Spine Flashcards
What injuries are most commonly associated with chance fractures?
Gastrointestinal injuries.
Criteria for burst fractures that can be treated non-operatively?
Neurologically intact and stable Less than 30 degrees of kyphosis (controversial) Less than 50% of vertebral height loss TLICS score 3 or less
Burst fractures that should be treated operatively.
Neurologic deficits with evidence of cord compression. Incomplete or complete cord injuries. Unstable injuries: TLICS 5 or greater, progressive kyphosis, PLC compromise, lamina fractures (controversial)
In general how many levels above and below should a burst fracture be instrumented.
One level above and one level below. Instrumentation should be under distraction.
Longer term complications of burst fractures?
Progressive kyphosis if PLC injury is unrecognized. Can lead to flat back deformity.
What is the boney morphology of a flexion teardrop fracture?
Large anterior lip fragments which distinguish it from an extension fracture. Also called quadrangular fractures.
Prognosis and treatment of most sub axial cervical burst fractures and flexion teardrop fractures?
Most are associated with spinal cord injuries.
Decompression and fusion.
In which arterial segment is the vertebral artery most vulnerable to traumatic injury?
V2 segment which is within the transverse foramina from C6-C1. Highest risk of injury is at the point of entry into the C6 foramen.
Which vertebral artery is usually dominant.
Left
How long after vertebral artery injury do complications occur?
Can be days to years following injury. Complications include: arteriovenous fistula, late-onset hemorrhage, pseudo aneurysm, thrombosis, cerebral ischemia/stroke, and death.
Indications for a CTA
There are many, any one of the following in a trauma patient is an indication: GCS<9 Unexplained central or materializing neurologic deficit. Evidence of acute cerebral infarct on CT scan of head. Diffuse axonal injury. Facial fracture or Le Fort type-II or III fracture. Cervical spine fracture of C1, 2, or 3 or fracture extension into transverse foramen. spinal cord injury hanging injuries major thoracic injury or first-rib fracture.
Removal of cervical collar without radiographic studies allowed if?
Patient is awake, alert, and not intoxicated. Has no neck pain, tenderness, or neurologic deficits. Has no distracting injuries.
When must radiographic cervical spine clearance be obtained?
Intoxicated or altered mental status. Neck pain or tenderness. Distracting injury.
What constitutes adequate radiographic cervical spine trauma imaging?
Cervical spine radiographic series: AP, Lateral, open-mouth odontoid view. CT scan. All imaging must include top of T1 vertebra
What are the complications associated with delayed c-spine clearance?
Increased risk of aspiration. Inhibition of respiratory function. Decubitus ulcers (occipital and submandibular areas. Possible increase in intracranial pressure.
What is the most common incomplete spinal cord injury?
Central cord syndrome.
What does sacral sparing mean when determining complete vs incomplete injury?
Sacral sparing best determined by the presence of VOLUNTARY ANAL CONTRACTION. If they have sacral sparing should also have intact perianal sensation. Need to differentiate this from bulbocavernosus reflex.
How do you determine neurologic level of injury?
Lowest segment with intact sensation and antigravity muscle function strength. In regions where there is no myotome to test, the motor level is presumed to be the same as the sensory level.
ASIA B
No motor function below the neurologic level. By definition must have preserved sensation.
ASIA C
Motor function is preserved below neurologic level- more than half of key muscles below the neurological level have a muscle GRADE LESS THAN 3.
ASIA D
Motor function is preserved below neurologic level- more than half of key muscles below the neurological level have a muscle GRADE OF 3 OR MORE.
What injuries can lead to complete loss of bulbocavernous reflex?
Conus and cauda equina injuries.
When should corticosteroids be given in the trauma patient with spinal injury?
Literature does not support it being given at any time.
When is systemic and or local hypothermia recommended for spinal cord injuries?
Not recommended. Can see the following complications: coagulopathy, sepsis, pneumonia, arrhythmias, and rebound hypertension.
When should decompression be performed for a complete spinal cord injury? Incomplete spinal cord injury? What recovery could this facilitate?
within 24 hrs within 24 hrs may facilitate nerve root function at level of injury (1-2 levels).
When should GSW of the spine undergo operative intervention?
Progressive neurological deterioration with retained bullet within the spinal canal. Cauda equina syndrome (treated like a peripheral nerve) Retained bullet or fragement within the thecal sac (CSF can breakdown of lead causing lead poisoning)
What is autonomic dysreflexia?
An increase in systolic blood pressure of at least 20% associated with a change in heart rate and accompanied by at least one of the following signs or symptoms: Signs: sweating, piloerection, facial flushing Symptoms: headache, blurred vision, stuffy nose This is all due to a stimulus such as over distended bladder or bowel impaction that can be seen in spinal cord injury patients.
Other causes include occult infections, skin irritation, decubitus ulcers, or lower extremity fractures.
What can loss of supra-spinal control of the sympathetic nervous system in spinal cord injury patients with lesions at T6 or higher lead to?
Both supine and orthostatic hypotension. Cardiac arrhythmias. Autonomic dysreflexia.
Does conus medullaris syndrome have a better or worse prognosis for recovery than a more proximal lesion.
Better.
What percent of complete spinal cord injuries can expect an improvement of one nerve root level? Two nerve root levels? Complete recovery?
80% 20% 1%
What are some trends of improvement in incomplete spinal cord injuries?
The greater the sparring the greater the recovery. Patients that show more rapid recovery have a better prognosis. When recovery plateaus it rarely resumes improvement.
What function would you expect for a spinal cord injury with a C1-C3 level?
Ventilator dependent, limited talking, electric wheelchair with head or chin control.
What function would you expect for a spinal cord injury with a C3-C4 level?
Initially ventilator dependent, but can become independent. Electric wheelchair with head or chin control.
What function would you expect for a spinal cord injury with a C5 level?
Ventilator independent. Cannot feed oneself because of lack of wrist extension and supination. Electric wheelchair with hand controls. Can achieve independent ADLs with assistive devices.
What function would you expect for a spinal cord injury with a C6 level?
Manual wheelchair. Independent living. Can drive a car with manual controls. Sliding board transfers. Much better function than C5.
What function would you expect for a spinal cord injury with a C7 level?
Daily use of a manual wheelchair with independent transfers.
What function would you expect for a spinal cord injury with a C8-T1 level?
Improved hand and finger strength and dexterity. Expected to be fully independent.
What are the descending tracts of the spinal cord?
Motor: lateral corticospinal tract and ventral corticospinal tract.
What are the ascending tracts of the spinal cord?
Sensory: Dorsal columns- deep touch, vibration, and proprioception Lateral spinothalamic tract- pain and temperature Ventral spinothalamic tract- light touch
What is hyperpathia
Burning in distal upper extremity. Seen in central cord syndrome.
Where is weakness worst in central cord syndrome?
Upper extremities affected more than lower extremities. Hands affected more than more proximal areas of UE. Represents selective injury to central areas of LCT.
What is injured and what is preserved in anterior cord syndrome?
LCT and LST are injured. Loss of pain and temperature. Motor loss with lower extremities affected more. DC (proprioception, vibratory sense) is preserved.
What is the prognosis of anterior cord syndrome?
worst prognosis of incomplete cord injuries. 10-20% chance of motor recover. Often mimics central cord syndrome.
What is Brown-Sequard Syndrome?
Ipsilateral deficit in motor function (LCS) and dorsal columns (proprioception and vibratory sense) Contralateral deficit pain and temperature (LST, remember this tract classically crosses two levels below) Usually seen with penetration trauma.
What is the prognosis of Brown-Sequard Syndrome?
excellent prognosis 99% ambulatory at final follow-up Best prognosis for functional motor activity of incomplete cord injuries.
What is the Anderson and Montesano Classification?
For Occipital Condyle fractures Type 1 Compression. Comminution of occipital condyle. Stable injury. Type 2 direct blow. Basilar skull fracture that extends into one or both occipital condyles. Usually stable injury. Type 3 rotation/lateral bending. Avulsion fracture of condyle in the region of the alar ligament. Potentially unstable. Suspect occipitocervical dissociation.
What is the primary stabilizer of the atlantoaxial junction?
Transverse ligament.
What are the intrinsic ligaments of the Craniocervical junction (CCJ) or occipitoatlantoaxial complex?
Transverse ligament Alar ligaments Apical ligament Tectorial membrane
Where does the transverse ligament of the CCJ attach?
posterior odontoid to anterior atlas arch.
Where do the alar ligaments attach?
Odontoid to occipital condyles.
Where does the apical ligament attach?
vertically from odontoid to foramen magnum.
What is and where does the tectorial membrane travel?
cephalic continuation of the PLL connects posterior body of axis to anterior foramen magnum.
What neurologic deficits are often seen with condyle fractures and craniocervical injuries?
Lower cranial nerve deficits. Most often CN 9,10, and 11.
When are occipital condyle fractures treated operatively?How are they treated?
Type 3 with obvious instability or any neural compression from a fracture fragment. Occiput to C2/C3 fusion.
Degenerative causes of atlantoaxial instability?
Down’s syndrome. Rheumatoid arthritis. Os odontoideum.
Traumatic causes of atlantoaxial instability?
Atlas fracture. Transverse ligament injury Type 1 Odontoid fracture.
Pediatric causes of atlantoaxial instability?
JRA Morquio’s Syndrome trauma/infection leading to rotatory atlantoaxial subluxation.
What percent of rotation does the C1-C2 joint provide?
50%
How many mm on sum of lateral mass displacement is predictive of a transverse ligament rupture?
>7mm
> 8.1mm with radiographic magnification
In an adult without RA what atlanta-dens interval (ADI) is considered normal, stable injury to transverse ligament, and unstable injury?
Normal <3mm (<5mm in a child)
3-5mm Distance between posterior border of anterior arch of C1 and odontoid.
>5mm suggests injury to transverse ligament as well as alar ligament, and tectorial membrane.
What is the risk of neurologic injury with atlas fractures and transverse ligament injuries? Associated injuries?
Low. 50% have an associated spine injury. 40% have associated axis fx.
What is a common anatomic variation of C1?
incomplete formation of the posterior arch
Describe Landells Atlas Fracture Classification
When is a Jefferson Fracture Treated operatively?
In general when there is a intrasubstance tear of the transverse ligament, but even then it is controversial.
All types of Jefferson fractures can be treated with a hard collar or halo for 6-12 weeks.
What can appear like a type II odontoid fx on x-ray?
How should it be treated?
Os odontoideum
Treatment is observations.
How many ossification centers does the axis have and when do they fuse?
Five ossification ceners.
between the dens and vertebral body that does not fuse until 6 yrs.
Secondary ossification center towards the tip of the dens. Doesn’t appear until 3 yrs and fuses at age 12.
What is the blood supply to the odontoid?
Apex is supplied by branches of internal carotid artery.
Base is supplies from branches of vertebral artery.
Limited blood supply in the watershed area between the apex and the base.
What is the normal ROM for the cervical spine?
What articulartion accout for the majority of the motion?
100 degrees rotation, 110 degrees of flexion/extension, and 68 degrees of lateral bend.
C1-C2: 50r, 50f/e, and 0 lateral bend
C2-C3: 50r, 50f/e, and 60 lateral bend.
What is a type I odontoid fracture?
Oblique avulsion fs of tip of odontoid due to avulsion of alar ligament.
Should rule out atlantooccipital instability with flex/ext views.
What fracture can be treated with an anterior odonoid screw?
Posterior inferior to anterior superior fracture line. The opposite needs posterior fixation.
How should Type III odontoid fractures be treated if no instability?
Hard collar. No evidence to suggest halo is better.
What are risk factors for Type II odontoid fracture non-unions?
>= 6mm displacement. Biggest reason to consider surgery
age > 50 yrs
fx comminution
smoker
fracture gap > 1mm
Angulation > 10 degrees
What is the major pro and con to anterior odontoid screw osteosynthesis?
Pro is preservation of atlantoaxial motion.
Con is higher failure rate than posterior C1-C2 fusion.
What percentage of people over the age of 65 show spondylotic changes regardless of symptomoatology?
85%
Which levels are most associated with spondylosis?
C5-C6 > C6-7.
Because these levels are associated with the most flexion and extension in the subaxial spine.
What makes up the cervical motion segment?
