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93 Cards in this Set

  • Front
  • Back
A forward leaning gait may be indicative of what spinal pathology?
Stenosis
What is the most common level to find cervical nerve root compression?
C5-C6
What is the root affected, muscles affected, sensory loss, and reflex abnormality seen with compression at the following cervical nerve root level?
C3-C4
Root: C4
Muscles: Scapular
Sensory loss: lateral neck, shoulder
Reflex: None
What is the root affected, muscles affected, sensory loss, and reflex abnormality seen with compression at the following cervical nerve root level?
C4-C5
Root: C5
Muscles: Deltoid, biceps
Sensory: Lateral arm
Reflex: Biceps
What is the root affected, muscles affected, sensory loss, and reflex abnormality seen with compression at the following cervical nerve root level?
C5-C6
Root: C6
Muscles: Wrist extensors, biceps, triceps (supination)
Sensory: Radial forearm
Reflex: Brachioradialis
What is the root affected, muscles affected, sensory loss, and reflex abnormality seen with compression at the following cervical nerve root level?
C6-C7
Root: C7
Muscles: Triceps, wrist flexors (pronation)
Sensory: Middle finger
Reflex: Triceps
What is the root affected, muscles affected, sensory loss, and reflex abnormality seen with compression at the following cervical nerve root level?
C7-C8
Root: C8
Muscles: Finger flexors, interossei
Sensory: Ulnar hand
Reflex: None
What is the root affected, muscles affected, sensory loss, and reflex abnormality seen with compression at the following cervical nerve root level?
C8-T1
Root: T1
Muscles: Interossei
Sensory: Ulnar Forearm
Reflex: None
What is the most common level for symptoms from spondylosis to occur?
C5-C6
C6-C7 is the second most common level
What is a normal diameter of the cord canal of the cerivcal spine? At what diameter should you be concerned?
17mm
Concern at 13mm. This can be measured on a lateral radiograph
What type of gait disturbance may be seen with severe myelopathy (compression of the cord) of the cervical spine?
ataxis, broad-based shuffling gait
What is the "finger escape sign" associated with cervical myelopathy?
What is an "inverted radial reflex"?
What is Lhermitte's sign?
Finger escape sign: The small finger spontaneously abducts because of weak instrinsics

Inverted radial reflex: Ipsilateral finger flexion when eliciting the brachioradialis reflex

Lhermitte's sign: Radiating lightning-like sensations down the back with neck flexion
Are false-positive MRIs for cervical discs common?
Yes. Twenty-five percent of asymptomatic patients older than 40 will have findings of either HNP or foraminal stenosis on cervical MRI which is why correlation with history and physical is so important
What is myelomalacia?
An intrinsic change within the spinal cord, not a compressive phenomenon. This will show an area of bright signal in the cord on T2-weighted imaging
What is the best use of electrodiagnostic testing?
These have a high false-negative rate. They are best used to differenitate peripheral nerve compression from radiculopathy and for detecting systemic diseases such as ALS
When might you consider surgery for the cervical spine?
1. Myelopathy with motor/gait impairment
2. Radiculopathy with persistent, disabling pain and weakness that has failed conservative management with NSAIDs, PT, and extraforaminal cervical nerve blocks
When might you consider performing posterior plating along with an ACDF?
Adjunctive posterior plating may be considered in cases involving prior laminectomy, multilevel copectomy, and strut grafting, or three-level ACDF
What are 3 early postoperative complications with ACDF and at what rate do they occur?
- Dysphagia from esophageal retraction (9.5%)
- Surgical site hematoma with airway compression (1-11%)
- Recurrent laryngeal nerve injury (higher with right-sided approach)
Nonunion is a late postoperative complication of ACDF. At what rate does this occur with 1-3 levels and what should the treatment be?
Single level: 5%
Two levels: 6%
Three levels: 10%

