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Z MCQ Of OrthoBullets > Spine (2008-2019) > Flashcards

Spine (2008-2019) Flashcards

1
Q
  1. 4 features of Brown-Sequard Syndrome (2010, 2012)
A
  • Ipsilateral voluntary motor loss
  • Unilateral UMN findings
  • Ipsilateral vibration loss
  • Contra-lateral pain/temperature loss
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2
Q
  1. List 3 features of central cord syndrome. (2011, 2014)
A

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

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

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
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5
Q
  1. Formula for pelvic incidence (2012)
A
  • Pelvic incidence = pelvic tilt + sacral slope
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6
Q
  1. ASIA score question. List the 11 myotomes and corresponding muscle groups. (Variations - 2011, 2012, 2013, 2014, 2016)
A
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7
Q
  1. 3 ways to do posterior C1-2 fusion (2012)
A
  • Trans-articular Screws (Magerl)
  • Sub-laminar wires
  • Lateral Mass Screw Fixation

 

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

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

JAAOS - MRI in the Spine

  • Scar tissue enhances (including granulation tissue, i.e. TB)
  • Infection
  • Tumors
  • ** Chronic disks are dark.
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10
Q

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
A

ANSWER: C

2013 

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

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11
Q

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
A

ANSWER: D

2010, 2013, 2015 (variants)

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12
Q

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
A

 ANSWER: C

2014, 2015

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13
Q

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
A

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
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14
Q

14.Injury to what causes of retrograde ejaculation

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

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

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
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16
Q

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
A

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
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17
Q

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
A

ANSWER: A

2011

Hoppenfeld:

  • The carotid sheath enclosing the common carotid artery, vein and vagus nerve can now be exposed
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18
Q

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
A

ANSWER: B

2013, 2016

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19
Q
  1. Can do PLIF/TLIF in all of the following except
  2. Pseudoarthoris
  3. Spondylolisthesis
  4. Infection
A

ANSWER: C

2012

JAAOS 2008 - Posterior Lumbar Interbody Fusion

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20
Q
  1. All of the following associations are right except? REPEAT
  2. Foot Dorsiflexion - L4
  3. Sensation over patella L2
  4. Hamstring reflex L5-S1
  5. Hip abductors – L5
A

ANSWER: B

2012

  • L3 provides sensation over patella
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21
Q
  1. Which of the following is associated with an increased risk of complications with halo treatment?
  2. Re-tightening the screws at an appropriate interval
  3. Placing the ring 2cm above the pinna
  4. Placing the ring closer to the skull
  5. Using 6 pins instead of 4
A

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.
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22
Q
  1. Spinal associations; all of the following are true EXCEPT:
  2. Isthmic spondylolisthesis and spina bifida occulta
  3. Isthmic spondylolisthesis and pars abnormality
  4. Folate and neural tube defects (worded exactly like this)
  5. Degenerative spondylolisthesis and spondylosis
A

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
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23
Q
  1. With regards to proteoglycans, all of the following are true except
  2. Proteoglycans are hydrophilic
  3. Proteoglycans are hydrophobic
  4. Proteoglycans are sulfated
  5. Proteoglycans are bound to a protein core
A

ANSWER: B

2012

AAOS Core Review 2:

  • Proteoglycans can trap water in the ECM by their negative charge, regulating matrix hydration
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24
Q
  1. During the posterior approach to the spine, the thecal sac can be retracted?
  2. Above the level of the conus
  3. Below the level of the conus
  4. Below T12
  5. Never
A

ANSWER: B

2014

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

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
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26
Q
  1. Patient with complete spinal cord injury; C7 spinal level. What is most likely to still be working?
  2. Wrist flexion, finger flexion, brachioradialis reflex, radial sensation
  3. Wrist flexion, finger extension, triceps reflex, absent medial forearm sensation
  4. Wrist extension, finger abduction, biceps reflex, medial forearm sensation
  5. Wrist extension, finger flexion, triceps reflex, radial sensation
A

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
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27
Q
  1. Benefit to cross-links in spine instrumentation:
  2. Increased resistance to flexion/extension
  3. Increased resistance to lateral bend
  4. Increased resistance to torsion
  5. Increased fusion rate
A