Intervertebral disc
two facet joints
two uncovertebral joints of luschka
Normal cervical canal diameter?
At what diameter are you considered to have central stenosis?
17mm
13mm
What causes nerve root irritation besides direct compression?
Chemical pain mediators: IL-1, IL-6, substance P, bradykinin, TNF alpha, prostaglandins.
What can be caused by a C4 radiculopathy?
Scapular winging
True or false cervical radiculopathy is often global and nondermatomal pain radiating down arm.
True
What percent of patients with cervical radiculopathy improve with non-operative management?
75%
What is an ideal indication for a posterior foraminotomy?
Soft foraminal disc herniation causing single level radiculopathy is most ideal.
Can olso be used for osteophytic foraminal narrowing.
What percent of patients can expect long term relief from a selective nerve root corticosteroid injection?
40-70%
What is the indication for cervical total disc replacement?
Single level disease with minimal arthrosis of the facets.
What are the pros and cons of a posterior foraminotomy?
Pros: avoids need for fusion, avoids problems associated with anterior procedure such as dysphagia.
Cons: More difficult to remove discosteophyte complex and disc height can not be restored.
What is the risk of pseudoarthrosis for ACDF?
How should revision surgery be performed?
Which has a higher fusion rate?
5-10% for single level. 30% for multilevel fusions
Can be either posterior or anterior, but should be anterior if persistent radiculopathy.
Posterior has higher fusion rate, but higher rate of complications.
What is the most common nerve injured during ACDF?
What is the risk?
Recurrent laryngeal nerve.
1% risk
Literature has not shown a right or left approach to have greater risk.
What is the recommended treatment for a recurrent laryngeal nerve injury?
6 weeks of observation
If still persisting then ENT consult for scope and teflon injection.
Where is the sympathetic chain found when performing ACDF surgery?
lateral border of longus coli muscle at C6.
What is a risk of anterior approached for the upper cervical spine?
hypoglossal nerve injury.
tongue will deviate to the side of the injury.
Which levels have higher risk of dysphagia in anterior cervical surgery?
upper levels, especially C3-C4.
What is a Hangman’s Fracture?
What is the mechanism?
traumatic anterior spondylolithesis of the axis due to bilateral fracture of pars interarticularis.
Hyperextension with secondary flexion.
True or false patients are usually neurologically intact after a traumatic spondylolisthesis of the axis?
True
Describe Levine and Edwards Classification of Hangman’s fractures.
Which facet in the cervical spine is most often fractured?
Superior facet.
What is the most frequently missed cervical spine injury on plain x-rays?
unilateral facet dislocation.
How much subluxation will you see with a unilateral facet dislocation?
How much for bilateral facet dislocation?
25%
50%
Where do the majoirty of facet dislocations occur?
Most occur within the subaxial spine (C3-C7).
75% of the time.
In a patient with a facet dislocation, what might loss of disc height indicate?
retropulsed disc in canal.
When can you consider performing a closed reduction in a patient without an MRI?
Patient with facet dislocion and deficits but no mental status changes.
They must be awake and cooperative.
What is the mechanism of lateral mass fracture separation?
Hyperextesion, lateral compression, and rotation.
Uncommon injury chracterized by a high degree of instability.
Usually has neurological deficit (66% of the time).
What is the success rate of non-operative treatment of lateral mass separation fractures?
less desirable.
Spontaneous fusion rate is only 20%
What is the perfered method of treatment for a lateral mass separation fracture?
Two level fusion via a posterior approach.
What time period is considered early decompression and has been show to improve neurologic outcomes?
Less than 24 hrs.
What is a clay-shovelers fracture?
Cervical spinous process fracture. Most commonly at C7.
Can affect C6 to T3.
How many pounds of force are Mayfield pints tightened to?
60 lbs
How tight should Gardner-Wells tongs be?
Until sping indicator is 1mm above the surface.
This is equivalent to 139 Newtons or 31 lbs of force.
overtightening by .3mm leads to 448 newtons or 100lbs.
What is the reduction maneuver for a unilateral facet dislocation?
Add weight in 10 lb increments every 20 minutes.
Reduction maneuver performed once the facet is perched.
Maintain axial load and rotate the head 30-40 degrees past midline in the direction of the dislocation.
Stop once resistance is felt.
Reduction maneuver for bilateral facet dislocation?
Add weight until in a perched position then apply an anterior directed force caudal to the level of the dislocation.
Rotate the head 40 degrees in each direction while axial traction is maintained.
Which motion is the Halo vest most effective at controlling?
atlantoaxial rotation.
Not very good for controlling motion in the subaxial spine.
What are absolute contraindications to Halow Vest?
Cranial fractures.
Infection.
Severe soft-tissue injury in the region of the vest.
What are relative contraindications to halo vests?
polytrauma.
severe chest trauma.
barrel-shaped chest.
obesity.
advanced age (recent evidence demonstrates an unacceptably high mortality rate in patients aged 79 years and older (21%).
What should be done in kids younger than 10 before applying a halo?
Need to get a CT scan to determine the thickness of the skull.
What is the safe zone for anterior halo pins?
What structures does this avoid?
1cm region just above the lateral one third of the eybrow at or below the equator of the skull.
This places the pin lateral to the supraorbital nerve and anterior and medial to temporalis fossa and muscle.
How many pins and inch-pounds of torque for an adult Halo?
4 pins at 8 inch-pounds
How many pins and inch-pounds for a pediatric halo?
6-8 pins
2-4 inch-pounds.
Children < 2yrs should use a Minerva cast.
What is the most common complication of Halo vests?
How should it be treated?
Loosening (36% of complications)
retightening if unsuccesful or continues to loosen pin exchange.
What do you do if a patient has a pin sight infection of their halo?
oral antibiotics if not loose.
If loose the pi should be removed.
What cranial nerve is most commonly injured with a halo?
Abducens nerve palsy.
Thought to be a traction injury.
Loss of lateral gaze on the affected side.
Where do fracture dislocations of the spine most often occur?
What is the most common mechanism?
thoracolumbar junction.
motor vehicle accident.
What is defined as the lumbothoracic junction?
T10-L2
Area of high mobility next to an area of lower mobility creats an area vulnerable to shearing forces.
True of false the level of neurological deficit does not align with apparent level of spinal injury on a MRI?
True
Describe the TLICS system.
What is the most common fragility fracture?
Vertebral compression fracture.
Affects 25% of people over 70 yrs.
Affects 50% of people over 80 yrs.
What is the strongest predictor of future vertebral fractures in postmenopausal women?
history of 2 VCFs.
How does the 1 yr mortality rates after a vertebral compression fracture compare to a hip fx?
What about at 2 yrs?
15% which is less than a hip fx (25%)
Equal.
What is an associated condition with vertebral compression fractures that can lead to increased mortality?
Increasing kyphosis that leads to reduced pulmonary function.
What sign on MRI is suggestive of an osteoporotic vertebral compression fracture and not another process?
fluid sign.
What is the risk of a concomitant spine fracture when one vertebral compression fracture is found?
20%
Consider obtaining radiographs of the entire spine.
What should be on your differential for a vertebral compression fracture?
Malignancy. Should be suspicious of fractures above T5, atypical radiographs, constitutional symptoms, and younger patients with no hx of trauma.
Should obtain CBC, BMP, inflammatory labs, and urine and serum protein electrophoresis if concerned of another process.
What medication can be given in acute fractures(within 5 days) to decrease pain?
How long can it be given?
Calcitonin.
4 weeks.
What is the AAOS recomendation on vertebroplasty?
Recommends strongly against.
What is the AAOS recommendation for kyphoplasty?
Limited recommendation strength.
Consider in patients with severe pain after 6 weeks of non-operative treatment.
cavity is created by a ballon so that cement can be injected with left pressure.
What is the most sensitive test for myelopathy?
Hoffman sign, found to be 59% sensitive while upward babinski and clonus were 13%.
What are causes of myelopathy other than spinal stenosis?
MS, ALS, multifocal motor neuropathy, and Guillain-Barre’s Syndrome.
When can the superior laryngeal nerve be injured in spine surgery?
Anterior cervical surgery between C2-C3.
Innervates a portion of the larynx (cricothyroid muscles) and vocal cords.
Modulates voice pitch and explosive sounds.
What are they symptoms of a recurrent laryngeal nerve injury?
hoarseness occurs in 3-11%. Permanent in .33%
Because many people become asymptomatic should have the vocal cords evaluated pre-operatively.
Do not want to operate on the opposite side of an existing vocal cord injury.
How much should an adult isthmic spondylolisthesis be reduced?
Petraco et al showed that L5 nerve injury is not linear with 71% of strain occuring in the second half of reduction.
Partial reduction may be safer than complete reduction for high grade spondylolisthesis.
What patient is most likley to have a pelvic fracture?
Elderly women.
True or false unilateral preservation of sacral nerves is not adequate for bowel and bladder control?
False, they are usually adequate.
Which x-ray provides the best assessment of sacral spinal canal?
Inlet view.
Which Denis zone fracture may be amenable to sacroplasty?
Zone 1 but cannot be displaced which risks symptomatic cement leakage.
What are the common forms of spinal cord monitoring?
EMG
SEP
MEP
What areas of the spinal cord is monitored by SEPs?
Dorsal column sensory pathways.
Where is signal initiation and recording with SEPs?
Signal initiation in lower extremity usually involves posterior tibial nerve. Upper extremity ulnar nerve.
Signal recording is transcranial from somatosensory cortex.
What is a disadvantages of SEPs?
Not reliable for monitoring the integirty of the naterior spinal cord pathways.
What is an advantage of MEPs?
effective at detecting an ischemic injury in anterior 2/3 of spinal cord.
What is a disadvantage of MEPs for spinal cord monitoring?
unreliable due to effects of anesthesia.
What is the difference and significance of “burst activity” and “sustained train” during mechanical electromyography?
Burst activity occurs with contact of a surgical instrument with a nerve root. Not due to an injury and not clinically significant.
Sustained train occurs with traction or significatn injury to a nerve root which may be clinically signficiant.
Advantage and disadvantage of mechanical electromyography?
Advantage- allows monitoring of specific nerve roots.
Disadvantage- overly sensitive. Sustained train does not always refelct nerve root injury.
How does electrical electromyography work for monitoring pedicle screw placement?
Bone conducts electricity poorly so only if a pedicle screw is breached will stimulation of a pedicle screw lead to activity of a specific nerve root.
Most common pathogen to cause of vertebral osteomyelitis or spondylodiskitis?
What is the second most common cause?
staph aureus (50-65% of the time).
staph epidermidis.
What pathogen other than staph aurues and staph epidermidis is associated with vertebral osteomyelitis and IV drug use?
pseudomonas.
True or false disc destruction is atypical of neoplasms?
True.
How often is fever present in vertebral osteomyelitis?
only 1/3 of the time.
Which inflammatory marker is more reliable for tracking the success of treatment of vertebral osteomyelitis?
CRP.
How often are blood cultures positive in patients with spondylodiskitis?
When positive how accurate are they for isolating the correct ogranism?
33% (reports from 25%-66%)
85%
What two findings on imaging support vertebral osteomyelitis over malignancy?
Disc space involvement.
End-plate erosion.
What is the most important prognostic indicator of clinical outcome in patients with epidural abscess?
preoperative degree of neurologic deficit.
Where are epidural abscesses most commonly located within the spine?
dorally in the thoracolumbar spine.
When can medical treatment of epidural abscess be effective?
What factors are associated with failure of medical treatment?
small abscesses with no neurologic deficits.
Diabetes, CRP >115mg/L, WBC> 12k/ml
Positive blood cultures, age >65 years, and MRSA.
Why is diskitis more common in pediatric patients than adults?
In children the blood vessels extend from the cartilaginous end plate into the nucleus pulpossus allowing direct innoculation. In adults it only extends to the annulus fibrosis.
What may be the earliest radiographic sign of discits in a child?
Loss of lumbar lordosis.
What must be ruled out if a patient with discitis is not getting better with antibiotic treatment?
Rule out TB.
Is TB becoming more or less common in the United States?
more common due to increasing immunocompromised population.
What is the most common extrapulmonary site for TB?
thoracic spine.
5% of all TB patients have spine involvement.
What two things are characteristic of early TB infection of the spine?