Tx: Posterior Fusion
At 10 years after ACDF, what what rate does symptomatic disease of an adjacent segment occur?
25%
A canal-expansive lamninoplasty is used in cases of osiffied posterior longitudinal ligament and multilvel spondylosis/myelopathy, when is it contraindicated?
In the setting of fixed kyphosis
Total disc arthroplasties have limited follow up data at present. What levels can these surgeries be used for?
C3-C7
What causes occipital headache complaints in a rheumatoid patient with cervical pathology?
Compression of the greater occipital branch of C2
In a rheumatoid patient, is the goal to reverse significant neurologic change with sugery?
No, it is to stabilize it, especially if a tight canal is present
Describe the classification by Ranawat for neurologic impairment due to cervical spine pathology in a patient with Rheumatoid Arthritis
Grade Characteristics
I Subjective paresthesias, pain
II Subjective weakness; upper motor neuron findings
III Objective weakness; upper motor neuron findings
IIIA Ambulatory
IIIB Nonambulatory
What is a normal Atlanto-Dens Interval (ADI)? The presence of how much motion at the ADI on flexion/extension views is indicative of instability?
In an adult in flexion, the ADI should be less than 3mm. In children in flexion, should be less than 3.5mm.

Motion > 3.5mm
In an adult in flexion, the ADI should be less than 3mm. In children in flexion, should be less than 3.5mm.

Motion > 3.5mm
What posterior atlanto-dens interval (PADI) measurement is an indication for surgery?
PADI less than 14mm
PADI less than 14mm
What cervicomedullary angle is an indication for surgery?
Cervicomedullary angle less than 135 degrees
Atlantoaxial subluxation occurs in 50-80% of RA patients secondary to pannus formation at synovial joints between the dens and the ring of C1, resulting in destruction of transverse ligament, dens, or both. In what direction is the most common type of subluxation?
What 2 measurements are associated with an incrased risk of neurologic injury and usually require surgical treatment?
Anterior subluxation is the most common.

A PADI less than 14mm and C1-C2 motion of more than 9-10mm
What is the treatment for a reducible c1-c2 instability?
What if it is non-reducible?
Reducible: Transarticular screw fixation (Magerl) across C1-C2. NOTE: You must acquire a preop CT to evaluate the location of the vertebral arteries

Non-reducible AA subluxation: Remove posterior arch of C1 to decompress the cord
The second most common cervical spine manifestation of rheumatoid arthritis is cranial settling (basilar invagination) which occurs in 40% of RA patients. What is the pathogenesis? What is the most reproducible measure on a lateral C-spine XR?
Caused by cranial migration of the dens from erosion and bone loss between the occiput and c1-c2; often seen in combination with fixed atlantoaxial subluxation.
Ranawat's line most reproducible
Caused by cranial migration of the dens from erosion and bone loss between the occiput and c1-c2; often seen in combination with fixed atlantoaxial subluxation.
Ranawat's line most reproducible
How is basilar invagination treated? When is it treated?
Tx with occiput to c2 fusion
Surgery if cervicomedullary angle less than 135 degrees on MRI, or the presence of vertical nystagmus, or if there is ANY suggestion of cranial settling in cases of AA subluxation fusion is the conservative approach
Subaxial subluxation in RA occurs in 20% of patients. What is the pathogenesis?
Pannus formation in uncovertebral joints (joints of Luschka) and facet joints
What are the radiographic markers of instability in subaxial subluxation associated with RA?
Subaxial subluxation of greater than 4mm or more than 20% of the body

