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3. OrthoBullets (General Knowledge) > Spine > Flashcards

Spine Flashcards

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1
Q

Safe zone for occipital screw placement

A

Triangular region created by connecting 2 dots 2cm lateral to the external occipital protuberance, and a point 2 cm inferior to it

Point B on the pictures

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2
Q

Slip angle greater than what degree is associated with greater risk of progression?

A

>50 degrees

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3
Q

6 things to do if a neuro alert during scoliosis surgery

A
  1. check equipment
  2. check blood pressure >90mmHg
  3. check Hgb
  4. reverse or lessen correction
  5. wake up test
  6. remove implants if spine stable
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4
Q

Risks of postoperative spinal infection

A

Longer OR time

Immunocompromised state

Increased blood loss (decreases circulating Abx)

Poor nutritional status

Obesity (BMI >35kg/m^2)

Use of instrumentation or OR microscope

Prior spinal surgery or local radiation

Longer constructs or more extensive procedures

Tobacco or alcohol use

Multiple trauma

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5
Q

Anklylosing spondylitis trauma

What must you do?

A

CT scan of spine

Often skip fractures

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6
Q

Fieldig Classification of AARD

A

Type I:

Unilateral facet subluxation with intact transverse ligament

Type II:

Unilateral facet subluxation with 3-5mm of anterior displacement (injured TL)

Type III:

Bilateral anterior facet displacement of >5mm

High risk of neuro compromise

Type IV:

Posterior displacement of Atlas (C1)

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7
Q

Safe zone for halo application (anterior pins)?

A

Lateral 1/3 of eyebrow, below the equator (site D in figure)

Avoids supraorbital and supratrochlear nerves

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8
Q

In facet dislocation, what must you do after successful reduction and why?

A

MRI - to look for disc herniation

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9
Q

What age does the secondary ossification center of the dens fuse with the rest of C2?

A

~12 years

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10
Q

Normal range of kyphosis in mid-thorcic spine (T5-12)

A

20-50 degrees

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11
Q

Power’s Ratio

A

Basion to posterior arch/Opisthion to anterior arch

Normal is 1

Abnormal: occipito-atlantal instability

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12
Q

Three types of Diastematomyelia?

A
  1. boney
  2. fibrous
  3. cartilaginous
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13
Q

Why do you have to use a paediatric spinal board for paediatrics? What age do you have to use it until?

A

To compensate for large head

Paediatric boards have an occipital cutout to compensate for this

Use until 8 years

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14
Q

Name 6 surgical options for degenerative spondy:

A

Laminoplasty

Laminectomy no fusion

Laminectomy UNinstrumented fusion

Laminectomy + instrumented fusion

(all of the above ± PLIF/ALIF/TLIF)

Dynamic stabilization (see pic)

Lumbar interspinous spacers (prevents extension)

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15
Q

Treatment algorithm for AARD

A

Acute

  • Soft collar, anti-inflammatories, exercise program

Acute >1 week

  • Head halter traction and bracing

Subluxation > 1month

  • halo traction and bracing

Subluation > 3 months, late diagnosis or neuro deficits

  • Posterior C1-2 fusion
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16
Q

If a patient presents with a cervical rotational deformity what injury should you think of?

A

Unilateral facet dislocation

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17
Q

Disc herniations at the following levels with affect which nerve root?

  1. C2-C3
  2. C7-T1
  3. T4-T5
  4. L2-L3
  5. L5-S1
A

1 - C3
2 - C8
3 - T4
4 - L3
5 - S1

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18
Q

Interpret:

a) ADI < 3 mm
b) ADI between 3 and 5 mm
c) ADI > 5 mm

A

a) Normal
b) Transverse Ligament Rupture
c) Transverse Ligament and Alar Ligaments Ruptured

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19
Q

Most common locations for pseudoarthrosis in adult spinal deformity?

A

L5-S1

Thoracolumbar junction

(so any junctional area)

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20
Q

Why is discography not so good?

A

It causes accelerated disc degeneration and loss of height.

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21
Q

What are the components of TLICS and what score means surgery?

A
  1. Morphology
  2. Neurologic injury
  3. Status of PLC

5 or more get OR

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22
Q

What type of vertebral malformation is most likely to cause a progressive congenital scoliosis?

A

Unsegmented bar with a contralateral hemivertebrae

Tx. is PSIF with resection of vertebrea

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23
Q

Components of PLC?

A

Supraspinous ligament

Interspinous ligament

Facet capsule

Ligamentum flavum

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24
Q

Complications of vertebroplasty/kyphoplasty

A

Cement extravasation

Cement Embolism

new fracture

neurologic compromise

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25
Q

How to improve outcomes (arthrodesis) in fusion for spondy?

A

Pedicle screws

Interbody fusion

Non-smokers (major risk for pseudoarthrosis)

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26
Q

Rate of tandem stenosis for patients with lumbar or cervical stenosis?

A

20%, so image other area if symptoms aren’t clear

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27
Q

5 conditions resulting in Atlanto Axial Instability?

A
  1. Downs
  2. RA
  3. Dens Fracture
  4. Atlas Fracture
  5. Transverse Ligament Rupture
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28
Q

Outcomes of SPORT trial with respect to degenerative scoli

A

Surgical intervention > non surgical at 2 years and 4 years

No difference in surgical method used

Patients with predominantly leg pain did the best

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29
Q

Pelvic incidence

Pelvic tilt

Sacral slope

Which are position dependent?

A

Pelvic tilt and sacral slope are position dependent

pelvic incidence does not change after skeletal maturity

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30
Q

What is abnormal structure in congenital muscular torticullis?

A

Tight SCM

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31
Q

Most common nerve injury with myelopathy decompression?

A

C5 palst

Treatment is observation

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32
Q

With OPLL and myelopathy, what guides your choice of appraoch?

A

1) If kyphotic = Have to go ANTERIOR and do corpectomy/OPLL resection

**** Risk of dural tear

2) If lordotic = Can go posterior and do laminoplasty or laminectomy/fusion without OPLL resection

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33
Q

Risk factors for pseudoarthrosis of anterior single rod technique

A

Smoking

Weight >70kg

Thoracic hyperkyphosis >40 degrees

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34
Q

Risks of Low back pain

A

Obesity

Smoker

Male

Lifting

Vibration

Prolonged Sitting

Job dissatisfaction

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35
Q

Two surgical options for a curve > 50 in a Juvenile patient?

A
  1. Growing rods, VEPTR
  2. Anterior and Posterior fusion (have to do both sides to avoid crankshaft phenomenon)
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36
Q

Physical exam findings of diastematomyelia:

a) 4 local findings
b) 5 associated conditions

A
  1. hairy patch
  2. skin dimple
  3. Subcutaneous mass
  4. teratoma
  5. scoliosis
  6. tethered cord
  7. cavus foot
  8. claw toes
  9. clubfoot
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37
Q

Describe Chamberlains line

A

Line from dorsal margin of hard palate->posterior edge of the foramen magnum

abnormal if tip of dens > 5 mm proximal Chamberlain’s line

normal distance from tip of dens to basion of occiput is 4-5 mm

this line is often hard to visualize on standard radiographs

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38
Q

What is the success rate of nerve root injections for lumbar herniations?

A

50%

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39
Q

Describe peltic tilt:

A

Angle formed between

  1. Line parallel to side of radiograph
  2. Line from center of femoral head to the center of the S1 endplate
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40
Q

Isthmic spondy (and spondy in general) is associated with what change in pelvic incidence?

A

Increased

THINK: higher incidence allows it to slip easier

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41
Q

indications for hemivertebrectomy

A
  • Hemivertebrae (failure of formation) with progressive curve causing truncal imbalance and oblique takeoff
  • Patients less than 4-5 years
  • Curve less than 40 degrees
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42
Q

Main finding of:

Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. - Wood 2003

A

Operative treatment of patients with a stable thoracolumbar burst fracture and normal findings on the neurological examination provided no major long-term advantage compared with nonoperative treatment.

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43
Q

Which of the following shows increased production when adisc herniates?

  • osteoprotegrin (OPG)
  • interleukin-1 beta
  • receptor activator of nuclear factor-kB ligand (RANKL)
  • parathyroid hormone (PTH)
A

All of them.

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44
Q

5 spinal conditions that can result in Juvenile Scoliosis?

A
  1. syringomyelia
  2. arnold-chiari
  3. tethered cord
  4. spinal dysraphism
  5. tumor
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45
Q

What percentage of Juvenile Scoliosis patients have an abnormal MRI?

