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Spine Flashcards

1
Q

Presentation of central cord syndrome

A

Motor: weakness of UE with lesser effect on LE

Sensory: varying degrees of disturbance below lesion

Myelopathic findings: sphincter dysfunction (usually urinary retention)

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2
Q

Etiology of central cord syndrome

A

Usually seen following acute hyperextension injury in an older patient with pre-existing stenosis from bony hypertrophy

May occur +/- cervical fracture or dislocation

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3
Q

Guidelines for acute central cord injuries

A
  1. maintain MAP 85-90 mmHg for the 1st week
  2. early reduction of fracture-dislocation injuries
  3. surgical decompression (for progressive deterioration- usually decompressive lami +/- fusion)
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4
Q

Etiology of anterior cord syndrome

A

Cord infarction in the territory supplied by the anterior spinal artery, may also result from anterior cord compression by dislocated bone fragment or traumatic herniated disc

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5
Q

Presentation of anterior cord syndrome

A

Paraplegia (if higher than C7 then quadriplegia)

Dissociated sensory loss below lesion: loss of pain/temp (spinothalamic) with preserved 2-point discrimination, joint position, deep pressure (posterior columns)

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6
Q

Classic findings of Brown-Sequard syndrome

A

Ipsilateral findings: motor paralysis, loss of proprioception and vibration

Contralteral findings: loss of pain and temp, preserved light touch (due to redundant ipsilateral and CL paths, anterior spinothalamic tracts)

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7
Q

Classification of atlanto-occipital dislocations

A

Type 1: anterior dislocation of occiput relative to the atlas

Type 2: longitudinal dislocation (distraction)

Type 3: posterior dislocation of occiput

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8
Q

Grisel syndrome

A

AA rotatory subluxation secondary to an infection of the head or neck (usually a retropharnyngeal abscess)

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9
Q

Classification of C1 fractures

A

Type 1: fractures involving a single arch

Type 2: burst fracture (classic Jefferson fracture)

Type 3: lateral mass fractures of the atlas

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10
Q

Definition of Jefferson fracture

A

Classically a 4 point burst fracture of the C1 ring, with bilateral fractures to the anterior and posterior arches, usually from axial load compression

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11
Q

Guidelines for isolated atlas fractures

A

If the transverse ligament is intact: cervical immobilization alone

If the transverse ligament is disrupted: either cervical immobilization alone or surgical fixation and fusion

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12
Q

Definition of Hangman’s fracture

A

Bilateral fracture through the pars interarticularis of C2 with traumatic subluxation of C2 on C3, most often due to hyperextension + axial loading

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13
Q

Guidelines for isolated Hangmans’ fracture

A

May initially be managed with external immobilizations

Surgical stabilization in the case of: severe angulation of C2 on C3, disruption of C2-3 disc space, or inability to establish or maintain alignment with external immobilization

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14
Q

Most common mechanism of odontoid fractures

A

Flexion is the most common mechanism of injury, with resultant anterior displacement of C1 on C2 (AA subluxation)

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15
Q

Classification of odontoid fractures

A

Type 1: avulsion of the attachment of the alar ligament

Type 2: through the base of the neck, the most common dens fracture

Type 2A: similar to type 2 but with large bone chips at the fracture site

Type 3: through body of C2

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16
Q

Clay Shoveler’s Fracture

A

Avulsion of spinous processes (usually C7)

This fracture is stable.

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17
Q

Mechanism of teardrop fracture

A

Results from hyperflexion or axial loading at the vertex of the skull with the neck flexed (eliminating the normal cervical lordosis)

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18
Q

Lhermitte sign

A

Cervical flexion/extension leads to shocklike sensation radiating down spinal axis and into arms/legs

