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Millers > Spine: TL > Flashcards

Spine: TL Flashcards

1
Q

Name the muscle/action to test for each nerve
L1
L3/4
L4/5
L5
S1

A

L1 - hip flexors
L3/4 - knee extension
L4/5 - ankle DF (foot drop)
L5 - EHL
S1 - PF

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2
Q

Motor grading 0-5

A

0 nothing
1 flicker
2 full ROM no gravity
3 full ROM w/ gravity
4 resistance but asymmetric
5 full strength against full resistance

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3
Q

Sensation for each nerve level
L1
L4
L5
S1
S2-5

A

L1 - inguinal crease
L4 - lateral thigh, medial shin
L5 - lateral calf, 1st dorsal webspace
S1 - posterior calf, plantar foot
S2-5 - perianal

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4
Q

Reflexes per level
L4
S1
S2-5

A

L4 - patella
S1 - Achilles
S2-5 - bulbocav

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5
Q

What pathology would you get an oblique XR for

A

Spondylolysis - scottie dog
Somewhat controversial because 80% pars issues will get picked up on the lateral alone

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6
Q

What is a SPECT scan? What pathology consider for?

A

Bone scan + CT
Pars stress frx
Isthmic spondy
If bright on the scan, think might have ability to heal on own

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7
Q

What is the difference between EMG and NCS

A

EMG: are the muscle electrical changes
ie is the muscle seeing some amount of deinnervation
ie a normal EMG doesn’t mean there isn’t radiculopathy, means the changes aren’t severe enough to cause muscle changes

NCS: shock -> record distal readings through the nerve
Better peripheral nerve stuff (carpal tunnel)

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8
Q

Name most common levels for degenerative L spine changes

A

L4/5 > L5/1 > L3/4

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9
Q

How does disc disease look on MRI

A

T2 loses intensity (dark disc disease) - loss of water
Lose GAGs - lose H2O

ie OA will show disc heigh loss and less bright T2 disc

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10
Q

Discogenic back pain
- What positions aggravate
- Treat

A

Worse w/ sitting, lumbar flexion
NON OP -> treat the disc (interbody fusion, lumbar disk replacement [lol])

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11
Q

Nerve that causes facet pain
Aggravating position

A

Medial br dorsal rami and sinuvertebral nerve
Extension - loading the facets

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12
Q

Traversing or exiting root compressed? (ie L4/5 disc, which nerve)
Posterolateral / lateral recess
Central
Foraminal / far lateral

A

PL/lat rec/central: traversing (L5)

Foraminal / far lateral : exiting (L4)

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13
Q

Treat disc herniation + recurrent herniation

A

NON OP
If op, do not fuse unless instability
Diskectomy - technique won’t matter

Recurrent: another diskectomy before fusing

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14
Q

Approach for far lateral disc herniation

A

Wiltse approach - not a midline incision
Between the paraspinals (multifidus, longissimus)

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15
Q

Spinal stenosis
- 4 anatomic causes
- Exam

A

Causes:
- Central disc
- Facet arthropathy / lig flav hypertrophy from the back
- Spondylosis (think bilateral, unilateral possible)
- Congenital = short pedicles (think achondroplasia)

Exam = neurogenic claudication
- Shopping cart sign (seeking lumbar flexion)
- Buttock/post thigh pain
- Pain walking DOWN hill (vs up)
- Standing pain
- Flexion increases canal volume = relief
*Check C spine for tandem stenosis

Test to differentiate vascular = ABIs

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16
Q

SPORT trial findings for management of spinal stenosis

A

4 yr fu, surg > non op
Both op and nonop improved from baseline

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17
Q

Define spondylolysis vs listhesis
Position that makes sx worse

A

Lysis - pars defect present (breaks in sup/inf facts)
Listhesis - split through it

Prognosis - if lysis w/o listhesis at skeletal maturity, will not go on to slip

Extension worse

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18
Q

Treat lysis/listhesis

A

NON OP - break from sports
- Nonunion common

Repair (preserves motion)
- No slip!
- Gr 1/2 (<50%) if failed conservative mgmt, progressive, or neuro involvement

Fusion
- Dysplasia bc high rates of progression / deformity (LS kyphosis)
- High grade slips (>3+ levels) may need mutli level fusion
- Reduction is controversial

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19
Q

How should you fuse adult isthmic spondy w/ foraminal stenosis that failed nonop

A

Interbody fusion = better fusion rate for isthmic spondy

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20
Q

If there is a degen spondy that has a slip <5mm and does not move on flex ex, how treat after fail non op

A

Decompression alone
Contrary to your gut which is fusion!