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”
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28
Q
  1. All of the following are associated with spinopelvic alignment, except:
  2. Isthmic spondylolisthesis is associated with decreased pelvic incidence
  3. Pelvic tilt does not change with position
  4. Pelvic incidence is a constant variable that does not change after skeletal maturity
A

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
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29
Q
  1. What is not associated with cervicomedullary syndrome:
  2. Hypotension
  3. Facial numbness
  4. LE > UE symptoms
  5. Complete or incomplete paralysis is possible
A

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
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30
Q
  1. 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
A

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”
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31
Q
  1. 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?
  2. Supraclavicular numbness
  3. Weakness of elbow flexion with lateral shoulder numbness
  4. Supraclavicular numbness + something else
  5. Hand weakness
A

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)
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32
Q
  1. Regarding spinal infection, all true, EXCEPT: 
  2. CRP and ESR decreasing are effective signs that medical management is working
  3. Most have an elevated WBC
  4. Greater than half are staph aureus
A

ANSWER: B

2016

  • Carraggee (JBJS 1997) Pyogenic Vertebral Osteomyelitis
  • CRP and ESR are almost always elevated
  • Leukocytosis in < 45%
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33
Q
  1. Where to put screws in occiput for strongest construct
  2. Midline because of thickest bone
  3. Inferior to nucchal line
  4. Laterally
  5. Medially and laterally

 

A

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
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34
Q
  1. Which would not alter your approach for a C-spine myelopathic patient
  2. Previous incision
  3. Sagittal alignment
  4. Location of compression
  5. Presence of radiculopathy
A

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
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35
Q
  1. Size of lumbar central canal is largest in which position
  2. Flexion
  3. Extension
  4. Supine
  5. Standing
A

ANSWER: A

2008, 2010

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36
Q
  1. Use of stiffer instrumentation for spinal fusion results in which of the following in the fusion mass:
  2. lower modulus of elasticity
  3. decreased volume density of bone
  4. lower load to failure
  5. increased vascularity
  6. higher pseudarthrosis rate
A

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
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37
Q
  1. Which of the following structures contain free nerve endings:
  2. PLL, Annulus, Facet joint capsule
  3. Joint capsule, Annulus
  4. Annulus fibrosis and Nucleus pulposis
  5. Annulus, Nucleus, PLL, joint capsule
A

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

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

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+
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40
Q
  1. What are 3 risks of vertebroplasty/kyphoplasty? (2015)
A

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
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41
Q
  1. List 6 causes of spondylolisthesis? (2015)
A

Wiltse Classification:

  • Isthmic
  • Degenerative
  • Traumatic
  • Dysplastic
  • Iatrogenic
  • Pathologic
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42
Q

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

A

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

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

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

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

JAAOS 2007 - Intra-operative Neurophysiologic Monitoring During Spinal Surgery

  • SSEPs - Somatosensory-evoked potentials
  • Transcranial electric motor-evoked potentials
  • Stagnara wake-up test
  • Electromyography
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47
Q
  1. 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?
  2. Anterior decompression
  3. Posterior decompression
  4. IV antibiotics
  5. Biopsy
A

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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q
  1. Most common cause of post-op spine infection?
  2. Bacteroides
  3. Staph epi
  4. Staph aureus
  5. E coli
A

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”

49
Q
  1. Epidural abscess: most common risk of neurologic outcome. All except:
  2. Staph aureus
  3. Steroids
  4. DM
  5. T10
A

ANSWER: A

2009

JAAOS 2016 - Bacterial Spine Infections in Adults

  • Diabetes
  • Older age
  • Rheumatoid Arthritis
  • Steroids
  • Infection above conus
50
Q
  1. 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?
  2. Costotransversectomy and corpectomy
  3. Laminectomy, transpedicular decompression
  4. Laminectomy and posterior decompression
  5. Anterior approach and decompression
A

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!