Large paraspinal abscess formation (Seen 50% of the time, usually anterior, more common than pyogenic infections).
Initially does not involve the disc space, can lead to it being misdiagnoses as a neoplastic lesion.
What is a finding of chronic TB infections of the spine?
kyphosis.
Adults it usually stays static with healing.
In childens it progresses 40% of the time with healing.
True or false back pain is a late finding of tuberculous spondylitis?
True.
What should tuberculin spine infections be tested for?
acid fast bacilli.
Can take 10 weeks to grow in cultures
PCR allows for faster identification.
What are other etiologies of granulomatous infection of the spine that may have similar clinical picture as TB?
Atypical bacteria: Actinomyces israelii, Nocardia asteroids, Brucella.
Fungi: Coccidioides immitis, Blastomyces dermatitidis, Cryptococcus neofromans, and Aspergillosis.
Spirochetes: Treponema pallidum.
What medication regimen should be used for Tuberculosis spinal infections?
RHZE for 2 months
RH for 9 to 18 months
R-rifampin
H-isoniazid
E-ethambutol
Z-pyrazanamide
What is the most common cause and type of peripheral nerve injury detected by electrophysiologic monitoring during anterior cervical spine surgery?
Brachial plexopathy following shoulder taping and application of countertraction.
What was associated with use of morphine nerve paste applied to the dura after spinal decompression?
epidemic levels of surgical site infections.
In addition to deferentiating peripheral nerve compression from radiculopathy what else are electrodiagnostic studies usefule for detectiong?
systemic neurologic disorders such as ALS.
Laminoplasty is contraindicated in?
setting of fixed kyphosis.
What percentage of asymptomatic patients over the age of 40 will have findings of HNP or foraminal stenosis on cervical MRI?
25%
Which factor has been associated with worse patient-reported outcomes for those undergoing surgical correction of adult spinal deformity? Obesity/Advanced Age/Pre-operative disability scores?
Obesity.
Age is associated with more complications but not worse patient reported outcomes.
How should a patient be treated with a GSW that has penetrated both spinal canal and abdomen with the projectile retained in the vertebral body?
Do not need to remove the projectile.
Broad spectrum IV abx for 7-14 days because of bowel contamination.
Who is a good candidate for laminoplaty?
Multilevel cercial myelopathy with preserved cervical lordosis.
No kyphosis
No Axial neck pain
Congenital cervical stenosis often ideal.
What is a positive predictor of return to play in professional atheletes after lumbar disc herniation?
Higher number of games played prior to injury.
Age was associated with a worse prognosis.
What affect to halogenated gases in anesthesia have on neuromonitoring?
Decrease in the threshold for tcMEP and increased latencies in SSEPs.
Not preferred
What findings in children with scoliosis have been associated with an increased risk of abnormal MRI findings?
Male gender, age younger than 11, absence of thoracic apical segment lordosis, and abnormal neurologic findings.
Radiographic that require screening MRI include left thoracic curve, absent pedicle, and congenital bar.
Abnormal abdominal reflex should lead one to suspect a syrinx.
What will radiographs for scoliosis in neurofibromatosis show.
Vertebral scalloping
Penciling of ribs( more than 3 ribs is a poor prognostic sign and associated with rapid curve progression).
Enlarged foramina.
When should patients with scoliosis and neurofibromatosis have an MRI of their spine?
Must be done prior to any surgical intervention to rule out an intracanal neurofibroma, dural ectasia, and a dumbbell lesion(neurofibroma on nerve root).
Treatment for dystrophic scoliosis in a patient who is 6 with neurofibromatosis.
Anterior and Posterior spinal fusion.
High rate of pseudoarthrosis with PSF alone (40%)
Perfrom early in this population < 7 yrs.
What is the most common presenting symptom of cauda equina syndrome?
Radicular leg pain.
Are SSEPs reliable for monitoring the integrity of the anterior spinal cord pathways?
No. It is possible for anterior motor tract damge to occure without concomitant changes in SSEPs.
Treatment for pediatric discitis/osteomyelitis?
Bedrest and IV antibiotics. Immobilization not found to affect outcomes.
If no clinical response after 7-10 days obtain biopsy.
Surgical debridement if not responding to treatment or there is a neurological deficit.
Indications for kyphoplasty?
Refractory and Severe pain for greater than 4-6 weeks that requires hospitilization, prevents ambulation, or requires long term narcotics
MRI showing edema in vertebral body on T2 images
Vertebral body ollapse not greater than 80%
Posterior vertebral body cortex intact. Prevents possibility of the cement retropulsing.
What is the treatment for a symptomatic os odontoideum with neurologic deficits?
C1-C2 fusion.
What are risk factors for airway complications after anterior cervical surgery?
Exosing more than three vertebral bodies
Blood loss > 300ml
Exposures that involve C2,C3,or C4.
Operative time > 5hours.
History of myelopathy, spinal cord injury, pulmonary problems, smoking, anesthetic risk factors, and the absence of a drain did not correlate with an airway complication.
What would be the TLICS score for a man with a T12 burst fracture, incomplete cord injury, and intact PLC?
5
How should scoliosis be treated in children with spina bifida?
Bracing is not effective.
ASF and PSF with pelvic fixation.
High pseudoarthrosis rate. Due to dysplastic posterior elements.
High incidence of infection 15-25% due to poor soft tissue coverage posteriorly.
What is a spinal deformity seen in children with Spina Bifida besides scoliosis?
Congenital Kyphosis.
Present in 10-15%
Gibbus deformity can cause recurrent skin breakdown due to pressur epoints when sitting.
Treater with kyphectomy and PSF.
How should scoliosis be approached in a patient with Marfan Syndrome?
Bracing not as effective as idiopathic.
Surgery indications largely the same.
Use longer construct and consider fusing to the pelvis.
Need an MRI prior to surgery to identify dural ectasia.
What complications are associated with scoliosis surgery in patients with Marfan Syndrome?
Fixation failure is most common. Secondary to poor bone.
Higher rate of infection, pseudarthrosis, dural tear, and cruve decompensation requiring reoperation.
Same amount of blood loss, hospital stay length, and postoperative neurologic defecits.
What work-up should be done in any patient with Duchenne’s undergoing surgery for scoliosis?
Cardiac and pulmonary function studies.
Patient may be too high risk.
What is the likelihood and prognosis of a patient with Duchennes in regards to scoliosis?
95% of patients develop this neurogenic curve after becoming wheelchair bound.
Begins with hyperlordosis and progresses to general kyphosis and scoliosis with varying degrees of pelvic obliquity.
Progresses 1 to 2 degrees per month starting at age 8 to 10. Most rapidly progressive from age 13-14.
Patients can become bedridden by age 16.
What is the recommended treatment for scoliosis in a patient with Duchenne’s?
Bracing contraindicated as it interferes with respiration.
Early PSF before pulmonary function declines. Indications: 20-30 degree curve in non-ambulatory patient. FVC less than or equal to 35%. Rapidly progressive curve.
What catastrophic complication can occur during PSF for scoliosis in a patient with DMD?
What pretreatment can be given?
Malignant Hyperthermia
Dantrolene
When should you instrument to the Pelvis when perfroming PSF for Duchenne’s?
Curves greater than 40 degrees
Pelvic obliquity greater than 10 degrees
Lumbar curves where apex is lower than L1
What are the spinal manifestations of Achondroplasia?
Lumbar stenosis.
Thoracolumbar kyphosis.
Foramen magnum stenosis.
What lumbar spine findings are characteristic of Achondroplasia?
Shortened pedicles.
Decreased interpedicular distance.
Vertebral wedging in thoracolumbar kyphosis
Posterior vertebral scalloping
What is the recommended treatment for thoracolumbar kyphosis in a patient with Achondroplasia?
90% will improve with observation.
If persistent vertebral wedging after age 3 can consider bracing.
Operative only considered after bracing has failed and kyphosis is > 45-60 degrees.
If operative PSF +/- anterior corpectomy with strut.
How is lumbar hyperlordosis treated in patients with Achondroplasia?
Observation.
What may need to be done for a infant with achondroplasia and sleep apnea?
surgical decompression of the foramen magnunm.
What spine issues can be seen with diastrophic dysplasia?
antlantoaxial instability- Occipital cervical fusion if there are neurologic symptoms.
Cervical kyphosis- usually resolves spontaneoulsy but if it doesn’t PSF.
Kyphoscoliosis of thoracolumbar spine- May require fusion.
What are the indications for non-operative vs operative treatment of scoliosis in children with OI?
Non-op: Observation for curves <45 degrees. Bracing ineffective and not recommended because of fragility of ribs.
Operative: Curves greater than 45 degrees in mild forms and > 35 degrees in severe forms. If FVC drops to 40%.
Associated with large blood loss.
Use allograft.
What percentage of patients with down syndrome will have Lumbar spondylolisthesis?
6%
Does treatment differ for scoliosis in down syndrome patients?
Not really.
Brace for curves greater than 25-30 degrees
PSF for curves > 50 degrees
What is powers ratio.
Used to determine if there is occipitocervical instability.
Seen in patients with down syndrome.
What treatment is recommended for occipitocervical instability in patients with down syndrome?
Observation with limitation of contact sports activity for vast majority.
If pt has progressive neurologic deficits and myelopathy then posterior occipitocervical fusion.
What are the general indications for C1-C2 fusion in a patient with down syndrome?
ADI >5mm in the symptomatic or ADI > 10mm
<14mm space available for the cord
Complication rate up to 50%
What percentage of patients with down syndrome will have atlantoaxial instability?
17.5%
What is the presentation of atlantoaxial instability in a patient with down syndrome?
Often subtle
Manifests as a loss or change in gait or bowel/bladder symptoms.
Should all patients with down syndrome get flexion-extension cervical radiographs at least once?
No
Should be done prior to intubation and if they want to participate in sports.
Patients with ADI > 4mm should not participate in contact sports, diving, gymnastics, high jump, or butterfly stroke.
What is considered a normal ADI in a patient withh down syndrome?
In general 5-10mm
Normal ADI is <5mm
What should be done for a child with down syndrome and a ADI of 9mm?
If no neurologic findings and >14mm SAC then routine follow-up with neurologic evals and repeat imaging.
Should avoid contact sports, diving, and gymnastics.
If symptomatic a syrinx usually presents with neurologic abnormailites similar to?
Central Cord Syndrome
All patients with neurofibromatosis and scoliosis must be evaluated with an MRI prior to surgical intervention of what to rule out what?
Entire spinal axis
Rule out both intracanal neurofibroma and dural ectastia
At what age does thoracolumbar kyphois in a child with achondroplasia typically improve?
Improves by 12-18 months as the child begins to walk and improve trunk strength.
What structure can be injured during and ALIF or a trans-psoas approach?
What symtoms can be seen post-op?
Sympathetic chain
Leads to post-sympathectomy dysfunction syndrome characterized by increased temperature, reduced perspiration, and reduced sympathetic skin responses in the ipsilateral lower extremity.
True or false patients with DISH hav an increased rate of isolated disease on the right side of the thoracic spine?
True
Does application of local corticosteroids anterior to ACDF constructs decrease postoperative dysphagia?
Yes
Systemic steroids have also been shown to decrease the rates of dysphagia.
What is the most common complication after a PSO?
Pseudoarthrosis 25-30% of cases.
Neurologic injuries have been reported to be <10%.
While topical vancomycin powder decreases surgical site infections what has been show to increase with its use?
The rates of gram-negative surgical site infections.
Culture-negative fluid collections
What is the advantage of the PROMIS assessment tool in spine surgery?
PROMIS= Patient-reported outcomes measurement information system.
Reduced floor and ceiling effects compared to other assessment tools.
Highly reliable and valid assessment
It is a form of computerized adaptive testing and has reduced number of questions. thereby reducing respondent and administrative burden.
Can be used for more than just spine.
How do you calculate Torg-Pavlov ratio?
What is a normal value?
canal/vertebral body width
< .8 is abnormal. 1 is normal.
Torg <.8 is not a contraindication of return to play.
What is the issue with spear tackling?
Leads to loss of cervical lordosis and gradual cervical stenosis
What is considered normal cervical canal diameter?
Relative stenosis?
Absolute stenosis?