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21
Q

Explain the bladder findings for cauda equina

A

S2-5 nerves
Bladder becomes deinnervated - fills
Can’t squeeze because paralyzed
Then overflow incontinence
Worst recovery prognosis after decompression

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22
Q

Best study for recurrent disk herniation

A

MR w/ contrast
Differentiates scar (enhances w/ contrast) from disk material (does not enhance with contrast)

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23
Q

What amount of facet defect creates instability?

A

> 50% bilateral
100% one facet (aka fracture)

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24
Q

What is the outcome of an incidental durotomy

A

If treated appropriately in OR, outcomes are equiv

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25
Presentation, imaging and trt post diskectomy diskitis
Pres: 3-6wks post op rapid onset LBP MR w/ contrast IV abx unless epidural abscess
26
How treat thoracic myelopathy from disc
RARE for it to be a disc in the L spine Have to do something from the front - can't retract the cord to do diskectomy Therefore, if taking the entire disc, need some additional fusion
27
Most common bug osteodiskitis Treat
Staph aureus CT guided biopsy for bug -> IV abx 6wks Surg only if abscess or instability
28
Ant vs post location for epidural abscess Trt
C = ant T/L = post Trt = laminectomy w/ abscess washout Beware, real life, can treat some abscess w/ abx only if not MRSA/neuro deficits/systemic illness
29
Describe pathology of spinal TB When to operate
Originates in metaphysis Spreads to adjacent vetrebra SPARES DISKS OR: neuro deficit, instability / progressive kyphosis
30
Most common location metastatic disease: C/T/L, upper vs lower
T, posterior elements
31
3 posterior element spine tumors
ABC Osteoid osteoma <2cm Osteoblastoma >2cm
32
Spine ABC - Imaging findings - Young or old - Histo - Treat
Fluid filled lesions in posterior elements Young - teens/20s Histo: blood filled spaces without endothelial lining Trt - En bloc / wide resection if in amenable location -> if not, poss radiotherapy - Curettage + bone graft (not curettage alone!)
33
Spine osteoid osteoma - Imaging findings - Young or old - Treat
Thin cut CT - nidus Young - kids Trt: en bloc removal Radiotherapy controversial near cord
34
Spine hemangioma - Imaging findings - Treat
Often anterior body XR: jail bar striations CT: polka dots MR: fluid bright lesion Trt: NTD
35
Spine eosinophilic granuloma - Imaging findings - Young or old - Treat
Vertebra plana KIDS Brace to prevent kyphosis
36
Spine giant cell tumor - Imaging findings - Young or old - Location - Treat
Destruction of the vertebral body 40/50s SACRUM Cant met to LUNGS Trt: - Surg excision = gold standard - High local recurrence - No rads 2/2 malig transf potential If someone wants non-op, can offer denosumab
37
Spine multiple myeloma - Imaging findings - Young or old - Labs - Treat
Lytic lesions Cold on bone scan OLD Labs: hyperCa, renal failure, anemia Trt: rads w/wo chemo
38
Chordoma - Imaging findings - Location - Treat
Slow growing lytic lesion Skull base or sacrum Trt: surg resection + recon - High local recurrence - NOT radiosensitive Dont confuse for GCT - many similarities
39
What are the components of the posterior ligamentous complex
Post joint capsule Interspinous lig Supraspinous lig
40
What is the difference between a compression and burst fracture?
Compression - anterior col only Burst - ant and middle col
41
What is vertebroplasty vs kyphoplasty
Vertebroplasty: pressurized cement, extravasates!!! = death Kyphoplasty = balloon creates a cavity, put low pressure cement into the balloon, lower extrav
42
What is a ligamentous vs bony Chance What is the difference for treatment
3 col flexion distraction injury Bony = posterior fracture - In theory can brace because bones heal Lig = PCL out - Fuse
43
What are the 3 part of a TLICS score What is the score threshold to operate
Morphology: compression, burst, translation, distraction PLC: intact, indet, disrupted Neuro: intact, nerve root, complete, incomplete <3 = nonop 4 = indet >4 = op
44
When do you give abx for spine GSW
If also abd organ injury (think transfer gut flora to CSF) Solid organ - oral abx Hollow organ - IV abx + tetanus
45
Describe neurogenic shock + trt
