Spine 2016 Flashcards
- In a well-designed prospective randomized study that provides level II evidence in favor of surgical treatment for the injury shown in Video 7, the primary outcome measure is the neck disability index (NDI) score, which shows an improvement of 5.5 points on a scale of 100 for patients treated with surgery (vs those who received nonsurgical treatment). This difference is statistically significant with a P value of 0.0001. The magnitude of difference and the P value suggests this difference
- is highly significant and should change treatment patterns in favor of surgery.
- is irrelevant because the study has only level II evidence.
- may or may not be a clinically important difference.
- does not reflect the number of patients enrolled in the study.
- has been miscalculated.
- may or may not be a clinically important difference.
RECOMMENDED READINGS
Vaccaro AR, Kepler CK, Kopjar B, Chapman J, Shaffrey C, Arnold P, Gokaslan Z, Brodke D, France J, Dekutoski M, Sasso R, Yoon ST, Bono C, Harrop J, Fehlings MG. Functional and quality-of-life outcomes in geriatric patients with type-II dens fracture. J Bone Joint Surg Am. 2013 Apr 17;95(8):729-35. doi: 10.2106/JBJS.K.01636. PubMed PMID: 23595072.
Young BA, Walker MJ, Strunce JB, Boyles RE, Whitman JM, Childs JD. Responsiveness of the Neck Disability Index in patients with mechanical neck disorders. Spine J. 2009 Oct;9(10):802-8. doi: 10.1016/j. spinee.2009.06.002. Epub 2009 Jul 25. PubMed PMID: 19632904.
- Figure 19 is the sagittal CT scan of a 57-year-old woman with symptomatic cervical myelopathy. The single factor favoring an anterior approach is
- a congenitally narrow spinal canal.
- multiple levels of pathology.
- kyphotic spinal alignment.
- degenerative disk disease.
- cervical spondylolisthesis.
- kyphotic spinal alignment.
RECOMMENDED READINGS
Lebl DR, Bono CM. Update on the Diagnosis and Management of Cervical Spondylotic Myelopathy. J Am Acad Orthop Surg. 2015 Nov;23(11):648-60. doi: 10.5435/JAAOS-D-14-00250. Review. PubMed PMID: 26498584.
Emery SE. Cervical spondylotic myelopathy: diagnosis and treatment. J Am Acad Orthop Surg. 2001 Nov-Dec;9(6):376-88. Review. PubMed PMID: 11767723.
- Video 27 is the CT scan of a neurologically intact patient who refuses surgical treatment for the injury shown, instead opting for treatment with a brace. Evidence-based medicine suggests that if this injury is treated with a brace rather than surgery, the result will be
- painful kyphosis, which will necessitate future surgery.
- better in the long term.
- better sagittal alignment.
- quicker recovery.
- an outcome comparable to surgery.
- an outcome comparable to surgery.
RECOMMENDED READINGS
Bailey CS, Urquhart JC, Dvorak MF, Nadeau M, Boyd MC, Thomas KC, Kwon BK, Gurr KR, Bailey SI, Fisher CG. Orthosis versus no orthosis for the treatment of thoracolumbar burst fractures without neurologic injury: a multicenter prospective randomized equivalence trial. Spine J. 2014 Nov 1;14(11):2557-64. doi: 10.1016/j.spinee.2013.10.017. Epub 2013 Oct 31. PubMed PMID: 24184649.
Alcalá-Cerra G, Paternina-Caicedo AJ, Díaz-Becerra C, Moscote-Salazar LR, Fernandes-Joaquim A. Orthosis for thoracolumbar burst fractures without neurologic deficit: A systematic review of prospective randomized controlled trials. J Craniovertebr Junction Spine. 2014 Jan;5(1):25-32. doi: 10.4103/0974- 8237.135213. PubMed PMID: 25013344.
- A lateral cervical radiograph is shown in Figure 35. Which abnormal laboratory value usually is associated with these findings?
- Rheumatoid factor (RF) or anti-citrullinated peptide/protein antibody (anti-CCP)
- Human leukocyte antigen B27 (HLA-B27)
- C-reactive protein (CRP)
- Trisomy 21
- Hemoglobin A1c (HgbA1c)
- Hemoglobin A1c (HbgA1C)
RECOMMENDED READINGS
Belanger TA, Rowe DE. Diffuse idiopathic skeletal hyperostosis: musculoskeletal manifestations. J Am Acad Orthop Surg. 2001 Jul-Aug;9(4):258-67. Review. PubMed PMID: 11476536.
Smith LL, Burnet SP, McNeil JD. Musculoskeletal manifestations of diabetes mellitus. Br J Sports Med. 2003 Feb;37(1):30-5. Review. PubMed PMID: 12547740.
