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Millers > Spine: C > Flashcards

Spine: C Flashcards

1
Q

What is the rate of tandem myelopathy/stenosis

A

20% lumbar pathology w/ cervical myelopathy

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2
Q

What are parameters for congenital cervical stenosis
What equation can be used

A

<10mm space available for the cord
Avg normal 17
Torg = B/A = <0.8 = stenosis

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3
Q

3 ways an acute cervical disc presents

A

Central cord
Acute myelopathy
Cervical radiculopathy

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4
Q

What are the 3 RA C spine manifestations

A

Basilar invagination = migration of the dens into the foramen magnum
C1-2 instability 2/2 pannus destroys the TAL
Subaxial instability (“stair step” deformity)

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5
Q

Why do patients have balance issues with cervical myelopathy

A

Posterior cord compression / posterior elements
Lose proprioception
Shuffle / stumble bc dont know where your feet are in space

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6
Q

What is Lhermitte sign

A

Flex neck causes electric shock
Myelopathy

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7
Q

What is Wartenburgs sign

A

Slightly greater abduction of the fifth digit
Weakness adducting palmar interosseous muscle
Unopposed radial innervated extensor muscles (digiti minimi, digitorum communis)

Cervical myelopathy

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8
Q

What is the Japanese Ortho Association (JOA) classification

A

Score to determine if your cervical myelopathy will improve with surgery
<14 = likely to improve
Higher score = more functional

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9
Q

What is the determining factor to determine ant vs posterior for C spine surgery

A

KYPHOSIS

> 10deg, need some anterior procedure to restore lordosis

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10
Q

If more than 3 levels C spine involved, what surgery:

If >10deg kyphosis
If <10deg kyphosis or lordotic (normal)

A

Kyphotic - anterior AND posterior

Normal - posterior alone or ant/post

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11
Q

Why should you never choose an answer with cervical laminectomy alone? (aka without fusion)

A

Post laminectomy kyphosis
Instead choose laminoplasty or lami/fusion (what you think of with fishtail from the back)

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12
Q

Surgical approach for OPLL

A

Posterior
High rate dural tear from anterior

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13
Q

What is cervical laminoplasty

A

Make a cut in the lamina that use a plate to put back together but with a gap to preserve additional cord space

Motion preserving - facets left unfused
Expands the canal
Preserves the PLC, decreasing risk of kyphosis

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14
Q

When should you choose front/back C spine surgery

A

> 3 levels ACDF (pseudo rate)
1 corpectomy (higher rates of graft displacement)
Kyphosis correction (if large enough)
Pts with high risk pseudoarthrosis (smoker, prev pseudo, inflam arthropathy)

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15
Q

Ddx for cervical myelopathy

A

Stroke
Tumor
Vit B12 def
MS - vision changes, uniL motor/sens, get MR w/ contrast (demyelin lesions, periventricular plaques)
AML (Lou Gehrig) - will have atrophy, CSF sample for dx

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16
Q

When can you return a transient quadriplegia/cord concussion to play

A

Sx: neuropraxia that resolves in mins/hrs

Return to play with sx resolve and normal MRI
CANNOT return if MRI findings stenosis

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17
Q

What congenital cervical stenosis is a CI to return to play

A

Speak Tackler’s spine
Spine straightens with trauma

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18
Q

Treat basilar invagination (RA pts)

A

Occiput - C2 fusion
- No brain stem compression
- Occiput gives you a better level arm to lengthen with than C1

Anterior + posterior - if need brain stem decompression

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19
Q

What are the ADI thresholds for AA subluxation

A

ADI = posterior aspect of the anterior atlas ring and the anterior aspect of the odontoid process

> 3.5 between flex/ext XRs = instability
10mm = surgery indication

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20
Q

What are the PADI/SAC thresholds for AA subluxation

A

PADI/SAC = distance from posterior surface of dens to anterior surface of posterior arch of atlas

<14mm = surgery indication

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21
Q

Trt AA subluxation

A

C1/2 fusion

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22
Q

What is the collagen type for annulus fibrosis vs nucleus pulposus?
What is the disc blood supply?