Hypotension + bradycardia Lose sympathetic pathway Trt = vol resus -> pressors
46
Describe ASIA classification
A = complete, no M/S B = incomplete, no M, S in C = incomplete, 1/2 M groups in, S in D = incomplete, decreased motor strength but all working, S in E = normal
47
Brown Sequard
Think stab/penetrating injury Ipsi motor, CL pain/temp Best prog ambulation
48
Central cord syndrome
Hyper ext inj UE > LE involvement
49
Ant cord syndrome
Vasc inj (+/- art Adamkiewicz) Motor, pain, temp loss Dorsal columns (proprioception) preserved Worst prognosis for ambulation
50
Posterior cord syndrome
Think late neurosyphilis Motor intact Lose proprioception (dorsal columns)
51
What spine trauma injuries are at risk for autonomic dysreflexia? Cause and presentation
T5 and above Cause: obstructed urinary cath / fecal impaction, boosting in para sports, unknown lower body fracture Sudden hypertension (potentially catastrophic) , flushing, blurred vision
52
What is the C7 plumb line
= SVA Middle C7 body to posterior corner of L5/S1 Does cross the T12/L1 junction? For sagittal balance
53
Define pelvic incidence - What is the goal PI - What does a high PI mean?
PI = SS + PT FIXED = line from center FH and line perpendicular to sacral endplate Goal PI = LL (within 10 deg) High PI = more horizontal sacrum So you have more lumbar lordosis to compensate for a horizontal sacrum
54
Goals for deformity correction LL-PI mismatch PT SVA target
LL-PI mismatch 9deg PT < 25deg SVA - 0 young patients - 0 in elderly can lead to PJK
55
What kind of osteotomy is: - Ponte / Smith Pete - PSO / VCO
Ponte / Smith Pete = posterior col *must have a flexible disc to correct through PSO/VCO = 3 col
56
What type of spondy is more common in kids/adults? What nerve is affected
Kids = isthmic spondy, L5/S1, exiting root L5 - Post elements stay still, rest moves forward, the central space is very open - Isthmic more likely to progress Adult = degen spondy, L4/5, trav root L5
57
What is the defining exam characteristics to differentiate conus vs cauda
Conus (T11-T12, T12-L1) - isolated bowel/bladder loss, NO MOTOR Cauda - back pain, LE motor weakness, b/b loss
58
Compare/contrast Jewett vs TLSO
Both control flex/ext Jewett - cheaper, better compliance TLSO - better rotational control
59
What are abscesses outside the spine associated with osteodiskitis in the C/T/L spine (may give you these as a hint to the underlying pathology)
C - retropharyngeal T - paraspinal L - psoas
60
Name contents of carotid sheath - how does this protect you during ACDF approach
AVN - art more medial Feel for the artery, go medial with dissection, all impt structures are protected lateral Common carotid art IJ Vagus n
61
Where does the recurrent laryngeal nerve recur on left vs right? Which is the "safer" side
L - aortic arch, lower, more consistent, "safer" R - subclavian, higher, more variable Injury = ipsi vocal cord paralysis
62
Where is the sympathetic chain live
Ant to longus coli Why don't want retractors riding up on the longus
63
How injury superior laryngeal nerve Which patients care about
High ACDF approach (C2/3) Retraction injury Lose high phonation - matters for singers
64
If you do a laryngoscope for a patient with suspected recurrent laryngeal nerve injury - what will you see
Vocal cords ADDucted Normal = aBducted
65
When can you do a pedicle screw in the C spine What is the more traditional C spine posterior screw
C2 and C7 if you confirm no vert on pre op MRI Otherwise C spine is lateral mass screws = up + out - Up = avoid exiting root - Out = avoid vert
66
Where is the artery of adamkiewicz
L SIDE - low thoracic spine (T8-12)
67
Where is the thoracic duct
L side T spine
68
For aging disc, what happens to chondroitin vs keratin sulfate?
Chondroitin DOWN Keratin UP
69
What is BMP mechanism, what one is for spine
TGF-B that pushes stem cells to differentiate to osteoblasts BMP2 - only for ALIF in a metal cage
70
Concern for BMP complication, 2 surgeries cannot use it
Retrograde ejaculation (swelling compromising the inf hypogastric plexus) - no diff CI if active or history of cancer - but doesn't cause cancer itself ACDF higher risk 2/2 swelling - never use PLIF don't use bc get HO along the insertion track
71
TLIF/PLIF vs ALIF for lordosis
ALIF best for restoring lordosis

Millers (29 decks)

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