Spine Degenerative Flashcards

Question

What are the indications for anterior corpectomy and fusion (ACF)

Answer 1

**Extensive retro-vertebral disease** cervical kyphosis preventing from adequate decompression posteriorly technique anterior fixation alone amenable in up to 2-level corpectomy use of static anterior cervical plate with struct graft combined anterior and posterior fixation indicated in 3-level corpectomy and above use of anterior strut graft and plating combined with posterior lateral mass screw construct anterior fixation alone in 3-level and aboveresults in a high (\>70%) catastrophic failure rate

Answer 2

▪ multilevel compression with kyphosis of \< 10 degrees **\> 13 degrees of fixed kyphosis is a contraindication for a posterior procedure** will not adequately decompress spinal cord as it is **"bowstringing" anterior**

Answer 3

**_Pros:_** * maintain motion and stability * Lower complication rates * avoids non-union **_CONS_** * higher average blood loss than anterior procedures * postoperative neck pain * still associated with loss of motion **_Contraindications:_** * \> 13 degrees is a contraindication to posterior decompression --\> "bowstringing" anterior * severe axial neck pain : relative contraindication and these patients should be fused **_Technique_** volume of canal is expanded by hinged-door laminoplasty followed by fusion usually performed from C3 to C7 * **_Open door technique_** hinge created unilateral at junction of lateral mass and lamina and opening on opposite side opening held open by bone, suture anchors, or special plates * **_French door technique_** hinge created bilaterally and opening created midline

Answer 4

post-laminectomy kyphosis

Answer 5

Posterior Approach

Answer 6

12% for single level fusions, 30% for multilevel fusions

Answer 7

**_Incidence_**: 4.6% **_Risk factors_**: Male and posterior laminectomy and fusion **_Prognosis_**: good **_Risk Factors for prolonged recovery_**: - Multilevel paresis - Motor Grade ≤2 - sensory involvement with intractable pain

Answer 8

MORE vulnerable to injury on the **RIGHT** due to a more aberrant pathway Recent studies have shown there is not an increased injury rate with a right sided approach **_Postoperative RLN palsy_** 1. watch over 6 weeks 2. Not improved --\> ENT consult to scope patient and inject teflon **_If performing revision anterior cervical surgery, and suspicion of a RLN from 1st operation_** --\> ENT consult to establish prior injury **_If patient has prior RLN nerve injury_** perform revision surgery on the same as the prior injury/approach to prevent a bilateral RLN injury

Answer 9

Multiple studies have demonstrated the application of local steroid in retropharyngeal space prior to wound closure decreases rate of dysphagia Application of local corticosteroid anterior to ACDF construct

Answer 10

1- Infection 2- C5 palsy 3- Dysphagia 4- Non union 5- Migration and hardware failure 6- Recurrent laryngeal nerve injury 7- Vertebral artery injury 8- Esophageal injury 9- Postlaminectomy kyphosis

Answer 11

Wartenberg’s sign. Cervical myelopathy is associated with intrinsic weakness. The small finger may drift into extension under the pull of the extensor digiti minimi due to a weakened palmar interossei.

Answer 12

Hyper-reflexia

Answer 13

NO. Evidence from the literature suggests that a history of smoking does NOT correlate with an increased risk of airway complications after anterior cervical spinal surgery, which is depicted in Figure A by a two-level anterior cervical discectomy and fusion (ACDF).

Answer 14

**_1- Degenerative cervical spondylosis_** **_2- Disc herniation ("soft disc")_** intraforaminal Posterolateral: most common midline herniation: usually presents with myelopathic symptoms **_3- Double-crush phenomenon_** combined cervical root compression and distal nerve compression decreased axoplasmic flow from root compression predisposes downstream nerves to peripheral entrapment syndromes **_4- Rare Causes_** * intraspinal/extraspinal tumors * trauma with nerve root avulsion * synovial cysts * meningeal cysts * dural arteriovenous fistulae * tortuous vertebral arteries

Answer 15

* **_occipital headache (common)_** * **_trapezial or interscapular pain_** * **_neck pain_** * **_unilateral arm pain_** aching pain radiating down arm often global and nondermatomal * **_Unilateral dermatomal numbness & tingling_** numbness/tingling in thumb (C6) numbness/tingling in middle finger (C7) * **_Unilateral weakness_** difficulty with overhead activities (C7) difficulty with grip strength (C7)

