Spine 2013 Flashcards
- Figures 7a through 7c are the radiograph and MRI scans of a 72-year-old woman who has had back and leg pain for 3 months. Her pain is worse with prolonged walking and relieved with bending forward. Examination reveals normal strength and sensation in her legs with intact pedal pulses. She has persistent pain despite physical therapy, medications, and epidural injections. What is the most appropriate treatment option?
- Laminectomy
- Laminectomy and instrumented fusion
- Laminectomy and uninstrumented fusion
- Endovascular aortic bypass
- Anterior lumbar interbody fusion
- Laminectomy and instrumented fusion
RECOMMENDED READINGS
Weinstein JN, Lurie JD, Tosteson TD, Zhao W, Blood EA, Tosteson AN, Birkmeyer N, Herkowitz H, Longley M, Lenke L, Emery S, Hu SS. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. Four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009 Jun;91(6):1295-304. PubMed PMID: 19487505.
- Figure 19 is the T2-weighted MRI scan of a 25-year-old man who is seen in the emergency department after falling off of a roof. Examination revealed he has 3/5 strength in his bicep muscles bilaterally but no motor or sensory function in his hands. For this type of injury, early decompression within 24 hours gives
what advantage?
- Reduced mortality
- Improved neurologic outcomes
- Lower risk for pulmonary embolus
- Decreased incidence of hospital readmission
- Earlier discharge to a skilled rehabilitation facility
- Improved neurologic outcomes
RECOMMENDED READINGS
Fehlings MG, Vaccaro A, Wilson JR, Singh A, W Cadotte D, Harrop JS, Aarabi B, Shaffrey C, Dvorak M, Fisher C, Arnold P, Massicotte EM, Lewis S, Rampersaud R. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One. 2012;7(2):e32037. Epub 2012 Feb 23. PubMed PMID: 22384132.
Fehlings MG, Rabin D, Sears W, Cadotte DW, Aarabi B. Current practice in the timing of surgical intervention in spinal cord injury. Spine (Phila Pa 1976). 2010 Oct 1;35(21 Suppl):S166-73. Review. PubMed PMID: 20881458.
- Figures 27a and 27b are the MRI scans of a 31-year-old woman with low-back and left leg pain radiating into her posterior thigh and calf for 2 weeks. Examination reveals a positive straight-leg raise, normal strength, and normal sensation in the lower extremities. What is the most appropriate treatment option?
- Nonsurgical care
- Microdiscectomy
- Subtotal discectomy
- Anterior decompression and fusion
- Posterior decompression and fusion
- Nonsurgical care
RECOMMENDED READINGS
Weinstein JN, Lurie JD, Tosteson TD, Tosteson AN, Blood EA, Abdu WA, Herkowitz H, Hilibrand A, Albert T, Fischgrund J. Surgical versus nonoperative treatment for lumbar disc herniation: fouryear Results for the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976). 2008 Dec 1;33(25):2789-800. PubMed PMID: 19018250.
Anderson PA, McCormick PC, Angevine PD. Randomized controlled trials of the treatment of lumbar disk herniation: 1983-2007. J Am Acad Orthop Surg. 2008 Oct;16(10):566-73. Review. PubMed PMID: 18832600.
- A physician shws interest in determining the evidence base fo use of a specific interbody fusion technique in the treatment of lumbar degenerative disc disease. A search of the literature reveals 4 studies that retrospectively reviewed outcomes for series comprising fewer than 20 patients each. Another study retrospectively compared results of the interbody fusion technique to posterolateral fusion. All of the studies reported satisfactory outcomes for the interbody fusion technique, while the comparative study found interbody fusion to be superior to posterolateral fusion. The quality of evidence supporting the use of the interbody fusion technique would be graded as
- B (fair-quality evidence), attributable to the fact that a single level III study supports use of the interbody fusion technique
- B (fair-quality evidence), attributable to the fact that multiple level IV studies and a single level III study support its use
- C (poor-quality evidence), attributable to the fact that multiple level IV studies and a single level III study support its use
- C (poor-quality evidence), attributable to the fact that multiple level V studies and a single level III study support its use
- I (no evidence), attributable to the fact that the studies found in the literature are of insufficient quality to allow recommendation in support of the technique
- C (poor-quality evidence), attributable to the fact that multiple level IV studies and a single level III study support its use
RECOMMENDED READINGS
Wright JG, Swiontkowski MF, Heckman JD. Introducing levels of evidence to the journal. J Bone Joint Surg Am. 2003 Jan;85-A(1):1-3. PubMed PMID: 12533564.