51
Q
  1. Tumor associated with Posterior spinal element
  2. Mets
  3. Hemangioma
  4. ABC
  5. GCT
A

ANSWER: C

2012

JAAOS 2012 - Benign Tumours of the Spine

Oh Oh Oh, Ahhhhh

  • Osteoid osteoma
  • Ostoeoblastoma
  • Osteochondroma
  • ABC
52
Q
  1. Rheumatoid spine, all are true EXCEPT: (recall not the best.)
  2. Lower cranial nerves can be affected in rheumatoid spine
  3. C1 – C2 is fibrous joint and therefore forms a pannus
  4. C1 - C2 collapse for both C1-C2 instability and Basilar invagination
  5. C1 - C2 lateral mass collapse can cause C1C2 and sub-axial instability
A

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

53
Q
  1. The most common cause of sudden death in RA?
  2. basilar invagination
  3. C1-2 instability
  4. subaxial instability
  5. Chernobyl took care of this patient
A

ANSWER: A

2011

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

JAAOS - Rheumatoid C-Spine

54
Q
  1. 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?
  2. In situ fusion with bone graft with or without fixation
  3. Close follow up in a 3 months with xray
  4. Return to clinic for follow up once symptoms progress
  5. Anterior fusion with or without fixation
A

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
55
Q
  1. 15 yo with grade II spondy. Failed all non-operative treatment. Fully N/V intact. What now
  2. L4-S1 posterolateral fusion
  3. L5 laminectomy with L5/S1 posterolateral fusion
  4. Pantaloon and hip spica
A

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

56
Q
  1. In performing reduction of a high-grade spondylolisthesis:
  2. Strain on the L5 nerve root is proportional to the amount of translational correction
  3. Incidence of L5 nerve root injury is 30%
  4. Risk of L5 nerve root injury is related to the degree of correction of the sacral angle
A

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

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
58
Q
  1. What nerve root(s) in adult L5-S1 isthmic spondylolisthesis will be affected?
  2. L5
  3. L5 and S1
  4. S1
  5. L4 and L5
A

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)

59
Q
  1. All of the following are associated with isthmic spondylolisthesis, except?
  2. Inuit heritage
  3. Elongation of the pars
  4. Increased disability from back pain
  5. Spina bifida occulta
A

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

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
61
Q
  1. 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:
  2. MRI shows normal signal in L5-S1 disc
  3. MRI shows normal signal in L4-5 disc
  4. L5-S1 spondylolisthesis present
  5. no neuro symptoms/signs
A

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

62
Q
  1. Patient presents with cervical myelopathy and upper motor neuron signs. All of the following are UMN signs except?
  2. Scapulohumeral reflex
  3. Jaw jerk
  4. Hoffmans
  5. Babinski
A

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
63
Q
  1. Patient with hyperreflexia and ataxic gait. MRI shows L4/5 severe spinal stenosis. What is the next step?
  2. Posterior decompression
  3. MRI C+T spine
  4. Fuse L4/5
  5. Physio
A

ANSWER: B

2016

64
Q
  1. Pt. With known lumbar spinal stenosis treated non operatively. Which exercises should he avoid?
  2. hip flexor stretching
  3. pelvic tilt
  4. flexion exercises
  5. Lumbar paraspinal extension stretching
A

ANSWER: D

2011

Position of provocation is extension

65
Q
  1. Spinal stenosis. What is least useful?
  2. physical exam
  3. treadmill stress
  4. MRI
  5. SF-36
A

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
66
Q
  1. What is NOT a predictor of poor outcome after lumbar stenosis surgery?
  2. Poor ambulation pre-op
  3. Poor general health pre-op
  4. Cardiovascular disease
  5. Patient required a decompression and fusion intra-op
A

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”

67
Q
  1. All of the following are true regarding a thoracic disc herniation, except:
  2. Resect the T9 rib head for a T8/9 disc
  3. Less common than cervical and lumbar disc degeneration
  4. Should be addressed with a posterior laminectomy
  5. May show calcifications on CT
A

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
68
Q
  1. What is not associated with Charcot spondyloarthropathy:
  2. Equal risk with all ASIA grades
  3. Associated with unrecognized low virulence surgical site infection
  4. Can be stabilized with a short segment fusion
A

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
69
Q
  1. What is advantage of dynamic plate for anterior spine- all advantages except
  2. Increased fusion rate
  3. Allows subsidence
  4. Load shares with subsidence
  5. Hasn’t been shown to make a difference
A