Specific but not sensitive for cervical spinal cord compression and myelopathy

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19
Q

Nerve root injury that produces Trendelenburg gait

A

Injury to L5 nerve root

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20
Q

Composition of annulus fibrosis

A

Type 1 collagen that is obliquely oriented, water, and proteoglycans

High collagen/low proteoglycan ratio

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21
Q

Composition of nucleus pulposis

A

Type 2 collagen, water, and proteoglycans

Low collagen/high proteoglycan ratio

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22
Q

Mechanism of neurogenic shock

A

Circulatory collapse from loss of sympathetic tone leads to decreased systemic vascular resistance, pooling of blood in extremities, and hypotension

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23
Q

Treatment of neurogenic shock

A

Swan-Ganz monitoring for careful fluid management

Pressors to treat hypotension

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24
Q

Presentation of spinal shock

A

Flaccid areflexic paralysis, bradycardia, hypotension, absent bulbocavernosus reflux

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25
Q

Most common cardiac arrhythmia in acute stage following SCI

A

Sinus bradycardia

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26
Q

Definition of syringomyelia

A

A syrinx within the spinal cord that progressively expands and leads to neurologic deficits

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27
Q

Definition of syringobulbia

A

A syrinx within the brain stem that leads to neurologic symptoms

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28
Q

Symptoms of syringobulbia

A

Symptoms related to CN involvement - tongue weakness and atrophy (CN XII), SCM and trap weakness (CN XI), dysphagia and dysarthria (CN IX, X), facial palsy (CN VII)

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29
Q

Definition of diastematomyelia

A

A fibrous, cartilagenous, or osseous bar creating a longitudinal cleft in the spinal cord

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30
Q

Most common intradural extramedullary tumors

A

Schwannoma, meningioma

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31
Q

Common location of intradural extramedullary Schwannomas

A

Arise from dorsal nerve root

Cervical spine (31%), cauda equina (24%), thoracic spine (22%)

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32
Q

Histology of intradural extramedullary Schwannomas

A

Biphasic, Antoni A (hypercellular) and B (hypocellular) pattern

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33
Q

Treatment of intradural extramedullary Schwannomas

A

Surgical resection

Post-operative radiation for malignant tumors

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34
Q

Most common location for intradural extramedullary meningiomas

A

Thoracic spine

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35
Q

Most common intradural intramedullary tumors

A

Ependymoma and astrocytoma

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36
Q

Imaging characteristics of intradural intramedullary ependymomas

A

On MRI, encapsulated lesion in the filum terminale

T1 - hypo or iso-intense

T2 - hyper-intense

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37
Q

Imaging characteristics of intradural intramedullary astrocytomas

A

On MRI, fusiform appearance with irregular margins

T1 - hypo or iso-intense

T2 - hyper-intense with variable contrast enhancement

Typically found in cervicothoracic junction in children

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38
Q

Common extradural tumors

A

Mets (lung, breast) and lymphoma

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39
Q

Imaging characteristics of extradural lymphoma

A

T2 - ill-defined hyperintense lesions with marked homogenous contrast enhancement

Usually found in cervical spine

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40
Q

Treatment of extradural lymphoma

A

Methotrexate

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41
Q

Symptoms of cauda equina syndrome

A

Bilateral leg pain

Bowel and bladder dysfunction (urinary retention and eventually overflow incontinence)

Saddle anesthesia

Lower extremity sensorimotor changes

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42
Q

Causes of cauda equina

A

Disc herniation (most common), spinal stenosis, tumors, trauma, spinal epidural hematoma, epidural abscess

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43
Q

Treatment of cauda equina

A

Urgent surgical decompression within 48 hours (diskectomy, laminectomy)

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44
Q

Anderson and Montesano Classification of occipital condyle fractures - type 1

A

Impaction type fracture with comminution of the occipital condyle

Due to compression between the atlanto-odontoid joint

Stable injury

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45
Q

Anderson and Montesano Classification of occipital condyle fractures - type 2

A

Basilar skull fracture that extends into one or both occipital condyles

Due to a direct blow to skull

Stable injury

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46
Q

Anderson and Montesano Classification of occipital condyle fractures - type 3

A

Avulsion fracture of condyle in region of the alar ligament attachment

Due to forced rotation with combined lateral bending

Has the potential to be unstable due to craniocervical disruption

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47
Q

Presentation of occipital condyle fractures

A 
High cervical pain
Reduced head/neck ROM
Torticollis
Lower CN deficits (most commonly IX, X and XI)
Motor paresis
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48
Q