A cervical height index (cervical body height / width) of less than 2 approaches 100% sensitivity and specificity in predicting neurologic compromise
What is spinal shock and how long does it last?
A 24-72 hour period of paralysis, hypotonia, and areflexia following spinal cord damage
What physical exam finding signifies the end of spinal shock? When might this exam finding not be present?
Return of the bulbocavernosus reflex (anal sphincter contraction in response to squeezing the glans or tugging on the foley). Injuries below the thoracolumbar level (conus or cauda equina) may permanently interrupt the bulbocavernosus reflex
How can you differentiate neurogenic shock from hypovolemic shock?
Neurogenic shock (secondary to loss of sympathetic tone) will be associated with a relative bradycardia in neurogenic shock. Selective vasopressors are effective in neurogenic shock
In the setting of polytrauma including trauma to the spinal cord, why might a swan-ganz catheter be useful?
Neurogenic and hypovolemic shock commonly occur together. Hypovolemic responds to fluid resuscitation
It is important to perform a thorough neurological exam on a patient with truama to document the lowest remaining level of function. How is this level defined?
The most cephalad level with normal BILATERAL motor and sensory function
What radiographic lines should be assessed in the cervical spine on plain films?
Anterior Spinal Line
Posterior Spinal Line
Spinolaminar line
Anterior soft tissue shadows - "6 at 2; 20 at 6"
 - At C2: 6mm
 - At C6: 20mm
Anterior Spinal Line
Posterior Spinal Line
Spinolaminar line
Anterior soft tissue shadows - "6 at 2; 20 at 6"
- At C2: 6mm
- At C6: 20mm
What type of cervical spine fracture may be missed by CT scan?
Type II Odontoid as this is an axial plane fracture
A complete cord injury is signified by no function below a given level. With complete injuries, an improvement of one nerve root can be expected in what percentage of patients? What percentage recover two functioning root levels?
80% recover one nerve level
20% recover two levels
What are the 3 generalizations that can be applied regarding prognosis of cord injuries concerning sparing, speed of recovery, and recovery plateau?
1. The greater the sparing, the greater the recovery
2. The more rapid the recovery, the greater the recovery
3. When recovery plateaus, no further recovery will happen
What is the most common incomplete spinal cord injury?
Central cord syndrome
What is the pathology of central cord syndromes (there are 2)?
Age > 50: The cord is compressed anteriorly by osteophytes and posteriorly by the infolded ligamentum flavum

Extension injuries
What are the characteristics of central cord syndrome?
The cord is injured in the central gray matter resulting in greater loss of motor function to the upper extremities  than the lower extremities. There is a motor and sensory loss with variable sensory sparing.
The cord is injured in the central gray matter resulting in greater loss of motor function to the upper extremities than the lower extremities. There is a motor and sensory loss with variable sensory sparing.
What is the second most common incomplete cord injury and what is the pathogenesis?
Anterior cord syndrome caused by a flexion-compression injury. This has a poor prognosis
Anterior cord syndrome caused by a flexion-compression injury. This has a poor prognosis
What are the characteristics of anterior cord syndrome? What tracts are spared? What tracts are injured? What is the prognosis?
Incomplete motor and some sensory loss. The damage is primarily in the anterior two thirds and the posterior columns (proprioception and vibration) are spared. There may be greater motor loss in the legs than the arms. This syndrome takes out the anterior and lateral corticospinal tracts as well as the lateral spinothalamic tract. It has the worst prognosis.
How does brown-sequard syndrome usually occur?
What are the characteristics?
What is the prognosis?
Usually occurs with penetrating injuries.
Ipsilateral loss of motor, vibration, and proprioception;  contralateral loss of pain and temperature usually 2 levels below the lesion

This has the best prognosis of the incomplete cord injuries
Usually occurs with penetrating injuries.
Ipsilateral loss of motor, vibration, and proprioception; contralateral loss of pain and temperature usually 2 levels below the lesion

This has the best prognosis of the incomplete cord injuries
When is high dose methylprednisolone indicated with spinal cord injuries?
For cord injuries (NOT ROOT INJURIES) with accompanying neurological deficit (NASCIS II & III)