A

AF = T1
NP = T2
BS = avascular, diffusion

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23
Q

What level do disc herniations affect in C spine

A

Nerve exits above the level

Really no traversing roots in C spine, so herniations always affect exiting root

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24
Q

Name the following dermatomes
C3
C6
C7
C8

A

C3 = occiput
C6 = thumb
C7 = middle finger
C8 = small finger

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25
Q

Name the motor group: C5 - T1

A

C5 = shoulder abduction (deltoid)
C6 = elbow flexion (BR) + wrist extension (ECRL)
C7 = elbow extension (triceps) + wrist flexion (FCR)
C8 = finger flexion/grip (FDS)
T1 = finger abduction (interossei)

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26
Q

What is the shoulder exam for patients with C spine radiculopathy

A

Improves with shoulder elevation / hand on head

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27
Q

What is considered instability on lateral flex/ex XRs

A

> 3mm shift or 11deg

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28
Q

Plate vs no plate for ACDF

A

Plate for multi level is standard bc of high subsidence rates

29
Q

Indications / outcome for cervical disc replacement

A

Young, no arthritis, single level

Neck pain = relative CI
Think radiculopathy or acute myelopathy

Outcomes equiv to ACDF, possible decrease in adj seg dis

30
Q

What are the soft tissue markers for the following levels: C2-6

A

C2 = angle mandible
C3 = hyoid
C4-5 = thyroid
C5-6 = cricoid
C6 = carotid tubercle

31
Q

Innervation of
SCM
Strap muscles

A

SCM = CN 11 = accessory
Strap = ansa cervicalis
- Omohyoid
- Sternothyroid
- Sternohyoid

32
Q

Contents of carotid sheath

A

Common carotid art
IJ
Vagus n

33
Q

What is the location of screw fixation in the C spine

A

C1 = lateral mass
C2 = pedicle > translaminar > pars
C3-6 = lateral mass
C7 and below = pedicle

34
Q

RF pseudarthrosis

A

Smoking
DM
Multi level surgery
Revision

35
Q

Recurrent laryngeal nerve
- Which cranial nerve
- Cause
- Strategy for revisions

A

CN X = vagus

Traction injury
- Left around aortic arch
- Right around subclavian artery (superficial)

Revision - see ENT first, approach from the same side (aka don’t bag the other side nerve)

36
Q

Cause/sx Hornerns syndrome

A

Over retraction of longus coli - sympathetic chain injury

Ptosis, miosis, anhidrosis

37
Q

Hypoglossal nerve injury
- What nerve roots
- Sx

A

C2-3, C3-4
Tongue deviates to SAME SIDE as injury

38
Q

Late presentation of esophageal injury

A

Mediastinitis - can be 50% mortality

39
Q

Risk factors for adjacent segment disease cervical spine

A

Plate <5mm from the adjacent level (aka too close)
Smoking
F>M

40
Q

What side is the artery of Adamkiewicz on? Spine levels

A

LEFT
T8-L1

41
Q

How do you determine ASIA level

A

Most proximal level w/ bilateral motor >3/5 strength w/ sensory intact

42
Q

How does neurogenic shock present

A

Low BP + HR
Bc of loss autonomic control aka sympathetic tone

43
Q

What is the evidence of steroids with spinal cord injury?

A

Not indicated - no clear benefit, real risks

44
Q

What is the operative timeline for incomplete vs complete spinal cord injury

A

Incomplete - surg <12hrs, goal to stabilize to save spinal function
Complete - surg <24hrs, goal to stabilize to facilitate rehab

45
Q

Presentation for anterior cord syndrome
I.e. sp emergent aortic aneurysm repair

A

Anterior spinal artery injury

LE strength loss&raquo_space; UE
Lose - motor, pain and temp

Keep - proprioception, vibration (dorsal column intact)

WORST PROGNOSIS

46
Q

What spinal cord syndrome has the best outcome

A

Brown Sequard
Ipsilateral motor
CL pain and temp

47
Q

Describe DISH spine

A

Nonmarginal syndesmophytes
Flowing candle wax XRs
Older pts
NO SI jt involvement
Associated with DM