Operative indications for occipital condyle fractures

A

Type 3 with overt instability

Neural compression from displaced fracture fragment

Associated occipital-atlantal or atlanto-axial injuries

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49
Q

Measurement used to diagnose occipitocervical dislocation

A

Powers ratio = C-D/A-B

C-D (distance from basion to posterior arch)
A-B (distance from anterior arch to opisthion)

Normal ratio is about 1
If > 1 = anterior dislocation

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50
Q

Type 1 atlas fracture

A

Isolated anterior or posterior arch fracture

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51
Q

Type 2 atlas fracture

A

Jefferson burst fracture with bilateral fractures of anterior and posterior arch resulting from axial load

Stability determined by integrity of transverse ligament

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52
Q

Type 3 atlas fracture

A

Unilateral lateral mass fracture

Stability determined by integrity of transverse ligament

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53
Q

Type 1 transverse ligament injury

A

Intersubstance tear

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54
Q

Type 2 transverse ligament injury

A

Bony avulsion

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55
Q

Non-operative treatment for atlas fractures

A

Hard cervical orthosis vs halo immobilization for 6-12 weeks for stable type 1, stable Jefferson, stable type 3

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56
Q

Indications for operative treatment of atlas fractures

A

Unstable type 2 and type 3 fractures (both controversial)

Technique - posterior C1-C2 fusion vs occipitocervical fusion

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57
Q

Blood supply to the odontoid

A

Apex is supplied by branches of ICA

Base is supplied by branches of vertebral artery

Vascular watershed area in between - thought to affect healing of type II fractures

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58
Q

Type 1 odontoid fracture

A

Oblique avulsion fracture of tip of odontoid

Due to avulsion of alar ligament

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59
Q

Type 2 odontoid fracture

A

Fracture through waist - high nonunion rate due to vascular watershed area

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60
Q

Type 3 odontoid fracture

A

Fracture extends into cancellous body of C2 and involves a variable portion of the C1-C2 joint

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61
Q

Treatment of type 1 odontoid fractures

A

Cervical orthosis

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62
Q

Treatment of type 2 odontoid fractures in younger patients

A

Halo immobilization if no risk factors for nonunion

Surgery if risk factors for nonunion

63
Q

Treatment for type 2 odontoid fractures in elderly patients

A

Cervical orthosis if not surgical candidates

Surgery if surgical candidates

64
Q

Treatment of type 3 odontoid fractures

A

Cervical orthosis

65
Q

Operative procedure for odontoid fractures

A

Posterior C1-C2 fusion

66
Q

Definition of Hangman’s fracture

A

Traumatic anterior spondylolithesis of the axis due to bilateral fracture of pars interarticularis

67
Q

Type 1 occipitocervical dislocation

A

Anterior occiput dislocation

68
Q

Type 2 occipitocervical dislocation

A

Superior occiput dislocation

69
Q

Type 3 occipitocervical dislocation

A

Posterior occiput dislocation

70
Q

Harris rule of 12 for occipitocervical dislocation

A

Basion-dens interval > 12 mm suggests occipitocervical dislocation

71
Q

Flexion teardrop fracture

A

Characterized by fracture of anterior inferior portion of vertebra, posterior portion of vertebra retropulsed posteriorly, often associated with posterior ligamentous injury

72
Q

Extension teardrop avulsion fracture

A

Characterized by small fleck of bone is avulsed of anterior endplate

73
Q

Indications for halo orthosis in adults

A 
Occipital condyle fracture
Occipitocervical dislocation
Stable type II atlas fracture (Stable Jefferson)
Type II odontoid fractures
Type II and IIA hangman's fractures
74
Q

