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OITE > Spine > Flashcards

Spine Flashcards

1
Q

Name the 3 spinal columns and their contents

A

Anterior Column: anterior 2/3 of vertebral body + ALL
Middle Column: posterior 1/3 of vertebral body + PLL
Posterior Column: pedicles, lamina, ligaments

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2
Q

When do you have a high likelihood of spinal instability after trauma?

A

When there is injury to 2 or more columns (and especially if there is injury to the posterior ligaments)

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3
Q

Clues of spinal instability after trauma

A

Chance fracture (posterior stability lost)
Widened interspinous distance/facet diastasis
Widened interpedicular distance on AP
Retropulsion/loss of posterior vertebral height on lateral
Progressive kyphosis with non-op management

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4
Q

What is a Chance fracture (Lumbar)

A
  • Involves all 3 columns, “seat belt injury”
  • Flexion-distraction injury (mechanism) where the anterior column fractures under compression and the middle and posterior columns fail under tension (often see a transverse fracture through the posterior vertebral body and fx through posterior column or injury to posterior ligaments).
  • Commonly have GI injuries
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5
Q

What is Neurogenic shock?

A

Systemic hypotension from diffuse vasodilation after SCI (does not refer to motor/sensory/reflexes)

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6
Q

What is Spinal shock?

A

Temporary neurologic response after SCI with absence of motor, sensation, reflexes (does not refer to circulatory collapse).
*Determine status of spinal shock by bulbocavernosus reflex (this is one of the first reflexes to return after spinal shock. Lack of motor and sensory function after the reflex has returned indicates complete SCI)

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7
Q

What is the ASIA classification?

A

-Grading scale for spinal cord injury, A->D
-Must not be in spinal shock (check bulbocavernosus reflex)
“E is for everyone” - totally normal

A = Complete, no motor, complete deficit sensory
B = Incomplete, no motor, incomplete deficit sensory
C = Incomplete, more than half of muscles below the level of injury have grade LESS THAN 3, incomplete deficit sensory
D = Incomplete, more than half of muscles below the level of the injury have grade GREATER THAN 3, incomplete deficit sensory
E = Normal, nl motor, nl sensory

*Level named is the last FULLY INTACT level, ex: C5 ASIA B means that deltoid is working but biceps is not

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8
Q

Central Cord Syndrome

A

Elderly person with neck hyperextension mechanism.
Symptoms: More profound motor weakness of the upper extremities and less severe weakness of the lower extremities. A varying degree of sensory loss below the level of the lesion and bladder symptoms (urinary retention) may also occur.
Most common incomplete spinal cord injury.
Affects lateral corticospinal tract.

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9
Q

Burst Fracture (Lumbar)

A

Fracture involving the anterior and middle columns.
Occurs from axial loading + flexion
Can cause retropulsion into canal which can cause neuro deficits (these fragments will resorb over time and it is rare to see progression of neuro deficits)
*Should get MRI to confirm no posterior ligament injury, if present this is not a burst fx
-Non-op = neuro intact and posterior column intact, WBAT
-Operative = if neuro deficit and imaging shows compression, if posterior column is not intact, treat with decompression (ie. laminectomy) + fusion

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10
Q

Compression fractures involve this column only

A

Anterior

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11
Q

Flexion teardrop fracture (cervical)

A

Equivalent of chance fracture in the cervical spine.

  • Failure of posterior column in tension
  • Usually have SCI present
  • Unstable and needs surgery
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12
Q

Extension teardrop fracture (cervical)

A

Avulsion from neck hyperextension

  • No posterior injury present
  • Usually non-op w/ C-collar
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13
Q

How many columns do each of these injuries involve..
Burst
Chance

A 
Burst = 2 columns (anterior and middle, although PLL should be intact)
Chance = 3 columns
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14
Q

Chance fracture mechanism?

A

Flexion distraction injury (“seat belt injury”) that disrupts all 3 columns. The anterior column fails in compression, the middle and posterior columns fail in tension.
Seat belt injury, thus commonly have GI injuries.
Posterior column can fail through ligaments or through bone.