Wright JG. A practical guide to assigning levels of evidence. J Bone Joint Surg Am. 2007 May;89(5):1128- 30. PubMed PMID: 17473152.
Okike K, Kocher MS. Evidence-based orthopaedics: levels of evidence and guidelines in orthopaedic surgery. In: Flynn JM, ed. Orthopaedic Knowledge Update 10. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011:157-165.
- Figures 45a and 45b are the sagittal and axial T2-weighted MRI scans of a 39-year-old man with a 30month history of symptoms. Examination findings are most likely to inidicate decreased sensation in the left.
- upper arm, with weakness in the biceps.
- index finger, with weakness in the hand intrinsics.
- small finger, with weakness in the wrist extension.
- middle finer, with weakness in wrist flexion.
- radial forearm, with weakness in shoulder abduction.
- middle finer, with weakness in wrist flexion.
RECOMMENDED READINGS
Rhee JM, Yoon T, Riew KD. Cervical radiculopathy. J Am Acad Orthop Surg. 2007 Aug;15(8):486-94. Review. PubMed PMID: 17664368.
Caridi JM, Pumberger M, Hughes AP. Cervical radiculopathy: a review. HSS J. 2011 Oct;7(3):265-72. Epub 2011 Sep 9. PubMed PMID: 23024624.
- Figures 55a and 55b are the radiograph and CT scan of a 61-year-old woman who has had neck pain after being involved in a high-speed motor vehicle collision. Examination reveals normal strength and sensation in both upper and lower extremities, normal rectal tone, and no other injuries. The C1-C2 lateral mass overhang measures 8.5 mm. What is the most appropriate treatment option?
- Halo-vest orthosis
- C1-C2 posterior cervical fusion
- Occiput to C2 posterior cervical fusion
- Cervical traction and closed reduction
- Open reduction and internal fixation of C1
- C1-C2 posterior cervical fusion
RECOMMENDED READINGS
Spence KF Jr, Decker S, Sell KW. Bursting atlantal fracture associated with rupture of the transverse ligament. J Bone Joint Surg Am. 1970 Apr;52(3):543-9. PubMed PMID: 5425648.
- Figure 67 is the MRI scan of a 43-year-old man with an acute onset of neck pain, bilateral upper-extremity weakness, and burning pain in his arms after hitting his head on a bookshelf. Examination initially revealed 3/5 strength in both upper extremities, with normal motor strength in the lower extremities. What is the best description of his spinal cord injury?
- Central cord syndrome
- Anterior cord syndrome
- Posterior cord syndrome
- Brown-Séquard syndrome
- Complete spinal cord injury
- Central cord syndrome
RECOMMENDED READINGS
Nowak DD, Lee JK, Gelb DE, Poelstra KA, Ludwig SC. Central cord syndrome. J Am Acad Orthop Surg. 2009 Dec;17(12):756-65. Review. PubMed PMID: 19948700.
Dvorak MF, Fisher CG, Hoekema J, Boyd M, Noonan V, Wing PC, Kwon BK. Factors predicting motor recovery and functional outcome after traumatic central cord syndrome: a long-term follow-up. Spine (Phila Pa 1976). 2005 Oct 15;30(20):2303-11. Erratum in: Spine. 2006 May 15;31(11):1289. Kwon, Brian [corrected to Kwon, Brian K]. PubMed PMID: 16227894.
- Figures 93a through 93c are the radiograph and CT and MRI scans of a 35-year-old man with diabetes mellitus. He had severe neck pain for 6 weeks. He now has fevers and progressive weakness and numbness in his upper extremities. Examination reveals 4/5 strength in both upper extremities, with decreased sensatrion in both arms and hands and hyperreflexia. What is the most appopriate treament option?
- Halo-vest fixation
- Intravenous antibiotics
- Posterior laminectomy
- Percutaneous aspiration
- Circumferential decompression and fusion
- Circumferential decompression and fusion
RECOMMENDED READINGS
Shousha M, Boehm H. Surgical treatment of cervical spondylodiscitis: a review of 30 consecutive patients. Spine (Phila Pa 1976). 2012 Jan 1;37(1):E30-6. PubMed PMID: 21494200.
Heyde CE, Boehm H, El Saghir H, Tschöke SK, Kayser R. Surgical treatment of spondylodiscitis in the cervical spine: a minimum 2-year follow-up. Eur Spine J. 2006 Sep;15(9):1380-7. Epub 2006 Jul 26. PubMed PMID: 16868782.
- For patients undergoing posterior lumbar fusion, which risk factor is most responsible for development of adjacent segment degeneration that necessitates further surgery?