Denko CW, Malemud CJ. Body mass index and blood glucose: correlations with serum insulin, growth hormone, and insulin-like growth factor-1 levels in patients with diffuse idiopathic skeletal hyperostosis (DISH). Rheumatol Int. 2006 Feb;26(4):292-7. Epub 2005 Feb 10. PubMed PMID: 15703952.
- Figure 45 is the MR image of a 79-year-old woman with hypertension who has a 3-month history of bilateral buttock pain while walking more than 200 feet. An evaluation should include
- examination of peripheral pulses.
- electromyography and nerve conduction studies.
- peripheral muscle biopsy.
- a serum coagulopathy profile.
- a CT myelogram.
- examination of peripheral pulses
RECOMMENDED READINGS
Grimm BD, Blessinger BJ, Darden BV, Brigham CD, Kneisl JS, Laxer EB. Mimickers of lumbar radiculopathy. J Am Acad Orthop Surg. 2015 Jan;23(1):7-17. doi: 10.5435/JAAOS-23-01-7. PubMed PMID: 25538126.
Issack PS, Cunningham ME, Pumberger M, Hughes AP, Cammisa FP Jr. Degenerative lumbar spinal stenosis: evaluation and management. J Am Acad Orthop Surg. 2012 Aug;20(8):527-35. doi: 10.5435/ JAAOS-20-08-527. Review. PubMed PMID: 22855855.
- The use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in spine fusions greatly decreased after which event?
- Published studies on 100% spine fusion with rhBMP-2 were redacted following an
investigation by the United States Department of Justice
- Iliac crest bone graft (ICBG) was shown to be better than rhBMP-2
- The Affordable Care Act (ACA) was enacted
- The Sunshine Act was enacted
- The original U.S. Food and Drug Administration (FDA) studies were subject to closer scrutiny
- The original US FDA studies were subject to closer scrutiny
RECOMMENDED READINGS
Laine C, Guallar E, Mulrow C, Taichman DB, Cornell JE, Cotton D, Griswold ME, Localio AR, Meibohm AR, Stack CB, Williams SV, Goodman SN. Closing in on the truth about recombinant human bone morphogenetic protein-2: evidence synthesis, data sharing, peer review, and reproducible research. Ann Intern Med. 2013 Jun 18;158(12):916-8. doi: 10.7326/0003-4819-158-12-201306180-00012. PubMed PMID: 23778911.
Carragee EJ, Hurwitz EL, Weiner BK. A critical review of recombinant human bone morphogenetic protein-2 trials in spinal surgery: emerging safety concerns and lessons learned. Spine J. 2011 Jun;11(6):471-91. doi: 10.1016/j.spinee.2011.04.023. Review. PubMed PMID: 21729796.
Martin BI, Lurie JD, Tosteson AN, Deyo RA, Farrokhi FR, Mirza SK. Use of bone morphogenetic protein among patients undergoing fusion for degenerative diagnoses in the United States, 2002 to 2012. Spine J. 2015 Apr 1;15(4):692-9. doi: 10.1016/j.spinee.2014.12.010. Epub 2014 Dec 15. PubMed PMID: 25523380.
- For patients with rheumatoid arthritis who are undergoing surgery for symptomatic cervical myelopathy, neurologic recovery after decompression is best predicted by presurgical
- basilar invagination less than 0.3 cm.
- subaxial subluxation less than 3.5 mm.
- atlanto-dens interval less than 2 mm.
- posterior atlanto-dens interval exceeding 13 mm.
- rotatory subluxation less than 10 degrees.
- posterior atlanto-dens interval exceeding 13 mm.
RECOMMENDED READINGS
Kim DH, Hilibrand AS. Rheumatoid arthritis in the cervical spine. J Am Acad Orthop Surg. 2005 Nov;13(7):463-74. Review. PubMed PMID: 16272271.
Garfin SR. Rheumatoid Arthritis of Cervical Spine Overview of Rheumatoid Spondylitis. Updated Dec 6, 2015. http://emedicine.medscape.com/article/1266195-overview (Accessed June 1, 2016).
- Video 77 is the CT scan of a patient who fell and hit his head. He does not have any upper or lower extremity weakness or numbness. He is ambulatory and has normal bowel and bladder function. Definitive treatment should include
- a rigid cervical collar.
- single-level anterior cervical diskectomy and fusion.
- combined anterior and posterior cervical surgery with a pedicle subtraction osteotomy.
- posterior cervical instrumentation and fusion.
- cervical disk arthroplasty to preserve motion and prevent adjacent segment degeneration.