Contraindications for halo orthosis

A

Cranial fractures

Infection

Severe soft-tissue injury

75
Q

Characteristics of osteoporotic bone

A

Bone is normal in quality but decreased in quantity

Cortices are thinned

Cancellous bone has decreased trabecular continuity

76
Q

Components of the anterior column of the spine

A

ALL, anterior 2/3rds of vertebral body and annulus

77
Q

Components of the middle column of the spine

A

PLL, posterior 1/3rd of vertebral body and annulus

78
Q

Components of the posterior column of the spine

A

Pedicles, lamina, facets, ligamentum flavum, spinous process, posterior ligament complex

79
Q

Components of posterior ligamentous complex

A

Supraspinous ligament, interspinous ligament, ligamentum flavum, facet capsule

80
Q

Definition of cervical spondylosis

A

Chronic disc degeneration and associated facet arthropathy that can lead to radiculopathy, myelopathy, and discogenic neck pain

81
Q

Causes of cervical myelopathy

A

Degenerative cervical sponylosis, congenital stenosis, OPLL, tumor, epidural abscess, trauma, cervical kyphosis

82
Q

Presentation of myleopathy

A

Neck pain and stiffness, extremity paresthesias, weakness and clumsiness, gait instability, urinary retention

83
Q

PE signs for myelopathy

A

UMN signs, weakness, decreased proprioception and pain sensations, positive Lhermitte sign

84
Q

Cord compression occurs when canal diameter is…

A

Less than 13 mm in diameter

85
Q

MRI findings of cord compression

A

Effacement of CSF, bright signal of T2 (myelomalacia)

86
Q

Definition of cervical radiculopathy

A

Clinical syndrome caused by nerve root compression in the cervical spine characterized by sensory or motor symptoms in the upper extremity

87
Q

Symptoms of cervical radiculopathy

A

Neck pain, unilateral arm pain, unilateral dermatomal numbness and tingling, unilateral weakness

88
Q

PE findings of C5 radiculopathy

A

Deltoid and biceps weakness

Diminished biceps reflex

89
Q

PE findings of C6 radiculopathy

A

Brachioradialis and wrist extension weakness

Diminished brachioradialis reflex

Paresthesias in thumb

90
Q

PE findings of C7 radiculopathy

A

Triceps and wrist extension weakness

Diminished triceps reflex

Paresthesia in the index, middle, and ring fingers

91
Q

PE findings of C8 radiculopathy

A

Weakness to distal phalanx flexion of middle and index finger

Paresthesias in the little finger

92
Q

Absolute cervical stenosis

A

Defined as canal diameter

93
Q

Relative cervical stenosis

A

Defined as canal diameter of 10-13 mm

94
Q

Differential for benign extradural tumors

A

Hemangioma, enchondroma/chondroma, osteochondroma, osteoma/osteoblastoma

95
Q

Differential for malignant extradural tumors

A

Osteosarcoma, chondrosarcoma, chordoma, Ewing sarcoma, giant cell, plasmacytoma, multiple myeloma

96
Q

Differential for intradural, extramedullary tumors

A

Meningioma, Schwannoma, neurofibroma, filum terminale ependymoma

97
Q

Differential for intradural, intramedullary tumors

A

Astrocytoma, ependymoma, hemangioblastoma

98
Q

Most common location of spinal hemangiomas

A

Vertebral bodies of thoracic and lumbar regions

99
Q

Characteristic imaging of spinal hemangiomas

A

Honeycomb appearance

100
Q

Management of spinal hemangiomas

A

Pre-operative angiography is used to visualize the tumor blush, and endovascular embolization should precede surgical resection to minimize blood loss in most cases

101
Q

Most common locations in osteomas/osteoblastomas

A

Mostly in the lumbar spine but can also be found in the cervical, thoracic, and sacral regions

102
Q

Difference between osteomas and osteoblastomas

A

Histologically identical

Osteoblastomas are larger than 2.0 cm

103
Q

Management of osteomas and osteoblastomas

A

Resection via curretage and possible grafting

Incomplete resection is associated with a high rate of recurrence therefore radiation therapy can be used as adjuvant therapy