- Male gender
- Single-level construct
- Patient age younger than 45 years
- Extension of the fusion to the sacrum
- Laminectomy adjacent to the fusion
- Laminectomy adjacent to the fusion
RECOMMENDED READINGS
Sears WR, Sergides IG, Kazemi N, Smith M, White GJ, Osburg B. Incidence and prevalence of surgery at segments adjacent to a previous posterior lumbar arthrodesis. Spine J. 2011 Jan;11(1):11-20. PubMed PMID: 21168094.
Cheh G, Bridwell KH, Lenke LG, Buchowski JM, Daubs MD, Kim Y, Baldus C. Adjacent segment disease following lumbar/thoracolumbar fusion with pedicle screw instrumentation: a minimum 5-year follow-up. Spine (Phila Pa 1976). 2007 Sep 15;32(20):2253-7. PubMed PMID: 17873819.
- Figures 124a and 124b are the MRI scans of a 74-year-old mam who has difficulty walking distances attributable to pain in both lower extremities. His leg pain is worse with lumbar extension and improves with forward flexion. Examination revecals full strength and sensation in all 4 extremities. He shows hyperreflexia and gait imbalance. He has tried physical therapy, medications and epidural inection without experiencing symptom relief. What is the most appropriate next step?
- Daily lumbar traction
- Referral to pain management
- Lumbar decompression surgery
- Spinal cord stimulator placement
- An MRI scan of the cervical spine
- An MRI scan of the cervical spine
RECOMMENDED READINGS
Bajwa NS, Toy JO, Young EY, Ahn NU. Is congenital bony stenosis of the cervical spine associated with lumbar spine stenosis? An anatomical study of 1072 human cadaveric specimens. J Neurosurg Spine. 2012 Jul;17(1):24-9. Epub 2012 Apr 27. PubMed PMID: 22540170.
Lee MJ, Garcia R, Cassinelli EH, Furey C, Riew KD. Tandem stenosis: a cadaveric study in osseous morphology. Spine J. 2008 Nov-Dec;8(6):1003-6. PubMed PMID: 18280216.
- Figures 141a and 141b are the lumbar CT scans of a 16-year-old baseball pitcher who has had low-back pain for 3 months. He has no radiating pain, numbness, or weakness. His pain is worsened by extension and relieved with flexion. Examinaiton reveals normal strength and sensation in his lower extremities. What is the most likely diagnosis?
- Spondylosis
- Spondylolysis
- Spondylolisthesis
- Osteoid osteoma
- Congenital dysplasia
- Spondylolysis
RECOMMENDED READINGS
Cheung EV, Herman MJ, Cavalier R, Pizzutillo PD. Spondylolysis and spondylolisthesis in children andadolescents: II. Surgical management. J Am Acad Orthop Surg. 2006 Aug;14(8):488-98. Review. PubMedPMID: 16885480.
Saifuddin A, White J, Tucker S, Taylor BA. Orientation of lumbar pars defects: implications forradiological detection and surgical management. J Bone Joint Surg Br. 1998 Mar;80(2):208-11. PubMed PMID: 9546445.
- Figure 162 is the CT scan of a 74-year-old woman who struck her head during a ground-level fall and has severe neck pain. Examination reveals normal strength and sensation in her upper and lower extremities. What is the most appropriate treatment option?
- Cervical traction
- Halo-vest orthosis
- Anterior single-level fusion
- Posterior single-level fusion
- Posterior multilevel fusion
- Posterior multilevel fusion
RECOMMENDED READINGS
Kubiak EN, Moskovich R, Errico TJ, Di Cesare PE. Orthopaedic management of ankylosing spondylitis. JAm Acad Orthop Surg. 2005 Jul-Aug;13(4):267-78. PubMed PMID: 16112983.
Whang PG, Goldberg G, Lawrence JP, Hong J, Harrop JS, Anderson DG, Albert TJ, Vaccaro AR. The management of spinal injuries in patients with ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis: a comparison of treatment methods and clinical outcomes. J Spinal Disord Tech. 2009 Apr;22(2):77-85. PubMed PMID: 19342927.
- Figure 181 is the MRI scan of a 59-year-old woman who has had no medical comorbidities but has had difficulty with walking and balance for the past 6 months. She has severe pain in her neck and arms as well as clumsiness and weakness in her arms. Examination reveals hyperrelexia in her upper and lower extremities, a positive Hoffmann sign, and inability to perform rapid alternating movements. What intervention would most likely produce the best long-term result?