- posterior cervical instrumentaiton and fusion
RECOMMENDED READINGS
Robinson Y, Robinson AL, Olerud C. Complications and survival after long posterior instrumentation of cervical and cervicothoracic fractures related to ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis. Spine (Phila Pa 1976). 2015 Feb 15;40(4):E227-33. doi: 10.1097/BRS.0000000000000726. PubMed PMID: 25494322.
Mathews M, Bolesta MJ. Treatment of spinal fractures in ankylosing spondylitis. Orthopedics. 2013 Sep;36(9):e1203-8. doi: 10.3928/01477447-20130821-25. PubMed PMID: 24025014.
Chaudhary SB, Hullinger H, Vives MJ. Management of acute spinal fractures in ankylosing spondylitis. ISRN Rheumatol. 2011;2011:150484. doi: 10.5402/2011/150484. Epub 2011 Jun 30. PubMed PMID: 22389792.
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. doi: 10.1097/ BRS.0b013e3181cc764f. PubMed PMID: 20421858.
- A patient with a smoking history has pain in her legs after walking. You are trying to distinguish a vascular etiology from a neurogenic etiology. Which response is associated with a vascular etiology?
- When walking, the pain will improve if she is leaning over a grocery cart
- Sitting down is necessary to relieve the pain
- Riding a bicycle does not cause any claudication
- Standing still relieves the pain
- Washing dishes at the sink aggravates the pain
- Standing still relieves the pain
Katz JN, Harris MB. Clinical practice. Lumbar spinal stenosis. N Engl J Med. 2008 Feb 21;358(8):818-25. doi: 10.1056/NEJMcp0708097. Review. PubMed PMID: 18287604.
Binder DK, Schmidt MH, Weinstein PR. Lumbar spinal stenosis. Semin Neurol. 2002 Jun;22(2):157-66. Review. PubMed PMID: 12524561.
- Based on the radiographic findings in Figures 110a through 110c, what is the most likely diagnosis?
- Diffuse interstitial skeletal hyperostosis (DISH)
- Ankylosing spondylitis (AS)
- Down syndrome with C1-C2 instability
- Rheumatoid arthritis (RA)
- Osteomyelitis
- Ankylosing spondylitis (AS)
RECOMMENDED READINGS
Kubiak EN, Moskovich R, Errico TJ, Di Cesare PE. Orthopaedic management of ankylosing spondylitis. J Am Acad Orthop Surg. 2005 Jul-Aug;13(4):267-78. PubMed PMID: 16112983.
Haroon N. Ankylosis in ankylosing spondylitis: current concepts. Clin Rheumatol. 2015 Jun;34(6):1003-7. doi: 10.1007/s10067-015-2956-4. PubMed PMID: 25935456.
Smith JA. Update on ankylosing spondylitis: current concepts in pathogenesis. Curr Allergy Asthma Rep. 2015 Jan;15(1):489. doi: 10.1007/s11882-014-0489-6. Review. PubMed PMID: 25447326.
- A study shows improved 1-month and 1-year survival rates for patients older than age 60 who undergo surgery for the injury shown in Video 124 vs survival for patients treated without surgery. If the study is a retrospective review and surgery was performed per surgeon preference, which type of bias is the most pressing concern?
- Selection
- Confirmation
- Recall
- Publication
- Interviewer
- Selection
RECOMMENDED READINGS
Chapman J, Smith JS, Kopjar B, Vaccaro AR, Arnold P, Shaffrey CI, Fehlings MG. The AOSpine North America Geriatric Odontoid Fracture Mortality Study: a retrospective review of mortality outcomes for operative versus nonoperative treatment of 322 patients with long-term follow-up. Spine (Phila Pa 1976). 2013 Jun 1;38(13):1098-104. doi: 10.1097/BRS.0b013e31828-6f0cf. PubMed PMID: 23354104.
Guyatt G, Rennie D, Meade MO, Cook DJ. Users’ Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. 3rd edition. New York, NY: McGraw Hill; 2015.
141b. Figures 141a through 141c are radiographs and an axial MRI scan. When discussing this patient’s condition, which statement is most accurate regarding the benefits and limitations associated with both surgery and continued nonsurgical care?
1. Continued nonsurgical treatment will produce the same long-term results as surgery
2. Fusion is absolutely required when considering surgery
3. Fusion should be done using bone morphogenetic protein (BMP)
4. Surgery will provide better short-term and long-term improvement
5. An instrumented fusion with pedicle screws and rods will provide a better result.
- Surgery will provide better short-term and long-term improvement.
RECOMMENDED READINGS
Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am. 1991 Jul;73(6):802-8. PubMed PMID: 2071615.