A

18-25%

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46
Q

Define Sacral slope

A

Angle formed between:

  1. horizontal line parallel to the bottom of radiograph
  2. Line parallel to the S1 endplate
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47
Q

Name 6 syndromes/diseases assocated with basilar invagination

A

Klippel-Feil

Osteogenesis imperfecta

Morquio syndrome

achondroplasia

spondyloepiphyseal dysplasia

occipitocervical synostosis

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48
Q

Describe cervicomedullary angle

A

Angle formed between:

line along ventral surface of medulla

line along upper cervical cord

less than 135 suggests impending neurologic compromise

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49
Q

What is the relationship between:

  1. sacral slope
  2. pelvic incidence
  3. pelvic tilt
A

pelvic incidence = pelvic tilt + sacral slope

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50
Q

Outcomes of SPORT trial regarding herniated nucleus pulposus?

A

Surgical intervnetion > nonoperative,

although both groups did well

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51
Q

Define instability on flexion-extension x-rays as it pertains to lumbar spine spondy

A

4mm of translation or 10 degrees of angulation of motion compared with adjacent motion segment

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52
Q

When do the basilar synchondrosis and secondary ossification centers fuse?

A

Basilar synchondrosis: age 6

Secondary ossification center: appears at 3, fuses at age 12

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53
Q

2 deformities associated with Klippel Feil?

A
  1. Scoliosis
  2. Sprengels
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54
Q

6 presenting symptoms in patients with DISH

A

Dysphagis and stridor

Hoarseness

Sleep apnea

Difficulty with intubation

Cervical myelopathy

Spinal Fracture

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55
Q

What is defined as instability on flex-ex radiographs?

A

Instability: >3.5mm of motion between flexion and extension views

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56
Q

Two common complications following Postero Decompression and instrumented fusion for degenerative spondylolisthesis?

A
  1. Pseudoarthrosis (5-30%)
  2. Adjacent level disease (2.5% per year)
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57
Q

4 clinical findings associated wiht Scheuermann’s

A

Hyperlordosis

Spondylolsis

Scoliosis

Pulmonary compromise in curves >100 degrees

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58
Q

For revision anterior cervical approach with previon RLN injury what do you do?

A

Go from the same side to avoid bilateral injury

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59
Q

Technique for posterior reduction of facet dislocations?

A
  1. Can only do after disc is dealt with if present
  2. Can burr tops of superior facets
  3. Put lateral mass screws in and then use these to reduce
  4. Fuse one level above and below
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60
Q

Scheuermann’s kyphosis.

What’s the outcome of non-op curves (by size)

A

>75 degrees: severe pain that affects ADLs

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61
Q

What percentage of RA patients have atlantoaxial instability?

A

50-80%

SO CHECK FOR IT - especially in oral exam

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62
Q

Indications & Contraindications for vertebroplasty/kyphoplasty

A

See pic

New studies show that it may be beneficial, at least in the short term, for vertebral compression fractures

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63
Q

Injury to what nerve structure causes retrograde ejaculation?

A

Superior hypogastric plexus

(retroperitoneal approach to spine)

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64
Q

What disorder causes a passively correctable chin-on-chest deformity?

A

Dropped head syndrome

vs. AS (non-correctable chin on chest)

Caused by cervical paraspinal weakness

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65
Q

What is more likely to present with dysphagia: OPLL, DISH or Ank Spon?

A

DISH

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66
Q

4 dangers of Smith-Robinson Anterior approach to C-spine

A

Recurrent laryngeal nerve

Sympathetic chain

Carotid sheath

Post-operative hematoma

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67
Q

Best phase on MRI to look for foraminal stenosis and what to look for?

A

T2

Look for loss of perineural fat

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68
Q

What is the treatment for low grade isthmic spondylolistheis that is painful and fails 6 months of physio?

A

12 weeks of TLSO

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69
Q

Hypoglossal (CN 12) injury during ACDF - tongues deviates which way?

A

towards side of injury

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70
Q

Indications for MRI in scoliosis workup (7)

A

Atypical curve pattern (left thoracic curve, short angular curve, apical kyphosis)

Signs of syndromic or neural axis pathology

  • Cavus feet
  • Signs of dysraphism
  • Asymmetric abdominal reflexes
  • neurologic symptoms or pain
  • Signs of Marfan’s/Down’s/Lysosomal storage disease

Rapid progression

Excessive kyphosis

Structural abnormalities

Child 20 degrees

All patients with congenital scoliosis

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71
Q

Collagen type in nucleus pulposus

A

Type II

It’s like articular cartilage

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72
Q

What is a Hangman’s fracture?

A

Traumatic anterior spondylolisthesis due to bilateral fracture of pars interarticularis

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73
Q

Halo application principles in adults (location, pins, tightness)

A

4 pins

  • 2 anterior pins over lateral 1/3 of eyebrow below equator
  • 2 posterior pins opposite of anterior ones

8 inch pounds of torque

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74
Q

Best treatment of this fracture?

A

Fracture separation of lateral mass

2 level posterior spinal instrumented fusion (PSIF)

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75
Q

If a patient has a hypoglossal nerve injury after anterior approach, what side will their tongue deviate towards?

A

Towards the affected side

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76
Q

4 complications with lumbar disc herniation surgery

A

Dural tear

Recurrent HNP

Discitis

Vascular catastrophy

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77
Q

What is the most common neurologic finding after cervical laminoplasty?

A

C5 palsy

NOT recurrent laryngel nerve palsy: you’re not going anterior for a laminoplasty

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78
Q

What is the treatment for syringomyelia?

A
  1. Cevical dempression without fusion initially once it becomes symptomatic
  2. Instrumented fusion 3-6 months later
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79
Q

In adults, what is the first line of treatment in spondylolysis with no neuro symptoms?

A

Observe

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80
Q

Difference between Type 2 and Type 2A Levine/Edwards?

A

Levine/Edwards is Hangman’s fractures

2 = > 3mm displacement, disc is compromised

Treat with traction then Halo vest.

2 A –> Horizontal fracture

NO TRACTION

Reduce with extension then Halo vest.

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81
Q

C-spine myelopathy. Indications for anterior only, posterior only and anterior + posterior decompression ± fusion

Name 1 absolute contraindication to posterior only decompression

A

Anterior only (ACDF): gold standard for 1-2 level disease

Posterior only: <13 degrees kyphosis

  • Some say <10 degrees but definitely <13 degrees

Anterior + Posterior: rigid kyphosis >10 degrees and multilevel disease (>2 levels)

Kyphosis >13 degrees is an absolute contraindication to any posteriorly only decompression

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82
Q

Changes during normal aging of IV discs

A

Changes are like that of articular cartilage

Decrease in:

  • Collagen II (changes to fibrocartilage)
  • nutritional support
  • water content
  • Absolute number of cells
  • Proteoglycans
  • pH

Increase in:

  • Collagen I
  • Keratin sulfate : chondroitin sulfate ratio
  • Lactate
  • Degradative enzyme activity

No change in:

absolute quantity of collagen

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83
Q

Subaxial insatbility is present in what percent of RA patients?

A

20%

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84
Q

How long do you have to culture acid fast bacili?

A

Up to 10 weeks

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85
Q

Do osteoblastoma respond to NSAIDs?

A

No

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86
Q

When do you brace in scoliosis for:

Congenital

Infantile

Juvenile

AIS

A

Congenital:

May brace supple compensatory curves

Infantile:

Cobb >20 (consider, but many resolve spontaneously)

Cobb >30 for sure

Juvenile:

Cobb >20

Adoelscent:

Cobb >25

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87
Q

Findings associated with Scheuermann’s kyphosis

A

Anterior wedging across 3 consecutive vertebra

Disc narrowing

Endplate irregularities

Schmorl’s nodes

  • Herniation of disc into vertebral endplate

Scoliosis

Compensatory hyperlordosis

Important to look for spondylylysis

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88
Q

What level does the aorta bifurcate?

A

L4

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89
Q

4 differences between DISH & AS spine

A

DISH:

right thoracic often in isolation (protective pulsatile aorta)

nonmarginal osteophytes

preservation of disc space

Flowing candle wax (vs. squared off bamboo spine of AS)

Non HLA-B27 association

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90
Q

What shoulde you rule out with muscualr torticullis with no palpable SCM mass?

