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ABOS-boards > Spine > Flashcards

Spine Flashcards

1
Q

Vertebral compression fx palm fxn

A

Each decreases ~10%, increased risk of mortality from pulm dysfxn

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2
Q

Vert compression fx 1 and 2 year mortality

A

1 year 15% (less than hip fx)

2 year 20% (same as hip fx)

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3
Q

Kyphoplasty indications and technique

A

Pain >6 wks with vert compression fx
AAOS recommended use, though limited
Transpedicular approach for canal –> Cavity created w/ ballon and injected w/ cement

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4
Q

Osteoporotic VCF imaging vs malignant VCF

A

osteoporotic VCF - low T1, high T2 and STIR

Malignant VDF - complete replacement of normal marrow, convex posterior cerebral border, pedicle involvement, mass

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5
Q

Only Tx with moderate evidence for osteoporotic VCF by AAOS?

A

Calcitonin for 4 weeks for acute injury (directly inhibits osteoclast activity by binding to surface cell-surface receptors)

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6
Q

Mortality risk order: DRF, VCF, hip fx?

A

Hip fx > VCF > DRF

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7
Q

Injury ass’d with chance fx?

A

Concomitant bowel injury (colonic rupture)

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8
Q

Predictors of medical tx failure for epidural abscess?

A 
Neuro deficits (strongest)
DM
CRP >115
WBC >12
age >65
MRSA
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9
Q

Pott’s dz/TB of spine XR/imaging

A

Predilection for anterior vertebral body, spares disk space until late, significant kyphosis/gibbus deformity

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10
Q

Pavlov ratio - definition and when causes issue in cervical spine?

A

Width of spinal canal divided by width of vertebral body

<0.8 = congenitally narrow canal

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11
Q

Cervical compression ratio definition and when issue in cervical spine?

A

CR = smallest AP diameter of cord/ largest transverse diameter
CR <0.4 has poor prognosis

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12
Q

Size of cord/dimension amendable to nonop tx in cervical myelopathy?

A

Larger transverse area of spinal cord (>70 mm2)

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13
Q

C5 palsy rates after ACDF and timeline to resolve?

A

3-12%

Resolve at 4-6 months

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14
Q

Contraindication for anterior only cervical operation (angle)?

A

Kyphosis >13 degrees

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15
Q

Risk factors for airway complications after ACDF?

A

Exposing >3 vertebral bodies
Blood loss >300 mL
Exposure upper cervical (C2-C4)
Operative time >5 hours

Smoking is NOT a risk factor

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16
Q

UMN Sx?

LMN Sx?

A

Exaggerated reflexes
Clonus
Spasticity
Weakness

Fasciculations
Flaccid paralysis

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17
Q

How often do cervical selective nerve root injxns provide long term relief?

A

40-70%

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18
Q

Time preop and postop for smoking cessation to decrease chance of pseudoarthrosis in cervical surgery?

A

4 weeks preop

6 months postop

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19
Q

ADI defining instability in RA? Indication for surgery?

A

Instability: >3.5 mm of motion on flex/ext
Surgery: >10 mm motion

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20
Q

PADI/SAC indication for surgery in RA? What rads finding predicts recovery after decompression?

A

surgery: <14 mm

>13 mm is MOST important rads finding to predict complete neural recovery after surgery

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21
Q

Indications for C1-2 fusion in RA vs O-C2?

A

C1-2: ADI >10 mm, PADI/SAC <14 mm

O-C2: same as above WITH basilar invagination

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22
Q

Basilar invagination definition? How to measure? MRI?

A

Def: superior migration of odontoid –> tip of odontoid above foramen magnum
Measure on XR with Runaway C1-C2 index: center of C2 pedicle to a line connecting the anterior and posterior arches of C1 (Nl 15-17 mm), distance <13 mm = impaction
MRI: Cervicomedullary angle <135 deg indication for surgery

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23
Q

Most common site for spine synovial cyst?

