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256 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Most common atlas fracture and most common mechanism?
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posterior arch; hyperextension
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What is a Jefferson fracture?
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simultaneous fracture of the anterior and posterior rings
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Treatment for most C1 injuries
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nonoperative
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If C1 fragments are displaced more than 7mm, what was most likely injured?
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transverse ligament
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What is a type I odontoid fracture?
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frx of tip
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what is a type II odontoid fracture?
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"Waist" of the dense
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What are risk factors for nonunion of Type II dens?
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age>60, >5mm displacement or 9deg angulation, smoking
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What is a type III dens fracture?
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through the body of C2
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what is the nonunion rate for Type II dens fracture?
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11-100%
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In the absence of instability, type I dens fractures can be treated how?
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cervical orthosis
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How should dens fractures type II fractures that are angulated >10deg be treated?
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posterior atlantoaxial arthrodesis
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What is a type I C2 fracture?
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through the neural arch at the base of the pedicle, <3mm translation
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what is a type II C2 fracture?
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translation >3mm through the neural arch
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What is a type III C2 fracture?
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facet dislocations at C2-C3 in addition to displaced pars fractures
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what is the treatment for type III C2 fracture?
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ORIF and posterior C2-C3 fusion
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what is the treatment for type II C2 fracture? What is contraindicated?
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halo; traction
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What is the treatment of type I C2 fracture?
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cervical collar
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What was studied in NASCIS 1?
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Moderate vs low-dose methylprednisolone at 6w, 6mo, 1 yr
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What were the 3 variables in NASCIS II?
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high-dose methylprednisolone vs naloxone vs placebo
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What was the conclusion of NASCIS II?
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If patients treated within 8 hours, high-dose MP resulted in greater motor function recovery at 6 weeks, 6 months and the final outcome.
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What were the 3 treatment wings in NASCIS III?
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Methylprednisolone x 24h, MP x 48h, tirilazad mesylate x48h
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What is the NASCIS protocol?
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If presenting within 8 hours of injury: 30mg/kg bolus over 1 hour, then 5.4mg/kg for 24 hours
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What was the conclusion of NASCIS III?
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Pts with SCI who recieve MP within 3hours of injury should be maintained on it for 24 hours. If >3 but <8h, maintain MP for 48h.
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MOst common primary malignant spine tumor
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multiple myeloma
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Most common location for spinal tumors
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extradural
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Most common benign primary spine tumor
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vertebral hemangioma
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Most common intramedullary spinal cord tumor
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ependymoma
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True or false: The majority of primary intramedullary tumors are malignant
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true
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spinal tumors that show mixed osteoblastic and osteolytic changes
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breast and lung
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spinal cord tumor that typically has a plane between the tumor and surrounding spinal cord thereby allowing it to be more easily resected
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ependymoma
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most common type of spinal cord injury associated with chronic radiation myelopathy
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Brown seqard
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imaging of choice for arachnoiditis
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MRI
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failure of transverse ligament is suspected with >?mm atlantoaxial instability
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3mm
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At what translation is atlantoaxial instability treated?
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>5mm
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Anything greater than 3mm is abnormal, anything greater than 5mm is unstable
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Most common cervical segment for spondylosis
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C5-C6 (followed by C6/c7) = most motion at these segments
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What is White's criteria for instability of cervical spine?
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translation of 1 vertebrae on another of 3.5mmm or angulation of adjacent vertebrae of 11 degrees
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normal canal diameter for c-spine
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17mm
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definition of central cervical stenosis
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10mmd
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What is the torg ratio?
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divides canal length by the length of the vertebral body; <0.8 is stenotic
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most common site of vertebral osteomyelitis
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lumbar spine
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when is surgery indicated in children with spinal TB?
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<15yo + >30 deg kyphosis
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most common site of epidural abscess
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thoracic
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epidural abscess from hematogenous spread are usually located anteriorly or posteriorly
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posterior
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What are the 3 types of findings on MRI for arachnoiditis
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Type 1: nerve roots clumped together
Type 2: nerve roots adherent to dura Tyoe 3: increased signal intensity of intradural compartment on T1 weighted images (minimal enhancement with gad because adhesions are not vascularized) |
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most common cause of myelopathy in HIV
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AIDS associated vacuolar myelopathy (CD4 counts <200)
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predominant sites of vacuolar myelopathy in the SC
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dorsal and lateral tract
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CMV classically causes necrotizing radiculomeylitis of this region of the SC
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cauda equina
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If pain is present with scoliosis in a young patient, this should be ruled out?