Answer 16

**_C4 radiculopathy_** scapular winging (Long thoracic Nerve) numbness and pain at the base of the neck **_C5 radiculopathy_** deltoid and biceps weakness diminished biceps reflex pain and numbness in the superior shoulder and lateral upper arm **_C6 radiculopathy_** brachioradialis and wrist extension weakness diminished brachioradialis reflex paresthesias in thumb, index finger **_C7 radiculopathy_** triceps and wrist flexion weakness diminished triceps reflex paresthesia in the middle finger most commonly affected nerve root in cervical radiculopathy in several studies **_C8 radiculopathy_** weakness to distal phalanx flexion of middle and index finger (difficulty with fine motor function) paresthesias in ring and little finger C8 radiculopathy is extremely rare and often manifests similarly as ulnar neuropathy **_T1 radiculopathy_** intrinsic hand muscle weakness axillary numbness ipsilateral Horner's syndrome

Answer 17

**_▪ Spurling's test_** simultaneous extension, rotation to affected side, lateral bend, and vertical compression reproduces symptoms in ipsilateral arm narrowing of the intervertebral foramina causes exacerbation of symptoms specific, but not sensitive for radiculopathy **_shoulder abduction test_** shoulder abduction relieves symptoms shoulder abduction (lifting arm above head) often relieves symptoms decreases tension on affected nerves valuable physical exam test to differentiate cervical pathology from other causes of shoulder/arm pain **upper limb tension tests** **valsalva maneuver** **neck distraction test**

Answer 18

Carpal tunnel syndrome Cubital tunnel syndrome Parsonage-Turner Syndrome Thoracic outlet syndrome

Answer 19

▪ 75% of patients with radiculopathy improve with nonoperative management improvement via resorption of soft discs and decreased inflammation around irritated nerve roots

Answer 20

after resolution of symptoms and repeat MRI demonstrating no cord compression

Answer 21

Studies have shown return to play expedited with brief course of oral methylprednisolone (medrol dose pack)

Answer 22

may be considered as therapeutic or diagnostic option provides long-term relief in 40-70% of cases increased risk when compared to lumbar selective nerve root injections with the following rare but possible complications, including dural puncture meningitis epidural abscess nerve root injury

Answer 23

* persistent and disabling pain that has failed three months of conservative management * progressive and significant neurologic deficits * static neurologic deficit associated with significant radicular pain

Answer 24

C1-2: inferior margin of the mandible C3-4: hyoid C4-6: thyroid cartilage C5-6: cricoid cartilage

Answer 25

▪ iliac crest fibular strut patella

Answer 26

5 to 10% for single level fusions, 30% for multilevel fusions

Answer 27

smoking diabetes multi-level fusions revision surgery

Answer 28

if asymptomatic observe if symptomatic, treat with either posterior cervical fusion or repeat anterior decompression and plating if patient has symptoms of radiculopathy improved fusion rates seen with posterior fusion

Answer 29

**Recurrent laryngeal nerve injury (1%)** **Hypoglossal nerve injury** **Horner's syndrome** characterized by ptosis, anhydrosis, miosis, enophthalmos and loss of ciliospinal reflex on the affected side of the face caused by injury to sympathetic chain, which sits on the lateral border of the longus coli muscle at C6

Answer 30

◦ higher risk at higher levels (C3-4) risk can be minimized with the use of zero-profile anchored cages less prominence of anterior hardware reduces irritation and impingement of prevertebral structures, such as espohagus

Answer 31

▪ prolonged surgical duration (\>5 hours) exposure above C4 greater than 4 levels involved in fusion construct

Answer 32

recurrent laryngeal nerve

Answer 33

When the upper border of the plate is located in close proximity to the cephalad adjacent disk, there is a higher incidence of osteophyte formation. The clinical implications of this are not yet understood.