17mm or greater
< 13mm
<10mm
Return to play after burner/stinger?
Spine abnormalities that are contraindications for return to play?
Spear tackler’s spine
Cervical neuropraxia with ligamentous instability.
UPPER C SPINE ABNORMALITIES: Odontoid hypoplasia, os odontoideum, atlantooccipital fusion.
Torg 1 Klippel-Feil anomaly (long fusion mass) absolute contraindication to play
Torg 2 Klippel-Feil (only 1 or 2 segements) if asymptomatic is a relative contraindication to return to play.
What are the symptoms and physical exam findings of a burner or a stinger?
Unilateral tingling in arm not typically isolated to a single dermatome.
Usually resolves quickly in 1-2 minutes
PHYSICAL EXAM: Full cervical ROM, no tenderness, unilateral transient weakness in C5, C6. Can have a positive Spurling test.
When is imaging indicated after a stinger or a burner?
Radiographs are usually unremarkable but should be obtained if a patient has recurring symptoms to rule out fx and cervical stenosis.
MRI is indicated whenever symptoms are bilateral as this is inconsistent with a stinger.
EMG is inidcated when symptoms periss after 3 weeks.
What amount of pre-vertebral soft tissue swelling at C2 is concerning for a possible transverse ligament injury?
7mm or greater.
What is a normal C7 Sabittal vertical axis measurement?
Less than 5cm as measured from the posterosuperior aspect of the S1 body.
What will you see on radiographs of the spine in a patient with psoriatic arthrits?
Sacroiliitis
Syndesmophytes
Paravertebral ossification
Destructive discovertebral lesions
Describe the Oswestry Disability Index (ODI)
Useful for all conditions that affect low back pain.
Considered the gold standarp of low back functional outcome tools.
Describe the Neck Disability Index (NDI)
Modification of the ODI. 10 item questionnaire. Most commonly used self-reported measure for neck pain. Intended for patients with chronic neck pain, musculoskeletal neck pain, whiplash, and cervical radiculopathy.
SCORING: Each of the 10 sections are added together (each section has a possible score of 0-5), divided by 50, and multiplied by 100 to determine a percentage.
0 points or 0% correlates with no activity limitations whereas 50 points or 100% correlates with complete acitivty limitation/disability.
What is the mJOA outcome measure?
Japanese Orthopaedic Association for the evaluation of operative results in patients with cercial myelopathy.
A point scoring system (17 total) based on function in the following categories:
Upper extremity motor function
Lower extremity motor function
Sensory function
Bladder function
Regarding congential kyphosis what is a type I and what is a type II deformity?
Which is more likely to progress?
Type I deformity is a failure of formation
Type 2 deformity is a failure of segmentation
Failure of formation have a higher likelihood of progressing and benefit from early surgical in situ arthrodesis.
Anterior surgeryis reserved for those with ebidence of neurologic compression or deformities exceeding 50 degrees.
Briefly describe Tokuhashi Score?
Prognostic score based on 6 elements:
general condition, extraspinal bony metastasis, number of vertebral bodies with metastasis, visceral metastasis, primary tumor, neurolgoic compromise.
Socre of 0-8: <6 months; 9-12 6-12 months; 12-15 > 1 year.
In the treatment of mestatic lesions to the spine when is palliative care recommended?
Radiation alone?
nuerologic decompression, spinal stabilization, and postoperative radiation?
Life expectancy < 6months -> palliative care
not a surgical dandidate or no signs of instability or compression without a neurologic deficit -> radiation alone
metastatic lesions with neuro deficits or instability with a life expectancy of > 6 months -> surgery
What is the NOMS framework when considering treatment of metastatic lesion of the spine?
Neurolgoic: measure of epidrual spinal cord compression (ESCC) 0-1 low grade. 2-3 high grade
Oncologic: responsiveness to radiation
Mechanical instability: spinal instability neoplastic score (SINS). See other side of card for description.
0-6 no surgical consultation required, 7-18 surgical consultation advisable.
Systemic illness: formulation of prognosis fromdisease burden, medical comorbidities, and functional status. Can use Eastern Cooperative Oncology Group’s Performance Status Rating (ECOG-PSR)
What is normal thoracic kyphosis?
35 degrees
Normal range is 20 to 50.
How does spinal canal diameter and spinal dord diameter vary within the thoracic spine?
Endplate area?
See image for spinal canal and cord dimenesions.
Endplate area progressively increases from T1 to T12.
How are the zygapophyseal joints oriented within the subaxial, thoracic, and lumbar spines?
C3-C7 45 degree sagittal angled superior-medially. Allows flexion-extension, lateral flexion, and rotation
Thoracic spine. 55 degrees sagittal and 20 degrees coronal. Facets are more in the coronal plane. Allows minimal flexion-extension. Some rotation. Overall 6 degrees of freedom.
Lumbar spine 90 degree sagittal plane. Allows alot of flexion-extension. Minimal rotation.
Describe Thoracic Pedicle Anatomy as it refers to:
Diameter
Length
Angle
Diameter: Pedicle wall is twice as thick medially as laterally.
On average T4 is most narrow. T12 is the largest and is usually larger than L1.
Length: decreses from T1 to T4 and then increases agian as you move distal in the thoracic spine. T1 20mm. T4 14mm T10 back to 20mm
Angle: transverse ange varies from 5 degrees Lateral at T12 to 25 degrees medial at T1. See image.
Sagittal pedicle angle is depicted on the previous page. It is 15-17 degrees cephalad for the majority of thoracic spine.
What are the erector spinae muscles from medial to lateral?
Spinalis- spinous process to spinous process
Longissimus- transverse process to transverse process
Iliocostalis- Origin on ilium and ribs that inserts on ribs and transverse processes.
Innervated by dorsal rami of spinal nerves.
Regardless of symptomatology what percent of patients demonstrate spondylotic change?
85% of patients
typically begins at age 40-50
More common in men than women
What is the most common levels in the cervical spine to develop spondylosis?
C5-C6 > C6-C7 because this is where the most flexion and extension takes place in the subaxial spine.
Risk factors include: excessive driving, smoking, lifting, and professional athletes.
What is normal canal diamter in the cervical spne?
In general below what diamter may patients start to develop myelopathy?
What motion within the cervical spine exacerbates this?
17mm
13mm
Worse during neck extension where the central cord is pinched between the degenerative disc and the hypertrophic facets and infolded ligamentum posteriorly. Ligament starts to infold because of the loss of disc height causing it to bulge.
What degenerative changes in the cervical spine leads to the majority of radicular symptoms?
uncovertebral jont arthrosis
Can also be due to spondylotic
True or false MRI has a high false positive rate when looking for degenerative changes in the cervical spine?
True.
28% of those over 40 will have findings of herniated nucleus pulposus or foraminal stenosis and these may not be clinically significant.
What chemical pain mediators cause irritation to nerve roots in disc herniations?
IL-1, IL-6, Substance P
Bradykinin, TNF alpha, and prostaglandins
What are some of the most common symptoms patinents have with cervical radiculopathy?
Occiptial headaches (one of the most common)
trapezial or interscapular pain.
Neck pain
Unilateral arm pain- often global and nondermatomal
Unilateral dermatomal numbness, tingling, and weakness.
What role do nerve conduction studies play in diagnosing cervical radiculopathy?
May be useful to distinguish peripheral from central process (such as ALS)
May show fibrillations and positive sharp waves in the affected distribution.
High false negative rate. Cannot rely on this soley.
What percent of patients with cervical radiculopathy will improve with nonoperative management?
75%
Resorption of soft discs and decreased inflammation around irritated nerve roots.
Multiple meds and rehab techniques of which very few are substantiated by evidence.
For professional athletes with cervical radiculopathy that presents with weakness what is the risk of spinal cord injury if they return to play after they are fully recovered and asymptomatic?
No increased risk.
Studies have shown return to play is expedited with a brief course of oral methylprednisolone.
Ok to return to play after resolution of symptoms and repeat MRI demonstrates no cord compression.
What are the risks of selective nerve root corticosteroid injections in the cervical spine?
What are the rates of long term relief?
Rare but possible: dural puncture, meningitis, epidural abscess, and nerve root injury.
Provides long-term relief in 40-70% of cases.
What risk factor has the greatest affect on pseudoarthrosis for single level ACDF?
Smoking.
Use of plate, allograft vs autograft, and use of collar post-operatively have been shown to have no effect.
What could have occured to cause enopthalmos and loss of ciliospinal reflex on the left eye after an ACDF?
Injury to the sympathetic chain that sits on the lateral border of the longus coli muscle at C6.
Enopthalmos is posterior displacement of the eye in the orbit.
Should see the more classic symptoms of ptosis, anhydrosis, and miosis as well.
What are the purported benefits of cervical disc replacement?
What are the risk?
Potential to preserve motion. Pseudoarthrosis not a concern. Quicker return to routine activities
Hardware failure with potential paralysis
Persistent neck pain from pain originating from facets.
There are shorter term RCT that show superiority to cervical fusion with regard to reoperation rate and quicker return to work but longer term studies are needed.
The lesser occipital nerve branches off what nerve root?
C2 nerve root
What are the three manifestations of instability in the cervical spine?
Atlantoxial subluxation
Basilar invagination
Subaxial subluxation
What percent of rheumatoid patients have atlantoaxial instability?
What is the mechanism?
What is the most common direction if instability?
50-80%
caused by pannus formation between dens and ring of C1 that leads to the destruction of the transverse ligament and dens.
Most common to have anterior subluxation of C1 on C2 but can have lateral and posterior as well.
How will atlantoaxial subluxation appear on radiographs?
What measurements are best used to evaluate its severity and/or progression?
Controlled flexion-extension views to determine motion between C1 ring and dens.
AADI (anterior atlanto-dens interval) instability defined as > 3.5mm of motion between flexion and extension views. Instability alone is not an indication for surgery. >7mm of motion may indicate disruption of alar ligament. > 10 mm of motion is an indication for surgery because of increased risk of neurologic injury.
PADI/SAC (posterior atlanto-dens interval and space available for cord describe the same thing)
<14mm is an indication for surgery.
>13mm is the most important radiographic finding that may predict complete neural recovery after decompressive surgery.
Treatment for Rheumatoid atlantoaxial subluxation?
11 mm of AADI with reducible C1/C2 junction?
SAC 10mm with basilar invagination?
When do you do odontoidectomy?
Stable antlantoaxial subluxation that has adequate space available for the cord and no neurologic deficits can be observed.
Posterior C1-C2 fusion. Do not need to remove posterior arch of C1 since it is reducible.
Occiput-C2 fusion. Have to do this to prevent worsening of basilar invagination. Need to perfrom resection of C1 arch if the C1-C2 junction is not reducible to completely decompress spinal canal.
Almost never. Only was done when pannus does not resolve after posterior fusion when significant time has passed.
For Rheumatoid patients what is the mechanism of basilar invagination?
How often is it present?
What radiographic lines are used to evaluate its presence, severity, and progression.
Treatment?
Cranial migration of dens from erosion and bone loss between occiput and C1 and C2.
Present in 40% of RA patients
Often seen in combination with fixed atlantoaxial subluxation.
C2 to occiput fusion- progressive cranial migration (>5 mm), neurologic compromise, and cervicomedullary angle <135 on MRI.
What are risk factors for subaxial subluxation in rheumatoid patients?
How often is it present?
How is it evaluated on radiographs?
Treatment?
Often combined with upper c-spine instability and occurs at multiple levels.
More common with: steroid use, males, seropositive RA, nodules present, and severe RA.
Subaxial subluxation of vertebral body of >4mm or >20% indicates cord compression.
Cercial heigh index (body height/width) <2.0 is almost 100% sensitive and specific for predicting neurologic compromise.
Posterior fusion and wiring if positive radiographic findings with intractable pain and neurologic symptoms.
What population if OPLL more common in?
Asian
Men > Women
Most common levels are C4-C6.
What is the cause of OPLL?
What are associated factors?
Cause is unclear. Multifactorial
Diabetes, obesity, high salt-low meat diet, poor calcium absorption, and mechanical stress on posterior longitudinal ligament.
Treatment for OPLL?
If kyphotic then anterior corpectomy. Do not remove OPLL from dura to aboid dural tear. Allows OPLL to float at corpectomy site.