Pearson AM, Lurie JD, Tosteson TD, Zhao W, Abdu WA, Weinstein JN. Who should undergo surgery for degenerative spondylolisthesis? Treatment effect predictors in SPORT. Spine (Phila Pa 1976). 2013 Oct 1;38(21):1799-811. doi: 10.1097/BRS.0b013e3182a314d0. PubMed PMID: 23846502.
Sigmundsson FG, Jönsson B, Strömqvist B. Outcome of decompression with and without fusion in spinal stenosis with degenerative spondylolisthesis in relation to preoperative pain pattern: a register study of 1,624 patients. Spine J. 2015 Apr 1;15(4):638-46. doi: 10.1016/j.spinee.2014.11.020. Epub 2014 Nov 29. PubMed PMID: 25450653.
Kepler CK, Hilibrand AS, Sayadipour A, Koerner JD, Rihn JA, Radcliff KE, Vaccaro AR, Albert TJ, Anderson DG. Clinical and radiographic degenerative spondylolisthesis (CARDS) classification. Spine J. 2015 Aug 1;15(8):1804-11. doi: 10.1016/j.spinee.2014.03.045. Epub 2014 Apr 3. PubMed PMID: 24704503.
- Figures 163a and 163b are the MR images of a 45-year-old woman who has neck pain that is radiating into her right shoulder and arm after 3 weeks of nonsurgical treatment. There is no neurologic deficit. What is the most appropriate treatment?
- Anterior cervical diskectomy and fusion
- Continued nonsurgical treatment
- Chiropractic manipulation
- Posterior cervical foraminotomy
- Cervical epidural injection
- Continued nonsurgical treatment.
RECOMMENDED READINGS
Ponnappan RK, Khan M, Matzon JL, Sheikh ES, Tucker BS, Pepe MD, Tjoumakaris FP, Nassr AN. Clinical Differentiation of Upper Extremity Pain Etiologies. J Am Acad Orthop Surg. 2015 Aug;23(8):492- 500. doi: 10.5435/JAAOS-D-11-00086. Epub 2015 Jun 26. PubMed PMID: 26116851.
Levine MJ, Albert TJ, Smith MD. Cervical Radiculopathy: Diagnosis and Nonoperative Management. J Am Acad Orthop Surg. 1996 Nov;4(6):305-316. PubMed PMID: 10797198.
- Although initial studies revealed no adverse events associated with rhBMP-2 and also demonstrated a clear benefit to its use when compared with iliac crest bone graft, what is now known about rhBMP-2?
- It represents the best alternative to iliac crest autograft that is currently available to stimulate
bone growth
- It is no longer available in the United States; it has been withdrawn because of the
manufacturer’s liability concerns
- It is associated with substantial cancer risk
- It is not permitted by the U.S. Food and Drug Administration (FDA) for off-label applications
- It is always inappropriate for use in orthopaedic surgery.
- It represents the best alternative to iliac crest autograft that is currently available to stimulate
RECOMMENDED READINGS
Laine C, Guallar E, Mulrow C, Taichman DB, Cornell JE, Cotton D, Griswold ME, Localio AR, Meibohm AR, Stack CB, Williams SV, Goodman SN. Closing in on the truth about recombinant human bone morphogenetic protein-2: evidence synthesis, data sharing, peer review, and reproducible research. Ann Intern Med. 2013 Jun 18;158(12):916-8. doi: 10.7326/0003-4819-158-12-201306180-00012. PubMed PMID: 23778911.
Carragee EJ, Hurwitz EL, Weiner BK. A critical review of recombinant human bone morphogenetic protein-2 trials in spinal surgery: emerging safety concerns and lessons learned. Spine J. 2011 Jun;11(6):471-91. doi: 10.1016/j.spinee.2011.04.023. Review. PubMed PMID: 21729796.
North American Spine Coverage Committee. Recombinant Human bone morphogenic protein 2: defining appropriate coverage positions. https://www.spine.org/PolicyPractice/CoverageRecommendations/e-book#p=1 Accessed 10-26-2015.
Martin BI, Lurie JD, Tosteson AN, Deyo RA
- A 45-year-old patient who was involved in a motor vehicle collision sustained the injury shown in Video 194. What is the most likely mechanism of injury?
- Distraction
- Extension
- Cannot determine without MR imaging
- Compression
- Rotational
- Compression
RECOMMENDED READINGS
Langrana NA, Harten RD RD, Lin DC, Reiter MF, Lee CK. Acute thoracolumbar burst fractures: a new view of loading mechanisms. Spine (Phila Pa 1976). 2002 Mar 1;27(5):498-508. PubMed PMID: 11880835.
Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976). 1983 Nov-Dec;8(8):817-31. PubMed PMID: 6670016.