Spine - RC Q's

Question 1

<div>RC 2018, 2016, 2014. What is the expected functional ability of a quadriplegic patient with C7 function?</div>

<div>a.Chin powered motorized wheelchair</div>

<div>b.Fully independent for transfers</div>

<div>c.Wheelchair manual for daily transport</div>

<div>d.Motorized wheelchair with some manual (short distances)</div>

Answer 1

C<div><ul> <li>Bruns AS (Spine 2001) Establishing prognosis and maximizing functional outcomes after spinal cord injury</li> <ul> <li>C7 patients gain functional strength in the triceps. The ability to forcefully extend the elbow allows the patient to lift their body weight.</li> <li>These patients can roll over, sit up in bed, and move about in the sitting position. Motivated patients can also transfer independently.</li> <li>Some assistance may still be required for toileting and dressing activities, particularly for the lower extremities. Eating can be done independently except for cutting.</li> <li>Independent wheelchair propulsion is possible for long distances on smooth surfaces.</li></ul></ul> <ul> <li>AAOS Comprehensive Review page 235</li> <ul> <li>C4 - wheelchair mobility with sip and puff controls, usually don’t need ventilator</li> <li>C5 - power wheelchair with hand controls. May even be able to use manual wheelchairs with grip enhancements with tremendous energy usage</li> <li>C6 - manual wheelchair with grip enhancements, most prefer power wheelchair, sometimes transfers with a slider</li> <li>C7 - most ADLs/IADLs independently or with very minimal assistance. Manual wheelchair can be used, troubles with uneven surfaces</li> <li>C8 - total independence</li> </ul></ul></div>

Question 2

<div>RC 2011 - Given a sagittal CT cut showing a T5 flexion distraction injury. What is the neurological injury? </div>

<ol> <li>anterior</li> <li>complete</li> <li>mixed UMN & Lower</li> <li>central</li></ol>

Answer 2

“<div>ANSWER: B</div> <ul> <li>2011</li> <li>Couldn’t find any evidence (neither could old groups) - debate between A and B</li> <li>My Logic:</li> <ul> <li>Flexion distraction in the thoracic and lumbar spine don’t have axial load to them to columns fail in TENSION. Therefore more likely to have either posterior based lesion or complete cord</li> <li>Anterior cord is compression to anterior spine</li> <li>Central cord is an extension injury</li> <li>No reason to have LMN signs in thoracic spine</li> </ul></ul>”

Question 3

<div>RC 2010 - MRI of severe cervical flexion injury with posterior displacement of the body. What is the most likely spinal cord injury?</div>

<ol> <li>UMN</li> <li>Anterior cord</li> <li>Central cord</li> <li>LMN</li></ol>

Answer 3

2.<div><ul> <li>Wheeless:</li> <ul> <li>Flexion tear drop fractures are associated with acute anterior cervical cord syndrome</li> </ul></ul></div>

Question 4

<div>RC 2012 - All of the following associations are right except?</div>

<ol> <li>Foot Dorsiflexion - L4 </li> <li>Sensation over patella L2 </li> <li>Hamstring reflex L5-S1 </li> <li>Hip abductors – L5</li></ol>

Answer 4

“B. L3 gives sensation over patella<div><br></br></div><div><div> <div> <div><img></img></div> </div></div></div>”

Question 5

RC 2016, 15, 14, 13, 12,… List the 11 myotomes in ASIA scale and corresponding muscle groups. (Variations - 2011, 2012, 2013, 2014, 2016)

Answer 5

“<div><img></img></div> <div>C7 also does wrist flexion (MCQ 2015)</div><div><br></br></div> <div><img></img></div><div><br></br></div><div><br></br></div>”

Question 6

RC 2015 - Patient with complete spinal cord injury; C7 spinal level. What is most likely to still be working? <ol> <li>Wrist flexion, finger flexion, brachioradialis reflex, radial sensation</li> <li>Wrist flexion, finger extension, triceps reflex, absent medial forearm sensation </li> <li>Wrist extension, finger abduction, biceps reflex, medial forearm sensation </li> <li>Wrist extension, finger flexion, triceps reflex, radial sensation</li></ol>

Answer 6

B.<div><br></br></div><div>wrist flexion = C7</div><div>finger ext = C6/7</div><div>triceps reflex = C7</div><div>medial forearm = C8</div>

Question 7

RC 2015 List 3 factors that would help you diagnose an incomplete spinal cord injury?

Answer 7

<ul> <li>JAAOS - Thoracolumbar Spine Trauma: I. Evaluation and Classification</li> <ul> <li>Sensory function below the level of the injury</li> <li>Voluntary motor control below the level of the injury</li> <li>Sacral Sparing</li> </ul></ul>

Question 8

<div>RC 2013 - List 3 examination features suggestive of sacral sparing</div>

Answer 8

<ul> <li>Sensory</li> <ul> <li>Presence of intact perianal sensation (light touch and pin prick)</li> <li>Presence of deep anal sensation (to deep pressure) on digital rectal exam</li> </ul> <li>Motor</li> <ul> <li>Presence of voluntary anal sphincter contraction</li> </ul></ul>

Question 9

<div>RC 2012, 2010 - List 4 features of Brown-Sequard Syndrome</div>

Answer 9

“<div><ul> <li>Ipsilateral loss of MVP: motor, vibration, proprioception</li> <ul> <li>Unilateral UMN findings</li> </ul> <li>Contra-lateral pain/temperature loss (spinothalamic tract)</li></ul><div>best prognosis, 90% recovery</div><div><br></br></div></div><div><img></img><br></br></div>”

Question 10

<div>RC 2014, 15 - A patient sustains a gunshot wound to the right side of the neck. He develops a Brown-Sequard syndrome. Which of the following is true regarding his neurologic deficits?<br></br></div>

<ol> <li>Loss of motor function to right upper and lower extremities, ipsilateral loss of pain and temperature </li> <li>Loss of motor function to right upper and lower extremities, contralateral loss of vibration and position sense</li> <li>Loss of motor function to right upper and lower extremities, contralateral loss of pain and temperature sensation</li> <li>Loss of motor function to right upper and lower extremities, contralateral loss of pain and vibration</li></ol>

Answer 10

C<div><br></br></div><div>BS = ipsilateral loss of mvp = motor, vib, pro; contralateral loss of pt</div>

Question 11

<div>RC 2017, 2014, 2011 - List 3 features of central cord syndrome</div>

Answer 11

<ul> <li>JAAOS 2009 - Central Cord</li> <ul> <li>Upper extremities are more severely affected than lower</li> <li>Distal more than Proximal</li> <li>Sacral Sparing (its an incomplete injury!)</li> <ul> <li>Bowel and bladder only in severe cases</li> </ul> </ul></ul>

Question 12

<div><div>RC 2015, 2008 - Given a sagittal MRI showing cervical stenosis and myelomalacia. Patient had fall and presents with neck pain. No neuro deficits described. What is the most likely physical exam finding</div> <ol> <li>UE > LE weakness, distal > proximal</li> <li>LE > UE weakness, distal > proximal</li> <li>UE > LE weakness, proximal > distal</li> <li>LE > UE weakness, proximal > distal</li></ol></div>

Answer 12

A. central cord syndrome<div><ul> <li>Upper extremities affected more than lower extremities</li> <li>Hands most affected</li> <ul> <li>Usually last to recover</li> </ul> <li>Urinary retention, bowel and sexual dysfunction in most severe cases</li></ul></div>

Question 13

<div>RC 2014 - A patient presents to ER with C5/6 jumped facets and complete quadriplegia following an MVC (or some other similar trauma). It is an isolated injury. The patient is bradycardic (HR 60?) and hypotensive (80/45 mmHg). So far the patient has been given 6L of crystalloid. What should you do now?</div>

<ul> <li>A. Slow IV to maintenance rate</li> <li>B. Start transfusing blood</li> <li>C. Give albumin</li> <li>D. Rapid bolus with IV crystalloid</li></ul>

Answer 13

A. neurogenic shock - do not overload pt. should actually give pressors<div><br></br></div><div><div>Treatment of neurogenic shock includes an initial fluid challenge, Trendelenberg positioning, vasopressors after central line insertion and atropine for treatment of bradyarrhythmia</div></div>

Question 14

<div>RC 2015, 14, 12, 11 - All of the following regarding spinal tracts true except:</div>

