Spine Flashcards
In the absence of trauma and “red-flag” signs, plain radiographs are not required unless …….
symptoms have persisted longer than 4 to 6 weeks
Cervical spondylosis most commonly occurs at
C5 - C6
Cervical nerve roots exit …………….their corresponding vertebrae (e.g., C5 exits at the C4-C5 neural foramen). Consequently, disc
herniation at C5-C6 involves the ……… nerve root.
Cervical nerve roots exit above their corresponding vertebrae (e.g., C5 exits at the C4-C5 neural foramen). Consequently, disc
herniation at C5-C6 involves the C6 nerve root.
The natural history of cervical spondylotic myelopathy is characterized by ?
stepwise deterioration in symptomatology followed by a period of stability.
What percentage of asymptomatic patients older than 40 years demonstrate a herniated nucleus
pulposus or foraminal stenosis?
25%
operative indications of Cervical spondylosis?
Operative indications include myelopathy with motor/gait impairment and radiculopathy with persistent disabling pain that
has failed nonoperative measures.
Anterior cervical discectomy and fusion complications include
recurrent laryngeal nerve injury, dysphagia, airway obstruction, nonunion, and adjacent segment disease
when is canal expansive laminoplasty used and when is it absolutely contraindicated?
Canal-expansive laminoplasty is used for multilevel spondylosis, congenital cervical stenosis, and ossification of the posterior longitudinal ligament. It is contraindicated in the setting of fixed
kyphosis.
what is the pavlov/Torg ratio?
The relationship between the diameter of the spinal canal and the corresponding vertebral body. The Torg ratio is calculated through radiographical or MRI measurement by dividing the sagittal diameter of the canal by the diameter of the vertebral body. <0.8 is abnormal and risk of neurological involvement.
what diameter of cervical spinal canal puts patient at increased risk and what is the absolute stenosis value?
13mm
10mm
Rheumatoid spondylitis most commonly presents as an occipital headache due to compression of ?
greater occipital branch of C2.
what is the cause of rheumatological spondylitis and what conditions result from this?
Progressive cervical instability secondary to pannus formation and erosion of the joints and capsular structures occurs in up to 90% of patients. This can manifest as (1) atlantoaxial instability, (2) cranial settling (basilar invagination), and (3) subaxial
subluxation.
Atlantoaxial subluxation is most common. A posterior atlantodens interval (ADI) l……………………mm is associated with an increased
risk of neurologic injury and usually requires surgical treatment.
Atlantoaxial subluxation is most common. A posterior atlantodens interval (ADI) less than 14 mm is associated with an increased
risk of neurologic injury and usually requires surgical treatment.
what is the Magerl technique? Harms technique?
Transarticular screw fixation (Magerl) across C1-C2
The Harms technique of stabilizing C1–C2 using fixation of the C1 lateral mass and the C2 pedicle with polyaxial screws and rods
reduced risk of vertebral artery injury in Harms technique.
Ranawat classification?
1, subjective symptoms
2 subjective symptoms with weakness
3 objective signs and weakness
a ambulatory
b non ambulatory (surgery less successful but still considered)
Always obtain ………………………. before elective surgery in patients with rheumatoid arthritis.
Always obtain flexion/extension films before elective surgery in patients with rheumatoid arthritis.
AS patient with neck pain …always think of ?
?cervical spine fracture
Spinal shock is over when
bulbocavernosus reflex returns.
what is neurogenic shock?
Neurogenic shock is secondary to loss of sympathetic tone and can be recognized by relative bradycardia.
Central cord syndrome?
most common, affecting elderly patients with a spondylotic cervical spine. It presents as motor and sensory loss greater in the upper than the lower extremity. Independent ambulation is regained in approximately half of
elderly patients and almost always in young patients.
Anterior cord syndrome?
second most common and has the worst prognosis. It presents as greater motor loss in the legs
than in the arms, with dorsal columns spared
Brown-Séquard syndrome ?
Brown-Séquard syndrome presents as motor weakness on the side of injury and contralateral loss of pain and temperature. It
has the best prognosis.