104
Q

Most common location of spinal chordomas

A

Cranially at the clivus or caudally at the sacrococcygeal region

105
Q

Plain x-ray characteristics of giant cell tumors

A

“Soap bubble” in the vertebra

106
Q

Important association of giant cell tumors

A

Pulmonary mets

107
Q

Common location for spinal meningiomas

A

At the foramen magnum, attached to the ventral rim

108
Q

Common presentation of spinal neurofibromas

A

Commonly associated with nerve roots and patients tend to present with weakness and radiculopathy

109
Q

Common presentations of intradural, intramedullary tumors

A

Myelopathy or radiculopathy

110
Q

Treatment of type 1 and 3 odontoid fractures

A

External immobilization

111
Q

Factors that support the use of surgical stabilization and fusion in type 2 odontoid fractures

A

Dens displacement 5 mm or more

Comminuted fracture (IIA)

Patient > 50 years old

> 6 months before injury and treatment

Failed alignment with external immobilization

112
Q

Non-surgical treatment of jumped facets

A

Gardner-Wells tongs - serially increasing traction weight to reduce dislocation has been shown to be safe in patients who are awake and able to cooperate with an exam

113
Q

Formula for determining the maximum weight during cervical traction

A

P = 3 to 4 kg (weight of head) + 2 kg per vertebral level away from the cranium

114
Q

Major complication associated with jumped facets

A

Vertebral artery injury resulting in Wallenberg’s syndrome

115
Q

Symptoms of Wallenberg’s syndrome

A

1) ipsilateral loss of pain/temp in the face, limbs, and trunk
2) nystagmus
3) tinnitus
4) diplopia
5) contralateral loss of pain/temp throughout the body
6) ipsilateral Horner’s syndrome
7) dysphagia
8) ataxia

116
Q

Physical exam findings of patients with degenerative cervical disc disease

A

More pain with neck extension than flexion

Pain with flexion is muscle or disc related; pain with extension is facet or foramen related

117
Q

Spurling’s sign

A

Extension and rotation toward the symptomatic side reproduces the radicular symptoms

118
Q

Pathologic reflexes in cervical spondylotic myelopathy

A

Finger escape sign, grip and release test, Hoffman’s, inverted radial reflex

119
Q

Finger escape sign for cervical myelopathy

A

Patient holds fingers extended and adducted

In patients with cervical myelopathy, the two ulnar digits will flex and abduct, usually in less than 1 minute

120
Q

Grip and release test

A

Normally, a patient can make a fist and rapidly release it 20 times in 10 seconds

Patients with myelopathy are unable to do this that quickly

121
Q

Inverted radial reflex

A

Tapping the distal brachioradialis tendon produces hyperactive finger flexion

122
Q

Scapulohumeral reflex seen in patients with high cord compression

A

Tapping the tip of the spine of the scapula elicits a brisk scapular elevation and abduction of the humerus if there is high cord compression

123
Q

Pavlov’s ratio for measuring spinal stenosis

A

Sagittal canal diameter divided by sagittal diameter of vertebral body

A ratio of 0.8 or less defines a congenitally narrow spinal canal, which puts the patient at higher risk for cord compression

124
Q

Measurement on a lateral plan radiograph that indicates cord compression

A

In patients with spondylosis, a spinal canal measurement on a lateral plain radiograph of 12 mm or less often indicates cord compression

125
Q

Determining cervical instability on flexion/extension views

A

Flexion and extension views show > 3.5 mm and/or translation > 11 degrees of angulation

126
Q

Radiographic findings in the cervical region that warrant earlier operative intervention

A

Smaller cord area, cord atrophy, signal changes indicative of myelomalacia, or the presence of a kyphotic deformity

127
Q

Definition of cranial settling

A

Superior migration of the odontoid leading to brainstem compression

128
Q

McGregor’s line used to determine cranial settling

A

Line drawn on the lateral view from the hard palate to the base of the occiput

Vertical settling of the occiput has been defined as migration of the odontoid > 4.5 mm above McGregor’s line

129
Q

Definition and significance of the high-intensity zone on MRI

A

The HIZ is identified as a small, round lesion that shows a bright signal along the posterior-inferior annulus on T2WI

These lesions are associated with an annular tear in more than 90% of cases with discography

130
Q

Type I Hangman fracture (Levine classification).