If lordotic then laminoplasty or laminectomy and fusion. Considered the safer and preferable approach.
In what percentage of patients is there tandem stenosis of both lumbar and cervical stenosis?
20%
What are some of the classification systems for myelopathy?
Nurick Classification
Ranawat Classification
Japanese Orthopaedic Association Classification
What symptoms are found in patients with cervical myelopathy?
neck pain and stiffness- Neck pain can often be absent. Occipital headaches are common.
Extremity paresthesias
weakness and clumsiness- difficulty with fine motor skills, dropping objects.
Gait instability- most important clinical predictor
urinary retention- rare and only appear late in disease progression. not very useful in diagnosis due to high prevalence of urinary conditions in this patient population.
What is the finger escape sing?
when patient holds fingers extended and adducted, the small finger spontaneously abducts due to weakness of intrinsic muscle.
Seen in patients with myelopathy.
Will patients with myelopathy have decreased pain and proprioception dysfunction?
Yes they can.
proprioception dysfunction- due to dorsal column involvement, occurs in advanced disease, and associated with a poor prognosis.
decreased pain sensation- pinprick testing should be done to look for global decrease in sensation or dermatomal changes. Due to involvement of lateral spinothalalmic tract.
vibratory changes are usually only found in severe case of long-standing myelopathy.
What are the spastic sings seen in patients with cervical myelopathy?
upper motor neuron signs = spasticity
hyperreflexia- may be absent when there is concomitant peripheral nerve disease (cervical or lumbar nerve root compression, spinal stenosis, diabetes).
inverted radial reflex- tapping distal brachioradialis tendon produces ipsilateral finger flexion.
Hoffmann’s sign- this is most common physical exam finding.
sustained clonus- > three beats defined as sustained clonus. Poor sensitivity (13%) but high specificity (100%)
Babinski test- positive with extension of great toe.
How do you measure the C2-C7 alignment angle?
How do you measure the local kyphosis angle?
C2-C7: determined by tengential lines on the posterior edge of the C2 and C7 body on lateral radiographs in neutral position.
Local kyphosis angle- the angle between the lines drawn at the posterior margin of most cranial and caudal vertebral bodies forming the maximum local kyphosis
What is the cord compression ratio?
What value portends a poorer prognosis?
Compression ratio = smalles AP diameter of cord / largest transverse diameter of cord.
compression ratio < .4 carries poor prognosis.
True or false: Two level corpectomies tend to be biomechanically vulnerable?
True
preferable to combine single level corpectomy with adjacent level diskectomy
7-20% rates of graft dislodgement with cervical corpectomy with associated severe complications, including death, reported.
What are the pros and cons of ACDF for cervical myelopathy?
Lower infection rate, less blood loss, and less postoperative pain.
Dysphagia is a disadvantage. Avoid in patinets with poor swalloing function.
How many level anterior cervical corpectomy can you perform without backing it up posteriorly?
Two level corpectomy with use of static plate and strut graft is acceptable.
3 level cervical corpectomies and greater need posterior stabilization as well.
Anterior fixation alone in 3-level and above results in a high (>70%) catastrophic failure rate.
What amount of fixed kyphosis is a contraindication to cervical laminectomy and fusion?
>10 degrees
will not adequately decompress spinal cord as it is “bowstrining: anteriorly.
Is laminoplasty outcomes equivalent to a multilevel anterior decompression and fusion?
Yes they are equivalent.
May consider laminoplasty more in patients at higher risk of pseudoarthrosis such as chronic steroid users and diabetics.
What is the rate of post-laminectomy kyphosis in ther cervical spine if no fusion is performed?
Ranges from 11-47%
Cervical laminectomy without fusion is discouraged.
What is the rate of C5 palsy after cervical surgery?
How does it differ between procedures?
What is the prognosis
4.6%
Higher in males
No difference between ACDF and laminoplasty.
Higher rate reported following Lami fusion.
Prognosis is generally good, but it is a prolonged recovery.
Prolonged recover associated with: multilevel paresis, motor grade less than or equal to 2. Sensory involvement with intractable pain.
What is the average amount of lumbar lordosis?
Range?
Where is the apex of the lordosis?
60 degrees
20 to 80 degrees
L3
True or false: the facets become more coronal as you move inferiorly in the Lumbar spine?
What happens to the pedicles?
True.
Angulate more medial as you move distal
L1: 12 degrees
L5: 30 degrees
S1: 39 degrees
L1 has the smalles pedicle diamter in the Lumbar spine.
How do you calculate Pelvic Incidence, pelvic tilt, and sacral slope?
Pelvic Incidence = pelvic tilt + sacral slope
Pelvic tilt = pelvic incidence- sacral slope
Sacral slope = pelvic incidence - pelvic tilt
In what spine procedure may the superior hypogastric plexus be injured?
Injury causes what complication?
Anterior retroperitoneal approach to lumbar spine.
Found over the L5 body.
Damage causes retrograde ejaculation.
What nerves are at tisk of injury besides the lumbar plexus with a transpoas approach?
Ilioinguinal -> groin paresthesias
iliohypogastric -> abdominal paresis
What is th compositions of the annulus fibrosus?
What is the composition of the nucleus pulposus?
What is the blood supply to the intervertebral disc?
What is the innervation?
The disc is avascular with capillaries terminating at the end plates.
Nutrition reaches the nucleus pulposus through pores in the endplates.
Annulus is not porous enough to allow diffusion
The dorsal root ganglion fives rise to the sinuvertebral nerve which innervates the superficial fibers of annulus. No nerve fibers extend beyond the superficial fibers.
When a disc herniation occurs what is there a spontaneous increase in the production of?
Osteoprotegrin (OPG)
Interleukin-1 beta
Receptor activator of nuclear factor-kB ligand (RANKL)
Parathyroid hormone (PTH)
Overall what does disc aging lead to?
What is specifically decreased?
Increased?
No change?
loss of water content and conversion to fibrocartilage.
Decrease in: nutritional transport, water content, absolute number of viable cells, proteoglycans, and pH
Increase in: keratin sulfate to chondroitin sulfate ratio, lactate, degradative enxyme activity.
Density of fibroblast-like cells.
No change: absolute quantity of collagen.
What percent of people will have low back pain in their lifetime?
For those where it is seriour enough to miss work what percent will return by 6 weeks?
12 weeks?
50-80% second only to respiratory infection as cause to visit doctors office.
60-70% by 6 weeks
80-90% by 12 weeks.
For inguinal pain in a patient where hip pathology has been ruled out. What other musculoskeletal cause should be ruled out?
Lumbar pathology.
For inguinal pain think L5-S1 spedifically.
What are the indications to obtain radiographs for back pain?
4 weeks of back pain that is refractory to non-operative treatment.
Any red flags: trauma, infection, cancer hx or malignancy concern, or red glad physical exam findings.
What is argued to be the only indication for lumbar total disc replacement?
single level disease with disease free facet joints.
Has been show to have better 2 year patient outcomes and lower rates of adjacent segment disease.
Patients often have persistent back pain which is thought to be facet joint in origin or instability of prosthesis. If this occurs either reviese or treat with posterior stabilization alone if implant is in good position.
What is the incidence, patient demographics, and location of most thoracic disc herniations?
Only 1% of all HNP.
Most commonly seen between 4th and 6th decades of life.
Usually involved middle to lower levels.
75% of all thoracic disc herniation occure between T8 and T12.
underlying Scheuermann’s disease may predispose to thoracic HNP.
Will you get any arm pain with a thoracic HNP?
Yes you can with HNP at T2-T5.
Patients can also develop Horner’s syndrome with HNP at these levels.
Will you see the follwoing symptoms with a thoracic HNP?
Sexual dysfunction?
Bowel or bladder changes?
Abnormal rectal tone?
Yes, you can see all of these things but they do not have to be present.
15-20% have bowel or bladder changes.
What is a disadvantage of MRI when examining the thoracic spine?
High flase positive rate
In a study of asymptomatic individuals.
73% had thoracic disc abnormalities
37% had frank herniations
29% of these had cord compression
Are the majority of thoracic disc herniation operative?
No, most will get better with activity modification, PT, and symptomatic treatments.
However, if any sings of myelopathy or neurologic decline should not hesitate to consider treating operatively.
Which type of disc herniation shows the greatest degree of spontaneous reabsorption?
What is the me
What nerve root usually has the greatest contribution to knee extension?
Often thought to be L3, but more contribution for L4.
Similar for Ankle dorsiflexion which has more contribution form L5 than L4.
Describe the following provocative tests that can be used in diagnosing a lumbar disc herniation?
Lesegue sign
Bowstring sign
Kernig test
Naffziger test
Milgram test
Lesegue sign- SLR aggravated by forced ankle dorsiflexion
Lesegue sign- SLR aggravated by compression on popliteal fossa
Kernig test- pain reproduced with neck flexion, hip flexion, and leg extension
Naffziger test- pain reproduced by coughing, which is instigated by lying patient supine and applying pressure on the neck veins
Milgram test- painreproduced with straight leg elevation for 30 seconds in the supine position
How do differentiate post-surgical fibrosus vs recurrent herniated disc on MRI?
Need an MRI with gadolinium.
Post surgical fibrosus enhances with gadolinium.
Recurrent herniated sic does not enhance with gadolinium.
How effective are epidurals and selective nerve blocks in patients with disc hernations?
Is there a kind of herniation that responds better?
50% have long lasting improvement. Compared to 90% improvement with surgery.
Works best inpatients with extruded discs as opposed to contained discs.
What has been shown to be positive predictors for good outcome with microdiscectomy surgery?
Negative predictor?
Leg pain is chief complaint. Positive straight leg raise. Weakness that correlates with nerve root impingement seen on MRI. Married. Profressional athletes (younger age, greater number of games played prior to injury)
NEGATIVE: Workers comp
What is the risk of the following with a microdiscectomy?
Dural tear?
Recurrent HNP?
Discitis?
Dural tear 1%. Has not been shown to adversely affect long term outcomes.
revision rate at 8 year follow-up is 15% according to SPORT trail.
Outcomes for revision discectomy have been shown to be as good as for primary discectomy.
Discitis 1%
What are the key features of Cauda equina syndrome?
Back pain.
Bilateral leg pain
bowel and bladder dysfunction (complete incontinence is more consistent). Urinary retention and eventually overflow incontinence.
Decreased rectal tone.
Bowel dysfunction is rare.
Saddle anestheisa (loss of sensation in genitalia most consistent)
Lower extremity sensorimotor changes.
Where do the majority of lumbar facet cysts occur?
L4-L5 60 to 89% of the time.
This is because it is the most mobile segment.
How will a facet appear on MRI?
How may different appearances on T2 sequences determine what kind of cyst it is and what treatment is recommended?
Best seen on T2.
Traditionally hyperintense cneters with hypointense rims on T2. Can have peripheral rim enhancement with gadolinium contrast.
High signal intensity on T2: more often synovial with a higher success rate with CT guided cyst rupture.
Low signal intensity on T2: gelatinous or calcified contents. Lower success rate with CT guided cyst rupture.
What is the general success rate of CT-guided cyst rupture, facet steroid injection, or cyst injection for lumbar facet cysts?
How about laminectomy, decompression?
50-75% pain relief at 1-year
Approximately 39% of patients will require surgical intervention at 7 months.
80-90% success rate in back and leg pain. However, there is a high incidence of recurrent back pain and cyst formation within two years.
Some consider first line of surgical treatment due to high recurrence rates to be facetectomy and instrumented fusion. compete resolution of symptoms in 80-90%. Lowest risk of persistent back pain and recurrence of cyst formation.
What is the incidence of lumbar spinal stenosis in peoples lifetime?
Risk factors?
20-25%
Slightly more common in males.
Most commonly occurs at L4-L5 (91%). Most motion at this segment.
Risk factors: Caucasian race, increased BMI. Congenital spine anomalies (20%)- failure of posterior elements to develop, leading to short pedicles and laminae.
What is a the name of the separate ossification center that projects posteriorly from the superior articular facet in the lumbar spine?
mamillary process
What is th eblood supply to the dura & posterior elements of the spine?
dorsal branches of the segmental arteries.
Under what cross-sectional area is there concern for central stenosis in the lumbar spine?
Less than 100mm2
AP canal diamter of less than 10 mm is also consistent with stenosis.
