90. You may have to excise the L2 pedicle to decompress
91. It is difficult to put an L5 pedicle screw in an isthmic grade III spondylolisthesis (no level given)

Answer 87

ANSWER: C

2019

• You may have to excise the L2 pedicle to decompress
• Lateral recess stenosis:
  
  • The lateral recess is defined by the superior articular facet posteriorly, the thecal sac medially, the pedicle laterally, and the posterolateral vertebral body anteriorly.
  • Superior articular facet pathology main culprit in lateral recess stenosis
  • Presents with symptoms of descending nerve root
  • At L4/5 level, the root of L5 is affected
  • However – inferomedial facet is technically partly within LR therefore can affect L5 nerve root – Parham*
• Wiltse approach – paraspinal posterolateral approach
  
  • Indications = far lateral disc herniation, pars defect
• Isthmic spondy
  
  • Most commonly L5-S1
  • Change in pedicle anatomy/morphology – pedicles smaller*
• L2 pedicle
  
  • Below conus medullaris (L1)
  • Therefore – there is really no scenario in which you would need to take out L2 pedicle to decompress – can just move cauda out of the way (Parham*)

Question 88

88. Which of the following is true:
89. Basilar-dental interval <12mm
90. Basilar-atlantal interval <12mm
91. Space available for cord <13mm
92. PADI <15mm

Answer 88

ANSWER: A

2019

• Again, what the foooook. Charles – changed A to < 12 for it to have an answer.
• Normal values
• PADI > 14mm (SAC)
• ADI < 3mm adults (<5 mm kids)
• Dens-Basion Interval (DBI) < 12 mm
• Basion to posterior dens -4 to 12 mm
• Basion-axis interval <12 mm

Question 89

89. All of the following are true regarding SCIWORA except:
90. Physiologic deficits do not correlate with anatomical abnormality
91. Higher level cervical injuries are worse than lower level cervical injuries
92. Thoracic deficits are the most common
93. 25% will present with delayed onset of neuro symptoms

Answer 89

ANSWER: C

2019

• Thoracic deficits are the most common – CERVICAL most common (87%)
• Objective clinical signs of posttraumatic spinal cord injury without evidence of fracture or malalignment on plain radiographs and computed tomography (CT) of the spine
• SCIWORA is most commonly seen in children with a predilection for the cervical spinal cord due to the increased mobility of the cervical spine, the inherent ligamentous laxity, and the large head-to-body ratio during childhood
• 20-50% of children will present with delayed symptoms

Question 90

90. All are true regarding spondylolisthesis EXCEPT:
91. High slip grades associated with decreased pelvic incidence
92. Associated with spina bifida occulta
93. Pelvic incidence is fixed
94. Pelvic tilt changes with position

Answer 90

ANSWER: A

2019

• Pelvic incidence >68.5° correlates strongly with the degree of slip (P = 0.03) 0.21

JAAOS oct 2009 - Adult Isthmic Spondylolisthesis + orthobullets

• Pelvic incidence has direct correlation with the Meyerding–Newman grade
• Correlates with severity of disease
• The pelvic incidence is a fixed morphological parameter, whose value remains more or less constant throughout adult life

Spondylolysis: a critical review - 2000

• Many studies have shown a strong association between pars defects and the presence of spina bifida occulta.
• The mean standing pelvic tilt was −2.1° ± 7.4°, with a range of −15.2° – 15.3°. Mean supine pelvic tilt was 4.1° ± 5.5°, with a range of −9.7° – 17.9°. Mean pelvic tilt in the flexed seated position was −1.8° ± 14.1°, with a range of −31.8° – 29.1°

Question 91

91. Regarding ACDF, which is true:
92. 70% risk of dysphagia
93. 80-85% fusion rate
94. Recurrent laryngeal nerve is the most common neurological injury
95. Titanium cage has better fusion rate than allograft

Answer 91

ANSWER: C

2019

JAAOS 2008 - Adverse Events Associated With Anterior Cervical Spine Surgery

https://thejns.org/spine/view/journals/j-neurosurg-spine/6/4/article-p298.xml

Complications and Risk Factors Using Structural Allograft Versus Synthetic Cage: Analysis 17 783 Anterior Cervical Discectomy and Fusions Using a National Registry - In this study, the

fusion rates were 98% versus 90% for titanium age and allograft/autograft, respectively.