A

Klippel feil

AARD (atlanto-axial rotatory deformity)

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91
Q

3 Indications for PLIF in spondylolisthesis

A

Severe slip

Neurologic compromise

Saggital imbalance

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92
Q

Name 5 mimickers of lumbar radiculopathy

A
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93
Q

Major technical factor in improving fusion rates in posterior spinal fusion?

A

pedicle screws

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94
Q

Differential for myelopathy? (5)

A
  1. Stroke
  2. B12 deficiency
  3. Movement disorder
  4. ALS
  5. MS
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95
Q

What type of sub-cervical spinal trauma almost always gets posterior instrumented fusion 2 levels in each direction?

A

Thoracolumbar Fracture Dislocation

Commonly occurs at junction (T10-L2)

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96
Q

What cobb angles will puts the patient at risk of cardiopulmonary decline and mortality?

A

Cardiopulmonary decline:

Thoracic curves >60 degrees affect pulmonary function tests

Thoracic curves >90 degrees affect mortality

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97
Q

What are three signs of segemental spinal instability (specifically lumbar)?

A
  1. Degenerative scoliosis
  2. Spondylolisthesis (degenerative or isthmic)
  3. Surgical over resection
    1. > 50% of either facter
    2. Complete laminectomy
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98
Q

4 risk factors for myelopathy in OPLL

A

>60% spinal canal stenosis

≤6 mm of space available for the cord

increased cervical range of motion

OPLL that is laterally deviated within the spinal canal

(JAAOS 2014)

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99
Q

Is bullet removal from spinal canal more likely to improve motor outcomes in incomplete injuries in T12-L4 or from T1-T11?

A

T12-L4

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100
Q

Most common type of spondylolysis/listhesis in adult?

A

Degenerative

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101
Q

Symptomatic acute osteoporotic spinal compression fracture (within 5 days). name the medical treatment?

A

Calcitonin x 4 weeks

AAOS 2010 - moderate evidence for

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102
Q

Who gets OPLL?

A

ASIANS, Men

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103
Q

Radiographic definition of central stenosis:

A

Cross sectional area less than 100cm2

or

less than 10mm AP diameter on axial CT

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104
Q

Where is the most common site for isthmic spondy and where is the most common location that predisposes to progression?

A

L5-S1 most common

L4-5 will progress

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105
Q

In Brown-Seqard syndrome what deficit is there in the contralateral limb?

A

Spinothalamic - pain and temperature

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106
Q

Findings in anterior cord syndrome

A

lower extremity affected more than upper extremity

loss:

LCT (motor)

LST (pain, temperature)

preserved:

DC (proprioception, vibratory sense)

Worst prognosis

May mimic complete cord

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107
Q

Where does pseudosubluxation happen and how do you verify diagnosis?

A

1) C2 on C3
2) Swischuks line should be wihting 1.5 mm of C2 sp and the deformity should reduce on extension xray

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108
Q

What is important to look for on physical exam if considering deformity correction or THA on a patient with Ank Spon?

A

Hip flexion contractures

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109
Q

In C-spine immobilization of a paediatric patient, where do you want to keep the external auditory meatus?

A

Keep external auditory meatus inline with the shoulders

This puts them in a slight position of extension

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110
Q

True or false: All congential scoliosis from vertebral malformations is progressive

A

False.

Depends on etiology. Things like a single unsegmented hemi vertebrae is unlikley to progress.

Unsegmented bars almost always progress.

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111
Q

What other organs do you need to image before surgery on congenital scoliosis?

A

Heart and kidneys

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112
Q

In doing a laminectomy and fusion, what is the biggest risk of adjacent level change?

A

Laminectomy (no fusion) at the adjacent level

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113
Q

In AARD, which side will the patient’s head be tilted and rotated to?

A

Ipsilateral rotation and contralateral tilt of the head in relation to the lateral mass of C1

Opposite of Torticollis

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114
Q

Best candidate for radiosurgery for spinal tumours?

A

Life expectancy > 1 months, b/c effects don’t come on for 3-4 weeks

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115
Q

How does a well repaired dural tear affect outcomes after lumbar decompression?

A

No effect

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116
Q

What is rate of overall complications with adult spine deformity correction?

A

10-20%

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117
Q

Most common surgical technique resulting in pseudoarthrosis in adult spinal defomrity correction?

A

Posterior fusion only

I think they mean no instrumentation??

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118
Q

Cord syndrome prognosis from best to worst

A

Brown-sequare (best)

Central cord

Posterior cord

Anterior cord (Worst)

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119
Q

What condition is the Wiltse appraoch best used for?

A

Far lateral lumbar disc herniation

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120
Q

What do you call a bar that crosses the spinal cord and causes a cleft in the spinal cord?

A

Diastematomyelia

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121
Q

T/F: helmets increase risk of c-spine injury

A

False

They do not increase risk of c-spine injury

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122
Q

4 conditions that pre-dispose to traumatic cervical spine trauma

A
  1. DISH
  2. Ank Spon
  3. Previous Fusion
  4. Connective Tissue Disorders
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123
Q

What is the most imporant radiographic finding that may predict complete neural recovery post decomrpessive surgery for atlantoaxial instability?

A

PADI/SAC > 13mm

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124
Q

Anterior reduction technique of facet dislocation?

A
  1. Can only do for a unilateral facet dislocation
  2. Caspar pins in proximal and distal bodies
  3. Rotate upper pin towards the dislocation
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125
Q

2 Treatment options for synovial facet cyst

A

Laminectomy & decompression

  • classically 1st line treatment but high recurrence rates

Facetectomy & instrmented fusion

  • Some now consider this first line
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126
Q

Most important factor when deciding treatment of Axis fracture?

A

Stability of Transverse Ligament

If it is ruptured then do either C1-C2 or Occ - C2 fusion

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127
Q

Harris Rule of 12: Describe

A

If either of:

Basion-Dens interval (BDI)

or

Basion posterior axia line interval (BAI)

>12mm, its a sign of occipito-atlanto instability/dislocation

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128
Q

What is radiologic definition of Scheurmans?

A

Anterior wedging of > 5 degrees accross 3 continuous vertebreas

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129
Q

Are results for revision lumbar discectomies worse, better or the same?

A

Equivalent

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130
Q

How do vertebral compression fractures affect mortality?

A

Increase it x2 to matched controls

Higher in men

higher with earlier age of fracture

However, improved with cement augmentation (kyphoplasty) by 2-7 years

(JAAOS 2014)

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131
Q

Functional level of the following spinal level injuries

C4

C5

C6

C7

A

C4 —> Electric wheelchair with head/chin controls
C5 —> electric wheelchair with hand control
C6 —> Manual wheelchair with sliding board
C7 —> Manual Wheelchair with independent transfers

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132
Q

What is the radiographic sign of an unstable degenerative spondylolisthesis?

A

> 4mm translation on flex/ex

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133
Q

Where do you find free nerve endings in the spinal unit?

A

PLL, annulus fibrosis, facet joint

NOT in the nucleus pulposus

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134
Q

Risks of pseudoarthrosis in adult spinal deformity correction (7)

A

Age >55

kyphosis >20 degrees

positive sagittal balance >5cm

hip arthritis

smoking

thoracoabdominal approach

incomplete lumbopelvic fixation

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135
Q

What reflex differentiates between intracranial and intraspinal lesions?

A

Jaw Jerk

If positive, then it’s an intracranial cause of myelopathic symptoms

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136
Q

Name 2 radiographic indices that indicate poor outcomes in Spondylolisthesis

A

Increased lymbosacral kyphosis

Positive sagittal balance

(not really the same)

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137
Q

HOw do you avoid junctional kyphosis post-op Scheuermann’s kyphosis?

A

Make proper selection of levels

Avoid overcorrection

limit to 50% of original curve

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138
Q

General indications for surgery in adult spinal deformity (6)

A

Curve > 50 degrees

Sagittal imbalance

Curve progression

Intractable back pain or radicular pain that has failed nonop

Cardiopulmonary decline:

Cosmesis (controversial)

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139
Q

What spinal lesion causes an occipital headache worse with valsalva?

A

Syringomyelia

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140
Q

What part of the spinal cord is least sensitive to radiation (ie for stereotactic radiosurgery)

A

Thoracic spine

(JAAOS 2014)

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141
Q

Describe TLICS

A

Max score: 10

>4 operate

4 = dealer’s choice

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142
Q

Radiographic findings of Scheuermann’s kyphosis

A

anterior wedging across three consecutive vertebrae

disc narrowing

endplate irregularities

Schmorl’s nodes (herniation of disc into vertebral endplate)

scoliosis

compensatory hyperlordosis

important to look for spondylolysis on lumbar films

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143
Q

What are the parameters for a structural minor curve according to lenke?