Relative contraindications: Pregnancy, age younger than 13, concomitant infection, penetrating spinal wounds, unctontrolled DM
How is skeletal traction performed for unstable, displaced cervical spine fractures?
Gardner-Wells tongs must be placed with pins parallel to the external auditory meatus. 5-10 pounds are added initially with the addition of 5-7 additional pounds per cervical level up to body weight. Sequential radiographs should be taken after weight is added
Is late decompression effective in improving root return in cervical spine trauma?
Yes, for up to 1 year
When is a gunshot injury to the spine treated surgically?
If there is progression of neurologic injuriy or if the bullet rests in the spinal canal. Note that penetrating spine injuries accompanied by gastrointestinal perforation should be treated with antibiotics for 7-14 days
What complication of spine injury most commonly follows spinal cord injuries above T6 and is marked by pounding heache (from severe hypertension), Anxiety, profuse head and neck sweating, nasal obstruction, and blurred vision
Autonomic dysreflexia
What are the 2 most common triggers of autonomic dysreflexia?
bladder distension or fecal impaction
This is a sports related injury commonly associated with stretching of the upper brachial plexus by bending the neck away from the depressed shoulder.
Stinger (burner)
Transient quadriplegia is usually caused by an axial load injury (spearing) but can also be seen with forced hyperextension or hyperflexion. What cervical levels are most commonly affected?
third and fourth
How does the water content of the discs change with age?
Decreases leading to tearing, mixomatous change, and herniation of nuclear material
What is the difference between protrusion and extrusion of a disc?
Protrusion: annulus intact, bulging nucleus

Extrusion: Through the anullus but confined by PLL
Thoracic disc disease is relatively uncommon (1% of all surgical HNPs). At what level do these most commonly occur, and what underlying disease may predispose patients to develop HNP?
Most herniations occur at T11 to T12, 75% occur at T8-T12.
Underlying Scheuermann disease may predispose to develop HNP
What approach is contraindicated for thoracic HNP? What approaches can be used?
Posterior approach (laminectomy) because of the high rate of neurologic injury.
For midline or central HNP, a transthoracic approach is usually used
For lateral HNP, a transpedicular approach is used
How do you look at the discs in a patient in which MRI is contraindicated?
Myelography
What is the most common disc involved in lumbar disc disease?
L4-L5. L5-S1 follows closely behind
What is the difference in location of the herniation as far as whether it gets the upper or lower lumbar nerve root?
Most herniations are posterolateral (where the PLL is the weakest) which would affect the traversing nerve root (L5 in an L4-L5 disease) leading to nerve root pain/sciatica