Hacker et al demonstrated higher fusion rates with ACDF using titanium cage in 1- and 2-level cases compared with uninstrumented allograft and autograft

http://orthopedics.imedpub.com/complications-of-spine-surgery-and-litigations–managing-malpractice-risk.pdf

Recurrent laryngeal = 0.1 %

https://thejns.org/spine/view/journals/j-neurosurg-spine/4/4/article-p273.xml

Recurrent laryngeal = 1-2 %

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843080/pdf/asj-10-385.pdf - yes RLN most common – no clear number for others

Question 92

92. All of the following are true regarding thoracic disc herniation except:
93. Resect the T9 rib head for T8/T9 disc
94. Less common than cervical and lumbar spine
95. Should be addressed with posterior laminectomy
96. It can be difficult to find the correct level in the thoracic spine

Answer 92

ANSWER: C

2019

Question 93

93. Which syndrome can leave you with lasting bowel and bladder dysfunction but return to walking within 3 months post injury?
94. Anterior Cord
95. Brown-Sequard
96. ASIA –A
97. Conus medullaris

Answer 93

ANSWER: D

2019

Overall, CEIs and CMIs have similar outcomes, which include ambulatory motor function and a variable persistence of bowel, bladder, and potentially sexual dysfunctions.

Question 94

94. What is most true with respect to cervical spondylolytic myelopathy?
95. Decreased proprioception
96. Less than 4 beats of clonus
97. Nerve root tension signs
98. Hyporeflexia in the upper extremity

Answer 94

ANSWER: A/C? - A always there in myelopathy. Radiculopathy may not be there so I suggest A.

2019

• Proprioception dysfunction
  
  • due to dorsal column involvement
  • Occurs in advanced disease
  • Associated with a poor prognosis
• Sustained clonus
  
  • > 3 beats defined as sustained clonus
  • Sustained clonus has poor sensitivity (~13%) but high specificity (~100%) for cervical myelopathy
• Hyperreflexia
  
  • May be absent when there is concomitant peripheral nerve disease (cervical or lumbar nerve root compression, spinal stenosis, diabetes)

Question 95

95. All of the following are correct landmarks for inserting an L3 pedicle screw EXCEPT?
96. Inferolateral aspect of L2-3 facet joint
97. Inferolateral aspect of L3-4 facet joint
98. Junction of the middle third of transverse process and a line through the center of the facet joint
99. Junction of the middle third of transverse process and a line through the mammillary process and pars

Answer 95

ANSWER: B

2014, 2019

• B would be an L4 pedicle screw
• AO Surgical Reference - Pedicle Screws
• “the entry point of the pedicle screw is defined as the confluence of any of the four lines”
• Pars interarticularis
• Mammillary process
• Lateral border of the superior articular facet
• Mid transverse process

Question 96

96. All following are associated with isthmic spondylosthesis, except?
97. Spina bifidia and isthmic spondy
98. Degenerative spondylolisthesis and spondylosisis
99. Pars elongation and isthmic spondy

Answer 96

ANSWER: B

2019

Question 97

97. What is true with respect to burst of the cervical spine
98. They are due to a pure axial load
99. They are the most common cervical spine fracture
100. Is rarely retropulses into the canal
101. it is more common in the upper than the lower cervical spine

Answer 97

ANSWER: A

2019

Question 98

98. When can you retract on the cord in spine surgery? 
99. Above the conus 
100. Below the conus 
101. Below T12 
102. Never appropriate 

Answer 98

ANSWER: B

2019

Question 99

99. What is the greatest risk factor for chronic pain after a whiplash mechanism? 
100. Severity of the pain at initial injury 
101. Mechanism 
102. Level of education 
103. Type of vehicle 

Answer 99

ANSWER: A and C

2019

The significant variables included high baseline pain intensity (greater than 5.5/10),

Question 100

100. Which syndrome will/can leave you with lasting bowel and bladder dysfunction but return to walking 3 months after injury?
101. Conus medullaris
102. Anterior cord syndrome
103. Brown-Sequard
104. ASIA – A

Answer 100

Answer: A (2017)

Overall, CEIs and CMIs have similar outcomes, which include ambulatory motor function and a variable persistence of bowel, bladder, and potentially sexual dysfunctions.

Question 101

101. What is TRUE with regards to Charcot spondyloarthropathy:
102. Equal risk with all ASIA grades
103. Associated with unrecognized low virulence surgical site infection
104. Can be stabilized with a short segment fusion
105. Is a reason for long term orthopaedic follow-up in patients with complete spinal cord injury

Answer 101

Answer: D (2017)

A – no higher is higher grades

B – Can’t find literature on this.

C - nope. Need to go big now.

D – Collapse happens.