A

> 25 degrees and do not bend out to less than 25 degrees with lateral bend

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144
Q

Patient placed in garder wells tongs and reduced with traction for jumped facets. Patient develop nystagmus and other stroke like symptoms.

What is the most likely cause?

A

Vertebrobasilar insufficiency

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145
Q

Rate of pseudo arthrosis in single elvel ACDF?

A

5-10%

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146
Q

45-year-old manual laborer presents to the office with acute onset back pain that radiates to his right leg after carrying a heavy object. He also has mild non-progressive weakness with ankle dorsiflexion on that side. What should be his initial treatment

A

PT and NSAIDs should be first line

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147
Q

Most common cause of sudden death in RA spine?

A

Basilar invagination

148
Q

Patient presents with pain and neuro symptoms.

Plan?

A

L4-S1 posterior instrumented fusion with anterior column support

149
Q

What is an absolute contraindication to C1-2 transarticular screws?

A

Aberrent vertebral artery

150
Q

Indications for surgery in Atlantoaxial instability: (3)

A

ADI >10mm (even if no neuro deficits)

SAC/PADI less than 14 (in RA)

Progressive myelopathy

151
Q

Describe pedicle screw start points in T/L spine

A

T-spine

  • midpoint of Transverse process and lateral pars
  • (note: midpoint in height, but you can also follow the superior aspect down to get to the same point - see image)

Mid T spine

  • Junction of midpoint of transverse process and lateral 1/3 of superior articular process

Distal T

  • Junction of transverse process and lateral pars

Lumbar

  • Junction of midpoint of transverse process and 2mm lateral to pars (lateral aspect of facet joint / mamillary process / lateral pars)
152
Q

Treatment for recurrant lyrangeal nerve injury with anterior approach?

A

Observe for 6 weeks, if no better consult ENT.

153
Q

What is the best type of MRI to look for spondylodiskitis?

A

T1 with gad and fat suppression

154
Q

How do you measure kyphosis at the C-spine level?

A

C2-7 kyphotic level

Local kyphotic level

155
Q

Describe Meyerdeng classification

A

I: <25%

II: 25-50%

III: 50-75%

IV: 75-100%

V: spondyloptosis

156
Q

Adult spondylolishtesis at L5-S1. What is the nerve root that is involved?

A

L5

It affects the exiting nerve root as it causes foraminal stenosis

157
Q

What is a hangman’s fracture?

A

Bilateral fracture of pars of Axis allowing for anterolisthesis of C2 on C3

158
Q

What are 5 indications for MRI in scoliosis?

A
  1. Abnormal curve (think Lenke)
  2. Neurologic deficit
  3. Infantile or Juvenile onset
  4. Male patient with large curve
  5. Thoracic kyphosis > 30 degrees
159
Q

3 techniques for C1-2 fusion

A

C1 Lateral mass + C2 pedicle/pars/translaminar (Harms)

C1-2 Transarticular (Magerl)

Sublaminar wiring (Brooks, Gallie)

160
Q

Describe McRae’s line

A

defines the opening of the foramen magnum

the tip of the dens may protrude slightly above this line, but if the dens is below this line then impaction is not present

161
Q

On x-ray, criteria for absolute and relative cervical stenosis:

A

Lateral xray:

Absolute: canal diameter less than 10mm

Relative: canal diameter 10-13mm

Normal canal diameter is 17mm

Torg-Pavlov ratio (canal:vertebral body width)

Normal is 1

Doesn’t work for athletes

162
Q

Halo application principles in paeds (location, pins, tightness, vest)

A

Generally: more pins, less torque

Pins

  • 6-8 pins
  • Anterior pins: must be lateral enough to avoid frontal sinuses, supratrochlear & supraorbital nerves
  • Posterior pins: anterior enough to avoid temporalis muscle

Torque

  • 2-4 inch pounds of torque, or “finger tight”

Brace

  • Less than 2 years: Minerva
  • >2 years: custom

±CT scan to:

  • avoid cranial sutures
  • avoid thin skull regions
  • limit complications
163
Q

6 dangers in retroperitoneal approach to lumbar spine?

A

Sympathetic chain: lateral aspect of vertebral body

Genitofemoral nerve: anterior surface of psoas muscle attached to fascia

Segmental lumbar arteries & veins: Branches from aorta

Aorta: Bifurcates at L4

Ureter: lies between psoas fascia and peritoneum

Superior hypogastric plexus: Injury leads to retrograde ejaculation

164
Q

Name as many syndromes/causes of dural ectasia (there are 9 on this list)

A

Dural ectasia: ballooning or widening of the dural sac which can result in posterior vertebral scalloping and is associated with herniation of nerve root sleeves

  • Marfan syndrome: dural ectasia has been observed in 60-90% of patients; in these patients, the dilatation of the dural sac is almost always in the lumbar region
  • neurofibromatosis type 1
  • Ehlers-Danlos syndrome
  • ankylosing spondylitis
  • osteogenesis imperfecta
  • trauma
  • post surgery
  • tumours
  • scoliosis
165
Q

What is the natural history of OPLL

What percentage of patients get myelopathy

A

Most will get radiological progression of OPLL

Only half experience worsening clinical symptoms

166
Q

Contraindications for RTS with cervical stenosis (3)

A

1) Loss of CSF around Cord or any cord deformity
2) Multiple episodes of transient quadraparesis
3) Bilateral symptoms

167
Q

Most powerful LOCATION for an osteotomy in AS

A

Lumbar spine

168
Q

What are the three ligaments of the C1-C2 ligamentous complaex?

A

Alar Ligaments

Apical Ligaments

Transverse Ligament

169
Q

Three findings associated with Ankylosing Spondylitis?

A
  1. sacroiliitis
  2. uveitis
  3. HLA-B27 +

(Bamboo spine)

170
Q

What do you need to look for on physical exam of a CP kid for consideration of scoliosis surgery?

A

hip or knee contractures

171
Q

What is the most important thing to look for in physical exam for AAI?

A

Myelopathy

172
Q

What is the name of the classification system of Spondylolysis? Describe it

A

Wiltse-Newman

I: dysplastic

II: Isthmic

  • a: pars fatigue
  • b: pars elongation due to multiple healed stress fracture
  • c: acute

III: degenerative: pars instability without a pars fracture

IV: traumatic

V: Neoplastic

173
Q

Which side do you approach from when using retroperitoneal approach to spine? Why?

A

Left: Aorta is more resistant to injury

174
Q

What finding on radiology suggests an occipital condyle is unstable?

A

Avulsion fractures of alar ligaments.

This is a type 3 injury.

Other types are stable and only need c-collar.

175
Q

Three characteristics of a pathologic scoliosis curve?

A
  1. painful
  2. rigid
  3. less severe than other types of scoliosis
176
Q

Who gets Charcot spine and how do you treat it?

A

Patients with a spinal cord injury (i.e. with neurologic damage)

It causes instability so the primary treatment is posterolateral instrumented fusion +/- TLIF at level of Charcot disk

177
Q

Mortality rate of halo in patients aged >79?

A

21%

Avoid it in this population

178
Q

What level of the Thoracic or Lumbar spine has smalles pedicle length and diameter?

A

T4

179
Q

Name 7 reasons for obtaining an MRI with a patient who presents with scoliosis (older)?

A
  1. atypical curve
  2. rapid progression
  3. increased kyphosis
  4. structural abnormality
  5. neurologic symptoms or pain
  6. deformity of foot
  7. assymetric abdominal reflexes
180
Q

4 techniques for pars repair

A

Screw

tension wiring

Screw + hooks

U rod

181
Q

Risks of type II odontoid fracture nonunion: (8)

A

>6mm displacement

Posterior displacement >5mm

Further posterior displacement after application of a Halo vest >2mm

Angulation > 10 degrees

comminuted fracture

Fracture gap >1mm

Age >50

Delay in treatment >4 days

*Highest rate of nonunion comes from posteriorly displaced an angulated Type II fractures

182
Q

IN stereotactic radiosurgery, why is the planning treatment volume (PTV) less than the clinical target volume?

A

To account fro any errors in targeting

(area to be treated with radiation is 2-3mm less than the CTV)

183
Q

What tract is the mainly affected in central cord syndrome?

A

Lateral Corticospinal

UE is more medial so more affected.

184
Q

Three differences between osteoblastoma and osteoid osteoma of the spine?