A

< 3 m subluxation of C2 on C3 and NO angulation.

131
Q

Type Ia Hangman fracture (Levine classification).

A

Anterior C2 VB may be subluxed 2-3 mm anteriorly on C3 and the C2 VB may appear elongated.

132
Q

Type II Hangman fracture (Levine classification).

A

Subluxation of C2 on C3 > 3mm and/or angulation.

133
Q

Type IIa Hangman fracture (Levine classification).

A

Little subluxation (usually < 3mm) but more angulation (can be > 15 degrees).

134
Q

Type III Hangman fracture (Levine classification).

A

Type II with bilateral C2-3 facet capsule disruption.

C2 posterior arch is free floating.

135
Q

Surgical indications for Hangman’s fractures.

A
  1. Inability to reduce the fracture (includes most Levine type III and some type II).
  2. Failure of external immobilization to prevent movement at fracture site.
  3. Traumatic C2-3 disc herniation with compromise of the spinal cord.
  4. Established non-union.
136
Q

Type 1 Modic endplate change.

A
  1. T1 low, T2 high.

2. Associated with pain and instability.

137
Q

Type 2 Modic endplate change.

A
  1. T1 high, T2 normal.
  2. Presence of yellow marrow accounts for shortening of T1 signal.
  3. More common than type 1.
138
Q

Type 3 Modic endplate change.

A
  1. T1 low, T2 low.

2. Less segmental instability secondary to advanced degeneration and sclerosis.

139
Q

Description of Klippel-Feil syndrome.

A
  1. Multiple fused cervical vertebrae due to failure of segmentation.
140
Q

Description of Type 1 Klippel-Feil syndrome.

A
  1. Fusion of many cervical and upper thoracic vertebrae.

2. High risk of scoliosis (30%).

141
Q

Description of Type 2 Klippel-Feil syndrome.

A
  1. Fusion at one or two interspaces combined with other congenital spinal abnormalities.
142
Q

Description of Type 3 Klippel-Feil syndrome.

A
  1. Fused cervical vertebrae with thoracic or lumbar fused vertebrae.
143
Q

Description of Type 1 split cord malformation.

A
  1. Characterized by two hemicords, each within its own dural tube, separated by a bony/cartilaginous septum.
144
Q

Description of Type 2 split cord malformation.

A
  1. Characterized by two hemicords in a single dural tube, separated by a fibrous septum.
145
Q

Power’s ratio.

A
  1. Ratio of distance from basion to C1 lamina divided by distance from opisthion to anterior ring of C1.
  2. Identifies anterior subluxation if ratio > 1.
146
Q

Harris’s rule of 12.

A
  1. A basion-axial interval or basion-dental interval > 12 is indicative of an atlantooccipital dissociation.
147
Q

Condyle-C1 interval.

A
  1. Distance between the occipital condyle and the C1 lateral mass on sagittal imaging.
  2. A value greater than 2.5mm is consistent with dissociation.
148
Q

Dickman type 1 classification of transverse alar ligament injuries.

A
  1. Midsubstance disruption of TAL.

2. Ligament will not heal.

149
Q

Dickman type 2 classification of transverse alar ligament injuries.

A
  1. Avulsion of the tubercle with TAL attached.

2. Bony injury that may heal.

150
Q

Rule of Spence.

A
  1. Greater than 7mm composite overhang is indicative of a TAL injury.
151
Q

Type 1 axis fracture.

A
  1. Minimal displacement (<3mm).
152
Q

Type 2 axis fracture.

A
  1. Significant displacement (>3mm) and angulation > 11 degrees.
153
Q

Type 2a axis fracture.

A
  1. Minimal displacement (< 3mm) but angulation > 11 degrees.
154
Q

Type 3 axis fracture.

A
  1. Associated with facet dislocation.

NS (25 decks)

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