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”
70
Q
  1. 5 radiographic or clinical features suggesting an unstable C spine injury (2012, 2014)
A
  • 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
71
Q
  1. What are the most important predictors of instability in a thoracolumbar fracture (3 points)? (2015)
A

TLICS:

  • Fracture morphology (translation/rotation and distraction are worst)
  • Neurologic Injury
  • Damage to posterior ligamentous complex
72
Q
  1. List 5 negative prognostic factors for Type 2 odontoid fractures (2010, 2011, 2016)
A

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
73
Q
  1. CT of upper C spine showing possible C0-C1 dissociation. All of the following except:
  2. Shows altantooccipital dissociation
  3. Powers ratio > 1
  4. Increased distance between dens and basion
  5. Basion dens interval decreased.
A

ANSWER: D

2008

JAAOS 2014 - Upper Cervical Spine Trauma

Increased BDI and BAI

74
Q

 

  1. 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?
  2. Unilateral facet fracture-dislocation
  3. Bilateral perched facets
  4. Flexion teardrop fracture
  5. It is likely just a cervical strain
A

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”
75
Q
  1. All of the following are true about a lumbar burst fracture, except
  2. It is usually the inferior endplate that is retropulsed
  3. Facet joints can be diastased
  4. Pedicles widened on AP
  5. Lamina often involved
A

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
76
Q
  1. Burst fracture; all of the following except?
  2. Anterior vertebral body is disrupted
  3. Posterior vertebral body is disrupted
  4. Lamina are fractured
  5. There is a linear correlation with the amount of retropulsion and neurological injury
A

ANSWER: D

2012

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

77
Q
  1. 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?
  2. L1 laminectomy
  3. T12-L2 posterior fusion
  4. Thoracoabdominal approach with L1 corpectomy and anterior column reconstruction
  5. Observation
A

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
78
Q
  1. Thoracolumbar burst fracture with significant canal compromises treated non-operatively. What happens to canal afterwards.
  2. Canal stays the same
  3. Canal increases in size
  4. Canal decreases in size
  5. Lateral recess stenosis
A

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
79
Q
  1. What is the most likely functional expectation of a quadriplegic with motor function intact to C7?
  2. Fully independent transfers
  3. Regular use of a manual wheelchair
  4. Electric wheelchair
  5. Ambulatory
A

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
80
Q
  1. Given a sagittal CT cut showing a T5 flexion distraction injury. What is the neurological injury?
  2. anterior
  3. complete
  4. mixed UMN & Lower
  5. central
A

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
81
Q
  1. MRI of severe cervical flexion injury with posterior displacement of the body. What is the most likely spinal cord injury?
  2. UMN
  3. Anterior cord
  4. Central cord
  5. LMN
A

ANSWER: B

2010

Wheeless:

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

82
Q
  1. Thoracolumbar fracture what is true? 
  2. UMN only
  3. LMN only
  4. Nerves in the cauda equina recover the same as peripheral nerve injuries
  5. conus end at L2-L3
A

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.
83
Q
  1. 3mm displaced odontoid fracture. Neuro intact. Fracture of posterior arch C1. All are possible treatments EXCEPT
  2. Halo Vest
  3. C1-C2 posterior wiring + Bone graft
  4. C1-C2 trans-articular screws + Bone Graft
  5. C1 lateral mass screws connected to C2 pedicle screws + Bone graft
A

ANSWER: B

2008

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

84
Q
  1. All are poor prognostic indicators of recovery after whiplash injury EXCEPT:
  2. Sedentary occupation
  3. Radiculopathy at time of injury
  4. Spondylosis preceding injury
  5. Female gender
A

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
85
Q
  1. What is true about hangman fractures
  2. Usually associated with neuro deficit
  3. Associated with C3-C4 interspinous ligament injury
  4. Good union rate with conservative management
  5. Usually a flexion mechanism
A

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)
86
Q
  1. Regarding Charcot spine:
  2. Low virulence postoperative infection
  3. Indication for long-term followup for SCI patients.
  4. Regardless of ASIA grade, equal risk of developing Charcot spine
  5. Short posterolateral fusion is sufficient
A

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

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*)
88
Q
  1. Which of the following is true:
  2. Basilar-dental interval <12mm
  3. Basilar-atlantal interval <12mm
  4. Space available for cord <13mm
  5. PADI <15mm
A