Autonomic dysreflexia?
syndrome of uncontrolled sympathetic nervous output occurring in patients with a spinal cord injury above T6. It presents as hypertension, pupillary dilation, headache, pallor, and reflex bradycardia. Treat with urinary catheterization, fecal
disimpaction, antihypertensives, and atropine in severe cases
Most thoracic herniated discs are treated nonsurgically.
• Indications for surgery include?
progressive thoracic myelopathy and persistent unremitting radicular pain.
Thoracic HNP is typically treated via an …………………………… approach for midline or central herniations. Anterior discectomy and hemicorpectomy are performed as needed. A ……………………………..is used for a lateral herniation.
Thoracic HNP is typically treated via an anterior transthoracic approach for midline or central herniations. Anterior discectomy and hemicorpectomy are performed as needed. A transpedicular
approach is used for a lateral herniation.
Posterior approach and laminectomy are contraindicated because?
an inability to retract the spinal cord and high rate of neurologic injury.
Back pain predominant
• Worse with flexion → ………………………………………………• Worse with extension → ………………………………………….
Leg pain predominant
Worse with flexion → ……………………………….
• Worse with extension → ……………………………………
Back pain predominant • Worse with flexion → discogenic back pain • Worse with extension → spondylolisthesis or facet arthropathy
• Leg pain predominant • Worse with flexion → lumbar disc disease
• Worse with extension → spinal stenosis
Most herniations are? why?
posterolateral (where the posterior longitudinal ligament is the weakest) and may present as back pain and nerve root pain/sciatica involving the lower nerve root at that level (L5 at
the L4-L5 level)
Far lateral herniation or foraminal stenosis involves the
exiting nerve root (L4 at the L4-5 level).
what is the most specific test for HNP
A positive contralateral straight-leg raising test
More than ………..of patients who seek treatment for low back pain recover in …… week, and 90% recover within …………………months. Half of patients with sciatica recover in 1 month. Conservative treatment is
with …………………………
More than half of patients who seek treatment for low back pain recover in 1 week, and 90% recover within 1 to 3 months. Half of patients with sciatica recover in 1 month. Conservative treatment is
with NSAIDs and physical therapy.
Sport trial outcome for HNP patients?
No significant differences in primary outcome measures for operative compared with nonoperative groups
• However, trends favoring surgical intervention in primary outcome measures
• Statistically significant improvement in secondary outcome measures for surgical intervention: sciatica bothersomeness,
self-rated improvement
treatment of dural tear?
Treatment of a dural tear includes bed rest and subarachnoid drain placement. If adequately repaired, clinical outcomes are
generally unaffected.
Classify Spinal stenosis?
Treatment of a dural tear includes bed rest and subarachnoid drain placement. If adequately repaired, clinical outcomes are
generally unaffected.
Central stenosis that fails nonoperative management should be treated with?
laminectomy and partial medial facetectomy.
What are the indications for fusion in spinal stenosis?
Surgical instability (via removal of a facet), a pars defect, spondylolisthesis (degenerative or isthmic), degenerative scoliosis and radiographic instability are indications for fusion.
reason for persistant radicular pain after laminectomy?
foraminal stenosis
sport trial outcome for spinal stenosis?
Significant improvement in pain and function for operative compared with nonoperative groups
The use of alendronate in spinal surgery has been shown to
decrease spinal fusion rates in animal models. Administration should be held in the
postoperative period.
what is spondylosis?
Spondylosis is a defect in the pars interarticularis.
Spondylolisthesis is divided into six types?
dysplastic isthmic degenerative traumatic neoplastic Iatrogenic
most common spondylolisthesis and level?
The most common is isthmic (L5-S1 level
degenerative spondylolisthesis most common level?
L4-L5
treatment of high grade L5-s1 slip?
bilateral PLF L4-S1
what nerve root is affected in Degen spondylolisthesis?
traversing root
outcomes of sport trial for spondylolisthesis?
Significant improvement in pain and function for operative compared with nonoperative groups
symptoms of Cauda equina?
what urgent investigation is needed?
Typically secondary to large extruded disc, surgical trauma, and/or hematoma.