<ol> <li>Anterior corticospinal tracts carry less motor than lateral corticospinal tracts</li> <li>Lateral corticospinal tracts are called pyramidal tracts</li> <li>Lateral corticospinal tracts arranged so that cervical spine is more central than sacral spine</li> <li>Posterior sensation tracts arranged so that the cervical spine ascending tracts are more central than sacral spine</li></ol>

Answer 14

“<b>D.</b><div><img></img><b><br></br></b></div>”

Question 15

<div>RC 2011 - What is associated with normal motor strength in the lower extremities, but loss of bowel and bladder function</div>

<ol> <li>Conus medullaris syndrome</li> <li>Brown sequard</li> <li>Anterior spinal syndrome </li> <li>Ascending spine syndrome</li></ol>

Answer 15

“A.<div><ul> <li>Conus medullaris syndrome,or injury of the sacral cord (conus) and lumbar nerve roots within the spinal canal, usually results in an areflexic bladder, bowel, and lower extremities. Most of these injuries occur between T11 and L2 and result in flaccid paralysis in the perineum and loss of all bladder and perianal muscle control. The irreversible nature of this injury to the sacral segments is evidenced by the absence of the bulbocavernosus reflex and the perianal wink. Motor function in the lower extremities between L1 and L4 may be present if nerve root sparing occurs.</li></ul> <ul> <li>Ascending spine syndromeis a pathological term referring to the softening of the spinal cord.<a>[1]</a> The disorder causes<a>flaccid paraplegia</a>(impairment of motor function in lower extremities), total<a>areflexia</a>(below normal or absence of reflexes) of the pelvic limbs and anus, loss of deep pain perception<a>caudal</a>(toward the coccyx, or tail) to the site of spinal cord injury, muscular<a>atrophy</a>(wasting away of muscle tissue), depressed mental state, and respiratory difficulty due to<a>intercostal</a>(muscles that run between the ribs) and diaphragmatic<a>paralysis</a></li></ul></div>”

Question 16

RC 2015 - What is not associated with cervicomedullary syndrome: <ol> <li>Hypotension</li> <li>Facial numbness</li> <li>LE > UE symptoms</li> <li>Complete or incomplete paralysis is possible</li></ol><ul><ul> </ul></ul>

Answer 16

<div><br></br></div>

<div>ANSWER: C</div>

<ul> <ul> <li>The essential clinical features are respiratory insufficiency or arrest, hypotension, varying degrees of tetraparesis, sensory changes from C1-C4 and sensory loss over the face in the onion skin or Dejerine pattern</li> <li>Arm > Leg weakness</li> <li>More severe involvement the more rostral the injury</li> </ul></ul>

Question 17

<div>RC 2014, 2012 - 5 radiographic or clinical features suggesting an unstable C spine injury</div>

Answer 17

“<ul> <li>General</li> <ul> <li>Flexion tear drop</li> <li>Translation on flex/ex films</li> <li>Bilateral facet fracture or dislocation</li> </ul> <li>C0-C1</li> <ul> <li>Harris Rule of 12s: BDI >12mm (N<12mm); BAI >12mm (N4-12mm)</li> <li>Power’s Ratio >1.0 or <0.7 (N=0.7-1)</li> <li>Vertical Displacement >2mm between occiput and C1</li> </ul> <li>C1-C2</li> <ul> <li>ADI > 3.5mm</li> <li>PADI < 14mm</li> <li>Combined C1 lateral mass displacement/overhang on open mouth odontoid view > 6.9mm</li> </ul> <li>Subaxial</li> <ul> <li>Anterolisthesis >3mm</li> <li>11o angulation</li> </ul></ul>”

Question 18

<div>RC 2017 - C5/6 quad, maxilla and mandible fracture, closed reduced with 15lbs traction, starts developing vertigo, diploplia, nystagmus, tinnitus, difficulty swallowing, something to do with palate elevation being asymmetric. What is the cause:</div>

<ol> <li>Vestibulobasilar insufficiency syndrome</li> <li>Subdural hematoma</li> <li>Unrecognized ocular trauma</li> <li>Ascending c-spine syndrome</li></ol>

Answer 18

A.<div><br></br></div><div>Basilar Artery Stroke: <div>The clinical presentation of basilar artery occlusion (BAO) ranges from mild transient symptoms to devastating strokes with high fatality and morbidity. Often, non-specific prodromal symptoms such as vertigo or headaches are indicative of BAO, and are followed by the hallmarks of BAO, including decreased consciousness, quadriparesis, pupillary and oculomotor abnormalities, dysarthria, and dysphagia.</div></div>

Question 19

<div>RC 2016, 2013 - How do you calculate the Power’s ratio where B=basion, A=anterior arch of atlas, O=opisthion, C=posterior arch of atlas </div>

<ol> <li>BA/CO </li> <li>BC/AO </li> <li>AC/BO </li> <li>AB/CO</li></ol>

Answer 19

“2.<div><br></br></div><div><img></img><br></br></div>”

Question 20

<div>RC 2008 - CT of upper C spine showing possible C0-C1 dissociation. All of the following except:</div>

<ol> <li>shows altantooccipital dissociation</li> <li>Powers ratio > 1</li> <li>Increased distance between dens and Basion</li> <li>Basion dens interval decreased.</li></ol>

Answer 20

“D. BDI normal <12mm<div><div> <div> <div><img></img></div> </div></div></div><div><ul> <li>JAAOS 2014 - Upper Cervical Spine Trauma</li> <ul> <li>Increased BDI and BAI (Harris Rule of 12s)</li> </ul></ul></div>”

Question 21

<div>RC 2017 - Which of the following is positive for occipital cervical instability</div>

<div>A. BAI <12</div>

<div>B . Basion Dens Interval > 12 </div>

<div>C . Odontoid above McCrae’s line</div>

<div>D. Increased ADI > 5mm</div>

Answer 21

“B.<div><ul> <li>Basion to posterior axial interval is > 12 mm in OC instability</li> <li>Odontoid above Mcrae’s line is a sign of basilar invagination</li> <li>Increased ADI > 5 mm is a sign of atlanto axial instability</li><li><div> <div> <div><img></img></div> </div></div></li></ul></div>”

Question 22

<div>RC 2016 - There is a patient that sustained a fall and now has radicular arm pain and neck pain. Given an xray showing 25% vertebral body translation indicative of a C4/5 unilateral jumped facet. What would you find on physical exam? </div>

<ol> <li>Supraclavicular numbness </li> <li>Weakness of elbow flexion with lateral shoulder numbness </li> <li>Supraclavicular numbness + something else </li> <li>Hand weakness</li></ol>

Answer 22

B.<div><br></br><div>C4/C5 - C5 nerve injury!</div></div>

Question 23

<div>RC 2016, 2011, 2010 - List 5 negative prognostic factors for Type 2 odontoid fractures.</div>

Answer 23

<div><ul> <li>JAAOS 2010 - Odontoid Fractures; FRCS Ortho Boards, Orthobullets</li> <ul> <li>Patient</li> <ul> <li>Age>50</li> <li>Delay in tx >4 days</li> </ul> </ul> <ul> <li>Fracture Pattern</li> <ul> <li>Posterior displacement > 5mm</li> <li>Comminution</li> <li>Angulation > 10o</li> <li>Fracture gap > 1mm</li> <li>Loss of position > 2mm (re-displacement)</li> </ul> </ul></ul></div>

Question 24

<div>RC 2017 - An old person has an odontoid fracture, all of the following are viable treatment option except:</div>

<ol> <li>Posterior angulation >10o, C1-2 fusion</li> <li>Minimally displaced fracture, Cervical collar</li> <li>Displaced fracture, odontoid screw</li> <li>Displaced fracture, halo</li></ol>

Answer 24

D.<div><br></br><div><div>JAAOS 2010 Odontoid Fractures: Update on Management</div> <ul> <li>In elderly patients, halo-vest immobilization is associated with a high rate of morbidity and mortality; thus, its use should be avoided. In a retrospective analysis, Tashjian et al52 reported that patients aged >65 years with a type II or III odontoid fracture managed with a halo vest had a 42% mortality rate, compared with a 20% rate in the nonhalo group (P = 0.03)</li> <li>Both anterior fixation and posterior atlantoaxial fusions have also led to acceptable healing rates when used in elderly patients</li></ul></div><div><br></br></div></div>