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osteoid osteoma (must have high index of suspicion)
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If pain is present in a young patient with scoliosis and xray is negative, what should be ordered?
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technetium bone scan to r/o osteoid osteoma or osteoblastoma
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eosinophilic granulomas are associated with this type of vertebral collapse
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vertebra plana (uniform collapse)
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Where is CSF located?
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the subarachnoid space
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Nucleus dorsalis of clarke is located in this laminae and sends exaon to this tract
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lamina VII, dorsal spinocerebellar tract
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intermediolateral cell column is located in this lamina
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lamina VII
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IN the anterior horn, describe the topographic organization of the nerves?
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extensors are ventral to flexors; axial muscles medial to distal muscles
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dorsal spinocerebellar tract is responsible for this
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controlling movement of individual lower limb muscles and postures
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anterior spinocerebellar tract is responsible for this
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conveys information regarding whole limb movements and postural adjustments to the cerebellum
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How is the spinothalamic tract organized?
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sacral and lumbar fibers lie dorsolateral to those of the thoracic and cervical fibers
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this is the opposite of the posterior tracts as these fibers cross
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What constitutes the anterior corticospinal tract?
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the 8% of corticospinal fibers that do not cross in the medulla
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The cerebral cortex and cerebellum can influence the activity of the alpha and gamma motor neurons thru this tract
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rubrospinal (Does not extend past cervical level)
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What is the action of the rubropsinal tract on flexor and extensors?
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facilitates flexors, inhibits extensors
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How many pairs of paravertebral ganglia?
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22
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What is the transmitter liberated by the SNS at the sweat gland and blood vessels of skeletal muscles?
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acetylcholine
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origin of anterior and posterior spinal arteries?
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vertebral artheries
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Angle of facets in cervical spine
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45 degrees
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angle of facets in thoracic spine
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60degrees
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angle of facets in lumbar spine
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90degrees
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what 2 findings of instability signify disruption of 3 columns of spine?
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displacement and wide vertebral canal
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What is the standard c-spine series?
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lateral, AP, and open mouth atlantoaxial projection
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under normal circumstances, there should never be more than ? mm of unilateral or bilateral atlantoaxial overlap
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2mm
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what motion is atlantoaxial joints most responsible for?
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flexion/extension
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Usual cause of jefferson fracture
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axial compression to top of head
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what determines stability of the jefferson fracture?
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integrity of transverse ligament
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in normal adults, the atlas-dens interval should not exceed how many mm?
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3mm
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most common mechanism for hangman's fracture?
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hyperextension + axial compression
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most serious cervical spine injury compatible with life because it almost always causes anterior cord syndrome
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flexion teardrop fracture
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clay shoveler's fracture is an avulsion of fracture of either of these spinous processes
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C7, C6, T1
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What is the mechanism of extension tear drop fractures?
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anterior longitudinal ligament avulses a fragment from the anterior-inferior border of the higher vertebral body( usually Stable)
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fracture line passes horizontally thru the spinous process and predicles into the vertebral body
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Chance fracture
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characteristic motility disorder of esophagus found in tetraplegic
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low amplitude contractions
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Lesions above this level may not feel classic heartburn
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T7
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Position patient should lie in after sitting upright to eat meal for SMA syndrome
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Right lateral recumbent for 1 hour
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higher incidence of biliary sludge seen at this level of SCI
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T10 or above
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gallbaldder receives sympathetic innervation from these levels
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t7-t10
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What is the sympathetic supply to the colon?
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T5-T12 mesenteric nerve
T12-L3 hypogastric nerve |
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Major contributor to pressure in the anal canal at rest
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internal anal sphincter
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inhibitory reflex still intact after LMN lesions to the gastrointestinal nervous system
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rectal-anal - so reflex relazation of the internal sphincter with rectal distension as stool advances
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nerve which mediates the anocutaneous reflex
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inferior hemorrhoidal branch of the pudendal nerve
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at what age does female SCI=male SCI
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<3
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Among children who sustained their SCI when they were 8 years of age or younger, ?% were paraplegic and ?% had complete injuries
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70%, 2/3rds %
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most common level of injury in lap belt injuries
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l2-L4
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SCI related breech delivery usually affect this area of the spinal cord
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lower cervical --> upper thoracic
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dosage of LMWH heparin in chidlren
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0.5mg/kg
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When is bracing with TLSO indicated in children <10 with scoliosis?