What are the four areas of stenosis in the lumbar spine?
Central stenosis- caused by ligamentum hypertrophy directly under the lamina and bluging discs.
Lateral recess stenosis (subarticular recess)- caused by facet joint arthropathy and osteophyte formation. overgrowth of the superior articular facet is usually the primary culprit.
Foraminal stenosis- occurs between the medial and lateral border of the pedicle. usually from compression by the ventral cephalad overhand of the superior facet and the bulging disc.
Extraforaminal stenosis- area lateral to the lateral edge of the pedicle. Far lateral disc herniations.
with regard to lumbar spinal stenosis:
What is the Kemp sign?
Valsalva test?
What is often found on neurolgoic exam?
Kemp sign- unilateral radicular pain from foraminal stenosis made worse by back extension.
Valsalva test- radicular pain not worsened by Valsalva as is the case with a herniated disc.
Patients with lumbar stenosis often have a normal neurologic exam.
What is hip-spine syndrome?
coexisting hip and spine pathology.
Must determine primary pain generator prior to surgical treatment.
May require diagnostic injections to aid in diagnosis. Inject both hip and lumbar spine.
Describe a pedicle-to-pedicle decompression of the lumbar spine.
Removal of what percentage of the facets leads to instability?
> 50% of facets
What is the most common cause of failed surgery in lumbar decompression for spinal stenosis?
recurrence of disease above or below decompressed level.
comorbid conditions are strongest predictor of clinical outcomes after decompression for lumbar spinal stenosis.
For symptoms that never improve persistent stenosis from inadequate decompression is the most common reason.
What are the major complications and their incidence after lumbar laminectomy?
Minor complications?
Wound infection up to 2%( most common reason for complication make up 10%), Pneuomonia (up to 5%), Renal failure (up to 5%), and neurologic deficits (2%)
MINOR COMPLICATIONS: UTI, anemia, confusion, dural tear,
Is degenerative spondylolisthesis more common in Men or women?
8 times more common in women. Thought to be due to increased ligamentous laxity related to hormonal chnages.
Also more common in African Americans, diabetics, and woman over 40 years of age.
Risk factors: sacralization of L5 and sagittally oriented facet joints.
What is defined as lumbar instability on lateral radiographs?
4mm of translation or 10 degrees of angulation of motion compared to adjacent motion segment.
What is a cortical bone trajectory screw?
What are the proposed advantages?
A srew that is designed to decrease the amount of lateral exposure for obtaining screw starting points.
Starting point is more medial and caudal.
Trajectory is more cephalad.
Advantages of lower blood loss, skin incision, and pain scores 1-week post-op.
Similar fusion rates and functional outcomes longterm.
controversy over which provides better fixation.
For degenerative spondylolisthesis that undergoes lumbar fusion what is the rate of
pseudoarhrosis?
Adjacent segment disease?
Surgical site infection?
Complications increase with?
5-30%. Smoking increases this risk despite cessation.
2.5% per year adjacent segment disease.
.1-2% surgical site infection.
Complications increase with: Older age, increased intraop blood loss, longer operative time, and number of levels fused.
Ture or false:
relatively few patients with L5/S1 spondylolysis with develop spondylolisthesis?
Slip progression more common in females?
Slip progressionusually occurs in adolescence and rare after skeletal maturity?
True
True
True
What is the Wiltse Newman Classification in spine used for?
Classification of spondylolisthesis.
Generally what period of nonoperative treatment should take place before considering operative treatment for either degenerative or isthmic spondylolisthesis?
6 months.
How does surgical treatment for a low grade isthmic spondylolisthesis vs a high grade isthmic spondylolisthesis differ?
Low grade: L5-S1 decompression and instrumented fusion. +/- on reduction. Should not be performed in pediatric cases. +/- on ALIF.
High grade: Generally cannot use ALIF to treat high grade isthmic spondylolisthesis due to tranlational and angular deformity.
Should consider L4-S1 decompression and insturmented fusion
Risk of traction injury to L5 nerve root with compelte reduction. For this reason in situ fusion or at most partial reduction is advocated.
How often is HLA-B27 histocompatability complex positive in ankylosing spondylitis?
90% of the time.
Exact mechanism unknown but theories involve:
HLA-B27 aggregates with peptides in the joint and leads to a degenerative cascade.
Cytotoix T-cell autoimmune reaction against HLA-B27.
What is enthesitis?
Seen mostly in the juvenile form of ankylosing spondylitis.
entheses inflammation leeads to bony erosion, surrounding soft-tissue ossification, and eventually joint ankylosis.
Preferentially targest sacroiliac joints, spinal apophyseal joints, and symphysis pubis.
This differentiates from RA, which is a synovial process.
What is the demographics of ankylosing spondylitis?
4:1 Male to female
Affects .2% of Caucasian population
Usually presents in 3rd decade of life.
Fewer than 10% of HLA-B27 positive patients have symptoms of AS
What is the diagnostic criteria of Ankylosing spondylitis?
positive HLA-B27 with a negative RF titer.
bilateral sacroiliitis and HLA-B27 is diagnostic. Uveitis is helpful but not required.
What are the systemic manifestations of Ankylosing spondylitis?
What are the orthopaedic manifestations?
Acute anterior uveitis and iritis. Hear disease (cardiac conduction abnormalities). Pulmonary fibrosis. Renal amyloidosis. Ascending aortic conditions (aortitis, stenosis, and regurgitation).
HLA-B27 individuals are more susceptible to Klebsilella pneumoniae synovitis
Bilateral sacroiliitis, progressive spinal kyphotic deformity, cervical spine fractures, and large-joint arthritis (hip and shoulder)
What may you see on physical exam of a patient with ankylosing spondylitis?
Limitation of chest wall expansion- <2cm of expansion is more specific than HLA-B27 for making diagnosis.
Decreased spin motion- schober test used to evaluate lumbar stiffness.
Kyphotic spine deformity- chin-on-chestt deformity. Caused by multiple microfractures that occur over time. Chin-brow-to-vertical angle (CBVA)
Hip flexion contracture.
Sacroiliac provocative tests: Faber test- flexion abduction external rotation of the ipsilateral hip causes pain.
What will you see on radiographs of a patient with Ankylosing spondylitis?
Squaring of vertebrae with vertical or marginal syndesmophytes.
Late vertebral scalloping (bamboo spine)
Will see bilateral symmetric sacroiliac erosion. Earliest finding is erosion of the iliac side.
Ferguson pelvic tilt view allows for improved visualization of anterior SI joint. xray beam directed 10 to 15 degrees cephalad.
50% of radiographs miss fractures in AS. acute pain is concerning for fracture. CT scan is most sensitive. MRIbest for looking for epidural hemorrhage.
What is a clinical non-lab test that can be helpful in diagnosing ankylosing spondylitis?
SI joint injection.
What are Romanus lesions?
“shiny corners” at attachement of annulus fibrosus
seen in ankylosing spondylitis.
What is HLA-B8 associated with?
common in patients with DISH and diabetes.
DISH is more common in diabetics. Usually not seen in patients with ankylosing spondylitis.
What medication is approved for use in both AS and RA?
Adalimumab
TNF-a inhibitor
What is first line treatment for Ankylosing spondylitis?
Second line?
NSAIDS, COX-w inhibitors, and therapy.
Therpay should be focused on maintaining flexion.
Steroids should be avoided.
Second line: TNA-alpha blocking agents. Includes infliximab, etanercept, adalimumab.
When do neurologic deficits occur after a fracture in a patient with ankylosing spondylitis?
often appear late so high index of suspicion should be maintained.
75% of patients will have neurologic involvement.
High mortality rate due to epidural hemorrhage.
How should the following injury be treated?
Patient has ankylosing spondylitis.
Should be treated with posterior fusion.
In general instrument 3 levels above and 3 levels below.
In a patient with ankylosing spondylitis and concern for chin on chest deformity what should be ruled out?
Need to eliminate hip contractures as a cause.
Examin patient standing and sitting.
When sitting any hip contracture should not affect spinal alignment.
What are the mortality rates of patients with DISH and cervical trauma?
How do they compare to AS?
15% for those treated operatively.
67% for those treated nonoperatively
Higher mortality rrates than cervical spine trauma with ankylosing spondylitis.
similar mortality rates to patinets with ankylosing spondylitis overall.
What two conditions are associated with sacroiliitis?
Ankylosing spondylits-
Reiter’s sndrome- oligoarticular arthrits, conjunctivitis, and urethritis.
Most commonly presents in teen to middle aged individuals.
Males > females.
What is the difference between burst activity and sustained train activity on mechanical electromyography?
burst activity- contact of a surgical instrument with nerve root will lead to this and has no clinical significance.
sustained train- significant injury or traction to a nerve root will lead to this and may be clinically significance. However it does not for sure reflect nerve root injury and may be overly sensitive.
Mechanichal electromyography relies on mechanical stimulation while Electrical electromyography functions on the concept that bone conducts electricity poorly and electrical stimulation can be used to determine if there is a breach in a pedicle screw by stimulating the screw.
What defines a coronal plane and sagiottal plane imbalance of the spine?
Coronal deformity is > 10 degrees
Sagittal imbalance of > 5cm
What is the most reliable predictor of clinical symptoms in adults with spinal deformity?
Sagittal plane imbalance.
What is the rate of curve progression for adult spinal deformity?
Depends on curve type, magnitude, and risk factors but in general.
thoracic > lumbar > thoracolumbar > double major. Right thoracic curves 1 degree per year. Right lumbar curves .5 degrees per year. Thoracolumbar curves .25 degree per year
Curves <30 degrees rarely progress. Curves ?50 degrees commonly progress.
Additional risk factors: increased risk whne intercrestal line is below L4-L5. Preexisting rotational changes exist.
What is a difference between a patients with neurogenic claudication that have scoliosis and a patients who does not have scoliosis?
Patients with scoliosis often do not obtain relief with sitting and foward flexion.
Stenosis partially caused by the curve and is worse on the concave side.
How is scoliosis in the coronal plane measured?
Cobb angle
Coronal balance can be measured by using C7 plumb line (C7PL) and center sacral vertical line (CSVL) see image
When may surgical curve correction with instrumented fusion be indicated in adult spinal deformity?
Curves > 50 degrees with one or more of the following issues:
sagittal imbalance
curve progression
intractable back pain or radicular pain that has failed nonsurgical efforts
cardiopulmonary decline: thoracic curves >60 degrees affect pulmonary function tests. Thoracic curves >90 degrees affect mortality.
What is a general rule for extending fusion to ilium?
Consider this if sacrum is included in fusion involving >3 levels
ADVANTAGE: increased stability and success of lumosacral fusion.
DISADVANTAGE: prominent hardware.
Should
When may a vertebral column resection be used?
Severe sagittal imbalance that requires correctio of up to 45 degrees.
hemivertebrae resection in thoracic/lumbar spines
rigid scoliosis or rigid thoracic spine kyphosis that may be associated with tumor, fracture, or infection.
What is the overall incidence of complications in surgery for adult spinal deformity?
What risk factor is most predictive of a major complication following surgery.
13.5%
Age > 60 years.
> or equal to three comorbid conditions was aslo predictive.
the most common major complications at follow up was instrumentation failure.
What is the overall rate of pseudoarthrosis in adult spinal deformity surgery?
What are the most common locations?
Risk factors?
5-25% reported
More common if posterior only fusion is performed.
Most common location are at L5-S1 and thoracolumbar junction.
Risks: age >55, kyphosis > 20 degrees, positive sagittal balance > 5cm, hip arthritis, smoking, thoracoabdominal approach, and incomplete lumbopelvic fixation.
incidence of acute neurological deficits following PSO?
18% due to nerve root injury, screw malposition, corrective maneuver.
Are some spondylolysis found in pediatric patients congenital?
No, they are not present at birth, they develop over time.
Seen in 4-6% of the population.
usually activity related and occurs from repetitive hyperextension.
Prevalence as high as 47% in certain athletes (gymnasts, weightlifters, football linemen)
What is a dysplastic spondylolisthesis?
Secondary to congenital abnormalities of lumbosacral articulation including maloriented or hypoplastic facets, sacral deficiency, poorly developed pars.
posterior elements are intact (no spondylolysis)
more significant neurologic symptoms.