Question 25

RC 2012 - List 3 ways to do posterior C1-2 fusion

Answer 25

"

• Trans-articular Screws (Magerl)
• Sub-laminar wires
• Lateral Mass Screw Fixation (Harms)

"

Question 26

RC 2011 - List  two important considerations to take into account for placing C1-C2 trans-articular screws

Answer 26

"

• Reduciblilty of C1-C2 articulation
• Location of vertebral artery
• Location of C2 nerve root (JAAOS ICL on C1/2 fixation)
• Hypoplastic C2 pars (variable individual anatomy)
• 
  

"

Question 27

RC 2008 - Where to put screws in occiput for strongest construct

1. Midline because of thickest bone
2. Inferior to nucchal line
3. Laterally
4. Medially and laterally

Answer 27

A. Caudad to EOP, midline

Question 28

"

RC 2008 - What is advantage of dynamic plate (over a rigid plate?) for anterior spine

1. Increased fusion rate
2. Allows subsidence
3. Load shares with subsidence
4. Hasn't been shown to make a difference

"

Answer 28

"D. (old answer C, but group consensus on D)

• Rigid anterior cervical plates lead to stress shielding of the bone graft
• Dynamic plates allow load sharing (therefore subsidence)
• ""it is unclear whether dynamic plates provide superior or even equivalent fusion rates to rigid plates""

"

Question 29

RC 2008 - Which would not alter your approach for a C-spine myelopathic patient

1. Previous incision
2. Sagittal alignment
3. Location of compression
4. Presence of radiculopathy

Answer 29

D.

• Previous incision important with ACDF
• Cannot do posterior only approach if spine is kyphotic
• Ideally like to approach from the side of the compression

Question 30

RC 2014 - Regarding the anterior approach to the cervical spine, all of the following are true EXCEPT?

1. Omohyoid transection improves access to the lower C spine
2. The parasympathetic trunk is at risk
3. Sub-platysmal fascial dissection improves exposure
4. The recurrent laryngeal nerve runs in the tracheoesophageal groove

Answer 30

B. sympathetic chain at risk

• Crossing Structures
• Must be preserved:
• Recurrent laryngeal nerve
• Superior laryngeal nerve
• Hypoglossal nerve
• Cross but can be sacrificed:
• Superior and inferior thyroid artery
• Omohyoid
• Runs distal lateral to cephalad medial at roughly C6
• Division allows more extensile exposure

• Transverse incision from midline to border SCM centered over level of interest
• Vertical dissection through platysma after bluntly undermining skin
• Blunt dissection through deep cervical fascia
• Retract SCM laterally and strap muscles medially
• Palpate for carotid artery in carotid sheath and then open pretracheal fascia medial to that; develop plane and retract carotid sheath laterally and esophagus and trachea medially
• Recurrent laryngeal lives in the TE groove
• Thyroid arteries are in this layer and can be ligated if necessary
• Once retract structures fully medially identify interval between the longus coli muscles in the vertebral midline (prevertebral fascia)
• Dissect sharply onto the vertebra between the longus coli muscles and gently spread them
• Sympathetic chain  is on lateral aspect of longus coli muscles
• Can use cautery to dissect through ALL onto vertebrae and clear off desired disc level (**confirm level with fluro)
• Incise disc, do what you have to do

• 
  

Question 31

RC 2011 - Contents of the carotid sheath include the carotid artery, internal jugular vein, and what other structure?

1. Vagus nerve
2. phrenic nerve
3. Vagus and phrenic nerve
4. Vagus and sympathetic

Answer 31

A.

Question 32

RC 2013 - Recurrent laryngeal nerve is branch of what

1. Vagus
2. Superior branch of laryngeal
3. Accessory spinal nerve

Answer 32

"A.

• left RLN
  • ascends in neck in tracheoesophageal groove after branching off from parent nerve the vagus at the level of the arch of the aorta 
• right RLN
  • runs alongside the trachea in the neck after hooking around the right subclavian artery
  • crosses from lateral to medial to reach midline
  • more vulnerable than left during exposure because
    • it has a more variable course
    • lies more anterolateral

"

Question 33

RC 2015 - What are the most important predictors of instability in a thoracolumbar fracture (3 points)?

Answer 33

• Morphology:

Compression

 1

Burst

+1

Rotation-translation

3

Distraction

4

• Neurologic Status:

Intact

 0

Nerve Root

2

Spinal cord/conus medularis

• Incomplete

3

        - Complete

2

Cauda Equina

4

• Posterior Ligaments:

Intact

0

Indeterminate

1

Disrupted

2

Question 34

RC 2015, 2013 - All of the following are true about a lumbar burst fracture, except

1. It is usually the inferior endplate that is retropulsed
2. Facet joints can be diastased
3. Pedicles widened on AP
4. Lamina often involved

 

Answer 34

A. RARELY inferior endplate

• Atlas SW (Am J Roentgenol 1986) The radiographic characterization of burst fractures of the spine
• Characteristic Features of a Burst:
• Posterior element fractures (fracture of necessity of the lamina)
• Vertical sagittal plane fracture through body
• Increased inter-pedicular distance
• Anterior wedging of the vertebral body with loss of height
• Retropulsion (SUPERIOR endplate retropulsed)
• Indicators of Potential Instability:
• Translation of one vertebra on another
• Loss of greater than 50% height
• Fracture through posterior elements
• Increased inter-pedicular distance
• Greater than 25 degrees kyphosis
• Multiple adjacent VB involved

Question 35

RC 2012 - Burst fracture; all of the following except?

1. Anterior vertebral body is disrupted
2. Posterior vertebral body is disrupted
3. Lamina are fractured
4. There is a liner correlation with the amount of retropulsion and neurological injury

Answer 35

D.

Neurologic injury is dependent on size of canal and level of injury in association with degree of retropulsion

Question 36

RC 2014, 2008 - One month following an L1 burst fracture with 60% canal stenosis, a patient presents with new onset numbness and weakness to both legs. What is the optimal treatment?

1. L1 laminectomy
2. T12-L2 posterior fusion
3. Thoracoabdominal approach with L1 corpectomy and anterior column reconstruction
4. Observation

Answer 36

"C. new neuro findings - treat!

• Thoracolumbar Spine Trauma II.  Principles of Management.  J Am Acad Orthop Surg 1995;3:353-360.
• In cases of significant canal compromise and incomplete or complete neurologic injury, we prefer anterior decompression by means of vertebral corpectomy and autologous iliac-crest strut grafting, followed by posterior compression instrumentation with the use of hooks or transpedicular screws.
• Thoughts:
• Can't do short posterior fusion at thoracolumbar junction (T11-L2)
• Bracing obviously a bad idea
• Laminectomy at L1 --> destabilize already kyphotic junction area and this is conus level so may not decompress

"

Question 37

 RC 2011 - Thoracolumbar burst fracture with significant canal compromises treated non-operatively.  What happens to canal afterwards.

1. Canal stays the same
2. Canal increases in size
3. Canal decreases in size
4. Lateral recess stenosis

Answer 37

B.

• JBJS 2003:
• RCT 47 patients with non-op bursts
• Changed from 34% canal compromise to 19% at 44 months
• CORR 1996:
• 6 patients
• 55% to 20% at final follow up

Question 38

RC 2015 - What are 3 risks of vertebroplasty/kyphoplasty? 

Answer 38

• JAAOS 2014 - Vertebroplasty and Kyphoplasty for the treatment of osteoporotic vertebral compression fracture
• Cement Leakage
• Embolization of the Cement
• New Fracture (adjacent vertebrae)
• NEJM 2009 - A RCT of Vertebroplasty for Painful Osteoporotic Vertebral Fractures
• Cement extra-vasation
• Fracture
• Osteomyelitis
• Tightness in back/rib cage
• Puncture site pain
• Chest pain

-Vertebroplasty NOT recommended , kyphoplasty maybe (balloon then cement)

Question 39

RC 2016 - What are 3 findings of spondylotic cervical myelopathy in the upper extremity?

Answer 39

• JAAOS - 2015 - Update on diagnosis and management of Cervical Spondylotic Myelopathy
• Motor
• Difficulty with fine motor tasks (buttons, keys)
• Myelopathy hand:
• Loss of power of adduction and extension of ulnar two digits
• Inability to grasp and release rapidly (<20 abnormal)
• Finger escape sign --> ulnar two digits drift into abduction
• Reflexes
• Hoffman Reflex
• Inverted brachioradialis reflex (hand goes down instead of up)
• Hyper-reflexia

Question 40

RC 2016 - What are 3 findings of spondylotic cervical myelopathy in the lower extremity? 