A
  1. OO more likely to respond to NSAIDs
  2. OB usually bigger (> 1.5 cm)
  3. OB more likely to have neural involvement
185
Q

Two surgical options for a symptomatic thoracic disc?

A

1) Anterior/ Transthoracic (can use VATs)
2) Costotransverectomy (Lateral)

186
Q

Name 1 poor and 5 good prognostic indicators for surgery to treat lumbar disc herniation

A

Positive predictors of good outcome with surgery

  • Leg pain is chief complaint
  • Positive SLR
  • Weakness that correlates with nerve root impingement on MRI
  • Married
  • Age >41

Negative predictors of outcome

  • Worker’s compensation
187
Q

Contraindications to Smith-Peterson Osteotomy?

A

Anterior fusion at level of osteotomy

b/c the osteotomy hinges through the disc space

188
Q

Anterolateral approach to lumbar spine

what crosses your field at L4-5

A

Iliolumbar vein

Crosses left to right as it drains into vena cava

189
Q

Post-op degenerative spony outcomes

A

Better pain relief

better functional outcomes

190
Q

Two indications for open debridement of pediatric diskitis?

A
  1. Failure of non-op
  2. Abcess pressing of thecal sac or paraspinal abscess
191
Q

Three xray findings of pediatric diskitis?

A

Loff of lordosis

Disc space narrowing

Late finding of end plate erosions ( 3 weeks)

192
Q

Burst fracture with retropulsion and > 50% collapse, TLICS score of 3, neuro intact, how do you treat?

A
  1. Fit for TLSO
  2. Dynamic views in TLSO
193
Q

Removal if C-collar is allowed if patient is:

A
  • Alert
  • Awake
  • Not intoxicated
  • Has no neck pain, tenderness or neurologic deficits
  • Has no distracting injuries

Must fulfill ALL above criteria

194
Q

What is the least useful exam for lumbar stenosis?

A. Physical exam

B. MRI

C. Treadmill test

D. SF-36

A

Physical exam

Often people present asyptomatic and will have a + treadmill test

195
Q

Describe a smith peterson osteotomy. How much correction can it give?

A

Posterior element osteotomy and hinging through disc

Gives 10 degrees of correction per level osteotomized

196
Q

What cervical approach has the higher infection rate?

A

Posterior

197
Q

What are the 6 primary manifestations of VACTERL?

A

1 ) Vertebral malformation

2) Anal atresia
3) Cardiac malformations
4) T-E fistula
5) Radial anomolies
6) Renal malformations

198
Q

What Spinal Cord Tumor am I?

Often found on filum terminale

Histology: Rosettes

Intramedullary

A

Ependymoma

199
Q

List 5 things to consider in an ank spond patient with a spine injury

A

More likely to have spine fractures than normal population

Low energy mechanism

High bleeding risk

High risk of epidural hematoma

More likely to be Osteoporotic

More likely to present with neuro deficit

More likely to have progressive (delayed) neuro deficit (b/c of epidural hematoma)

Always unstable (long lever arms and involved anterior and posterior columns)

Higher rate of loss of reduction

30% mortality

50% morbidity

Difficult to brace b/c of severe kyphosis

Lots of reported complications with non-op treatment such as traction and bracing

Profound medical co-morbidities (lungs especially)

200
Q

3 indications for emergent MRI with Facet injury?

A
  1. Altered mental status
  2. Neuro decline during reduction
  3. Failed closed reduction

Otherwise get after reduction before OR

201
Q

Negative prognostic indicators in spinal stenosis surgery

A

CV comorbid conditions (most important)

Increased comorbid conditions

disorder affecting gait

depression

back pain

scoliosis

202
Q

Damage to what nerve with anterior approach to lumbar spine causes retrograde ejaculation?

A

superior hypogastric plexus on L5 body

203
Q

What non-fracture spinal sequelae can be fatal in AS patients?

A

Epidural hematoma

Get MRI if suspected

204
Q

(3) Absolute contraindications to Halo application. Name as many relative ones as possible (5)

A

Absolute:

  • Cranial fracture
  • Infection
  • Severe soft tissue injury (especially near pin sites)

Relative

  • Polytrauma
  • Severe chest trauma (b/c of vest)
  • Barrel-shaped chest
  • Obesity
  • Advanced age (this is becoming more absolute)
205
Q

>12mm on BDI or BAI indicates what?

A

Anterio rC0-1 displacement

(the classification states that it’s C0 anterior on C1)

206
Q

Two requirements for treating Chance fracture with TLSO?

A

1) Neuro intact
2) PLC Intact

** follow over time for progressive kyphosis

207
Q

Factors contributing to development of sagittal imbalance in adult spinal deformity (4)

A

Osteoporosis

Preexisting scoliosis

Iatrogenic instability

Degenerative disc disease

208
Q

Post-traumatic spinal pain in AS patient, what MUSt you do?

A

CT it

x-rays are not enough

+/- MRI

209
Q

How do the columns fail in a Chance fracture?

A

Anterior in compression.

Middle, posterior in tension.

210
Q

What sense is preserved in anterior cord syndrome?

A

Dorsal columns - prorioception and vibration

211
Q

Large/Anterior spinal abscesses are hallmarks of what infection?

A

TB

212
Q

3 x-ray findings for lumbar disc herniation

A

Loss of lordosis

Loss of disc height

Lumbar spondylosis (degenerative changes)

213
Q

In congenital vertebra, name which have the most risk of scoliosis progression from highest risk to lowest risk

A

Unilateral bar + contralateral hemi (5-10 deg)

double hemi (4-10 deg - double of a single hemi)

Unilateral bar (5-6 deg)

Unilateral hemi (2-5 deg)

Wedge vertebra (less than 2 deg)

Block vertebra (less than 2 deg)

214
Q

4 conditions associated with dural ectasia?

A

Marfan syndrome

Ehlers-Danlos syndrome

neurofibromatosis type I

ankylosing spondylitis

215
Q

After pseudoarthrosis of ACDF, what is the preferred treatment?

It is associated with higher rates of what?

A

Posterior fusion

Higher rates of fusion & overall complications

Even though it has higher overall complications, it is still preferred treatment b/c of higher fusion rates

216
Q

What is the main prognostic difference between flexion and extension teardrop fractures?

A
  1. Flexion are unstable whereas extension are usually stable
  2. Extension is usually smaller fleck and common at inferior C2 endplate
  3. Flexion is larger piece and has posterior subluxation into canal of remaining body
217
Q

Congenital scoli with in kid younger than 5 years old. How do you treat if failure of formation vs. failure of segmentation (describe with curve magnitude)

A

Failure of formation:

Age less than 5 AND

Curve less than 40: hemiepiphysiodesis

Curve > 40: excision

Failure of segmentation

In-situ fusion

218
Q

10 Complications of OR for spinal stenosis

A

Major complication

  • wound infection (10%)
  • deep surgical infections are to be treated with surgical debridement and irrigation
  • pneumonia (5%)
  • renal failure (5%)
  • neurologic deficits (2%)

Minor complication

  • UTI (34%)
  • anemia requiring transfusion (27%)
  • confusion (27%)
  • dural tear
  • failure for symptoms to improve
219
Q

Combined lateral mass overhang should be:

A

less than 7 mm (8.1mm with radiographic magnification)

220
Q

Incidence of L5 nerve root injury with spondy reduction

A

30%

NOT proportional in any way to amount/degree of reduction

221
Q

Most common nerve injured with halo application and resultant deficit?

A

CN 6 (Abducens)

Lack of lateral eye movement

Usually treat with observation.

222
Q

Operating on which side anteriorly in the cervical spine has a higher rate of recurrent laryngeal nerve palsy?

A

Equivalent

Classically right sided was worse but new studies show injury rates are equivalent

223
Q

Risks of prolonged immobilization in rigid C-collar

A

increased risk of aspiration

Inhibitions of respiratory function

Increased risk of decubitus ulcers

Possible increase in intracranial pressure

224
Q

Three indications for OR with lumbar disc herniations?

A

1) Failed conservative treatment (6 weeks)
2) Progressive or significant weakness
3) Cauda Equina

225
Q

Powers ratio. Interpret

>1

less than 1

A

>1: anterior dislcoation C0-1 (head goes anterior)

Less than 1:

Posterior atlanto-occipital dislocation (head goes posterior)

Odontoid fracture

Ring or atlas fracture

226
Q

How do you test for CSF (ie dural tear) on swab/analysis

A

beta-2-transferrin

227
Q

Two causes of a pathologic scoliosis?