A

L4-5 (60-90%), most mobile segment

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24
Q

Pathology of synovial cyst?

A

Synovial cells covering a stroma with vascular granulation tissue

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25
Q

Most common level for lumbar disk herniation? What %improve with nonop?

A

L5/S1, 3:1 M:F ratio, only 5% symptomatic
90% improve in 3 months w/ nonop
Sequestered disc herniations (free fragment) greatest spontaneous resorption (macrophage phagocytosis)

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26
Q

MRI w/ contrast post op fibrosis vs recurrent herniated disc?

A

Postop fibrosus - enhances w/ gad

Recurrent herniated disc - does NOT enhance

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27
Q

Indications for microdiscectomy?

A
  • Pain >6 weeks failed nonop
  • Progressive weakness
  • Cauda equina
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28
Q

Size definition of central lumbar stenosis?

A

<100 mm^2 or <10 mm A/P on axial CT

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29
Q

Strongest predator of clinical outcome after lumbar spine decompression?

A

Comorbid conditions

30
Q

Characteristics ass’d w/ good outcome with lumbar disc herniation surgery?

A

Age>41 years
Absence of joint problems
Married

31
Q

Most common site of Adult isthmic spondylolisthesis?

A

82% at L5/S1
11% at L4/5
-Facets more coronal at these levels, forces greatest in lumbar spine at these levels

32
Q

Which level will isthmic spondy at L5/S1 affect?

A

L5 - foraminal stenosis causing compression of exiting nerve root (L5)

33
Q

Types of spondylolisthesis (I through V)

A

Type I: Dysplastic (congenital defect in pars)
Type II: Isthmic (pars fatigue fx, healed stress fx, acute fx)
Type III: Degen - facet instability w/o pars fx
Type IV: Traumatic -acute posterior arch fx other than pars (ex: pedicle fx)
Type V: Pathologic destruction of pars

34
Q

Definition of instability on flex/ext films/lumbar spine?

A

4 mm translation

10 degrees angulation of motion compared to adjacent motion segment

35
Q

Levels to fuse for low grade and high grade spondylolisthesis (adult) at L5/S1?

A

Failed nonop for 6 months

  • Low grade: L5-S1 decompression/fusion
  • High grade: L4-S1 decompression/fusion
36
Q

Annulus fibrosus composition? collagen:proteoglycan ratio?

vs nucleus pulposus?

A

Annulus fibrosus
Type I collagen, oblique oriented fibers
high collagen/low proteoglycan

Nucleus pulposus
Type II collagen, 88% water
Proteoglycans interact w/ water and resist compression
Aggrecan responsible for maintain water content of disk**
Low collagen/high PG **

37
Q

Herniated disk ass’d with increased production of what factors?

Disc aging causes what changes?

A

OPG
IL-1 beta
RANKL/ NF kappa B
PTH

Disc aging:
loss of H20 and conversion to fibrocartilage***

Decrease in:
Nutritional transport
H20***, # viable cells
Proteoglycans***
pH

Increase in:
Keratin sulfate to chondroitin sulfate ratio*
lactate, degradative enzyme activity
Density of fibroblast like cells** (these reside in annulus only ***)

NO CHANGE in quantity of collagen***

38
Q

What is annulus fibrosus derived from? Nucleus polposus?

A

Annulus: sclerotome***

Nucleus: Notochord***

39
Q

Which molecule increases intervertebral discs production of MMPs, NO, IL-6 and PGE2?

A

Interleukin-1 beta***

40
Q

Where does neovascularization of the intervertebral disc originate with aging?

A

From the outer annulus fibrosus***

41
Q

Embryology of spinal cord

Neural tube becomes? If doesn’t close cranially? Caudally?

Neural crest becomes?

Notocord?

A

Neural tube comes spinal cord***
Formed from primitive streak –> primitive/midsagittal groove –> Neural tube
Failure to close cranially = anencephaly
Failure to close caudally - spina bifida occult, meningocele, myelomenigocele

Neural crest
Dorsal to neural tube***
becomes: peripheral nervous system, pia mater, spinal ganglia, sympathetic trunk

Notocord
Forms ventral to neural tube***
Becomes: vertebral bodies, discs

42
Q

Which direction do ankylosing spondylitis THAs risk dislocation?