Answer 40

• Motor
• Wide based, ataxic gait
• Difficulty with Tandem gait, Rhomberg Sign
• Reflexes
• Hyper-reflexia
• Clonus
• Babinski sign (up-going toes)

Question 41

RC 2012 - Patient presents with cervical myelopathy and upper motor neuron signs. All of the following are UMN signs except?

1. Scapulohumeral reflex
2. Jaw jerk
3. Hoffmans
4. Babinski 

Answer 41

2.

• Jaw Jerk tests CN V
• Tap on mandible below lips --> masseter muscles jerk mandible upwards
• Usually pretty minimal, unless hyperreflexia present
• Indicates UMN lesions but must be above spinal cord
• Only DTR above the foramen magnum
• Scapulohumeral Reflex:
• Tap spine near medial acromion
• Scapula elevates and/or arm abducts = abnormal if hyperactive
• Indicates C1-3 compression

Question 42

Patient with hyperreflexia and ataxic gait. MRI shows L4/5 severe spinal stenosis. What is the next step?

1. Posterior decompression
2. MRI C+T spine
3. Fuse L4/5
4. Physio

Answer 42

b.dont be dumb.

Question 43

RC 2015 - All of the following are true regarding a thoracic disc herniation, except:

1. Resect the T9 rib head for a T8/9 disc
2. Less common than cervical and lumbar disc degeneration
3. Should be addressed with a posterior laminectomy
4. May show calcifications on CT

Answer 43

C. historical

• T8/T9 level means the T9 rib is in the way (it articulates with the superior costal facet (on the T9 pedible)
• JAAOS 2000 - Thoracic Disc Disease
• The frequency of morbidity associated with posterior laminectomy has led to the abandonment of this technique
• Calcifications very common with thoracic disc herniations
• May indicate adhesions b/w disc and dura OR an intradural location
• can make removal tricky
• found in 45-70% of symptomatic herniated discs (10% incidence in asymptomatic)

Question 44

RC 2008 - Which of the following structures contain free nerve endings:

1. PLL, Annulus, Facet joint capsule
2. Joint capsule, Annulus
3. Annulus fibrosis and Nucleus pulposis
4. Annulus, Nucleus, PLL, joint capsule

Answer 44

A.

Pacini endings concentrated around facet joint capsules and ventrolateral surface of the annlus fibrosus, free nerve endings found in the ALL and PLL, none found in nucleus pulposis

Question 45

RC 2010: What is true about the degenerative disc disease?

a. It transfers more stress to the facet joints

b. Increase in Type II collagen in the annulus fibrosis and the nucleus pulposus

c. There is an increase in chondroitin to keratin sulfate ratio

Answer 45

A. as the disc collapses you then transfer more stress to the facet joints.

B - false. Get an increase in Type I cartilage, nucleous was mostly type II, but being taken over by fibrocartilage, so increase in type I (like the annulus)

c - false. there is an increase in keratin

 

From Degenerative Lumbar Spinal Stenosis (JAAOS, 2012) – Disk space narrowing and loss of the normal shock absorptive capacity of the spinal segment results in an increased transfer of stress to the facet joints, which accelerates facet joint cartilage degeneration and osteophyte formation. 5,7 Facet joint hypertrophy, infolding of the ligamentum flavum, and development of bulging disk osteophyte complexes all contribute to circumferential narrowing of the central spinal canal and lateral recesses, that is, the area of the spine bordered  by the superior articular facet posteriorly, the disk and vertebral body anteriorly, the thecal sac medially, and the pedicle laterally.

 

Question 46

RC 2015 - List 6 causes of spondylolisthesis?

Answer 46

• Wiltse Classification:
• Isthmic (nonunion, elongation, acute fracture)
• Degenerative
• Traumatic
• Dysplastic (ie. Congenital)
• Iatrogenic
• Pathologic

Question 47

RC 2010, 2008 - 15 yo with L4/5 grade II spondy.  Failed all non-operative treatment.  Fully N/V intact. What now

1. L4-S1 posterolateral fusion
2. L5 laminectomy with L5/S1 posterolateral fusion
3. Pantaloon and hip spica

Answer 47

Answer: A

• JBJS Current Concepts Review 2015:
• Single level fusion associated with a 17% non-union rate
• Recommend L4-S1 fusion

Question 48

RC 2013 - Middle aged woman. Picture of a grade II – III spondylo with lots of sacral beaking but slip angle 80-90.  Neuro intact but has had mild back pain for 12 years. What is the best treatment?

1. In situ fusion with bone graft with or without fixation
2. Close follow up in a 3 months with xray
3. Return to clinic for follow up once symptoms progress
4. Anterior fusion with or without fixation

Answer 48

C.

• JAAOS 2009 - Adult Isthmic Spondylolisthesis
• No guidelines have been established for surgical intervention in adults with isthmic spondylolisthesis specific to the degree or progression of slip
• Indications for surgical stabilization in young adults and adolescents include symptomatic grade III or greater slip and progressive deformity
• Some argument for B - safer option, monitor for progression. I have chosen C because an isthmic spondy is unlikely to progress rapidly in an older patient so trigger for surgery would be development of symptoms

Question 49

RC 2015 - In performing reduction of a high-grade spondylolisthesis:

1. Strain on the L5 nerve root is proportional to the amount of translational correction
2. Incidence of L5 nerve root injury is 30%
3. Risk of L5 nerve root injury is related to the degree of correction of the sacral angle

Answer 49

"2. (group consensus)

• JAAOS 2006 - Spondylolisthesis in Children and Adolescents
• ""Isolated radiculopathy of L5, the most common complication, has been reported in as many as 30% of patients""
• Argument - Strain definitely related to translation, however, isn't linear so hard to correlate with question

"

Question 50

RC 2014 - What is not an appropriate situation in which to do primary repair of a pars defect: young adult with L5-S1 isthmic spondylolysis with the following findings:

1. MRI shows normal signal in L5-S1 disc
2. MRI shows normal signal in L4-5 disc
3. L5-S1 spondylolisthesis present
4. no neuro symptoms/signs

Answer 50

3.

• JAAOS 2006 Spondylosis and Spondylolisthesis in children and adolescents
• In situ L5-S1 posterolateral fusion is standard for L5 isthmic defects
• Repair of pars defect indicated for L1 through L4 

Question 51

RC 2013 - List 4 dysplastic features in a developmental spondylolisthesis that predicts the risk for progression

Answer 51

• Clinical Presentation
• Female
• Dysplastic (=congenital) vs isthmic (=fatigue #) spondylolisthesis (32 vs 4%)
• Pre-Peak height velocity (puberty)

• Radiographic
• Incompetent posterior arch
• Sagittally oriented facets
• Hypoplastic facets
• Trapezoidal L5 body
• Rounded superior endplate of S1
• Dysplasia/Deficiency of facets, posterior elements (pars), sacrum
• Bilateral defects
• Presentation with >50% slip
• Slip angle (lumbosacral kyphosis) > 45 deg
• Not a RF for progression:  dome shaped sacrum, trapezoidal L5

Question 52

 RC 2011 - Spinal Associations; all of the following except

1. Isthmic Spondylolisthesis and spina bifida occulta
2. Isthmic Spondylolisthesis and pars abnormality
3. Folate and Neural Tube defects (worded exactly like this)
4. Degenerative spondylolisthesis and spondylosis

Answer 52

D?

ABC all true...

Question 53

RC 2015 - Regarding spondylolisthesis, all of the following are true except:

1. Degenerative spondylolisthesis occurs most commonly at L5/S1
2. Superior articular facet contributes to lateral recess stenosis
3. Palpable gap with a degenerative spondy at L4/5 will be felt at the same level as with an isthmic spondy at L5/S1

Answer 53

"A. degen occurs at L4L5, whereas isthmic occurs at L5-S1

C- true. 

"

Question 54

RC 2014 - What nerve root(s) in adult L5-S1 isthmic spondylolisthesis will be affected?

1. L5
2. L5 and S1
3. S1
4. L4 and L5 

Answer 54

A. exiting nerve root; no risk of stenosis in isthmic

in degenerative - it is the traversing nerve root thats affected 

Question 55

RC 2018, 2015 - All of the following are associated with isthmic spondylolisthesis, except?