A

Osteoid osteoma

Osteoblastoma

228
Q

In adult spinal deformity, what is the best predictor of pre and post-operative symptoms?

A

Sagittal balance (ie kyphosis)

229
Q

What are the 2 approved uses of rhBMP?

A

rhBMP-2 is FDA approved for:

use together with the lumbar tapered fusion device (LT Cage; Medtronic) in single-­level ALIF from L2 to ­S1 levels in degenerative disc disease.

Open tibial shaft fractures treated with IM nail with 14 days

230
Q

Radiographic signs of unstable C1 fracture

A

Combined lateral mass displacement of >7mm (8.1mm with radiographic magnification) on open mouth view

ADI >3mm (normal is <3mm)

  • ADI 3-5mm: TL injury, alar & apical ligaments intact
  • ADI >5mm: Injury to TL & alar ligaments ± tectorial membrane
231
Q

Describe ranawat classification for RA C-spine

A

I: pain only

II: subjective weakness, hyperreflexia, dysaesthsia

IIIa: objective weakness, long tract signs, ambulatory

IIIb: objective weakness, long tract signs, non-ambulatory

232
Q

What are two types of strut graft that can be used for an anterior decompression for spondylodiskitis?

A

1) tricortical autograft from Ilium, rig or fibula
2) Titanium mesh cage filled with autograft

233
Q

In AIS, what curves are least and most likely to progress?

A

Skeletally mature:

Least: curves <45

Most: Thoracic curves >55 degrees

45-55 - don’t know

Skeletally immature:

>25-30 deg will progress

234
Q

Difference on x-ray between DISH and AS?

A

DISH spares the disc spaces

vs.

AS: discs will be ossified, resulting in fusion of vertebrae

See pic of AS

235
Q

Briefly Describe a pedicle subtracting osteotomy. How much correction can you get from a PSO?

A

Posterior osteotomy including vertebral body

Can give 30-35 degrees of correction

236
Q

How do these lesions affect disc space?

  1. TB spondylodiskitis
  2. Pyogenic spondylodiskitis
  3. Tumor
A
  1. TB spondylodiskitis = No early disk involvement
  2. Pyogenic spondylodiskitis = Involves the disk space
  3. Tumor = Spares the disk space
237
Q

Where should sagittal C7 plumb line end?

A

posterior superior corner of S1

238
Q

Procedure if neurologic event (as per MEPs, SSEPs) occurs intraop:

A

Take control of the room

Check for technical errors

Test screws

Make sure there is no anesthetic affecting readings

Check blood pressure and evaluate if low

MAP > 75-90mmHg

Check hemoglobin and transfuse as necessary

Check O2 sats >90%

Lessen/reverse correction

Administer Stagnara wake up testWake the patient up and evaluate voluntary motor function

Ask them to move their feet

Remove instrumentation if spine is stable

Call for second opinion

Give steroids

239
Q

What is the relationship between pelvic incidence and Spondylolisthesis?

A

Direct linear relationship between pelvic incidence and the severity of the spondylolisthesis

240
Q

Three indications for surgery according to Wai?

A
  1. unpinch a nerve
  2. instability
  3. restore a balanced spine
241
Q

Two techniques to increase maximal insertional torque for pedicle screws?

A

1) under tap by 1 mm
2) Straightfroward trajectory parallel to superior endplate

242
Q

Describe pedicle - nerve root match/mismatch

A

Pedicle - nerve root:

Mismatch: different level nerve root travels under numbered pedicle

ie: C-spine: C6 nerve root travels under C5 pedicle

Match: same level nerve root exits numbered pedicle

ieL L-spine: L5 nerve root travels under L5 pedicle

C8 nerve root allows transition b/c no C8 pedicle

243
Q

Most sensitive and specific test for predicting neurologic compromise in subaxial instability?

A

Cervical height index

=body height/width

<2 is 100% sensitive & specific for predicting neurologic compromise

*So normally should be 2x taller than it is wide - flattened is bad

244
Q

Contraindications to transarticular (Magerl) technique

A

Large, medially located vertebral artery

Hypoplastic C2 pars

Inability to obtain an anatomic reduction of C1 over C2

Substantial thoracic kyphosis that precludes the angle necessary for this approach

245
Q

Causes of AARD (10)

A

Degenerative:

  • Down’s syndrome
  • RA/JRA
  • Os odontoideum

Traumatic

  • Type I odontoid fracture (rare)
  • Atlas fracture
  • Transverse ligament injuries

Other:

  • Grisel’s disease (retropharyngeal irritation)
  • Morquio’s
  • Tumour
  • Congenital
246
Q

Are uni or bilateral facet dislocations easier to reduce?

Which are easier to maintain reduction once reduced?

A

Bilateral easier to reduce

Unilateral easier to maintain reduction once reduced

247
Q

What is the incidence of neural axis abnormalities in infantile scoli?

A

Same as that of juvenile idiopathic

20-30%

248
Q

What is Swischuk’s line?

A

the Spinolaminar line drawn from C1-C3

Tests for pseudosubluxation of C-spine in paeds

normal: C2 should be within 1.5mm of spinolaminar line

249
Q

Antibiotic treatment for Potts disease?

A

Isoniazid

Rifampin

Pyrazanimide

*** 9 - 18 months!!!

250
Q

What is characteristic of a Type IIA Hangman’s fracture? What is indicated and contraindicated in treatment?

A

IIA: Horizontal fracture line

Absolute contraindications: traction

Classic treatment: ACDF

251
Q

When is calcitonin useful for compression fractures?

A

Acute (, 4 days old) osteoporotic compression fractures.

Use for four weeks.

Useful for pain.

252
Q

Where is diastematomyelia most common?

A

L1 - L3

253
Q

What percent of RA patients has basilar invagination?

A

40%

254
Q

What is Swischuks line?

A

Line from Sp of C1 to C3, the SP of C2 should be within 1.5 mm in true pseudosubluxation

255
Q

In patients with adult scoliosis requiring long thoracolumbar fusions, what is the major advantage of extending the fusion to the sacrum as opposed to ending at L5

A

Improved correction and maintenance of sagittal balance

256
Q

Describe retroperitoneal approach to L-spine

A
  • Oblique Incision From posterior half of 12th rib to lateral border of rectus abdominis
  • incise subcutaneous fat
  • expose aponeurosis of external oblique muscle
  • divide external oblique in line with fibers
  • divide internal oblique in line with incision and perpendicular to muscle fibers
  • divide transverus abdominis in line with skin incision
  • bluntly dissect plane between retroperitoneal fat and psoas fascia
  • retract peritoneal cavity medially
  • bring ureter medially with peritoneal cavity
  • follow surface of psoas muscle to vertebral bodies
  • tie off segmental lumbar arteries of aorta in the field of dissection
  • L4/5 disc space
  • mobilize aorta to the contralateral side
  • place needle in disc and take lateral xray to identify level
  • L5/S1 disc space
  • work between the bifurcation of aorta
  • place needle in disc and take lateral xray to identify level
257
Q

Which side of the curve do osteoid osteomas live in?

A

concave side, usually at the apex

258
Q

Acute managmement of occipito-cervical instability

A

NO movement of the head

Must immobilize head/neck with sandbags & tape (C-collar doesn’t do much in these cases)

Mark patient with instructions not to move head

259
Q

3 radipgrahic lines for basilar invagination:

A

Ranawat’s line

McGregor’s line

Chamberlain’s line

McRae’s line

260
Q

Diagnostic criteria Scheuermann’s kyphosis

A

>3 consecutive wedged vertebrae > 5 degrees

Thoracic kyphosis >45 degrees

or

Thoracolumbar kyphosis > 30 degrees

261
Q

Positive predictors for spinal stenosis surgery

A

good self reported health (most important)

higher income (most important)

good self reported ambulatory status

central stenosis

shorter duration of symptoms

younger

male

more expectations for function

262
Q

T/F: helmets control rotational forces

A

True

263
Q

Which myelopathy classification is based on physical exam findings and which is based on functional ability?

A

a) Nurick is Functional
b) Ranawat is based on exam

264
Q

4 indications and 1 contraindication to pars repair

A

spondylolytic defects L1 through L4:

spondylolytic defects of multiple vertebral levels

low-grade but reducible spondylolisthesis at levels
cephalad to L5 with an intact vertebral disk at the level of slippage

Contraindicated in L5 and below

265
Q

Is DM a risk of pseudoarthrosis of the spine after PSIF?