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15
Q

Chance fracture treatment

A

Operative in most cases via surgical decompression and stabilization
-indications: neurologic deficit, patients with injury to the posterior ligaments
Nonoperative
-indications: bony chance fracture in posterior column which lends to stability and no neurologic deficits

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16
Q

Compression fracture involves what column

A

anterior

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17
Q

Compression fracture treatment

A

Nonoperative:
- Almost everyone
- Calcitonin x4 weeks for pain improvement
- Consider starting bisphosphonates for osteoporosis management
- Bracing not necessary but can help pain
Operative:
- Kyphoplasty can be considered if at 6 weeks still having pain
-DO NOT DO VERTEBROPLASTY (AAOS Guideline)

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18
Q

Facet dislocations occur via this mechanism

A

flexion + distraction

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19
Q

Facet dislocation treatment

A

Awake patient…
- Closed reduction, then MRI, then fusion
- Monitoring neuro status during reduction
- If change in neuro status during reduction this triggers MRI and then more immediate operative fusion (MRI can demonstarte disc herniation, myelomalacia, whether posterior ligaments intact)
Obtunded patient…
- MRI first, then open reduction + fusion
(Need to know if you have a disk fragment pushing on the cord to plan anterior vs posterior surgery)

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20
Q

Dens fracture location and classification

A

Type 1: Tip -> C-collar
Type 2: Base of dens (watershed) -> Operative (Halo possible if patient is young to preserve ROM)
Type 3: Extends into C2 body -> C-collar

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21
Q

Lumbar disc herniation location types and nerve roots affected…

A

Considering L4-5 disc herniation as an example…

  • Central Prolapse: associated with back pain and cauda equina
  • Paracentral (aka posterolateral): most common (weak area of PLL), affects the traversing/descending nerve root (L5) as it travels inferior around the inferior lumbar pedicle.
  • Foraminal (far lateral): affects exiting or upper nerve root (L4)
22
Q

Ankylosing spondylitis

A

Seronegative autoimmune arthropathy (ie negative rheumatoid factor)
+HLA B-27
4:1 male to female, begins in 20s
May be associated with uveitis
-Inflammation of enthesis -> bony erosion -> tissue ossification
- Affects SI joints, spinal joints, pubic symphysis, disc annulus

23
Q

Exam findings in ankylosing spondylitis

A

<2 cm chest wall expansion

Painful SI joint exams (+FABER)

24
Q

Ankylosing spondylitis commonly has advanced arthritis of hips and shoulders. If patients have hip dislocations after THA, they are at a much higher risk of dislocating _____

A

anteriorly

This is true because of the fixed spinal deformity where they often compensate by hyperextending through their hips

25
Q

Trauma in ankylosing spondylitis

A

Have a high suspicion for spinal injury. If any neck or back pain get a CT.
Three column fractures are common.
There is high mortality rate due to epidural hemorrhage. and 75% develop neurologic injury, but these can often present late.
Treatment is almost always operative, and because the autofusion of the spine creates a long lever arm the construct needs to be long in order to get healing.

26
Q

Diffuse Idiopathic Skeletal Hyperostosis

A

Flowing ossification - melting candle wax
Disc space preserved
Occurs later in life (50+)
Risk Factor: diabetes
Can have major injuries with small trauma due to vertebra being fused in long lever arms

27
Q

Risk factors for vertebral osteomyelitis

A

IV drug use, diabetes, recent infection

28
Q

Most common offending pathogen of vertebral osteomyelitis

A

Staph aureus

Hematogenous seeding of vertebral endplate

29
Q

Vertebral osteomyelitis HPI

A

sever pain of atraumatic onset. Unrelenting and worse with activity.
Labs: ESR and CRP elevated
XR: can be negative initially (10+ days, loss of lumbar lordosis is most common finding)
***Get an MRI with contrast to diagnose

30
Q

Vertebral osteomyelitis treatment

A

CT guided aspiration for culture, then nonop with IV antibioitics and bracing.