1. Inuit heritage
2. Elongation of the pars
3. Increased disability from back pain
4. Spina bifida occulta 

Answer 55

C.

Bottom line: Isthmic spondy

• DOES NOT cause increased disability
• Is COMMON in Inuit’s
• DOES involve elongation of pars
• IS PRESENT IN SPINA BIFIDA OCCULTA
• isthmic - exiting nerve root
• Incidence of slip progression is ~5% in asymptomatic adults
• associated with high PI (MCQ 2018)

Question 56

RC 2018, 2016 - Regarding isthmic spondylolytic spondylisthesis, all of the following are true except:

1. Has been associated with a lower pelvic incidence
2. The slip grade does not tend to change in adulthood
3. Neurologic injury corresponds with the exiting nerve root
4. Can be associated with spina bifida occulta

Answer 56

A. it is associated with high PI

• DOES NOT cause increased disability
• Is COMMON in Inuit’s
• DOES involve elongation of pars
• IS PRESENT IN SPINA BIFIDA OCCULTA
• isthmic - exiting nerve root
• Incidence of slip progression is ~5% in asymptomatic adults
• associated with high PI (MCQ 2018)

Question 57

RC EXAM - All of the following are true regarding scoliosis with associated spondylolisthesis, EXCEPT:

• 2/3 of postural curves will correct with management of spondy
• 10% of idiopathic scoliosis have spondylolisthesis
• Idiopathic curves will correct with lumbosacral fusion
• 20-50% of spondylolisthesis will develop scoliosis

Answer 57

"C. postural curves will correct but NOT idiopathic curves

• D true - Incidence of scoli and spondy 15-50% 
• B - true - incidence of spondy w/ scoliosis is 6.2%...close to 10%? 
• A - true - Pure spasm scoliosis with low-grade angular and rotation value: pain reaction explains scoliosis genesis in the case where pain resolution leads to a total or partial curve resolution
• If symptomatic spondylolisthesis is treated before spine deformity becomes structured, the ending of the muscle spasm can reduce or resolve the deformity in the majority of the cases
• Olisthetic scoliosis
• Def'n: scoliosis usually is not structural & is second to lumbar muscle spasm
• asymmetric olisthetic defect, the curve demonstrates more rotation than is usual in an idiopathic scoliosis curve of similar magnitude [18 ]. The spondylolytic, and not the apical, vertebra has the maximal torsion, as would be the case in idiopathic scoliosis
• In the case of curve associated with asymmetric olisthesis often, an in situ fusion of the affected level, that should reduce antalgic curve, is unable to correct the deformity or even to halt the curve progression = therefore C is incorrect

"

Question 58

RC 2015 - What is not associated with Charcot spondyloarthropathy:

1. Equal risk with all ASIA grades
2. Associated with unrecognized low virulence surgical site infection
3. Can be stabilized with a short segment fusion

Answer 58

A. 

• Barrey C (Annal Phys Rehab Med 2010)
• Review of 111 cases
• Only 38% have neurologic change indicating an incomplete SCI --> only 13% have sensorimotor changes
• Interpretation: majority of cases have complete SCI
• 14% have history of infection
• Short segment fusion recommended for patients with minimal boney destruction

Question 59

RC 2015 - All of the following are associated with spinopelvic alignment, except:

1. Isthmic spondylolisthesis is associated with decreased pelvic incidence
2. Pelvic tilt does not change with position
3. Pelvic incidence is a constant variable that does not change after skeletal maturity 

Answer 59

"

RECALL

Facts:

-isthmic spondy assx with increased PI

-pelvic tilt does change with position

-PI is fixed (normal PI is 60)

"

Question 60

Pelvic balance parameters and goals of surgery? NOT a RC Q

Answer 60

"PI = PT + SS

Goals

-LL-PI = <10 deg

-SVA < 4cm

-PT<20 deg

"

Question 61

RC 2014 - Type 2 collagen is the primary component of which structure

1. Annulus fibrosis
2. Nucleus pulposis
3. Vertebral body

Answer 61

ANSWER - B - nucleus has water in it - H2O - type 2 col!

• 2014
• Roberts S (JBJS 2006) - Histology and Pathology of the Human Intervertebral Disc
• Nucleus pulposus cells generally synthesize only type-II collagen in alginate beads, whereas anulus fibrosus cells produce both type-I and type-II collagen

Question 62

RC 2012 - With regards to proteoglycans, all of the following except

1. Proteoglycans are hydrophilic
2. Proteoglycans are hydrophobic
3. Proteoglycans are sulfated
4. Proteoglycans are bound to a protein core

Answer 62

"B.

• Proteoglycans can trap water in the ECM by their negative charge, regulating matrix hydration
• ""Proteoglycans are macromolecules of the cell surface or ECM in which one or more glucosaminoglycan chains are joined covalently to a membrane protein or a secreted protein""
• Most of the main GAG chains are sulfated, i.e. chondroitin sulfate, heparan sulfate
• ""The very hydrophilic clusters of carbohydrate alter the polarity and solubility of the proteins with which they are conjugated""

"

Question 63

RC 2017, 2015 - What are 4 indications for surgical management of the rheumatoid cervical spine 

Answer 63

JAAOS 2005 Rheumatoid arthritis in the cervical spine

• CPx
• Progressive neuro deficit
• Unresponsive mechanical neck pain
• Radiographic risk factors for neuro injury
• AAI: PADI < 14mm, SAC <14mm, CMA <135 degrees
• Basilar invag
• >5mm cranial migration to McGregor’s line
• Ranawat <13mm in women <15mm in men
• Tip of dens proximal to McRae’s line

Question 64

RC 2011 - The most common cause of sudden death in RA?

1. basilar invagination
2. C1-2 instability
3. subaxial instability
4. Chernobyl took care of this patient

Answer 64

A.

Question 65

RC 2008 - All are poor prognostic indicators of recovery after whiplash injury EXCEPT

1. Sedentary occupation
2. Radiculopathy at time of injury
3. Spondylosis preceding injury
4. Female gender

Answer 65

A.

Côté et al found that older age, female sex, Radicular symptoms, multiple areas of pain, and being unprepared for impact portend a worse prognosis.

Question 66

RC 2014 - All of the following are correct landmarks for inserting an L3 pedicle screw EXCEPT?

1. Inferolateral aspect of L2-3 facet joint
2. Inferolateral aspect of L3-4 facet joint
3. Junction of the middle third of transverse process and a line through the center of the facet joint
4. Junction of the middle third of transverse process and a line through the mammillary process and pars 

Answer 66

"2.

"

Question 67

RC 2017, 2010 - List 4 risk factors for neurological deterioration in vertebral osteomyelitis 

Answer 67

• Pt factors
• Diabetes
• Rheumatoid Arthritis
• Systemic steroids
• Age > 60
• Immunocompromised (Caragee JBJS 1997)

• Infection Factors
• Infx above conus
• Associated epidural abscess

• Treatment factors
• Delay in treatment

Question 68

RC 2016 - Regarding spinal infection, all true, EXCEPT: 

1. CRP and ESR decreasing are effective signs that medical management is working
2. Most have an elevated WBC
3. Greater than half are staph aureus

Answer 68

B. Leukocytosis in < 45%

Question 69

RC 2013 - 53yo nurse with 2 day history of severe arm pain. She presents with upper extremity motor weakness and confusion.  MR was given and showed a large posterior epidural abscess.  Management?

1. Anterior decompression
2. Posterior decompression
3. IV antibiotics
4. Biopsy

 

Answer 69

B. neuro deterioration warrants OR

Question 70

RC 2009 - Epidural abscess; all are RFs for poor neurologic outcome EXCEPT: 

1. Staph aureus
2. Steroids
3. DM
4. T10

Answer 70

A.

• JAAOS 2016 - Bacterial Spine Infections in Adults
• Diabetes
• Older age
• Rheumatoid Arthritis
• Steroids
• Infection above conus

Question 71

RC ORAL: MR Features consistent with TB vs pyogenic

Answer 71

• Well-defined abnormal paraspinal signal
• Thin and smooth abscess walls
• Presence of paraspinal or intraspinal abscesses on T2/FS T1
• Disc space is preserved
• Sub-ligamentous abscesses classic

Question 72

RC 2016 - List 4 predictors of instability and deformity in pediatric tuberculosis of the spine 

Answer 72

"

• Gapping of the facet joints
• Retropulsion of infected vertebra in relation to adjacent normal levels
• Lateral listhesis
• Toppling

 

"

Question 73

RC 2012 - Tumor associated with Posterior spinal element

1. Mets
2. Hemangioma
3. ABC
4. GCT

Answer 73

3.