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
89
Q
  1. All of the following are true regarding SCIWORA except:
  2. Physiologic deficits do not correlate with anatomical abnormality
  3. Higher level cervical injuries are worse than lower level cervical injuries
  4. Thoracic deficits are the most common
  5. 25% will present with delayed onset of neuro symptoms
A

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
90
Q
  1. All are true regarding spondylolisthesis EXCEPT:
  2. High slip grades associated with decreased pelvic incidence
  3. Associated with spina bifida occulta
  4. Pelvic incidence is fixed
  5. Pelvic tilt changes with position
A

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°
91
Q
  1. Regarding ACDF, which is true:
  2. 70% risk of dysphagia
  3. 80-85% fusion rate
  4. Recurrent laryngeal nerve is the most common neurological injury
  5. Titanium cage has better fusion rate than allograft
A

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

92
Q
  1. All of the following are true regarding thoracic disc herniation except:
  2. Resect the T9 rib head for T8/T9 disc
  3. Less common than cervical and lumbar spine
  4. Should be addressed with posterior laminectomy
  5. It can be difficult to find the correct level in the thoracic spine
A

ANSWER: C

2019

93
Q
  1. Which syndrome can leave you with lasting bowel and bladder dysfunction but return to walking within 3 months post injury?
  2. Anterior Cord
  3. Brown-Sequard
  4. ASIA –A
  5. Conus medullaris
A

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.

94
Q
  1. What is most true with respect to cervical spondylolytic myelopathy?
  2. Decreased proprioception
  3. Less than 4 beats of clonus
  4. Nerve root tension signs
  5. Hyporeflexia in the upper extremity
A

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)
95
Q
  1. All of the following are correct landmarks for inserting an L3 pedicle screw EXCEPT?
  2. Inferolateral aspect of L2-3 facet joint
  3. Inferolateral aspect of L3-4 facet joint
  4. Junction of the middle third of transverse process and a line through the center of the facet joint
  5. Junction of the middle third of transverse process and a line through the mammillary process and pars
A

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
96
Q
  1. All following are associated with isthmic spondylosthesis, except?
  2. Spina bifidia and isthmic spondy
  3. Degenerative spondylolisthesis and spondylosisis
  4. Pars elongation and isthmic spondy
A

ANSWER: B

2019

97
Q
  1. What is true with respect to burst of the cervical spine
  2. They are due to a pure axial load
  3. They are the most common cervical spine fracture
  4. Is rarely retropulses into the canal
  5. it is more common in the upper than the lower cervical spine
A

ANSWER: A

2019

98
Q
  1. When can you retract on the cord in spine surgery? 
  2. Above the conus 
  3. Below the conus 
  4. Below T12 
  5. Never appropriate 
A

ANSWER: B

2019

99
Q
  1. What is the greatest risk factor for chronic pain after a whiplash mechanism? 
  2. Severity of the pain at initial injury 
  3. Mechanism 
  4. Level of education 
  5. Type of vehicle 
A

ANSWER: A and C

2019

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

100
Q
  1. Which syndrome will/can leave you with lasting bowel and bladder dysfunction but return to walking 3 months after injury?
  2. Conus medullaris
  3. Anterior cord syndrome
  4. Brown-Sequard
  5. ASIA – A
A

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.

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

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.

102
Q
  1. 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.
  2. Horner’ syndrome
  3. Ascending cervical syndrome
  4. Spinal shock
  5. Vertebrobasilar insufficiency
A

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

103
Q
  1. All of the following are landmarks that can be used to find the start point for L3 pedicle screws except:
  2. The confluence of the transverse process and the midpoint of the facet
  3. The confluence of the transverse process and the lateral lamina
  4. The inferolateral portion of the L3/L4 facet
  5. The inferolateral portion of the L2/L3 facet
A

Answer: C (2017)

Yes

Yes

That would give L4

Yes. That would give L3

104
Q
  1. 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?
  2. Transpedicular decompression + fusion
  3. Posterior laminectomy and fusion
  4. Transthoracic decompression + fusion
  5. Costotransversectomy
A