Answer 34

towards the side of the injury.. towards the right

Answer 35

C8 radiculopathy would also involve **flexion weakness of the long and index fingers** C8 radiculopathy usually presents with sensory symptoms about the medial border of the forearm and hand, as well as finger flexion weakness (the C8 nerve root provides innervation to the flexor digitorum superficialis, flexor digitorum profundus (FDP), and flexor pollicis longus). It is important to differentiate a C8 radiculopathy from a peripheral ulnar neuropathy, which also presents with sensory symptoms in the ulnar hand and fingers. One way to do so is to test DIP flexion of the middle and index fingers. The function of the flexor digitorum profundus in the index and middle fingers can be affected by a C8 cervical radiculopathy, but they are not affected by ulnar nerve entrapment (the FDP of the index and middle fingers is supplied by the median nerve, specifically the anterior interosseous nerve).

Answer 36

Shoulder Abduction test

Answer 37

$100 billion in annual cost second only to respiratory infection as cause to visit doctors office

Answer 38

◦ muscle strain: most common cause of low back pain most common degenerative disorders lumbar spinal stenosis lumbar disc herniation discogenic back pain

Answer 39

◦ obesity, smoking, gender lifting, vibration, prolonged sitting job dissatisfaction

Answer 40

infection (IV drug user, h/o of fever and chills) tumor (h/o or cancer) trauma (h/o car accident or fall) cauda equina syndrome (bowel/bladder changes)

Answer 41

90% of low back pain resolves within one year

Answer 42

system to evaluate non-organic back pain symptoms. clinically significant if three positive signs are present: 1. superficial and non-anatomic tenderness 2. pain with axial compression or simulated rotation of the spine 3. negative straight-leg raise with patient distraction 4. regional disturbances which do not follow dermatomal pattern 5. overreaction to physical examination

Answer 43

* pain lasting \> one month and not responding to not nonoperative management * red flags are present

Answer 44

Most adults (up to 80%) will experience an episode of low back pain in their lifetime. In those whose pain is severe enough to cause them to miss work, 60 to 70% will return by 6 weeks, and 80 to 90% will return by 12 weeks. 5 to 10% develop chronic pain. Recurrence of pain is common, and is part of the natural history, occurring in 20 to 72% of patients. After 12 weeks, return to work rates are slow.

Answer 45

The amount of bone edema on MRI inversely correlates with the age of the fracture.

Answer 46

In patients with chronic disabling work-related musculoskeletal disorders, high pre-rehabilitation ratings of pain intensity, as measured by high Visual Analog Scale (VAS) scores, is a negative predictor for a successful outcomes.

Answer 47

Bone morphogenic proteins have been shown to increase chondrogenic phenotype expression and increase matrix synthesis of the intervertebral disc in animal studies. Bone morphogenetic protein-2, bone morphogenetic protein-7, and transforming growth factor-beta are morphogens that have been shown to alter the phenotype of target cells without increasing cellular proliferation. Within the intervertebral disk, these factors have the potential to increase the chondrogenic phenotype among disk cells, and this results in the increased production of the disk matrix. Mitogenic molecules, such as insulin-like growth factor-1 and fibroblast growth factor, function to increase cellular proliferation. Miyamoto et al. evaluated rabbits that underwent annulus fibrosus (AF) injury where they either injected a control or BMP into the nucleus pulposus. The BMP injection significantly restored disc height and improved the modulus as compared to control injections. They concluded the biochemical data suggested that the OP-1-induced restoration of the disc space was a consequence of the increased activity of anabolic pathways that resulted in biochemical changes in the IVD. Kim et al. evaluated mRNA levels of BMP-2, BMP-7, and TGF-beta in a rabbit model of intervertebral discs. Compared to young rabbits, old rabbits generally had higher levels of mRNA expression of these three cytokines in both the annulus fibrosus and nucleus pulposus. The similar patterns of up-regulation in gene expression with age shown by these 3 anabolic cytokines suggest a common pathway in terms of regulation and transcription in the early stage of disc degeneration.

Answer 48

axial low back pain without radicular symptoms pain exacerbated by * bending * sitting * axial loading

Answer 49

Accelerated disc degeneration including * increased incidence of lumbar disc herniations * loss of disk height * endplate changes

Answer 50

▪ no statistically significant difference in ODI at short (1 year) or long term (10 years) for patients treated with cognitive and exercise therapy compared to lumbar diskectomy with fusion

Answer 51

Several studies have shown total disk arthroplasty has safety and efficacy comparable to fusion at 2-year followup for isolated degenerative disc disease in select patients.