• Osteoid osteoma
• Ostoeoblastoma
• Osteochondroma
• ABC

Question 74

RC 2008 - Ankylosing Spondylitis, what is false

1. Seronegative spondyloarthropathy
2. HLA B27 95% of time
3. 10-15% positive family history
4. Starts in the disc before SI joints

Answer 74

D.

Sacroiliitis is hallmark of early disease

Question 75

RC 2014 - Name three clinical findings in Ankylosing Spondylitis (other than SI joint)

Answer 75

"

• JAAOS Orthopedic Management of Ank Spond
• Modified New York Diagnostic Criteria:
• Low Back pain lasting greater than 3 months (improved by exercise)
• Limited lumbar spine ROM
• Decreased chest expansion

• Systemic manifestations (Orthobullets/Miller's)
• Anterior uveitis
• Heart disease (conduction abnormalities)
• Right bundle branch block, 3rd degree block
• Pulmonary fibrosis
• Renal amyloidosis
• Ascending aortic conditions (aortitis, stenosis, aortic regurg)
• More susceptible to Klebsiella pneumonia synovitis
• Large joint arthritis
• 33% hip involvement
• Spinal kyphotic deformities (thoracic)
• Sacral iliitis
• Colitis
• Arachnoiditis
• HLA B27+

"

Question 76

RC 2010 - Ank spond patient with completely fused spine and gets a c-spine injury.  All except:

1. laminectomy contraindicated
2. most do well with conservative treatment
3. increased bleeding

Answer 76

2.

• AS patient with new onset neck or spine pain = fracture until proven otherwise!!
• Progressive neural deterioration
• Loss of reduction
• Fracture usually involves all columns and results in marked neck deformity
• Be cautious about placing on spine board as their baseline is usually that of significant cervico-thoracic kyphosis
• Epidural hematoma
• Neurologic deficit occurring at higher level than at frx site may indicate expanding hematoma which is more common in AS than normal patients with spine fracture
• Nonunion
• Occult frx
• Progressive kyphosis
• Severe osteopenia
• Death in 30% of cases
• Very challenging cases as the long lever arm of the fused spine segments makes the fracture site highly unstable. Furthermore, these patients are often brittle, lose more blood and fixation into their osteopenic spine is bunk.

Question 77

RC ORAL - Dural tear managament

Answer 77

• Close even partial tears (can rupture late when patient mobilizes)
• Principles:
• Protect neural elements
• Neural paddy when suctioning

• Position: trendelenburg (head down)

• Ensure proper visualization
• Dry surgical field
• gelfoam
• Headlight
• Microscope/loops 

• Primary repair with suture
• No superiority with any one suture material
• Water tight closure
• Augment with grafts if necessary
• Fat grafts
• Fascial patches
• Fibrin glue
• Collagen matrix
• Test repair:
• Valsalva
• Layered wound closure

Question 78

RC 2017 - What are 8 risk factors for peri operative vision loss with spine and orthopedic surgery?

Answer 78

• Pt factors

1. Male gender
2. Obesity
3. Preop anemia
4. PVD
5. Smoking (controversial)

Surgical Factors

• Prolonged surgical time (>6 hours)

1. Increased blood loss
2. Patient positioning (prone)

Anesthesia Factors

1. High CVP
2. High PCO2

Question 79

RC 2014, 2013, 2009 Injury to what causes of retrograde ejaculation

1. Inferior hypergastic plexus
2. Superior hypogastric plexus
3. Inferior hypogastric plexus
4. Superior hypergastric plexus

Answer 79

B.

Damage to the superior hypogastric plexus during exposure of the anterior lumbosacral spine can denervate this bladder neck sphincter, resulting in retrograde ejaculation. 

Question 80

RC 2011, 2010 - List 3 ways to monitor for a spinal cord injury when performing spinal deformity correction?

Answer 80

• JAAOS  2007 - Intra-operative Neurophysiologic Monitoring During Spinal Surgery
• SSEPs - Somatosensory-evoked potentials
• Transcranial electric motor-evoked potentials
• Stagnara wake-up test
• Electromyography

Question 81

RC 2014 - Most common cause of post-op spine infection?

1. Bacteroides
2. Staph epi
3. Staph aureus
4. E coli

Answer 81

C.

Question 82

RC 2017 - Which of the following is incorrect for surgery for lumbar stenosis

1. Surgery isn’t beneficial in those with only motor symptoms
2. Bilateral laminectomy is an absolute indication for fusion
3. Need an MRI to determine location of stenosis
4. …

Answer 82

B. Fusion is not indicated except in the setting of concomitant spondylolisthesis, scoliosis, or iatrogenic instability

Question 83

RC 2011 - Pt. With known lumbar spinal stenosis treated non operatively.  Which exercises should he avoid?

1. hip flexor stretching
2. pelvic tilt
3. flexion exercises
4. Lumbar paraspinal extension stretching

Answer 83

D. extension provokes pain

Question 84

RC 2011, 2008 - Spinal stenosis.  What is least useful?

1. physical exam
2. treadmill stress
3. MRI
4. SF-36

Answer 84

A.

Discussed with Dr. Lewkonia, and he says that he the answer is physical exam. The SF36 was used in the SPORT trials and is useful in determining outcomes for spine patients apparently. He said that the physical exam poorly correlates with level of stenosis. 

Question 85

RC 2009, 2008 - What is a predictor of poor outcome after lumbar stenosis surgery?

1. Poor ambulation pre-op
2. Poor general health pre-op
3. Cardiovascular disease
4. Patient required a decompression and fusion intra-op

Answer 85

"This Q should likely be 'all except' with D as the answer

""Depression, cardiovascular comorbidity, disorder influencing walking ability, and scoliosis predicted poorer subjective outcome. Better walking ability, self-rated health, higher income, less overall comorbidity, and pronounced central stenosis predicted better subjective outcome. Male gender and younger age predicted better postoperative walking ability

"

Question 86

RC 2010, 2008 - Size of lumbar central canal is largest in which position

A. Flexion

B. Extension

C. Supine

D. Standing

Answer 86

A.

Question 87

RC EXAM -  A recent study about injections for lumbar spinal stenosis revealed?

1. They are of no help.

2. Helped pts put off surgery for up to 2 years.

3. Pt required surgery in 5 years regardless.

4. Nerve block Helped somewhat.

Answer 87

Answer: 4

Epidural steroid injections can also be used to provide temporary relief of radicular symptoms in select patients. 20 In a prospective study of 34 patients with radicular pain caused by degenerative lumbar spinal stenosis, Botwin et al21 treated patients with fluoroscopy-guided lumbar  transforaminal epidural injections. The authors reported that 75% of  patients noted at least a >50% reduction in pain scores, 64% had improved walking tolerance, and 57% had improved standing tolerance at 1-year follow-up. Other studies have reported temporary improvement in pain and function following epidural

** The above study is from 2002** Quote from JAAOS, 2012 Degenerative Lumbar Spinal Stenosis

Question 88

RC 2014, 2010 - Regarding anterior approach to T-spine, which is false?

1. Aorta blocks visualization of high to mid-T-spine on left
2. liver blocks visualization of lower T-spine on right
3. Resect T11 rib head to access T11-12 disc space
4. Resect a rib 1-2 levels above the area of interest during approach

Answer 88

C.

JAAOS 2004 Thoracolumbar fracture management: Anterior approach

T6-T11 —> Aorta, Heart, Major vessel block left sided approach

T12-L1 —> Liver and vena cava block right side approach

To access an area of interest typically you need to resect 1-2 ribs above the planned level ie. Resect ribs 10 and 11 for access to T11 and T12 fractures 

Question 89

RC 2013 - Patient has metastatic disease in multiple places with more than 6 months to live and progressive neuro symptoms. You are shown an MRI with tumor at T9 pushing on cord anteriorly.  Which is wrong?

1. Costotransversectomy and corpectomy
2. Laminectomy, transpedicular decompression
3. Laminectomy and posterior decompression
4. Anterior approach and decompression

Answer 89

"C.