What is a listhetic criss?
Severe back pain in a paitent with spondylolisthesis that is aggravated by extension and relieve by rest.
Have a neurologic defecit
Hamtstring spasms, watch with a crouched gait.
seen in pediatric patients.
When is an attempt at repair of a sponylolysis more indicated in a pediatric patinet?
For pars defects at L4 and above.
At L5 fusion is generally more indicated.
What is a provocative physical exam test that should elicit pain in patients with spondylolysis and spondylolisthesis?
Single leg stance with lumbar extension.
What does this image depict most likely if it is from a teenage football player with an insidious onsent of back pain?
spondylolysis can often present as sclerosis as seen in the previous image not just defects as seen on the image below.
What radiographic parameter correlates with severity of disease in patients with spondylolisthesis?
Pelvic incidence.
When is TLSO bracing indicated for spondylolysis?
Acute pars stress reactions for spondylolysis
Isthmic spondylolysis that has failed to improve with physical therapy.
Low grade spondylolisthesis that has failed to improve with physical therapy.
Brace immobilization is superior to activity restriction alone for acute stress reaction spondylolysis.
Where are the most common spinal injuries in a 5 year old child?
Where are the most common spinal injuries in a 11 year old child?
60% of spinal injuries in the pediatric population are in the cervical spine.
87% of injuries in children < 8 years old are at or above C3.
In children 8 years or older more adult patterns or lower cervical injuries are more common.
On a cross table lateral of a pediatric cervical spine, which of these are normal findings:
prevertebral swelling > 2/3 of adjacent vertebral width?
retropharyngeal space <6 mm at C2 and <22 mm at C6?
Retrotracheal space <16mm?
7 year old with ADI of 4mm?
Vertebral body wedging?
Loss of cervical lordosis?
C3-C4 subluxation of 3mm?
Not normal- prevertebral swelling should be < 2/3 of adjacent vertebral width
Normal- retropharyngeal space < 6mm at C2 and < 22mm at C6.
Not normal- retrotracheal space should be < 14mm
Normal- ADI < 5mm in childen and < 3mm in adolescents
Normal- 7% of noral children will have wedge shaped vertebral body, usually at C3.
Normal to hav eloss of cervical lordosis
Normal- Can have C2-C3 or C3-C4 pseudosubluxation < 4mm as long as the posterio laminar line is smooth and contiguous.
How may atlantoaxial rotatory displacement (AARD) treatment change in a pediatric patient if it is acute vs subacute, vs chronic?
General rule for AARD
Acute- cervical collar
Subacute- Halo
Chronic- Fusion
What are indications for surgical stabilization as oppossed to collar or halo in pediatric patients with cervical trauma?
unstable c-spine with cord injury.
atlantoaxial instability. Can also treat this with a halo though.
Chronic atlantoaxial rotatory displacement AARD
What are the common causes of atlantoaxial rotatory displacement (AARD)?
fixed C1-C2 rotatory instability caused by subluxation or facet dislocation.
Infection (35% of the time)
Trauma (25%)
Recent head or neck surgery (20%)
idiopathic
Associated conditions: Down syndrome, rheumatoid arthritis, tumors, and congenital anomalies.
What is though to be the pathoanatomy of atlantoaxial rotatory displacement?
thought to be related to ligamentous laxity.
transverse ligament is intact so spinal canal stenosis can only occur with severe rotation and facet dislocation.
transverse ligament is ruptured and there is a component of anterolisthesis (>5mm), then spinal canal stenosis can occur with less rotation (45 degrees)
Vertebral arteries may also be at risk in these cases.
What is the difference of head rotation on physical exam betwen Atlantoaxial rotatory displacement and congenital muscular torticollis?
AARD: sternocleidomastoid spas occrs on the SAME side as the chin (e.g. right sided facet subluxation will have chin rotated to the left and the left SCM will be spastic. This protective spasticity occurs to reduce further subluxation.
Congenital muscular torticollis: SCM spasm occurs on the OPPOSITE sife of the chin (e.g. left SCM spasm will roate the head to the right, and chin will be on the right)
What is the gold standar for diagnosis of atlantoaxial rotatory displacement?
Dynamic CT is the gold standard.
Take the CT with head stright forward and then in maximal rotation to right and left.
Will see fixed rotation of C1 and C2 which does not change with dynamic rotation.
What will you find regarding rotation of head and the chin on phsical exam with a child with atlantoaxial rotatory displacement?
Ipsilateral rotation and contralateral tilf of the head in relation to the lateral mass of C1
Chin rotated to the side opposite the facet subluxation (e.g. right sided facet subluxation will have chin rotated to the left).
What is Grisel’s disease?
condition of atlantoaxial rotatory displacement in a patient following a respiratory infection or retropharyngeal abscess.
Though to be linked to lymphatic edema in area of cervical spine
What is the treatment for atlantoaxial rotatory displacement?
What conditions are associated with congenital muscular torticollis?
Other packaging disorders- Developmental dysplasia of the hip (5-20% of the time) and metatarsus adductus.
Traumatic delivery
Plagiocephaly (asymmetric flattening of the skull)
Congenital atlanto-occipital abnormalities.
What is another cause of restricted or unsualy neck motion in a pediatric patient other than congenital muscular torticollis and atlantoaxial rotatory subluxation?
Klippel-Feil syndrome
Classic triad of short neck, low hairline, and restricted neck motion.
What are the complications of untreated congenital muscular torticollis?
Permanent rotational deformity
positional plagiocephaly( flat head syndrome)
Facial asymmetry
Dysplasia of kull base, atlas, and axis.
What is the recommended treatment for congenital muscular torticollis?
If present for less than 1 year and limitation less than 30 degrees -> passive stretching. Technique should include lateral head tilt away from the affected side and chin rotation toward the affected side (opposite of the deformity). 90% respond to passive stretching of the sternocleidomastoid in the first year of life.
Failure to respond to at least 1 year of stretching or significant deformity -> bipolar release of SCM or Z plastic lengthening. Good results reported even in older children (4-8 years). Post-op: consider immobilization in over corrected position.
What is Klippel-Feil syndrome?
Associated conditions:
Congenital fusion of 2 or more cervical vertebrae
Due to failure of normal segmentation or formation of cervical somites at 3-8 weeks gestation.
SGM1 gene on chomrosome 8. Notch and Pax genes.
Congential scoliosis. Sprengel deformity (33%). Renal disease (aplasia in 33%). Deafness (30%). Congenital heat disease (5-30%)
Atlantoaxial instability (up to 50%). Adjacent level disease (100%)
What is importatn about the location of fusions in Klippel-Feil Syndrome?
Fusions above C3, especially those with occipitalization of the atlas are most likley to be symptomatic and require abstaining from contact sports
Fusions below C3 are least likley to be symptomatic, and most likey to have a normal life span.
What is an indication for an MRI in adolescent idiopathic scoliosis?
Left thoracic curve.
Get an MRI to rule out cyst or syrinx.
Right thoracic curve is most common.
What is the incidence and female to male ratio for adolescent idopathic scoliosis?
3% for curves between 10 to 20 degrees.
.3% for curves > 30 degrees. 10:1 Female to male for these size curves.
1:1 male to female ratio for smaller curves.
What are risk factors for progression in adolescent idiopathic scoliosis?
Curve magnitude: >25 degrees before skeletal maturity will continue to progess.
After skeletal maturing >50 degree thoracic curve will progress 1-2 degrees / year. > 40 degree lumbar curve will progress 1-2 degrees / year.
Remaining skeletal growth: <12 years at presentation. Tanner stage < 3 for females. Risser 0-1. Open triradiate cartilage.
Curve type: thoracic curves more likely to progress. Double curves more likely to progress than single.
What is the best predictor of curve progression in adolescent idiopathic scoliosis?
Peak growth velocity.
If curve is > 30 degrees before peak height velocity there is a strong likelihood of the need for surgery.
In females it occurs just before menarche and before Risser 1 (girls usually reach skeletal maturity 1.5 yrs after menarche)
Tanner-Whitehouse III (radius, ulna, selected metacarpals and phalanges) method for determining skeletal maturity correlates most closely with the cure acceleration phase.
Assymetirc abdominal reflexes in a patient with adolescent idopathic scoliosis is concerning for?
Syringomyelia.
Obtain on MRI.
The MRI should extend from posterior fossa to conus
What are indication to obtain an MRI in a patient with adolescent idiopathic scoliosis?
Atypical curve pattern (left thoracic cuve, short angular curve, apical kyphosis
Rapid progression
Excessive kyphosis
Structural abnormalities
Neurologic symptoms or pain
Foot deformities
Asymmetric abdominal reflexes
On radiographs of a patient with adolescent idiopathic scoliosis describe the following terms:
Stable zone, Stable vertebrae, neutral vertebrae, end vertebrae, apical vertebrae, clavicle angle?
stable zone- zone between lines drawn vertically from lumoscral facet joints.
stable vertebrae- most proximal vertebrae that is most closely bisected by central sacral vertical line
Neutral vertebrae- rotationally neutral (spinous process equal distance to pedicles on PA xray)
End vertebrae- end vertebra is defined as the vertebra that is most tilted from the horizontal apical vertebra.
Apical vertebrae- the apical vertebrae is the disk or vertebra deviated farthest from the center of the vertebral column.
Clavicle angle- best predictor of pospoerative shoulder balance.
What is the indication for bracing in a patient with adolescent idiopathic scoliosis?
Outcomes?
Cobb angle from 25 to 45 degrees. Only Effective for felxible deformity in skeletally immature patient (Risser 0,1,2)
50% reduction in need for surgery wtih compliant brace wear of at least 13 hours a day.
Poor prognosis associated with: poor in brace correction. Hypokyphosis (relative contraindication). Male. Obese. Noncompliance.
When is an anterior procedure indicated in adolescent idiopathic scoliosis?
Larger curves (>75 degrees) or stiff curves.
Young age (Risser grade O, girls <10 yrs, boys < 13 yrs) in order to prevent crankshaft phenomenon.
Best for thoracolumbar and lumbar cases with a normal sagittal profile.
What type of brace would you use for an adolescent idiopathic scoliosis with the apex at T6?
Apex at T10?
What defines bracing failure?
Wat defines bracing success?
curves with apex above T7- Milwaukee brace (cervicothoracolumosacral orthosis)
Apex at T7 or below- TLSO, Boston-style brace (under arm), or Charleston Bending Brace is a curved night brace.
Success- <5 degree curve progression
Failure- 6 degree or more curve progression at orthotic discontinuation (skeletal maturity). Absolute progression to >45 degrees either before or at skeletal maturity, or discontinuation in favor of surgery.
Skeletal maturity for purposes of adolescent idiopathic scoliosis is defined as?
Risser 4
< 1cm chane in heigh over 2 visits 6 months apart
2 years postmenarchal
What is a risk for pseudoarthrosis with anterior spinal fusion only for idipathis scoliosis with a single rod for insturmentation?
Thoracic hyperkyphosis degined as > 40 degrees between T5 and T12.
weight > 70 kg
Smoking
What is the incidence of the following in adolescent idiopathic scoliosis?
Pseudoarthrosis?
Infection?
Pseudoarthrosis: 1-2% presents as late pain, deformity progression, and hardware failure.
An asymptomatic pseudoarthrosis with no pain or loss of correction should be observed.
Infection: 1-2% Will present as late pain. Incision often looks clean. Beware of propionibacterium acnes which requires 2 weeks for culture incubation.
What is crankshaft phenomenon?
Rotational deformity of the spine created by continued anterior spinal growth in the setting of a posterior spinal fusion.
Can occur in very young patinets when PSF is performed alone.
Avoid by doing anterior discectomy and fusion in very young patients.
What is SMA syndrome that can occur after surgical correction of scoliosis?
SMA = superior mesenteric artery
Compression of 3rd part of duodenum due to narrowing of the space between SMA and aorta.
SMA arises from anterior aspect of aorta at level of L1 vertebrae
Presents with symptoms of bowel obstruction in first postoperative week: associated with electrolye abnormalities, nausea, bilious vomiting, and weight loss.
Risk factors: heigh perentile <50%; weigh percentile < 25%; sagittal kyphosis
Treat with NG tube and IV fluids.