Answer 52

1- Pain characteristics 2- Neuro Exam 3- Instability 4- R/O red flags

Answer 53

* Relatively uncommon and makes up only 1% of all HNP * **T11-T12 most common level** Thoracic disc herniations rarely occur in the upper thoracic spine, with only 1% of cases occurring from T1-5. Approximately 50% to 75% of disc herniations occur from T8 to L1.

Answer 54

underlying Scheuermann's disease may predispose to thoracic HNP

Answer 55

1. Bulging nucleus: annulus remain intact 2. Extruded disc: through annulus but confined by PLL 3. Sequestered: disc material free in canal

Answer 56

◦ central posterolateral Lateral

Answer 57

* Axial back or chest pain is most common symptom * Thoracic radicular pain * band-like chest or abdominal pain along course of intercostal nerve * arm pain (see with HNP at T2 to T5) * Horner's syndrome seen with HNP at T2 to T5

Answer 58

- Majority Non-operative treatment - Operative: discectomy with possible hemi-corpectomy or fusion * If progressive neurologic deterioriation

Answer 59

If central disc herniations --\> Trans-thoracic discectomy If Lateral disc herniation --\> Costo-transversectomy

Answer 60

Intercostal neuralgia

Answer 61

thoracic laminectomy is a patient in whom imaging has demonstrated evidence of spinal canal stenosis _secondary to hypertrophy of the posterior elements_ no herniated disc

Answer 62

only ~5% become symptomatic

Answer 63

L5/S1 most common level

Answer 64

90% of patients will have improvement of symptoms within 3 months with nonoperative care.

Answer 65

size of herniation decreases over time (reabsorbed) sequestered disc herniations show the greatest degree of spontaneous reabsorption macrophage phagocytosis is mechanism of reabsorption

Answer 66

1- central prolapse 2- posterolateral (paracentral) most common (90-95%) PLL is weakest here affects the traversing/descending/lower nerve root at L4/5 affects L5 nerve root 3- Foraminal (far lateral, extraforaminal) less common (5-10%) affects exiting/upper nerve root at L4/5 affects L4 nerve root herniated disc material directly compresses dorsal root ganglion can manifest with more severe pain than traditional posterolateral disc herniation 4- Axillary: can affect both exiting and descending nerve roots

Answer 67

▪ straight leg raisesensitivity/specificity most important and predictive physical finding for identifying who is a good candidate for surgery contralateral SLR: crossed straight leg raise is less sensitive but more specific Lesegue sign: SLR aggravated by forced ankle dorsiflexion Bowstring sign: SLR aggravated by compression on popliteal fossa Kernig test: pain reproduced with neck flexion, hip flexion, and leg extension Naffziger test: pain reproduced by coughing, which is instigated by lying patient supine and applying pressure on the neck veins Milgram test: pain reproduced with straight leg elevation for 30 seconds in the supine position Trendelenburg gait: due to gluteus medius weakness which is innervated by L5

Answer 68

▪ pain lasting \> one month and not responding to nonoperative management or red flags are present infection (IV drug user, h/o of fever and chills) tumor (h/o or cancer) trauma (h/o car accident or fall) cauda equina syndrome (bowel/bladder changes) MRI with gadolinium useful for revision surgery allows to distinguish between post-surgical fibrosus (enhances with gadolinium) vs. recurrent herniated disc (does not enhance with gadolinium)

Answer 69

1. Non operative 2. Selective nerve root cortico injections 3. Laminotomy and discectomy (microdiscectomy) 4. Far lateral microdiskectomy

Answer 70

* leads to long lasting improvement in ~ 50% (compared to ~90% with surgery) * results best in patients with extruded discs as opposed to contained discs

Answer 71

**_Indications_**: * persistent disabling pain lasting more than 6 weeks that have failed non-operative options (and epidural injections) * progressive and significant weakness * cauda equina syndrome

Answer 72

4 to 6 weeks

Answer 73

outcomes with surgery compared to non-operative: **improvement in pain and function greater with surgery** _positive predictors for good outcome with surgery_ * leg pain is chief complaint * positive straight leg raise * weakness that correlates with nerve root impingement seen on MRI * married status * professional athletes younger age, greater number of games played prior to injury _negative predictors for good outcome with surgeryworker's compensation_ WC patients have less relief from symptoms and less improvement in quality of life with surgical treatment