Question 102

102. A 56yo female is involved in an MVC and suffers a C5/6 fracture dislocation. She is treated with closed reduction, and the fractures reduces with 15 pounds of traction. A halo vest is applied. Later, she complains of diplopia and vertigo. She is found to have nystagmus on exam. What is most likely the cause.
103. Horner’ syndrome
104. Ascending cervical syndrome
105. Spinal shock
106. Vertebrobasilar insufficiency

Answer 102

Answer: D (2017)

The vertebrobasilar system is responsible for the blood supply of 10 cranial nerves, all ascending and descending tracts, parts of the cortical hemispheres, and the end-organs of hearing and balance. Thus, dysfunction of this system can lead to a wide variety of symptoms: impaired hearing, impaired vision, tinnitus, or headache

Question 103

103. All of the following are landmarks that can be used to find the start point for L3 pedicle screws except:
104. The confluence of the transverse process and the midpoint of the facet
105. The confluence of the transverse process and the lateral lamina
106. The inferolateral portion of the L3/L4 facet
107. The inferolateral portion of the L2/L3 facet

Answer 103

Answer: C (2017)

Yes

Yes

That would give L4

Yes. That would give L3

Question 104

104. Old guy with known metastatic disease. Shown x-ray of thoracic spine with acute kyphosis and retropulsion. He now has myelopathy. All of the following are surgical options except?
105. Transpedicular decompression + fusion
106. Posterior laminectomy and fusion
107. Transthoracic decompression + fusion
108. Costotransversectomy

Answer 104

Answer: B (2017) – need to take pedicles down at least to decompress vertebral body retropulsion.

Question 105

105. Guy gets stabbed in the neck. What are the following SCI findings you would expect to see?
106. Ipsilateral loss of motor, contralateral loss of vibration and proprioception
107. Ipsilateral loss of motor, contralateral loss of light touch
108. Ipsilateral loss of motor, ipsilateral loss of temp/pain
109. Ipsilateral loss of motor, contralateral loss of temp/pain

Answer 105

Answer: D (2017) – brown sequard syndrome

• Caused by complete cord hemitransection
• usually seen with penetrating trauma
• Exam
• ipsilateral deficit
• LCS tract
• motor function
• dorsal columns
• proprioception
• vibratory sense
• contralateral deficit
• LST (Crosses Over at cord)
• pain
• temperature
• spinothalamic tracts cross at spinal cord level (classically 2-levels below)

Question 106

106. OC dislocation plain radiographic parameters.?
107. BDI > 12mm
108. ADI > 3mm
109. SAC < 13mm
110. BAI < 12mm

Answer 106

Answer: A (2017, 2019)

Question 107

107. Question about concomitant scoliosis and spondy. What is not true?
108. Correcting spondy will lead to resolution of postural curves
109. Correcting scoliosis will eliminate nerve root symptoms associated with L5/S1 spondylolisthesis
110. Spondylolisthesis is associated with decreased pelvic incidence
111. Correcting spondylolisthesis will lead to resolution of adolescent idiopathic scoliosis.

Answer 107

Answer: C (2017) – the most wrong

A- true

B - true?

C- false – associated with INCREASED pelvic incidence

D - true

• Pelvic incidence was significantly higher in patients with low- and high-grade isthmic spondylolisthesis as compared with controls and had significant correlation with the Meyerding-Newman grades
• Scoliosis may be associated with spondylolysis35. When the scoliosis is due to pain, it (the scoliosis) usually resolves spontaneously following successful treatment of the spondylolysis.
• The standard posteroanterior radio- graphic view allows evaluation of coexisting scoliosis that may be secondary to paraspinal spasm, whether idiopathic or olisthetic (ie, the result of asymmetric forward vertebral translation at the level of the spondylolisthesis)

Question 108

108. In treating an elderly man with lumbar stenosis all of the following are true except:
109. Radiographs should be used to help plan the surgical procedure.
110. MRI is used to plan surgical procedure
111. Bilateral laminectomies are an absolute indication for posterior spinal fusion.
112. Age will play a role in determining the correct surgery.

Answer 108

Answer: C (2017)

A – yup need xrays to lok for slip

B – MRI needed for what to decompress

C- nope, only if >50 facet is gone

D – yea, fusion vs not.

Question 109

109. All of the following are treatment options for odontoid fractures in the elderly except:
110. Posterior screw-rod constructs in comminuted fractures
111. Collar immobilization in undisplaced fractures.
112. Halo vest immobilization in undisplaced fractures.
113. Posterior screw-rod constructs in displaced fractures.