Herniations lateral to the neural foramen, "far lateral herniations" affect the exiting nerve root, L4 in L4-L5 disc disease
What has been reported to lead to the best outcomes with cauda equina syndrome?
Surgical decompression within the first 48 hours
What is the difference in location of pain with cauda equina and nerve root compression?
Cauda equina localizes to the buttocks or posterior thighs, true radicular pain due to nerve root impingement typically occurs distal to the knee
How is disc pathology changed with flexion vs extension in the lumbar spine?
Worsened with flexion, relieved with extension
What is the "inverted v" triad on the Minnesota Multiphasic Personality Invetory which has been identified as a significant adverse risk factor for lumbar disc surgery?
Hysteria, hypochondriasis, and depression
What is the nerve root, sensory loss, motor loss, and reflex loss for the following level?
L1-L3
Nerve Root: L2, L3
Sensory Loss: Anterior thigh
Motor Loss: Hip flexors
Reflex Loss: None
What is the nerve root, sensory loss, motor loss, and reflex loss for the following level?
L3-L4
Nerve Root L4
Sensory Loss Medial Calf
Motor Loss: Quads, tib ant
Reflex Loss: Knee Jerk
What is the nerve root, sensory loss, motor loss, and reflex loss for the following level?
L4-L5
Nerve Root : L5
Sensory Loss: Lateral calf, dorsal foot
Motor Loss: EDL, EHL
Reflex Loss: None
What is the nerve root, sensory loss, motor loss, and reflex loss for the following level?
L5-S1
Nerve Root: S1
Sensory Loss: Posterior calf, Plantar foot
Motor Loss: Gastroc/soleus
Reflex Loss: Ankle jerk
What is the nerve root, sensory loss, motor loss, and reflex loss for the following level?
S2-S4
Nerve Root: S2, S3, S4
Sensory Loss: Perianal
Motor Loss: bowel/bladder
Reflex Loss: Cremasteric
S2, S3, S4 Perianal Bowel/bladder Cremasteric
Are tension signs important with lumbar disc pathology?
Tension signs such as straight-leg raising or the bowstring sign (L4-L5 or L5-S1) and the femoral nerve stretch test (L2-L3 or L3-L4) are critical findings that suggest HNP and are important when discectomy is considered.
What is the most specific physical exam finding for lumbar disc pathology?
Contralateral straight-leg raising
What is the best study for a recurrent HNP?
MRI with gadolinium
At what point is further evaluation of back pain with an MRI necessary?
After 6 weeks of no improvement with conservative therapy
What is the next step in a patient who has predominantly leg pain (sciatica) in whom conservative therapy fails?
Lumbar epidural steroids may help in 40-60% of patients
What are the recurrence rates in patients with following disc surgery in which there is a massive posterior annulus loss or without a contained defect?
20-40%
How is intraoperative pulsatile bleeding due to deep penetration managed in the setting of lumbar surgery?
Rapid wound closure, IV fluids and blood, repositioning the patient, and a transabdominal approach to find and stop the source. Mortality may exceed 50%
How is a dural tear managed in lumbar disc surgery?
Primary repair is necessary to avoid the development of a pseudomeningocele or spinal fluid fistula. This is more common with revision surgery, and a fibrin adhesive sealant may be a useful adjunct. Bed rest and subarachnoid drain placement should be done if a leak is suspected
Does discitis following lumbar disc surgery require repeat surgery?
Usually not
When should cauda equina caused by an extruded disc, surgical trauma, and hematoma be suspected following disc surgery and what should the initial test be?
It should be suspected with postoperative urinary retention. Digital rectal exam is used for the initial diagnosis
What is the definition of absolute stenosis?
A cross-sectional area of less than 100mm^2 or 10mm of AP diameter as seen on CT cross section
Why is central stenosis more common in men?
Men's spinal canal is smaller at the L3 to L5 levels than in women
What are the boundaries of the lateral recess in the lumbar spine?
Defined by the superior articular facet posteriorly, the thecal sac medially, the pedicle laterally, and the posterolateral vertebral body anteriorly
What are the boundaries of the intervertebral foramen?
Bordered superiorly and inferiorly by the adjacent level pedicles, posteriorly by the facet joint and lateral extensions of the ligamentum flavum, and anteriorly by the adjacent vertebral bodies and disc
What is the normal foraminal height and width in the lumbar spine?
Normal height: 20 to 30 mm
Superior width: 8 to 10 mm
What are the indications for fusion when operating for spinal stenosis?
- Surgical instability (removal of one facet or more)
- Pars defects (including those that are postsurgical) with disc disease
- Symptomatic radiographic instability
- Degeneraative or isthmic spondylolisthesis
- Degenerative scoliosis
Impingement of nerve roots lateral to the thecal sac as they pass through the lateral recess and into the neural foramen is associated with disc disease and what other process?
Facet joint arthropathy (superior articular process enlargement)
Does lateral recess stenosis affect the traversing nerve root or the exitiing?
Traversing (L5 in an L4-L5 disease)
Does foraminal stenosis affect the traversing or the exiting nerve root?
Exiting (L4 in L4-L5 pathology)
What is the subarticular recess in the lumbar spine?
Bounded by the takeoff of the nerve root from the dural tube to the medial border of the pedicle. Narrowing of this causes lateral stenosis and affects the traversing nerve root