A

No

Had 91% fusion rates at 5 months, which is comparable to non-DM

(JAAOS 2014)

266
Q

What are the different means of getting to a thoracic disc (deep approaches)?

A
  1. laminectomy/hemilaminectomy
  2. transpedicular
  3. costotransversectomy
  4. lateral extracavitary
  5. anterior intracavitary
    1. thoracotomy
    2. VATS (video assisted thoracoscopic surgery)
267
Q

In early onset scoliosis, what are radiologic signs for risk of progression (4)

A

Rib phase 2 (rib-apical vertebra overlap)

RVAD (Mehta angle) > 20degrees (80% progress)

Cobb angle > 20 degrees

Thoracolumbar curve

Conversely, phase 1 rib (no overlap), RVAD

RVAD

268
Q

Which nerve roots do central, paracentral and far-lateral discs affect higher than C8 and lower than C8?

A

Cervical:

central and foraminal disc will affect the same nerve root

Always the exiting one

due to horizontal nerve root anatomy

Lumbar:

paracentral and far lateral affect different roots

paracentral: affects traversing nerve root

Far lateral: affects exiting nerve root

269
Q

6 Indications for surgery with spondylodiscitis?

A
  1. intractable neck pain
  2. septicemia
  3. epidural abscess
  4. neurological compromise
  5. gross kyphotic deformity with extensive destruction
  6. failure of conservative treatment.
270
Q

Type of pars defect in degenerative spondy

A

NO PARS DEFECT

This differentiates it from adult/paeds isthmic spondy

271
Q

When will osteoid osteoma caused scoli resolve?

A

After resection only if performed 15-18 months of age in a child

272
Q

Indication for bracing in Scheuermann’s kyphosis

A

Observation alone:

  • Kyphosis less than 60 degrees and asymptomatic
  • Most patinets fall into this group

Bracing with extension type orthosis Modified milwaukee brace:

  • Kyphosis 60-80 degrees in patients Risser 3 or below & asymptomatic
273
Q

How does Scheurmans differ from physiologic kyphosis?

A

> 45 degrees

can be painful

rigid

anterior vertebral wedging

274
Q

Dangers of retroperitoneal (anterolateral) approach to spine?

A

Sympathetic chain

Ureter

Genitofemoral nerve

Aorta

Segemental lumbar vertebral arteries

Superior hypogastric plexus

275
Q

Definidtion of instability on flex-ex views in degenerative spondy?

A

4mm translation

10 degrees of angulation

276
Q

When is an isthmic spony most likely to progress?

A

in adolescence during growth spurt

277
Q

What is a type 1 Dens fracture and what imaging should be performed in these cases?

A

Avulsion of tip of Dens.

Should do flex/ex views to check for AAI.

278
Q

Infantile scoliosis normally is which direction?

A

Left thoracic

(vs AIS: right thoracic)

279
Q

What is the only cervical dermatome with an autonomous zone?

A

C4 - over AC joint

280
Q

After facet dislocation, what is an absolute indication for an anterior approach?

A

Herniated disc

281
Q

Two reasons to add posterior instrumentation after doing an anterior decompression and strut graft for spondylodiskitis?

A

1) Severe kyphosis
2) If the anterior decompression was multilevel

282
Q

5 Indications for MRI for lumbar discogenic pain

A

Pain > 1 month and not responding to nonoperative managmeent

Infection (IVDU, hx of fevers/chills)

Tumour: hx of cancer

Trauma

Cauda equina syndrome

283
Q

Risk factors for OPLL

A

idiopathic skeletal hyperostosis

Hypoparathyroidism

hypophosphatemic rickets

hyperinsulinemia

obesity

Body mass index

insulinogenic index (serum insulin divided by serum glucose)

284
Q

Two most common types of extradural spinal cord tumours?

A

Mets

Lymphoma

285
Q

What lab test confirms CSF fluid?

A

beta-2 transferrin

286
Q

Anterolateral approach to lumbar spine

What crosses your field at the sacral promontory (L5-S1)

A

Median sacral artery

287
Q

What finding on radiology do you need to check for if doing an anterior cervical decompression?

A

OPLL (can result in dural tears)

288
Q

T/F? Spony is not associated with increased risk of back pain in adulthood compared to age-matched individuals

A

True

NO risk of back pain in adults

289
Q

What percentage of asymptomatic patients have cord compression from thoracic disc pathology?

A

29%!!

290
Q

What is the typical proximal levels with scoliosis correction in CP?

A

T1 or T2

291
Q

Spinal ring enhancing lesion on MR + Gad?

A

Abscess

292
Q

Where should incision for thoracotomy be?

A

2 levels above where you want to go

293
Q

Classic triad of Klippel Feil?

A
  1. short webbed neck
  2. decreased cervical ROM
  3. low posterior hairline
294
Q

Outcomes of SPORT trial regarding lumbar stenosis

A

surgical > nonsurgical at 2 & 4 years

295
Q

What is a syrinx?

What is a syringomyelia?

A

a) Fluid filled cavity in spinal cord
b) Fluid filled cavity that expands and causes deficits

296
Q

Most common site for adult isthmic spondylolysis/listhesis?

A

L5-S1

L4-L5 is second most common

297
Q

Indications for decompression of TB spinal Abscess?

(4)

A
  1. Neuro deficit
  2. Presence of caseation
  3. Failure of 6 months non-op
  4. Progressive kyphosis or instability
298
Q

Collagen type in annulus fibrosis

A

Type I

299
Q

3 pathological processes associated with sacroiliitis

A

Ankylosing spondylitis

Reiter’s syndrome (oligoarticualr arthritis, conjunctivitis, uveitis)

Joint arthritis

300
Q

Burst fracture with retropulsed fragment and neuro injury, TLICS is 6:

1) How do you decompress?
2) If posterior, how many levels to instrument?

A

1) Either anterior or posterior via transpedicle decompression or indirect decompression with distraction and ligamentotaxis
2) One level above and below (old fashioned is three above and below)

301
Q

What is favoured treatment for sympotmatic synovial facet cyst?

A

Facetectomy and instrumented fusion

(Lower recurrance rate than laminectomy)

302
Q

Main problem with MRI of thoracic disc herniation?

A

High false + rate

303
Q

C1-2 instability

How does treatment differ if it is redicible vs. irreducible

A

Irreducible:

Cannot do Magerl

Must do laminectomy and then fuse

304
Q

Most likley associated injury in a chance fracture?

A

GI (50%)

305
Q

Name 4 approaches to the lumbar spine:

A

Posterior

Wiltse

Anterior intra-peritoneal

Anterior retroperitoneal approach

306
Q

2 signs on MRI to suggest significant stenosis

A
  1. effacement of CSF
  2. Myelomalacia (bright on T2)
307
Q

Two conditions associated with vertebral malformations?

A

1) VACTERL
2) Klippel Feil

308
Q

How much torque should be on an adult and pediatric halo pin?

A

a) Adult is 8 inch lbs
b) Pediatric is 2-4 inch lbs, you use more pins to make up for the decrease in torque

309
Q

Difference between vertebroplasty & kyphoplasty? Which is recommended/not recommended?

A

Kyphoplasty: creates a cavity in which cement can be injected into. Recommended by AAOS (although limited evidence)

vs.

Vertebroplasty: straight injection of cement into vertebral body - no cavity (NOT recommended by AAOS)

310
Q

What kind of spondy is associated with spina bifida?

A

Isthmic

311
Q

Most common complication following Anterior/ Transthoracic approach (+/- VATs)?

A

Intercostal neuralgia

312
Q

A patient has a compression fracture, what are 4 signs that it may be caused by a Met?

A
  1. Higher than T5
  2. Atypical radiographs
  3. Constitutional symptoms
  4. Young patient with no trauma history
313
Q

How do you immobilize a c-spine in a patient younger than 8?

A

They have relatively large heads. Use a coard with a cut out for the head or sandbags. The auditory meatus should be in line with the shoulder.

314
Q

What is an absolute indication for fusing to the pelvis with CP scoliosis?

A

Pelvic obliquity > 15 degrees

315
Q

anterior decomrpession of OPLL has higher rates of what complication?

A

Dural tear

316
Q

Describe McGregor’s line

A

For basilar invagination

317
Q

Timeline for treatment of cauda equina syndrome

A

decompression within 48 hours

shows better recovery of bladder and bowel function and motor and sensory recovery than delayed surgery >48 hours

318
Q

What is cephalomedullary angle and what does it predict?