48
Q

Describe disc space DISH vs ank spond

A

DISH - disc space preserved
Ank spond - ossified

49
Q

What is the HLA for DISH vs ank spond

A

DISH - HLA B8
Ank spond - HLA B27

50
Q

Describe ank spond spine

A

Marginal syndesmophytes
Bamboo spine, squared vertebral bodies
YOUNGER pts
Bilateral SI joint involvement

51
Q

When do you decompress a spinal epidural abscess

A

Weakness / deficits

52
Q

What is the C2 watershed area

A

Apex of dens - internal carotid
Base dens - vertebral art

53
Q

Treat the types of dens fractures

A

T1 - apex, nonop
T2 - waist, highest rate non union
<50
- Nonop = halo
- Op = displaced w/ non union risk factors

> 50
- Non op - orthosis (NEVER halo)
- Unlikely to be operative candidate

T3 - body, non op

54
Q

What restriction is placed on people with os odontoideum

A

CI contact sports

55
Q

What are RF for type 2 odontoid nonunion

A

Older (>50)
>6mm displaced **greatest RF
>10deg post angulation
Comminution
Delayed treatment
DM

56
Q

What are the operative techniques for type 2 odontoid frx

A

C1-2 screw
- C2 pedicle > translaminar > pars

Wire w/ C1-2 transarticular screw
- If aberrant vert art = ABSOLUTE NO

Anterior screw
- Perpendicular frx
- Intact TAL
- No barrel chest

57
Q

How do you determine if a C1 fracture is operative

A

Sum of lateral mass displacement on open mouth >8.1mm = TAL injury = unstable

Trt with occ-C2 fusion

58
Q

Trt cervical facet dislocation

A

Alert/NV intact = CR -> MRI -> OR

AMS/deficits = MR -> OR

59
Q

What is the difference in operative strategy for cervical facet dislocation that can be reduced vs not

A

ACDF alone if reducible / unilateral
Consider front back if not reducible

60
Q

What other injuries are associated with cervical facet dislocation

A

Occipitocervical dissociation
Transverse foramen fracture
Basilar skull fracture

61
Q

What are two subaxial C spine injuries that have anterior bone flecks? How treat differently?

A

Extension tear drop / avulsion = mild ext injury
- Orthosis

Flexion teardrop = ant frag stays with ALL, posterior frag retropulses into the canal
- Ant vs ant/post fixation

62
Q

Treat a floating lateral mass

A

Lamina and pedicle

2 level fusion
- Post if need reduction
- Anterior if already reduced

63
Q

What fractures are good for halo

A

Upper cervical - controls flex/ex and rotation

NOT good for subaxial spine
- Poor control of lateral bend
- Bell ringer phenomenon = increased subaxial motion with a halo on

64
Q

Absolute CI for halo

A

Cranial frx
Infx
Soft tissue injury preventing pin placement
<2yo

65
Q

pins and # inch-pounds for halo pins
Kids vs adults

A

Adults: 4 pins, 8 inch-lbs
Kids: 8 - 4

66
Q

What is safe pin placement for adults halo

A

Ant pin:
- lateral side of orbit
- 1cm above supra-orbital ride
- Nerves at risk = supraorbital and supratrochlear

Post pin
- 180 deg from ant

BOTH below the equator

67
Q

Nerve palsy seen for halos

A

Abducens (CN 6) = one eye drifts centrally

68
Q

What do SSEPs measure?
Pro/con
What are the alert levels?

A

Somatosensory evoked potentials

SENSORY = dorsal column
Transcranial leads read somatosensory cortex response

Con: slower to respond to injury
Pro: less influenced by anesthetics

Alert level:
- Drop 50% amplitude
- Increase 10% latency

69
Q

What do MEPs monitor?
Con
Alert level

A

Motor evoked potentials
MOTOR
Transcranial stim motor cortex - measure the muscle contraction

Detect anterior cord injury (ischemia)

Con: can be unreliable depending on anesthesia

Alert
- >75% decrease in amplitude (sustained)

Millers (29 decks)

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