Answer 109

Answer: C (2017) – elderly, increase risk delirium and won’t tolerate HALO.

Question 110

110. What are the clinical findings in Brown-Sequard syndrome? Lesion is on the left side.
111. Left motor deficit, temp/pain and vibration/proprioception deficit on right
112. Left motor deficit, vibration/proprioception deficit on right
113. Left motor deficit, temp/pain deficit in right
114. Left motor, left temp/pain deficit

Answer 110

Answer: C (2017)

Question 111

111. An 80-year-old man sustains a ground level fall. He does not lose consciousness but has some trouble getting up and is taken to hospital. You are shown an image (extremely blurry saggital MRI with subaxial degen and actual arrows pointing to an area of meylomalacia). What will you expect to find on physical exam?
112. Upper extremity weakness > lower extremity weakness, distal weakness >proximal weakness
113. Lower extremity weakness > upper extremity weakness, distal weakness >proximal weakness
114. Upper extremity weakness = lower extremity weakness, distal weakness >proximal weakness
115. Lower extremity weakness >upper extremity weakness, proximal weakness > distal weakness

Answer 111

ANSWER: A

2018

Spinal stenosis –> central cord syndrome

Question 112

112. In c spine flexion-distraction trauma, which of the following is a relative contraindication to ACDF at the C5-C6 level?
113. C5 superior process fracture
114. C5/6 annulus tear
115. C6 facet fracture
116. C6 superior end plate fracture

Answer 112

ANSWER: D

2018

Question 113

113. All of the following are true with respect spinal cord nerve tracts except:
114. The lateral and anterior corticospinal tracts are considered pyramidal tracts and have something to do with the medulla in the brain
115. The lateral corticospinal tract contains more nerve fibers than the anterior corticospinal tract
116. The tracts in the dorsal column of the spine are arranged such that the fibers responsible for cervical areas are more central
117. The tracts in the lateral corticospinal tract of the spine are arranged such that the fibers responsible for cervical areas are more central

Answer 113

ANSWER: C

2018

Lateral is the main descending motor pathway (minor = ant)

Cervical areas are more lateral

Question 114

114. A patient has a C7 spinal level injury. What is his expected function?
115. Fully independent transfers
116. Daily use of a manual wheelchair
117. Use of a motorized wheelchair
118. Electric wheel chair with head control

Answer 114

ANSWER: B (not FULLY independent for transfers)

2019

Question 115

115. Which of the following is true regarding hemiepihiseodesis for congenital scoliosis?
116. You get 15 degrees of correction per year
117. It is best done between ages 5 and 10
118. It is best for unilateral bars
119. It is best for curves <50 degrees

Answer 115

ANSWER: D

2018

Unilateral bar = in situ arthrodesis

Hemivert(without imbalance) <5yo <40 degree = hemiepiphysiodesis

Hemivert (WITH imbalance) < 6yo < 40 degree =vert excision

Question 116

116. Patient falls and has neck pain and radicular arm pain. Xray given (Showed 25% vertebral body translation at C4/5). What is the most likely deficit on physical exam?
117. Right supraclavicular numbness and right shoulder shrug (abduction) weakness
118. Weak shoulder abduction and numbness along shoulder
119. Right lateral shoulder numbness and right elbow flexion weakness – c5 nerve root
120. Right lateral shoulder numbness and right wrist flexion weakness

Answer 116

ANSWER: C

2018

Question 117

117. Which of the following regarding isthmic spondylolisthesis is true?
118. Occurrence in the Inuit population is rare
119. It is most common at L4/5
120. It is not associated with an increased risk for back pain as an adult

Answer 117

ANSWER: C

2018

Rate of back pain same as general population (JAAOS)

Question 118

118. Which of the following is TRUE about the rheumatoid spine? (This is def a repeat but I can’t find it!!!)
119. C1-C2 lateral mass erosion is responsible for subaxial subluxaion
120. Atlantodens joint is a fibrous joint which makes it prone to pannus formation which causes the atlantoaxial instability
121. Pathology at the C1-2 articulation is responsible for basilar invagination and atlantoaxial instability

Answer 118

ANSWER: C

2018

C1-C2 lateral mass erosion is responsible for subaxial subluxaion

• Responsible for atlanto-axial instab – NOT subaxial

Atlantodens joint is a fibrous joint which makes it prone to pannus formation which causes the atlantoaxial instability

• Atlantodens joint is synovial – NOT fibrous

Pathology at the C1-2 articulation is responsible for basilar invagination and atlantoaxial instability