- Immobilization
- Physical therapy
- Surgical decompression
- Neurology consultation
- Cervical epidural injection
- Surgical decompression
RECOMMENDED READINGS
Harrop JS, Naroji S, Maltenfort M, Anderson DG, Albert T, Ratliff JK, Ponnappan RK, Rihn JA, Smith HE, Hilibrand A, Sharan AD, Vaccaro A. Cervical myelopathy: a clinical and radiographic evaluation and correlation to cervical spondylotic myelopathy. Spine (Phila Pa 1976). 2010 Feb 10. [Epub ahead of print] PubMed PMID: 20150835.
Emery SE. Cervical spondylotic myelopathy: diagnosis and treatment. J Am Acad Orthop Surg. 2001 Nov-Dec;9(6):376-88. Review. PubMed PMID: 11767723.
- Figures 190a and 190b are the sagittal and axial T2-weighted MRI scans of a 75-year-old man who is experienceing progressively worsening bilateral lower-extremity pain and difficulty walking distances. In another 4 years, nonsurgical treatment of his condition–compared to surgical treatment–is expected to result in
- equal improvement in pain.
- equal improvement in function.
- less improvement in pain.
- more improvement in pain.
- more improvement in function.
- less improvement in pain.
RECOMMENDED READINGS
Weinstein JN, Tosteson TD, Lurie JD, Tosteson A, Blood E, Herkowitz H, Cammisa F, Albert T, Boden SD, Hilibrand A, Goldberg H, Berven S, An H. Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial. Spine (Phila Pa 1976). 2010 Jun 15;35(14):1329-38. PubMed PMID: 20453723.
Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Blood EA, Hanscom B, Herkowitz H, Cammisa F, Albert T, Boden SD, Hilibrand A, Goldberg H, Berven S, An H; SPORT Investigators. Surgical versus nonsurgical therapy for lumbar spinal stenosis.N Engl J Med. 2008 Feb 21;358(8):794-810. doi: 10.1056/ NEJMoa0707136. PubMed PMID: 18287602.
198.
Figure 198 is the T2 sagittal MRI scan of a 47-year-old woman who has experienced pain in her lower back and difficulty waking distancs during the past 3 years. She has tried physical therapy, nonsteroidal anti-inflammatory drugs, and multiple epidural injections without symptomatic releif. Which surgical treatment is associated with the best outcome?
- L4-L5 microdiscectomy
- L4-L5 anterior interbody fusion
- L4-L5 laminectomy
- L4-L5 laminectomy and posterior uninstrumented fusion
- L4-L5 laminectomy and posterior instrumented fusion
- L4-L5 laminectomy and posterior instrumented fusion
RECOMMENDED READINGS
Kornblum MB, Fischgrund JS, Herkowitz HN, Abraham DA, Berkower DL, Ditkoff JS. Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective long-term study comparing fusion and pseudarthrosis. Spine (Phila Pa 1976). 2004 Apr 1;29(7):726-33; discussion 733-4. PubMed PMID: 15087793.
Majid K, Fischgrund JS. Degenerative lumbar spondylolisthesis: trends in management. J Am Acad Orthop Surg. 2008 Apr;16(4):208-15. Review. PubMed PMID: 18390483.
- Figures 222a and 222b are the radiograph and MRI scan of a 41-year-old man who has had severe leg pain for 6 months despite physical therapy and medications. Examination reveals normal strength and sensation in both lower extremities. What is the most effective treatment option?
- Lumbar interlaminar epidural injection
- Lumbar transforaminal epidural injection
- Posterior lumbar laminectomy
- Posterior lumbar laminectomy and fusion
- Posterior lumbar laminectomy and interbody fusion
RECOMMENDED READINGS
Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Blood E, Hanscom B, Herkowitz H, Cammisa F, Albert T, Boden SD, Hilibrand A, Goldberg H, Berven S, An H; SPORT Investigators. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med. 2008 Feb 21;358(8):794-810. PubMed PMID: 18287602.
Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010 Apr 7;303(13):1259-65. PubMed PMID: 20371784.
- Figure 236 is the lateral radiograph of a 77-year-old man who had neck pain after a low-speed motor vehicle collision. He had diffuse tenderness to palpation over his posterior cervical spine but the remainder of the examination was unremarkable. Plain radiographs including Figure 236 were negative
or any evidence of fracture. What is the best next step in management?