Treat operatively with vertebral corpectomy if,

  • Neuro deficit
  • Progressive deformity/instability
  • Refractory to antibiotic treatment
31
Q

Epidural abscess treatment

A

Decompress the abscess and stabilize the spine

32
Q

Spinal tuberculosis findings

A
  • Spine is the most common site of TB after the lungs.
  • Spreads under the anterior longitudinal ligament, SKIPPING OVER THE DISCS, and can infect adjacent vertebra.
  • Can lead to progressive kyphosis
33
Q

Spinal tuberculosis treatment

A

Nonop
- Antibiotics with TLSO to prevent deformity
Operative
- Corpectomy if neuro deficit or progressive, severe kyphosis

34
Q

Pelvic Incidence

A

Pelvic Incidence = Pelvic Tilt + Sacral Slope

35
Q

Neurogenic vs Vascular Claudication

A

Neurogenic (spinal stenosis)
- Gets better with flexed posture, worsens with spine in extension such as with walking upright
- Does not get better when you stop walking but remain standing
- Will have normal neuro exam
Vascular
- Comes on during walking due to metabolic command, improves with rest and not positional
- Check distal pulses, ABIs to evaluate

36
Q

Findings of cervical myelopathy

A

Loss of manual dexterity (buttons on shirt)
Gait instaibility (most important clinical predictor)
Wartenburg sign (small finger escape)
Hyperreflexia
Hoffman sign

***Stepwise progression - slow detioration overtime with periods of stability

37
Q

Deciding on operative approach for cervical myelopathy

A

Anterior (ACDF), if have >10 deg of kyphosis through c-spine

Posterior (Laminoplasty), if <10 deg of kyphosis through c-spine

38
Q

If you are going to do a decompression on a patient, you should get these xrays to assess for instability and see if the patient would be indicated for fusion, as well

A

Flexion/extension radiographs

39
Q

Degenerative spondylolisthesis

A

Occurs because discs wear out and have residual laxity between vertebra causing translation. Attempt nonop but if persistent pain then fusion.

40
Q

Isthmic spondylolisthesis

A

Occurs because of defect/fracture in pars
Almost always occur at L5-S1
Higher pelvic incidence = higher likelihood of slip
Try nonop, however if painful then fusion

41
Q

AIS the curve morphology is most commonly

A

Right thoracic curve

42
Q

Achondroplasia can develop infantile scoliosis at the thoracolumbar region. Treatment should be…

A

Observation.

This scoliosis almost always resolves at walking age.

43
Q

Verterbral disc annulus is made of what?

A

Annulus is the outer ring of the disc. It is made of type 1 collagen and is more elastic in its properties.

44
Q

Vertebral disc nuclues pulposus is made of what

A

Type II collagen and proteoglycans which renders high water content which is resistant to compressive forces.

45
Q

Due to spinal cord shift/translation after cervical decompression via laminoplasty, this nerve is most commonly affected…

A

C5 (shoulder abduction)

46
Q

Function of external superior laryngeal nerve

A

Innvervates the vocal cords and controls phonation.

47
Q

Function of the internal superior laryngeal nerve

A

Innervates laryngeal mucosa and stimulates the cough reflex

48
Q

Contraindications to cervical laminoplasty (2)

A

1) Cervical kyphosis >13 deg
2) K-line negative ossification

The k-line is a line drawn from the midpoint of the cerivcal canal at C2 to the midpoint at C7 on a lateral radiograph. If the posterior longitudinal ligament crosses the k-line it is, K-line negative and best treated with anterior approach. If the K-line is ventral and the PLL does not cross the k-line (k-line positive), then posterior laminplasty can be indicated

49
Q

MRI indications of loss of posterior ligamentous complex stability

A

Loss of normal low signal intensity of ligamentum flava or supraspinous ligaments on T1 and T2. This finding is a better indicator than edema without clear rupture or a high signal intensity of the interspinous ligaments along the facet joints on T2 STIR.

50
Q

Significance of McRae’s line?

A

Line drawn from anterior to posterior aspect of the foramen magnum. If the dens passes this line it indicates basilar invagination which increases the risk of sudden death from pressure being applied to the brainstem.

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