"

Question 90

RC 2018, 2014, 2011 Which of the following is associated with an increased risk of complications with halo treatment?

1. Re-tightening the screws at an appropriate interval
2. Placing the ring 2cm above the pinna
3. Placing the ring closer to the skull
4. Using 6 pins instead of 4

Answer 90

B

Question 91

RC EXAM -  Halo applied, with regards to motion allowed:

a. Most motion is at C1/C2

b. Most motion is at C3 to C7

c. 70% of flexion is inhibited in spine

d. Is worn by the Angel of Death

Answer 91

B.

A – no, you use it to immobilize the spine with these fractures, B – Yes, C – Yes

The Halo vest immobilizes the skull relative to the torso. Therefore is is ideal for controlling motion at upper cervical spine and atlantoaxial joint. Halo immobilization allows for intercalated paradoxical motion in the subaxial cervical spine, and is therefore less ideal for lower cervical spine injuries. Johnson et al evaluated the ability of different cervical orthoses to control cervical range of motion at each cervical intervertebral joint. At the atlanto-axial joint, the halo vest restricted flexion-extension by 75%, which compared to only 45% by conventional cervical braces. The halo vest was less effective at controlling motion in the subaxial cervical spine below C3.

Question 92

RC EXAM What is the most common complication of halo application?

1. Loss of reduction

2. Pin loosening

3. Pin infection

4. Severe pain 

Answer 92

2.

• Complications
• Pin loosening (up to 36%) - RC EXAM
• Pin site infection (up to 20%)- superficial vs deep
• Pressure necrosis 2-11%
• Dural puncture 1-4%
• Supra-orbital n injury 2%
• Elderly
• Resp distress 8%
• Dysphagia 10%
• death

Question 93

RC 2014, 2013 - Give 3 considerations for safe application of a pediatric Halo

Answer 93

• CT indicated in kids under 10 to determine bone thickness and rule out cranial fractures
• Greater number of pins (10-12)
• Torque at 2 in-lb
• Wheeless
• Avoid suture lines
• Avoid anterior pins (protect supraorbital nerves)
• Position: split mattress for slight extension

Question 94

RC 2016 - What are 4 adverse effects of BMP-2 in spinal fusion? 

Answer 94

• Retrograde ejaculation
• Osteolysis
• Seroma formation
• Post-operative radiculitis
• Ectopic bone formation
• Massive soft-tissue swelling

Question 95

RC 2014 - Type 2 collagen is the primary component of which structure

1. Annulus fibrosis
2. Nucleus pulposis
3. Vertebral body
4. ?

Answer 95

2. Nucleus pulposus cells generally synthesize only type-II collagen in alginate beads, whereas anulus fibrosus cells produce both type-I and type-II collagen

Question 96

RC 2013 - Rubrospinal tracts in the spinal cord carry: (these were long answers; look up your spinal cord anatomy.)

1. Autonomic
2. Voluntary Motor Control
3. Flexor Muscles
4. Loss of muscle tone and involuntary muscle movements.
5. Sexual Function

Answer 96

"c.

 

"

Question 97

RC 2014 - Vertebral body forms from?

1. mesoderm
2. ectoderm
3. endoderm
4. neural crest

Answer 97

1. 

• Mass of ectodermal cells forms archenteron
• Floor of this becomes notochondral plate
• Forms neural structures
• Mesoderm breaks up into blocks of cells to form the somites which become vertebral bodies and discs

Question 98

RC 2014, 13, 12, - List 3 spine conditions that enhance with gadolinium enhanced MRI

Answer 98

• Scar tissue enhances (including granulation tissue, i.e. TB)
• Infection
• Tumors
• ** Chronic disks are dark

Question 99

RC 2015, 2011, 2008 - Regarding MRI with gadolinium, all of the following are TRUE except?

      a.  Epidural abscess rim enhances

      b.  Discitis enhances on T2

      c.  Epidural fibrosis does not enhance

      d.  Recurrent disc material does not enhance

Answer 99

"C

JAAOS 2009 - MRI of the Spine ""Contrast enhancement is used to distinguish scar tissue, which enhances on MRI scans, from fragments of disk tissue in the epidural space that, lacking capillaries, do not enhance""

gad enhanced = scar tissue, tumor, infection, NOT chronic discs

"

Question 100

RC EXAM -  You do a discectomy on a young patient. He bends down, acute sharp pain and you think he all the signs and symptoms of recurrent disc herniation. How do you image this:

a. CT myelogram

b. Plain MRI

c. MRI with gadolinium

d. Plain CT

Answer 100

C.

Question 101

RC 2018: In c spine flexion-distraction trauma, which of the following is a relative contraindication to ACDF at the C5-C6 level?

1. C5 superior articular process/facet fracture
2. C5/6 annulus tear
3. C6 facet/superior process fracture
4. C6 superior end plate fracture
5. Anterior annulus rupture

Answer 101

"D.

""Endplate fractures of the inferior level in jumped facets appears to be a major risk factor of biomechanical failure. However, a facet fracture may not be a risk factor for failure. In the absence of an endplate fracture, ACDF is a reasonable treatment option in patients with single-level cervical facet dislocation.""

"

Question 102

RC 2013 - Patient with knee pain.  Which could not cause it?

a.     L3

b.     L1

c.     Knee OA

d.     Hip OA

Answer 102

"B

"

Question 103

RC Oral - Loss of neuromonitoring approach?

Answer 103

• R/O Technical Causes
• Check electrodes
• Check Stim machine
• Check for interference
• Microscope
• Warmers
• Bovie
• Anesthetic Changes
• NM blockers
• Inhaled paralytics
• Reverse if possible
• Metabolic Causes
• Lytes, low glucose
• Elevate MAP to 90 (Parsons says 75)
• Increase oxygenation
• Reverse anemia
• Spine
• Reverse what you just did
• Remove a screw
• Decrease distractions
• Decrease traction
• Remove a rod
• Irrigate with warm saline
• Wake up test
• If real issue
• Maximize blood flow to cord
• 100% O2
• Maintain MAP 75
• Provisional stabilization needed if decortication done…
• low lumbar screws unlikely to cause frank cord changes, so take ‘em out, check their position, and/or leave in.
• Can put transverse hooks proximal, so that nothing in canal and uncorrected rod to have stability
• Close and send to MR

Question 104

RC 2014 - During the posterior approach to the spine, the thecal sac can be retracted?

a.     Above the level of the conus

b.     Below the level of the conus

c.     Below T12

d.     Never

 

Answer 104

B

Question 105

RC - bullshit. Thoracolumbar fracture what is true? 

a.     UMN only

b.     LMN only

c.     Nerves in the cauda equina recover the same as peripheral nerve injuries

d.     conus end at L2-L3

Answer 105

"A/D

·       UMN/LMN depends on where the conus is

o   Some variability in end point between T12 and L3

·       JAAOS - Cauda Equina:

o   Unlike peripheral nerves that are protected by a series of successive layers of connective tissue known as the epineurium, perineurium, and endoneurium, the nerve roots of the cauda equina have only one layer, the endoneurium. In the cauda equina, the layers equivalent to the perineurium and epineurium are cerebrospinal fluid and the dura sac, respectively. This relative lack of protection leaves the nerve roots of the cauda equina particularly susceptible to traumatic injury.

·       Jess argument: sure the conus can be a bit low, but L2/3 is pretty low in an adult.  I take a thoracolumbar fracture to mean around T12/L1, where the conus really should be involved. Therefore it would cause an UMN injury.  I bet this question wasn't remembered well, though.

o   Conus can have both UMN and LMN symptoms with injury

"

Question 106

RC 2016 - Which of these is true about the MPFL?

a.     Isometric throughout the ROM

b.     You want it loose in extension and tight in flexion

c.     If too proximal, loose in flexion

d.     If too distal, creates extensor lag

Answer 106

D.

Question 107

Which of the following is associated with persistent bowel/bladder dysfunction, but improved ambulation at 3 months post injury?

A. ASIA A

B. Conus medullaris syndrome (CMS)

C. Anterior cord syndrome

D. Brown-Sequard syndrome

Answer 107

"B. CMS

CM includes both upper and lower motor neurons wheras the CE consistns solely of LMN. 

Overlapping features: LBP, lower limb weakness, perineum or saddle anesthesia and bowerl and/or bladder dysfuntion. Assumed that recovery of UMN worse than LMN and that CMS may have worse prognosis.