- Pulmonary function testing
- An MRI scan of the cervical spine
- Physical therapy and oral steroids
- Immobilization in a rigid cervical collar for 6 weeks
- Referral to a rheumatologist
- An MRI scan of the cervical spine
RECOMMENDED READINGS
Whang PG, Goldberg G, Lawrence JP, Hong J, Harrop JS, Anderson DG, Albert TJ, Vaccaro AR. The management of spinal injuries in patients with ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis: a comparison of treatment methods and clinical outcomes. J Spinal Disord Tech. 2009 Apr;22(2):77-85. PubMed PMID: 19342927.
Caron T, Bransford R, Nguyen Q, Agel J, Chapman J, Bellabarba C. Spine fractures in patients with ankylosing spinal disorders. Spine (Phila Pa 1976). 2010 May 15;35(11):E458-64. PubMed PMID: 20421858.
Westerveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. Eur Spine J. 2009 Feb;18(2):145-56. Epub 2008 Sep 13. Review. PubMed PMID: 18791749.
- Figure 260 is the MRI scan of an 84-year-old woman who is admitted to the hospital with pain in her mid back that started 8 weeks ago after a fall from a standing height. Examination reveals normal strength and sensation. Her reflexes and rectal tone are normal. According to the most recent AAOS clincal practice guideline, The Treatment of Symptomatic Osteoporotic Spinal Compression Fractures, which recommendation is based on conclusive evidence for the treatment of her pain?
- Brace
- Calcitonin
- Ibandronate
- Bed rest and opioids
- A supervised exercise program
- Ibandronate
RECOMMENDED READINGS
Esses SI, McGuire R, Jenkins J, Finkelstein J, Woodard E, Watters WC III, Goldberg MJ, Keith M, Turkelson CM, Wies JL, Sluka P, Boyer KM, Hitchcock K. The treatment of symptomatic osteoporotic spinal compression fractures. J Am Acad Orthop Surg. 2011 Mar;19(3):176-82. PubMed PMID: 21368099.
Sieber P, Lardelli P, Kraenzlin CA, Kraenzlin ME, Meier C. Intravenous bisphosphonates for postmenopausal osteoporosis: saftey profiles of zoledronic acid and ibandronate in clincal pactice. CLin Drug Investig. 2013 Feb;33(2):117-22. doi: 10.1007/s40261-012-0041-1. PubMed PMID: 23184667.
- Figures 271a and 271b are the MRI scans of a 49-year-old woman with pain that has been radiating down her right lower extremity to the dorsum of her foot for the last 3 weeks. Examination revelas significant pain with a straight-leg raise and decreased sensation in the right big toe. What is the most appropriate next step in management?
- Right L4-L5 microdiscectomy
- Posterior L4-L5 decompression and fusion
- Trial of nonsteroidal anti-inflammatory drugs
- Neurology referral for nerve conduction studies
- Transcutaneous electrical nerve stimulation treatment for 3 hours daily
RECOMMENDED READINGS
Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Hanscom B, Skinner JS, Abdu WA, Hilibrand AS, Boden SD, Deyo RA. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006 Nov 22;296(20):2441-50. PubMed PMID: 17119140.
Weinstein JN, Lurie JD, Tosteson TD, Skinner JS, Hanscom B, Tosteson AN, Herkowitz H, Fischgrund J, Cammisa FP, Albert T, Deyo RA. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA. 2006 Nov 22;296(20):2451-9. PubMed PMID: 17119141.
Weinstein JN, Lurie JD, Tosteson TD, Tosteson AN, Blood EA, Abdu WA, Herkowitz H, Hilibrand A, Albert T, Fischgrund J. Surgical versus nonoperative treatment for lumbar disc herniation: fouryear results for the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976). 2008 Dec 1;33(25):2789-800. PubMed PMID: 19018250.
- Figures 274a and 274b are the MRI scans of a 53-year-old woman who has had severe, increasing midback pain for 3 weeks. She had a small bowel transplant 10 years ago. Examination reveals tenderness to palpation over the thoracic spine. She has full strength and sensation in all extremities, is normoreflexic throughout, and is currently afebrile. What is the most appropriate next step in management?
- Whole-body bone scan
- Outpatient physical therapy
- CT-guided biopsy of the thoracic spine
- Thoracic decompression and stabilization
- Referral to pain management for an epidural injection
- CT-guided biopsy of the thoracic spine
RECOMMENDED READINGS
Tay BK, Deckey J, Hu SS. Spinal infections. J Am Acad Orthop Surg. 2002 May-Jun;10(3):188-97. Review. PubMed PMID: 12041940.
Cousins JP, Haughton VM. Magnetic resonance imaging of the spine. J Am Acad Orthop Surg. 2009 Jan;17(1):22-30. Review. PubMed PMID: 19136424.