A

Anterior***

Acetabulum is more vertical and anteverted

43
Q

Which chromosome for AS/HLA B27?

Which HLA for DISH in patients with DM?

A

Major locus in MHC on chromosome 6

HLA-B8 ass’d w/ DISH in patients with diabetes

44
Q

Eponym for DISH?

A

Forestier disease

45
Q

Diagnostic criteria for DISH?

A

Flowing ossification along anterolateral aspect of at least 4 continuous vertebrae*
Preservation of disk height*
Absence of facet-joint ankylosis/SI erosion

Throacic spine often involved in isolation
usually T7-T11 on RIGHT side

46
Q

DISH vs AS mortality after cervical spine trauma? Overall mortality?

A

DISH has higher mortality after cervical spine trauma than AS***

DISH and AS have similar overall mortality***

47
Q

Pediatric spondylolisthesis: what % with pars lesion progress to slip?
What level most common?
Risk of progression?

A

15% w/ pars lesion progress to spondy***

Most common level = L5-S1***

Risk for progression: larger slips, dysplastic slips

48
Q

PE of peds spondy?

A

Flattened lumbar lordosis
Palpable step off of SP’s
Limited flex/Exxt
Pain w/ single limb standing lumbar extension **

Measure popliteal angle to eval for hamstring tightness

49
Q

How to measure slip angle?

Slip angle vs PI relations to spondy?

A

1: draw line on posterior aspect of sacrum
2: Mark cephalic point on S1
3: draw line through cepahlad point that is 90 deg to first line over post sacrum
4: Draw line on inferior endplate of L5
5: measure angle between line drawn in step 3 and 4

Slip angle vs PI
Slip angle correlates with PROGRESSION*
PI correlates with SEVERITY OF DISEASE*

50
Q

Operative tx of spondylolysis?

A

Pars repair for L1 to L4 isthmus defect that failed nonop

L5-S1 in situ fusion:
L5 spondylolysis that fails nonop***
Grade I or II spondy

L4-S1 fusion +/- reduction, +/- ALIF
High grade spondy

51
Q

Common gait with peds spondy?

A

Shortened stride length with flexion at hips and knees***

52
Q

Tx of + imaging for spondylolysis in peds with pain?

A

TLSO bracing

NOT PT***, avoid strenuous activities to prevent formation pars defect completing

53
Q 
Tx of atlantoaxial rotary displacement:
<1 week
>1 week
>1 month
>3 months
A

<1 week - soft collar, NSAIDs

> 1 week: halter traction, NSAIDs, Benzos, then hard collar for 3 months
tx w/ 5 lbs at home or hospital

> 1 month: halo traction, then halo vest for 3 months
Also for failed halter traction x2 weeks

> 3 months: Posterior C1/C2 fusion
Also if there is a Neuro deficit or recurrent subluxation

54
Q

What is Grisel syndrome?

A

Spontaneous atlantoaxial rotary sublimation that occurs after an acute URI

Tx with soft collar for one week

If no improvement, then transition to halter traction + muscle relaxants for 3 weeks

if no improvement then halo traction

If no improvement, then C1-C2 fusion

55
Q

What conditions ass’d with congenital torticollis?

PE of congenital torticollis?

A

Other packaging disorders:
DDH
Metatarsus adductus

PE: head tilt TOWARD affected side and chin AWAY from affected side

56
Q

AIS age definition?

Most common curve?

When to get an MRI?

A

Age: 10-18 y/o

Most common: right thoracic curve***

MRI: Left thoracic curve, short angular curve, apical kyphosis, rapid progression, neuro sx, foot deformities, abnormal abdominal reflexes***

57
Q

natural hx of AIS if not treated?