Answer 74

Far lateral microdiskectomy approach of Wiltse

Answer 75

- Dural matter tear - Recurrence - Discitis - Chronic low back pain - Vascular catastrophe **_Dural tear (1%)_** if have tear at time of surgery then perform water-tight repair has not been shown to adversely affect long term outcomes **_Recurrent HNP_** can treat non-operatively initially revision rate a 8-year-follow-up is 15% according to SPORT trial outcomes for revision discectomy have been shown to be as good as for primary discectomy **_Discitis (1%)_** **_Chronic low back pain_** Not completely understood but **central sensitization** may be a factor amplification of neural signaling within the central nervous system (CNS) that elicits pain hypersensitivity. Pain diagrams may be useful in identifying patients with an increased likelihood of pain sensitization, psychosocial load, and utilizing pain management resources **_Vascular catastrophe:_** caused by breaking through anterior annulus and injuring vena cava/aorta

Answer 76

can treat non-operatively initially revision rate a 8-year-follow-up is 15% according to SPORT trial outcomes for revision discectomy have been shown to be as good as for primary discectomy

Answer 77

1-6% of lumbar disc herniations

Answer 78

▪ most commonly occurs at the L4-5 level

Answer 79

* presence of saddle anesthesia or bladder dysfunction is associated with worse outcomes * surgical decompression after 48 hours is associated with worse outcomes

Answer 80

* Unilateral or bilateral leg pain is the most common presenting symptom after back pain * Saddle anesthesia * Impotence * Sensorimotor loss in lower extremity * Neurogenic bladder dysfunction * Disruption of bladder contraction and sensation leads to urinary retention and eventually to overflow incontinence * Reduced or absent sensation to pinprick in the perianal region (S2-S4 dermatomes), ▪ decreased rectal tone or voluntary contracture

Answer 81

PVR values \< 200 ml with a 97% negative predictive value for cauda equina syndrome

Answer 82

**_bony structures_** * facet osteophytes * uncinate spur (posterior vertebral body osteophyte) * spondylolisthesis **_soft tissue structures_** * herniated or bulging discs * hypertrophy or buckling of the ligamentum flavum * synovial facet cysts

Answer 83

▪ most common reason for lumbar spine surgery in patients \> 65 years old seen in 20-25% slightly more common in males (1.5:1) average age at presentation is 65 years old

Answer 84

▪ most commonly occurs at L4-5 (91%)

Answer 85

* Caucasian race * increased BMI * congenital spine anomalies (20%) failure of posterior elements to develop, leading to short pedicles and laminae

Answer 86

* degenerative spondylolisthesis * degenerative scoliosis * cauda equina syndrome

Answer 87

**_Acquired_** * degenerative/spondylotic changes (most common) * post-surgical * post-traumatic (vertebral fractures) * inflammatory (ankylosing spondylitis) * secondary to systemic diseases (Paget disease, acromegaly, fluorosis) **_Congenital_** * short pedicles with medially placed facets * can be subdivided into * idiopathic * developmental (achondroplasia)

Answer 88

1. Central stenosis: Flavum Hypertrophy; \<100mm2 or 10 mm AP 2. Lateral Recess Stenosis: Facet Joint arthropathy: Descending Nerve Root 3. Foraminal Stenosis: Exiting Nerve Root

Answer 89

* Back Pain * Neuro Claudication * Recurrent UTI * Normal Neuro Exam

Answer 90

* presence of coexisting hip and spine pathology * must determine primary pain generatory prior to surgical treatment * may require diagnostic injections to aid in diagnosis

Answer 91

1. persistent pain for 3-6 months that has failed to improve with nonoperative management 2. progressive neurologic deficits (weakness or bowel/bladder)

Answer 92

With signs of instability: 1. Listhesis 2. Complete laminectomy 3. \>50% of facets removed

Answer 93

\>30% at 10 years

Answer 94

Co-morbid conditions

Answer 95

Spine Patient Outcomes Research Trial (SPORT)

Answer 96

Sympathic chain injury (**_hypogastric plexus_**) --\> **post-sympathectomy (post-SE) dysfunction** **syndrome:** **retrograde ejaculation**, **Anhidrosis** * increased temperature * reduced perspiration * reduced sympathetic skin responses in the ipsilateral lower extremity.