What defines juvenile idiopathic scoliosis?
idiopathic scoliosis in children 4-10 years of age.
15% of all idiopathic scoliosis cases
females >males
Still most commonly appears as a right main thoracic curve like adolescent.
What are the associated conditions with juvenile idiopathic scoliosis?
syringomyelia
Arnold-Chiari syndrome: cerebellar tonsils are elongated and protruding through the opening of the base of the skull and blocking CSF flow.
Tethered cord
dysraphism (incomplete fusion)
spinal cord tumor
What is the general prognosis of juvenile idiopathic scoliosis?
High risk of progression: 70% require treatment (50% bracing and 50% surgery)
very few experience spontaneous resolution
can be fatal if not treated appropriately
What test can eliminate leg length inequality as cause of scoliosis?
Seated adams forward bend test.
What is the demographic, location, and risk factor of infantile idiopathic scoliosis?
4% of idiopathic scoliosis.
males > females
Usually left thoracic
Risk factor: + family history. Autosomal dominant with variable history.
What are the associated conditions with infantile idiopathic scoliosis?
Plagiocephaly (skull flattening)
Congenital defects
Neural axis abnormalities- 22% of patients with curves > 20 degrees will be affected. 80% of these patients will need neurosurgical involvement.
Thoracic insufficiency syndrome: decreased thoracic growth an dlung volume. leads to pulmonary hypertension and cor pulmonale. Pulmonary impairment associated with corves > 60 degrees. Cardiopulmonary issues associated with curves > 90 degrees.
What is the prognosis of ifantile idiopathic scoliosis?
Most resolve spontaneously
If progressive by age 5, >50% of children will have a curve > 70 degrees
Mehta predictors of progression: Cobb andle > 20 degrees. RVAD > 20 degrees. Phase 2 rib-vertebral relationship (rib-vertebral overlap).
True or false dimpling in the glutela fold is usually benign in terms of spinal or neural axis abnormalities?
False.
Dimpling oustide of the gluteal fold is usually bening and less concerning.
What are the different rib phases in infantile idiopathic scoliosis?
Phase 1: usually resolves. No overlap of rib and vertebral body.
Phase 2: Progressive. Rib on convex side overlaps the vertebral body.
How do you measure the Mehta angle?
Also known as rib vertebrae angle difference or RVAD
> 20 degrees is linked to high rate of progression
<20 is associated with spontaneous recovery.
What treatment is recommended for infantile idiopathic scoliosis?
RVAD < 20 or Cobb angle < 30 degrees 90% will resolve spontaneously with just observation.
Flexible curves, cobb angle > 30 degrees, RVAD > 20 degrees, or PHASE 2 rib -> serial Mehta casting (derotational) or thoracolumosacral orthosis (TLSO).
Bracing is rarely used and only in incompletely corrected curves after Mehta casting. Late presenting cases where the spine is still flexible.
OPERATIVE: Cobb angle 50-60 degrees or failed Mehta casting -> Growing rod or VEPTR. Delay fusion until as close to skeletal maturity as possible. Fusion before age 10 years results in pulmonary compromise.
What is the general technique for dual rods or VEPTR?
Permits growth of affected part of spine up to 5 cm
Use anchors proximally and distally
Serial lengthening required every six to eight months.
What are some of the causes of congenital scoliosis?
Most cases occur spontaneously
Maternal exposures to the following can be a cause: diabetes, alcohol, valproic acid, and hyperthermia.
Genetics is uncertian.
What conditions are associated with congenital scoliosis?
Systemic anomalies up to 61% of the time: Cardiac defects (10%), Genitourinary defects (25%), and spinal cord malforatmions.
Underlying syndromes and chromosomal abnormalities: VACTERL (38-55%)
Goldenhar/OculoAuricularVertebral Syndrome- hemifacial microsomia and epibulbar dermoids
Jarcho-Levin Syndrome/Spondylocostal dysostosis- Short trunk dwarfism with multiple vertebral and rib defects and fusion. Often associated with thoracic insufficiency syndrome
Klippel-Feil syndrome
Alagille syndrome- peripherla pulmonic stenosis, cholestasis, and facial dysmorphism.
What is the risk of pregression of congenital scoliosis?
Determined by the morphology of the vertebrae.
Greatest rate of progression with unilateral unsegmented bar with contralateral hemivertebra. Potential to progress 5 to 10 degrees/year
Least risk of progression is block vertebrae. progress <2 degrees/year.
Most rapid progression in the first 3 years of life.
anterior failure of formation is rapidly progressive and often results in paralysis.
Presence of fuse ribs increases risk of progression.
What additional studies are important to obtain in a patients with congenital scoliosis?
Renal ultrasound
Echocardiogram
True or false: A patient with a failure of formation with conralateral failure of segmentation at any age reuires hemi-vertebrectomy and spinal fusion?
This is unilateral bar opposite a hemivertebra
True
Otherwise it will rapidly progress.
Ideally try to do it when the child is 3-8 years old. Younger it is difficult to get good fixation.
Best candidates are those <6 years and flexible curve < 40 degrees.
What is different about neurogenic spinal curves vs idiopathic curves?
More rapidly progressive
May progress after maturity
Associated with pelvic obliquity
Are longer and involve more vertebrae (may involve cervical vertebrae)
Have a higher rate of pulmonary complications with surgery.
Patients with neuromuscular scoliosis have increased wound complications when?
Poor nutritional status (serum albumin <3.5 g/dl)
Immunocompromised status (WBC <1500 cells/ucL)
Presence of a ventriculoperitoneal (VP) shunt
Severe spastic quadriplegia nonambulatory status with seizures
For the following diseases that lead to neuromuscular scoliosis describe the recommended nonoperative and operative treatments.
What is the incidence of scoliosis in cerebral palsy patients?
Overall is 20%
The more involved and severe the cerebral palsy, the higher the likelihood of scoliosis.
Spastic quadriplegic at highes risk.
Bedridden children incidence approaches 100%
Regardgin lumbar spine alingment hamstring contractures leads to?
Hip contractues leads to?
Hamstring contracture = decreased lumbar lordosis
Hip contracture = increased lumbar lordosis
What is the incidence of spondylolisthesis in patients with spastic diplegia?
4-21%
What role does things like observation, custom seat orthosis, bracing, and botox play in treatment for scoliosis in patinets with cerebral plasy?
Observation for nonprogressive curves < 50 degrees or patients in the early stages that are < 10 years of age (goal is to delay surgery if possible until they are older)
Custom seat orthoses and braces can imrprove sitting balance but they do not affect the natural course of disease.
Botox may provide some short term benefits.
What is the difference between group 1 and group 2 curves in cerebral palsy patients?
This is the Weinstein classification
Group I - double curves with thoracic and lumbar components and minimal pelvic obliquity
Group II - large lumbar or thoracolumbar curves with marked pelvic obliquity
Treatment differs. Group II curves more likely to be fused to the pelvis.
How would you treat a patient with cerebral plasy who is 12 years old, has a 70 degree curve with 10 degrees of pelvic obliquity and ambulates? What if they didn’t ambulate?
How about a patient with a Group II curve that ambulates?
PSF without extension to pelvis
PSF with extension to pelvis +/- anterior fusion
PSF with extension to pelvis +/- anterior fusion
What preoperative assessment and work-up should be done in a patient with cerebral palsy that has scoliosis and is going to undergo operative fixation?
What is the incidence of wound infection in cerebral palsy patients who undergo operative fixation of scoliosis?
More common than idiopathic scoliosis
Occurs in 3-5%
usually can be treated with local wound debridement alone.
What are principles of fusion levels in patients with scoliosis and cerebral palsy regarding:
Proximal fusion level?
Distal fusion level?
Extending to the pelvis?
Should extend to T1 or T2 to decrease risk of proximal thoracic kyphosis.
Due to long curves often will extend to L4 or L5.
Extend to pelvis whenever pelvic obliquity is > 15 degrees
What is the outcome of treatment for pathologic scoliosis caused by an osteoid osteoma?
Outcomes are good after resection of the tumor as long as:
Performed within 15-18 months of onset of curvature
Child is less than 11 years of age
Scoliosis is thought to develop in response to painful paraspinal muscle spasms.
Curves are often rigid.
What is Scheuermann’s Kyphosis?
demographics?
Genetics?
Rigid thoracic hyperkyphosis that is by definition in a curve > 45 degrees.
Caused by anterior wedging of > 5 degrees across three consecutive vertebrae, narrowed disc spaces.
most common type of structural kyphosis in adolescents
typical age of onset is from 10-12 years
Males > females
autosomal dominant
What is the prognosis of Scheuermann’s kyphosis?
Increased back pain that very rarely limits daily activities.
Curves > 75 degrees or more likely to cause severe thoracic pain.
Progression in 80% but does not often lead to severe deformity
Long standing compensatory lumbar hyperlordosis may lead to lumbar spondylolysis (33%)
33% also have scoliosis
Does Scheuermann’s kyphosis occur in the lumbar spine?
Yes
Thoracolumbar/Lumbar Scheuermann’s Kyphosis:
Far less common form
Curve from T4/5 to L2/3 with apex near thoracolumbar junction
Associated with increased back pain
More likely to be progressive and symptomatic
More irregular end-plates noted on radiographs, less vertebral body wedging.
What is a Schmorl’s node?
herniation of disc into vertebral endplate
Seen in Scheuermann’s Kyphosis.
How do you differentiate postural kyphosis from Scheuermann’s Kyphosis?
Obtain hyperextension lateral radiographs:
Supine lateral radiograph wiht patient lying in hyperextension over a bolster
Scheuermann’s kyphosis usually relatively inflexible on bending radiograph.
What treatment is recommended for Scheuermann’s Kyphosis?
What is the incidence of distal junction kyphosis after PSF for Scheuermann’s kyphosis?
20-30%
Most commonly occurs if fusion is stopped at first lordotic disc distally.
Avoid by: Making proper slection of fusion levels (use the first stable sagittal vertebra)
avoiding overcorrection (correction should not exceed 50% of original curve)
Proximal junction kyphosis is less common than distal. Typically secondary to overcorrection and negative sagittal balance.
What percentage of patients with a spinal cord injury suffer from Major Depressive Disorder?
Approximately 11.4% according to Bombardier et al.
MDD was associated with poorer subjective health, lower satisfaction with life, and more difficulty in daily role functioning.
What anatomically defines the lower motor neuron?
What characterizes a lower motor neuron lesion on exam?
From the anterior horn of the spinal cord to the peripheral muscle.
Fasciculations and flaccid paralysis. Also weakness, wasting, hypotonia, and hyporeflexia. Think 2 Ws, Fs, and Hs.
Upper motor neuron is from the motor cortex of the brain to the anterior horn of the spinal cord.
Where does the ligamentum flavum originate and insert?
It originates 60-70% of the way up on the anterior surface of the cranial lamina.
It inserts on the superior edge of the caudal lamina.
Where does the spinal cord terminate?
The spinal cord terminates as the conus medullaris at the lower portion of L1 in women and the pedicle of L1 in men.
How much does bisphosphonate therapy decrease the incidence of new vertebral fractures in osteoporotic patients?
According to Harris et. al article: 65% following one year of treatment.
41% followin three years of treatment.
What are the mechanisms by which steroids are thought to prevent neuroligc injury after a traumatic spinal cord injury?
Decreasing the are of ischemia in the cord
Reducing TNF-alpha expression and NF-kB binding activity.
Decreasing free radical oxidation and thus stabilizing cell and lysosomal membranes.
Checking the influx of calcium into the injured cells, thus reducing cord edema.
What is the prognois for patients under 50 with central cord syndrome without fractures or dislocations that are ASIA C and D with regards to the probability that they will eventually become ambulatory?
What is the prognosis for patients older than age 50 who are ASIA C?
According to Penrod et al. 29 out of 30 patients or almost all regained the ability to walk.
7 out of 17. 40% walked.
In pediatric patients with high grade isthmic spondylolisthesis what radiographic measurement is most predictive of progression?
What measurement is most predictive on severity of disease?
Slip angle for progression
Pelvic incidence for severity of disease.
What kind of curve besides a left thoracic curve should trigger obtaining an MRI in adolescent scoliosis?
Rith thoracic with hyperkyphosis.
Most common curve is right thoracic with hypokyphosis.