A
  1. Angle between cerebrum and branstem on saggital MRI
  2. Severity of Basilar Invagination
319
Q

What nerve is most commonly injured with reduction of an isthmic spondylolisthesis?

A

L5

320
Q

Where is the most common extrapulmonary site for TB?

A

Thoracic Spine

321
Q

Normal BDI/BAI?

A

less than 12mm

>12mm indicates atlanto-occipital dissociation

322
Q

In Infantile Scoliosis what degrees of curve are associated with a) pulmonary insufficiency and b) cardio pulmonary insufficiency?

A

a) 60
b) 90

323
Q

Nerves at risk with medial Halo pins?

A

Supraorbital

Supratrochlear

324
Q

What percentage of vertebral compression fractures come to clinical attention?

A

Less than 30%

325
Q

4 positive predictors of success in lumbar discectomy and 1 negative predictor

A

Positive: Leg pain, + SLR, Weakness that corresponds with MRI, Married

Negative: Workmans Comp.

326
Q

Pedicles angulate more as you move distal.

A

medial

327
Q

What part of ATLS do you change for a patient with AS?

A

May skip C-collar

Do not “correct” their deformity to fit them into a collar

This will cause more damage

328
Q

What Spinal Cord Tumor am I?

Common

Associated with NF 2

Histology: meningothelic whorls

A

Meningioma

329
Q

Three conditions common for RA involving the c-spine?

A
  1. Atlanto-Axial istability
  2. Basilar Invagination
  3. Sub-Axial Subluxation
330
Q

What does a fluid sign on MR suggest with a vertebral body lesion?

A

Osteoporotic vertebral compression fracture

331
Q

What Spinal Cord Tumor am I?

Very common

Associated with NF 2

Forms at dorsal nerve root

S-100 +

A

Schwanoma

332
Q

4 angles or clnical tests for AS

A

Schober test

Chin-brow angle

Occiput to wall angle

Gaze angle

333
Q

What are Waddells signs?

A
  1. Over-reaction
  2. Simulation (reaction to simulated test)
  3. Distraction (neg. SLR when distracted)
  4. Regional (non-dermotermal)
  5. Tenderness (to light touch)
334
Q

How much correction can you get with a vertebral column resection?

A

45 degrees

335
Q

What spinal condition shows sparing of the right thoracic area?

A

DISH

336
Q

What must you do before operating on a c-spine?

A

CT scan to look for course of vertebral artery

337
Q

Name the following vertebral levels and landmarks

C2-3

C3

C4-5

C6

C7

T3

T8

T10

L4

S1

A

C2-3: Mandible

C3: Hyoid

C4-5: thyroid

C6: Cricoid

C7: vertberal prominence

T3: Spine of scapula

T8: nipples

T10: xiphoid

L4: bifurcation of aorta

S1: Bifurcation of iliacs

338
Q

3 pediatric causes of AAI?

A
  1. Morquios
  2. JRA
  3. Rotatory AA subluxation
339
Q

Spondy incidence in Inuit

A

high!

Not rare

340
Q

Describe pelvic incidence:

A

Pelvic Incidence = pelvic tilt + sacral slope

Angle formed by:

  1. a line from the center of the femoral head to the middle of the S1 end plate
  2. a line perpendicular to the S1 endplate
341
Q

5 signs of UMN injury:

A
  1. increased reflexes
  2. inverted radial reflex
  3. Positive hoffmans
  4. Positive babinsky
  5. Sustained CLonus (more than 3 beats)
342
Q

PADI/SAC: less than what amount is associated with risk of neurologic injury and an indication for surgery?

A

less than 14mm

>17 is normal

14-17mm is grey zone

343
Q

Poor prognostic indicators for spinal stenosis

A

cardiovascular comorbidity

Disordered walking condition

Scoliosis

Depression

344
Q

Three indications for surgery with spondylodiskitis?

A

1) Refractory to medical amagement
2) Neurologic deficits
3) Progressive kyphosis or gross instability

345
Q

If you have an anterior fusion, what kind of spinal osteotomy can you do?

A

Pedicle subtracting osteotomy

b/c it does not hinge on the disc, but the vertebral body instead

346
Q

Whar is the most reproducible measure of basilar invagination on xray?

A

Ranawat Index

(shoulde be > 14 mm)

Measure from center of C2 pedicle to a line connecting the anterior and posterior C1 arches

normal measurement in men is 17 mm, whereas in women it is 15 mm

distance of

most reproducible measurement

Also: cervicomedullary angle on MRI

347
Q

What are 4 factors supporting pseudosubluxation in paediatric C-spine?

A

Reduction of subluation with neck extension

Spinolaminar line within 1.5mm of C2

No hx of exam findings of significant trauma

Absence of anterior soft-tissue swelling

348
Q

What Spinal Cord Tumor am I?

Found at cervicothoracic junction in kids

Histology: Fusiform

Intramedullary

A

Astrocytoma

349
Q

Treatment of spine fracture in ank spond?

A

Long PSIF construct

350
Q

What abdominal pathology can cause paresthesias along medial aspect of knee that may be confused with L3 sensory symptoms?

A

PSOAS Abcess

351
Q

What is Spear Tacklers Spine?

A

Cervical stenosis due to multiple microtrauma caused by bad tackling technique.

No RTS.

352
Q

Management of cauda equina syndrome

A

Decompression

Classic: wide laminectomy + discectomy. “pedicle to pedicle decompression”

However, no comparative studies for wide decompression and discectomy vs. microdiscectomy

353
Q

What is the organization of the cauda equina?

describe location of Sacral and lumbar roots

Motor and sensory fibers

A

Sacral roots central to lumbar

Motor fibers anterior, sensory dorsal

354
Q

What is the indication for pars repair?

A

Spondylolysis at L4 or above with no listhesis.

Fails bracing.

If at L5 you have to fuse .

355
Q

Mortality rate of patients over 79 treated with Halo?

A

21%

356
Q

Which side do you approach from during an anterior/transthoracic appraoch to the spine? Why?

A

Left side

Aorta is more resiliant to injury

Avoids liver

357
Q

How many occipital screws are optimal in an occiput - C2 fusion?

A

6

358
Q

First line of treatment for adult spondylolisthesis?

A

Nonoperative observation

NOT TLSO, although it may be beneficial

This was an orthobullets question

359
Q

Describe Smith-Robinson Approach

A

Incision

make transverse skin crease incision at appropriate level

extend obliquely from the midline to the posterior border of the SCN

Superficial Dissection

incise fascia over platysma

spit platysma with finger

identify anterior border of SCM

incise fascia and retract SCM lateral

identify and retract strap muscles medially (sternohyoid and sternothyroid)

identify the carotid pulse and retract carotid sheath lateral

cut through pretrachial fascia

localize superior and inferior thyroid arteries and tie off if necessary

Deep dissection

split longus colli muscles and anterior longitudinal ligament

be aware of sympathetic chain that lies on longus colli lateral to vertebral body

subperiostally disect to expose anterior surface of vertebral body

retract longus colli muscles and ALL laterally

identify level with needle in disc space and lateral xray

360
Q

How is treatment of Type 2 Dens fractures different in the elderly?

A

They can’t tolerate Halo so lower threshold to fuse.

In the young can do Halo if no risk factors for non-union. Benefit is preservation of ROM.

361
Q

What orientation are a) Thoracic and b) Lumbar facets (largest dimension)?

A

a) coronal
b) saggital

362
Q

How do you decide betwwen Occiput –> C2 and C1 –< C2 posterior fusion in treatment of AAI?

A

Either the presence of significant basilar invagination or if C2 is not reducible suggests you should do occ. –> C2 fusion

363
Q

What percentage of SCI patients have major depressive disorder?

A

11%

364
Q

Why do Down’s get occipitalcervical instability and how is it treated?

A

1) Hypoplastic occipital condyles
2) Occiput –> C2 fusion if symptomatic

365
Q

What is the finger escape sign suggest?

A

Myelopathy

(due to intrinsic weakness)

366
Q

Indication for surgery in Scheuermanns kyphosis

A

Kyphosis >75 degrees that is rigid in a skeletally mature patient

Neurologic deficit

Spinal cord compression

Severe pain in adults

367
Q

Name 5 complications with anterior approach to the cervical spine

A

Postoperative C5 palsy incidence

Recurrent laryngeal nerve injury

Hardware failure and migration

Postlaminectomy kyphosisPostoperative axial neck pain

Vertebral artery injury

Esophageal Injury

Dysphagia & alteration in speech

3. OrthoBullets (General Knowledge) (20 decks)

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