Answer 97

The LF originates approximately 60-70% of the distance from inferior to superior on the ventral surface of the lamina (i.e. **closer to superior edge than inferior edge**). It inserts on the superior edge of the caudal lamina.

Answer 98

Sagittal balance is the most reliable predictor of clinical symptoms and HRQL outcomes on the SRS 29, SF-12, and Oswestry Disability Index.

Answer 99

No if well repaired

Answer 100

In patients in the postoperative period, if there is suspicion of a dural leak (headache, vertigo), an MRI should be performed to look for a CSF leak. Once the diagnosis is confirmed, the gold standard treatment is reoperation. Less invasive methods of treatment include percutaneous fibrin glue, subarachnoid drainage or an epidural blood patch. If these fail to relieve symptoms, reoperation is mandatory.

Answer 101

Radicular Symptoms

Answer 102

rare ## Footnote 60% to 89% occur at the L4-L5 level (most mobile segment)

Answer 103

Standing MRI Cyst size increases with standing

Answer 104

1. Conservative: NSAIDs and PT 2. CT guided Rupture: 50-75% pain relief at 1-year approximately 39% of patients will require surgical intervention at 7 months 3. laminectomy with decompression and cyst excision; High incidence of recurrent back pain and cyst formation within two years 4. facetectomy and instrumented fusion: demonstrated to have the lowest risk of persistent back pain and recurrence of cyst formation in recent studies

Answer 105

• Lumbar spondylolisthesis without a defect in the pars absent of pars defect differentiates from adult isthmic spondylolithesis

Answer 106

~8 times more common in woman than men (increased ligamentous laxity related to hormonal changes) 5-fold more common at L4/5 than other levels this is different that isthmic spondylolisthesis which is most commonly seen at L5/S1

Answer 107

▪ sacralization of L5 (transitional L5 vertebrae) sagittally oriented facet joints

Answer 108

Grade I: \< 25% Grade II: 25 to 50% Grade III: 50 to 75% (Grade III and greater are rare in degenerative spondylolithesis) Grade IV: 75 to 100% Grade V: Spondyloptosis (all the way off)

Answer 109

◦ mechanical/ back pain: primary presenting symptom neurogenic claudication & leg pain cauda equina syndrome (very rare)

Answer 110

• 4 mm of translation 10° of angulation of motion compared to adjacent motion segment

Answer 111

in degenerative spondylolisthesis adding an interbody cage increases hospital costs without increasing fusion rates

Answer 112

lower intraoperative blood loss smaller skin incision decreased pain scores at 1-week post-op greater screw pullout strength given cortical contact of screw generally smaller than traditional pedicle screws

Answer 113

**Pseudo-arthrosis (5-30%)** **Adjacent segment disease (2-3%)** : 20-29% at 10 years **Surgical site infection (0.1-2%)** **Dural tear** **Positioning neuropathy** _LFCN_: iliac bolster _ulnar nerve_ or _brachial plexopathy_ from prone positioning with inappropriate position

Answer 114

older age increased intraoperative blood loss longer operative time number of levels fused

Answer 115

- failed 6 months conservative - Progressive Neuro - Cauda equina

Answer 116

cephalad laminectomy

Answer 117

**_Post-operative smoking cessation_** has been found to decrease the risk of nonunion following lumbar spinal fusion, though **the risk still remains elevated over nonsmokers**. The impact of preoperative smoking cessation on nonunion remains to be elucidated.

Answer 118

Defect in the pars inter-articularis (spondylolysis): pars defects usually acquired and caused by microtrauma

Answer 119

4-6% of population increased prevalence in sports that involve repetitive hyperextension (gymnasts, weightlifters, football linemen) 82% occur at L5/S1

Answer 120

◦ relatively few patients (5%) with spondylolysis with develop spondylolisthesis slip progression more common in females slip progression usually occurs in adolescence and rare after skeletal maturity

Answer 121

Type I • Dysplastic: a congenital defect in pars Type II-A • Isthmic - pars fatigue fx Type II-B • Isthmic - pars elongation due to multiple healed stress fx Type II-C • Isthmic - pars acute fx Type III • Degenerative: facet instability without a pars fx Type IV • Traumatic: acute posterior arch fx other than pars Type V • Neoplastic: pathologic destruction of pars