- Distinction based on exam alone is difficult

- Level T12-L1, be concerned re: CMS

- Patients with CMN tend to have symmetric findings, vs. CES which can be asymmetric

Harrop et al (Spine, 2010)

• Greater apparent neurologic improvement rate of the conus is most likely because of the greater proportion of lower to upper motor neurons
• 93% of conus patients had a neurologic recovery of 1 ASIA score or more

From Miller’s and other texts: 

• Central cord syndrome is most common, affecting elderly patients with a spondylotic cervical spine. It presents as motor and sensory loss greater in the upper than the lower extremity. Independent ambulation is regained in approximately half of elderly patients and almost always in young patients.
• Anterior cord syndrome is the second most common and has the worst prognosis of incomplete SCI. It presents as greater motor loss in the legs > arms.  Chance of motor recovery 10-20%.
• Brown-Séquard syndrome presents as motor weakness on the side of injury and contralateral loss of pain and temperature. It has the best prognosis. Chance of motor recovery at final follow up 99%.  Because the involvement of the descending autonomic pathways is unilateral, bladder dysfunction does not occur.
• ASIA B has only a 4% chance of motor recovery to an ASIA E, so ASIA A would be worse odds. It would have persistent bowel/bladder dysfunction. 
• Conus medullaris syndrome has a mixture of UMN & LMN findings
• Tendency for the nerve roots at the site of a SCI to recover = root escape

"

Question 108

23F with left hip deformity reduced in the ED. CT slice shows femoral head fracture that is flipped and malreduced. What surgery would you offer?

A. Surgical hip dislocation and ORIF

B. Fixation through lateral approach

C. Excision of fragment

D. Total hip arthroplasty

Answer 108

Ans: A

Depends where the femoral head fracture is for approach, but overall choice would potentially be anterior or posterior w/surgical hip dislocation. In young female would try and fix, therefore eliminate THA and excision of fragment likely (agian dependent on size and location)

Question 109

Which of the following is associated with atlantooccipital dissociation? (RC 2019)

A. Basion dens interval (BDI) > 12mm

B. Space available for the cord <13mm

C. PADI <15mm

D. Basion axis interval <12mm

Answer 109

"Ans: A

For atlantooccipital dislocation

- Power's ratio - >1 indicates instability of the AA joint. Good for anterior dislocations, can miss posterior dislocations

- BAI. Normal 4-12mm. >12mm can suggest AO dissociation

- BDI. Normal <12. >12 can suggest AO dissociation. 

BAI and BDI = Harris rule of 12

SAC and PADI not related to OC dissociation

"

Question 110

What is true regarding Klippel-Feil Syndrome?

A. Short neck, low ROM,  low hairline

B. Webbed neck, low ROM, low hairline

C. Short neck, normal ROM, high hairline

D. Short neck, increased ROM, high hairline

Answer 110

"

Answer: A

• Fusion in C-spine
• Limits neck ROM
• Shortened neck
• Low hairline
• Hearing abnormalities, eye abnormalities, GU abnormalities, +/- cleft palate, +/- Sprengel’s, CV anomalies
• AD inheritance in GDF6 or 3, AR in MEOX1

"

Question 111

Regarding lumbopelvic parameters, all of the following are true except?

A. Isthmic spondylolisthesis is associated with decreased pelvic incidence

B. Pelvic tilt changes with position

C. Pelvic incidence is a constant variable that does not change after skeletal maturity

D. Spondylolisthesis is associated with spina bifida

Answer 111

Answer: A

Isthmic spondy is associated with INCREASED PI

Spina bifida is associated with spondylolysis in 12-35% of cases

Question 112

Regarding thoracic disc herniations - which is false? (RC 2019)

A. You follow the T9 rib head to get to the T8/9 disc

B. Posterior laminectomy is most common method of treatment

C. Are less common than lumbar or cervical disc

D. Higher rates of degenerative change

Answer 112

Answer: B

A - true

B - Historical. Frequent neural injury, inadequate decompression, continued symptoms

Note: calcifications are very common in thoracic discs

Symptomatic thoracic disc disease is quite rate

Question 113

"

Regarding charcot spinal arthropathy what is true? (RC 2019)

A. It is a reason to follow SCI patients

B. A short construct is a predictable way to treat patients with instability due to charcot spinal arthropathy

C. Rates are identical in all degrees of spinal cord injuries

D. Associated with low virulence infection

"

Answer 113

"Answer: A

Ref: Jacobs et al. Surgical management of Charcot spinal arthropathy: a single-center retrospective series highlighting the evolution of management. J Neurosurg Spine 2012;17:422–431.  

1: Associated with low-virulence infection: (infection is NOT common, but It can be present ~ 17%)
2: Short segment fusion could decrease occurrence <-- this is the answer although choice wording is poorly remembered

• Long constructs increase forces at adjacent levels and increase likelihood of CSA
• In paper, data “raises the possibility of shorter segmental fusions … may reduce the incidence of CSA…”

3: Almost always ASIA A; can be ASIA B too; has to be complete motor deficit)

"

Question 114

What is not an accurate description of the start point for an L3 pedicle screw? (RC 2019)

A. Inferomedial aspect of L2-3 facet joint

B. Inferomedial aspect of L3-4 facet joint

C. Junction of the middle third of the transverse process and a line through the center of the facet joint

D. Junction of the middle third of transverse process and a line through the mammillary process and pars

Answer 114

"

Answer: B

• B would be an L4 pedicle screw
• AO Surgical Reference - Pedicle Screws
• ""the entry point of the pedicle screw is defined as the confluence of any of the four lines""
• Pars interarticularis
• Mammillary process
• Lateral border of the superior articular facet

• Mid transverse process

"

Question 115

"

Far lateral disc herniation at L4/5. What is the deficit? (RC 2019)

A. Plantar flexion

B. Toe extension

C. Ankle dorsiflexion

D. Hip flexion

"

Answer 115

"

Answer: C

• Compresses the exiting nerve root at L4/L5, which is the L4 nerve root.

"

Question 116

"Cervical myelopathy - what is the most reliable physical exam?

1. Loss of Proprioception
2. Neural root tension signs
3. Clonus < 4 beats
4. Hyporeflexia in the extremities

"

Answer 116

"

Answer: A

• Signs & symptoms should reflect those of UNM.
• The presence of > 4 beats of clonus also suggests UMN dysfunction. 
• Neurologic compression of the cervical spinal nerve root may result in LMN findings (eg, hyporeflexia), whereas compression of the cervical spinal cord may result in UMN findings (eg, hyperreflexia). 
• Proprioception dysfunction
• Due to dorsal column involvement 
• Occurs in advanced disease
• Associated with a poor prognosis
• In general, the clinical features of CSM are:
• Axial neck pain and decreased ROM
• Gait instability/balance impairment (diminished proprioception due to dysfunction of posterior column)
• Diminished hand dexterity/difficulty with fine motor tasks
• Bowel/bladder dysfunction (advanced CSM)
• Inability to ambulate (advanced CSM)

"

Question 117

"

What is associated with the development of chronic pain from Whiplash Associated Syndromes?

A. Immediate severe pain following injury

B. Type of Vehicle

C. Low education

D. Mechanism

"

Answer 117

"

Answer: A

REF: Schofferman et al. Chronic Whiplash and Whiplash Associated Disorders. JAAOS 2007 

• Clinical studies have shown, however, that 15% to 40% of patients with acute neck pain after MVC develop chronic pain; 5% to 7% of patients become permanently partially or totally disabled.
• Natural history: Most persons do not develop neck pain after an MVC. However, those who experience acute neck pain immediately following the MVC are 3x more likely to report chronic neck pain 7 years later than are patients involved in MVCs who had no acute neck pain and patients not involved in a prior MVC.

• Prognostic Factors:
• Strongest predictor: Initial high intensity of pain
• Controversial:
• Gender, older age, litigation
• Côté et al found that older age, female sex, radicular symptoms, multiple areas of pain, and being unprepared for impact portend a worse prognosis. 
• Côté P, et al. A systematic review of the prognosis of acute whiplash and a new conceptual framework to synthesize the literature. Spine 2001;26:E445-E458. 
• Inconclusive:
• Radicular symptoms, cognitive impairment, poor concentration, prior HA, velocity change > 10km/h

"