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

105
Q
  1. Guy gets stabbed in the neck. What are the following SCI findings you would expect to see?
  2. Ipsilateral loss of motor, contralateral loss of vibration and proprioception
  3. Ipsilateral loss of motor, contralateral loss of light touch
  4. Ipsilateral loss of motor, ipsilateral loss of temp/pain
  5. Ipsilateral loss of motor, contralateral loss of temp/pain
A

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)
106
Q
  1. OC dislocation plain radiographic parameters.?
  2. BDI > 12mm
  3. ADI > 3mm
  4. SAC < 13mm
  5. BAI < 12mm
A

Answer: A (2017, 2019)

107
Q
  1. Question about concomitant scoliosis and spondy. What is not true?
  2. Correcting spondy will lead to resolution of postural curves
  3. Correcting scoliosis will eliminate nerve root symptoms associated with L5/S1 spondylolisthesis
  4. Spondylolisthesis is associated with decreased pelvic incidence
  5. Correcting spondylolisthesis will lead to resolution of adolescent idiopathic scoliosis.
A

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)
108
Q
  1. In treating an elderly man with lumbar stenosis all of the following are true except:
  2. Radiographs should be used to help plan the surgical procedure.
  3. MRI is used to plan surgical procedure
  4. Bilateral laminectomies are an absolute indication for posterior spinal fusion.
  5. Age will play a role in determining the correct surgery.
A

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.

109
Q
  1. All of the following are treatment options for odontoid fractures in the elderly except:
  2. Posterior screw-rod constructs in comminuted fractures
  3. Collar immobilization in undisplaced fractures.
  4. Halo vest immobilization in undisplaced fractures.
  5. Posterior screw-rod constructs in displaced fractures.
A

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

110
Q
  1. What are the clinical findings in Brown-Sequard syndrome? Lesion is on the left side.
  2. Left motor deficit, temp/pain and vibration/proprioception deficit on right
  3. Left motor deficit, vibration/proprioception deficit on right
  4. Left motor deficit, temp/pain deficit in right
  5. Left motor, left temp/pain deficit
A

Answer: C (2017)

111
Q
  1. 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?
  2. Upper extremity weakness > lower extremity weakness, distal weakness >proximal weakness
  3. Lower extremity weakness > upper extremity weakness, distal weakness >proximal weakness
  4. Upper extremity weakness = lower extremity weakness, distal weakness >proximal weakness
  5. Lower extremity weakness >upper extremity weakness, proximal weakness > distal weakness
A

ANSWER: A

2018

Spinal stenosis –> central cord syndrome

112
Q
  1. In c spine flexion-distraction trauma, which of the following is a relative contraindication to ACDF at the C5-C6 level?
  2. C5 superior process fracture
  3. C5/6 annulus tear
  4. C6 facet fracture
  5. C6 superior end plate fracture
A

ANSWER: D

2018

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

ANSWER: C

2018

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

Cervical areas are more lateral

114
Q
  1. A patient has a C7 spinal level injury. What is his expected function?
  2. Fully independent transfers
  3. Daily use of a manual wheelchair
  4. Use of a motorized wheelchair
  5. Electric wheel chair with head control
A

ANSWER: B (not FULLY independent for transfers)

2019

115
Q
  1. Which of the following is true regarding hemiepihiseodesis for congenital scoliosis?
  2. You get 15 degrees of correction per year
  3. It is best done between ages 5 and 10
  4. It is best for unilateral bars
  5. It is best for curves <50 degrees
A

ANSWER: D

2018

Unilateral bar = in situ arthrodesis

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

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

116
Q
  1. 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?
  2. Right supraclavicular numbness and right shoulder shrug (abduction) weakness
  3. Weak shoulder abduction and numbness along shoulder
  4. Right lateral shoulder numbness and right elbow flexion weakness – c5 nerve root
  5. Right lateral shoulder numbness and right wrist flexion weakness
A

ANSWER: C

2018

117
Q
  1. Which of the following regarding isthmic spondylolisthesis is true?
  2. Occurrence in the Inuit population is rare
  3. It is most common at L4/5
  4. It is not associated with an increased risk for back pain as an adult
A

ANSWER: C

2018

Rate of back pain same as general population (JAAOS)

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

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

Z MCQ Of OrthoBullets (27 decks)

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