Answer 122

▪ correlates with severity of disease pelvic incidence has direct correlation with the Meyerding–Newman grade

Answer 123

**_Conservative_**: **Most patients can be treated non-operatively** NSAID role of injections unclear bracing may be beneficial especially in the acute phase **OperativeL5-S1 decompression and instrumented fusion +/- reductionindications** reduction: improved sagittal balance with reduction --\> risk of stretch injury to L5 nerve root with reduction **_L4-S1 decompression and instrumented fusion +/- reduction_** L5-S1 high-grade spondylo-lithesis with persistent and incapacitating pain that has failed 6 months of nonoperative management **_ALIF_**

Answer 124

In patients undergoing a reduction of high-grade spondylolisthesis, **71% of nerve root strain occurs during the second half of a complete reduction.** This is an often-cited reason for partial reduction of high-grade spondylolisthesis.

Answer 125

- Brace? TLSO? - Conservative MRI could be used in children in diagnosis in children of acute pars reaction

Answer 126

posterior lumbar decompression with an instrumented fusion from L4 to S1 with anterior column support.

Answer 127

* 50-60% of cases occur in lumbar spine * 30-40% in thoracic spine * ~10% in cervical spine Adults in 50-60 years

Answer 128

* IV drug abuse * diabetes * recent systemic infection (UTI, pneumonia) * malignancy * immunodeficiency or immunosuppressive medications * obesity * malnutrition (serum albumin \< 3 g/dL indicative of malnutrition) * trauma * smoking

Answer 129

**_Bacterial_** Staph aureus: most common (50-65%) Staph epidermidis: is second most common cause gram negative infections: increasing over last decade and often associated with gram negative infections of the GU and respiratory tract Pseudomonas: seen in patients with IV drug use Salmonella: seen in patients with sickle cell disease Fungal Tuberculosis

Answer 130

defined as a collection of pus or inflammatory granulation tissue between dura mater and surrounding adipose tissue

Answer 131

- **_MRI with gadolinium contrast_** : if performed early, finding may be interpreted as degenerative changes repeat MRI to see progression may be required - combined Technetium Tc99m and gallium 67 scan is both more specific and more sensitive than Technetium Tc99m alone

Answer 132

Hemocultures (33%) CT-guided biopsy (68-86%) If not open biopsy via transpedicular approach

Answer 133

* disc space involvement * end-plate erosion * significant inflammation

Answer 134

* Cervical vertebral osteomyelitis * Progressive neurologic deficits * Progressive deformity & gross spinal instability * Refractory cases * Large abscess formation

Answer 135

Collection of pus or inflammatory granulation tissue between the dura mater and surrounding adipose tissue

Answer 136

entire spine MRI should be performed to rule out skip epidural abscesses

Answer 137

* \> 60° in adult (because deformity won't progress versus it will progress in 40% of the cases for children) * progressive kyphosis in child * ≥3 vertebrae involved with loss of ≥1.5 vertebral bodies in thoracic spine * children ≤ 7 years with ≥3 vertebral bodies affected in T/TL spine and ≥ 2 at risk signs are likely to have progression and should undergo correction * late onset paraplegia (from kyphosis) * cosmetic correction of kyphosis controversial * advanced disease with caseation preventing access by antibiotics * failure of nonoperative treatment after 3 to 6 months * diagnosis uncertain * panvertebral lesion

Answer 138

Spinal TB with Gibbus

Answer 139

Involvement of anterior and posterior column Involvement of the anterior and posterior elements is the variable that is most predictive of kyphosis progression once the patient has reached the healed phase. Factors that suggest further progression of the healed TB spine: * thoracolumbar level or any of the four radiographic signs of a 'spine at risk' * separated facets * posterior retropulsion * lateral translation * toppling sign Having 2 or more of these signs predicts an increase in 30 degrees of kyphosis and a final angle of 60 degrees for which surgery should be recommended.

Answer 140

in pediatric patients, blood vessels extend from the cartilaginous end plate into the nucleus pulposus in adult patients, blood vessels extend only to the annulus fibrosis

Answer 141

loss of lumbar lordosis may be earliest radiographic sign

Answer 142

Topical Vancomycin powder in spine surgery has been shown to decrease the rate of SSI. However, when an infection does occur, there is a higher rate of gram-negative SSI.