A

Increased incidence of acute and chronic pain in adults if left untreated

Curves >90 deg ass’d w/ cardiopulmonary dysfunction, early death, pain, decreased self image

58
Q

Risk factors for curve progression in AIS?

A

Curve magnitude***
Before skeletal maturity: >25 will continue to progress
After maturity: >50 thoracic will progress 1-2 deg/yr
>40 deg lumbar will progress 1-2 deg/year

Remaining skeletal growth*
Younger age, <12 at presentation
Tanner <3 for females
Risser 0-1** (Risser 0 = first 2/3 of pubertal growth spurt)
Open irradiate cartilage **
‘Peak growth velocity* –> BEST predictor of curve progression
Peak velocity happens in females just before menarche and before Risser 1 –> correlates with Tanner-Whiehouse III RUS

59
Q

Stable vertebrae?
Neutral vertebrae?
End vertebrae?
Apical vertebrae?

A

Stable: Most proximal vertebrae that is most closely bisected by central sacral line

Neutral: rotationally neutral SP on PA XR

End: Vertebra most tilted from horizontal apical vertebra (where measure from)

Apical: deviated farthest from center of vertebral column

60
Q

Tx of AIS - when to observe, when to brace, OR?

A

Observation: <25 deg

Bracing: 25-45 deg
Must wear 13 hrs/day (50% reduction in need for surgery with compliant brace wear)**

OR: Cobb >45 deg

61
Q

Bracing of AIS: who does worse?

What type of brace for above T7? Below T7?

What defines bracing success?

What defines skeletal maturity in AIS?

A

Bracing for 25-45 deg
Must use 13 hrs/day*** (Recommended 16-23 hrs/day)

13 hours give success 90-93% of time in lvl 1 studies**

Poor prognosis:
Poor brace fit
Hypokyphosis (relative contra)
Male
Obese
Noncompliant

Above T7: Milwaukee (CTLSO)

Below T7: TLSO

Success: <5 deg curve progression

Skeletal maturity: Risser 4, <1 cm height change over 2 visits >6 mo apart, 2 years postmenarchal

62
Q

Neurocentral synchondrosis (NCS) develops between which 2 spinal elements and closes in what order?

A

Centrum and posterior neural arches

Cervical (6 y/o), then lumbar (12 y/o), then thoracic (14-17 y/o)

NCS is growth plate implicated as potential cause of AIS

63
Q

Patient has congenital scoliosis, what imaging tests to get?

A

MRI of entire spine
Renal u/s **
Echo **

64
Q

Which side of the spinal curve does an osteoid osteoma occur?

What portion of the spine does osteoid osteoma occur on?

A

Side: concave portion of the curve

Portion: posterior elements usually, can be in the vertebral body

65
Q

AS vs DISH

Which undergoes more OR?

Which has more neuro events due to vascular issue?

Higher mortality?

HLA B8?

A

AS undergoes more OR***

More vascular issues in AS due to EPIDURAL HEMATOMA due to tethering of epidural vessels***

Mortality equal overall for the two

HLA B8 = DISH, HLA B27 for AS***

66
Q

How to reduce rate of postop dysphagia after multi level ACDF?

A

Local steroid to the retropharyngeal area**

Can also by systemic during procedure**

67
Q

Most common peripheral nerve injury detected by eletrophysiologic monitoring during anterior cervical?

A

1: Brachial plexopathy following SHOULDER TAPING and counetrtraction*
2: Brachial plexopathy on NECK EXTENSION**
3: ULNAR NEURPATHY is third most common* (from malpositioned UE’s)*

68
Q

% of peds patients with concurrent spinal column injury after trauma (Pt transferred with known T6 burst fx)

A

30-55%

69
Q

Mortality risk of type II odontoid in elderly with surgery vs nonop?

A

Surgery = 1 year mortality of 14%

Nonsurgical: 1 year mortality of 26%***

70
Q

Worst prognosis for cervical myelopathy patient with what types of changes in cord on MRI?

A

INCREASED T2, and DECREASED T1***

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