• Presents with bowel and bladder dysfunction, saddle anesthesia, and varying degrees of lower extremity weakness
• Urgent/emergent MRI can help assess for compression of the cauda
equina, with surgical decompression as soon as possible.
what feature of a adult scoliosis puts it at the higest risk of progression
Right thoracic curves of greater than 50 degrees are at the highest risk for progression (usually 1 degree/yr), followed by right lumbar
curves.
what is the strongest predictor of disability when dealing with scoliosis?
sagittal plane imbalance
Fusion to L5 is associated with?
development of L5-S1 degenerative disc disease and progressive sagittal imbalance.
Fusion to the sacrum is associated with?
increased incidence of pseudarthrosis and gait disturbance
list a few causes of kyphosis?
osteoporotic compression fractures,
post fractures
postlaminectomy kyphosis,
junctional kyphosis above or below a previous surgical
scheurmanns disease
the most common malignancy of the spine? and location?
metastatic disease and mainly the vertebral body.
“Red flags” for metastatic disease include
a history of cancer, unexplained weight loss, night pain, and age older than 50.
DEcompressive surgery techniques:
- Upper cervical spine → ……………. approach
- Posterior element tumor of lower cervical, thoracic, or lumbar spine → ……………..approach
- Majority of lower cervical, thoracic or lumbar spine → …………….approach because most tumors are located in the …………..
• Multilevel involvement or en bloc spondylectomy → combined
anterior/posterior approach
Decompressive surgery techniques:
- Upper cervical spine → posterior approach
- Posterior element tumor of lower cervical, thoracic, or lumbar spine → posterior approach
- Majority of lower cervical, thoracic or lumbar spine → anterior approach because most tumors are located in the body
• Multilevel involvement or en bloc spondylectomy → combined
anterior/posterior approach
2 earliest radiographic signs of discitis?
loss of lumbar lordosis and disc space narrowing the earliest findings.
main course of treatment for discitis?
IV abx and monitor CRP
Pyogenic vertebral osteomyelitis is usually from hematogenous spread and involves …………….. in 50% to 75%
of cases.
Staph A.
Epidural abscess typically presents with patients being…….. an treatment often involves?
more systemically ill than osteodiscitis and osteomyelitis patients.
• Management is typically surgical, with irrigation and débridement of
infected tissue.
name 4 ways in which TB of spine differs from pyogenic spinal infection?
Originates in metaphysis of vertebral body
spreads under the anterior longitudinal ligament
- Large anterior abscesses • Discs are preserved.
- Severe kyphosis more common
AS is associated with ?
HLA B27
why is HLA B27 used in diagnosing AS?
only 2% of ptx with HLA B27 have AS.
3 radiographic signs of AS
Sacroiliac joint obliteration (iliac side affected first) and
marginal syndesmophytes allow radiographic differentiation from diffuse
idiopathic skeletal hyperostosis.
banboo spine
how do you differentiate DISH and AS on xrays?
DISH = non marginal syndesmophytes.
list the ASIA classification
ASIA E = Normal
ASIA D= >or equal 3/5 power and incomplete sensory loss
ASIA C = <3/5 power and incomplete sensory loss
ASIA B = no motor power but incomplete sensory function
ASIA A= complete paralysis. no motor or sensory below level
C1 burst fractures (Jefferson) may be stable or unstable, depending on the integrity of the transverse ligament. how do you assess this ?
combined lateral mass over hand of C1 lateral mass if > 7 mm==PSF recommended
treatment of T1 peg fracture
rigid cervical orthosis
what orientation of fracture of T2 Peg fracture would prevent screw fixation?
anterior oblique
thus post oblique perfect as screw will be perpendicular to fracture.
Risk factors for type II peg nonunion:
displacement greater than 5 mm, angulation greater than 10 degrees, posterior
displacement, age older than 40 years, delayed treatment
Type 3 peg fracture treatment?
Halo Vest.
Hangman fracture acceptable reduction:
less than 4 mm translation and less than 10 degrees angulation
The safe zone for halo anterior pins
middle to lateral third above the eyebrow to avoid the supraorbital nerve, below th equator.
how many pins do adults and children need for halo, and at what pressure?
Adults require 4 pins at 6 to 8 inch-lb pressure. Children need 8 to 10 pins with 2 inch-lb pressure
pre-requists for closed reduction of facet dislocations pre MRI?
Closed reduction before MRI can be considered in an awake, alert, and cooperative patient who can participate in a full neurologic
examination.