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qwhen curve > 20-45 degrees
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When should surgery be done to correct scolioiss in children >10?
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>40 degrees
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average onset of HO in pediatric population
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14 months
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most common site of pathologic fracture (including children)
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supracondylar region of femur and proximal tibia
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paralyzed muscles undergo this muscle fiber transformation
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type I to type II
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Most common symptoms of syrinx
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pain
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peak incidence of HO in adults
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2 months
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most common type of spine tumor
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extramedullary
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most common type of intramedullary tumor in adults? in children?
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ependymoma, astrocytoma
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location of most extramedullary ependymomas
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filum terminale, conus medullaris and cauda equina
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most common location for intramedullary astrocytomas
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thoracic cord
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type of ependymoma seen at the distal part of the spinal cord usually
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myxopapillary
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von Hippel Lindau syndrome is associated with this spinal intramedullary tumor
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hemangioblastoma
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most common area for meningioma
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thoracic
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spinal tumor that has a "polka-dot" appearance on Ct
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hemangioma
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benign tumor that has a unique tendency to affect the posterior part of the vertebra
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osteoid osteoma
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most common extramedullary tumor
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sheath tumors (neurofibromas, schwannomas)
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With nerve sheath tumors, shwannomas tend to affect this part of the nerve root and neurofibromas the other part
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schwannoma --> dorsal
neurofibromas--> ventral nerve root |
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most common location of intradural meningiomas
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posterolateral thoracic cord
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these may preclude gadolinium enhancement for meningiomas
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calcificatiosn
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well circumscribed astrocytoma
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pilocytic
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most common location of spinal cord tumor in children
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intramedullary astrocytoma in the thoracic cord
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intraspinal lipomas are most commonly seen with disorder
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spinal dysraphism
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developmental tumors in children are predominately seen in this area of the spinal cord
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lumbosacral
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pathophysiology of SCI from AVM
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increased venous pressure
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number 1 symptom of AVM in spine
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sensory symptoms
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most common AVM in the spine
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Type 1 (dural AV fistulas)
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Which 2 tracts are most commonly affected in subacute combined degeneration?
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posterior columns and corticospinal tracts
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What is found on MRI in subacute combined degeneration?
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hyperintense T2 weighted images confined to posterior columns
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most commonly affected spinal segment in subacute combined degenerations
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lower cervical
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is sphincter disturbance common in subacute combined degeneration?
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no
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vitamin E deficiency may lead to this neurologic abnormality
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spinocerebellar degeneration
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Neurolathyrism presents most commonly with this
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motor weakness
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myelopathy in SLE is commonly associated with this laboratory marker
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anticardiolipin antibodies
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surgical event associated with hepatic myelopathy
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portosystemic shunting
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pathologic finding in hepatic myelopathy
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demyelination of lateral tracts
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most common cancers for paraneoplastic necrotizing myelopathy
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small cell lung CA, ovarian CA, and lymphoma
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time course for early radiation myelopathy
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6 weeks to 6 months
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onset for delayed radiation myelopathy
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6months to 4 years
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cases with shorter latency of delayed radiation myelopathy showed this on autopsy
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white matter changes (vs vascular lesions that showed on delayed cases)
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Internal anal sphincter closure is maintained by this
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sympathetic discharges L1-L2
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What is the rectal--anal inhibitory reflex?
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internal sphincter tone is inhibited with rectal dilatation by stool (or by digital stimulation)
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normal anion gap
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8-16
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normal HCo3
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22-26
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Purpose of BR to ECRB tendon (at the base of the 3rd metacarpal)
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to augment wrist extensor strength
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What is the Moberg Procedure?
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FPL is sutured to the palmar aspect of the radius so that when the wrist is extended, the thumb opposes the side of the index finger
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deltoid must have this amount of strength to do deltoid to triceps transfer
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4/5
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ideal stimulation frequency for upper extremity and lower extremity (NMES)
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12-16hz upper, 18-25Hz lower
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Cervical level that most NMES units are targeted for
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C5-C6
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electrical stimulation of this sacral n. is most important for detrusor contraction
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S3
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stimulation of this sacral root may cause erection
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S2
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normal latency for phrenic nerve on nerve conduction studies
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7.5ms
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preferred approach for phrenic n. stimulation (cervical vs thoracic)
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thoracic due to less risk of activation of other nerves and less risk for mechanical stress from movement of the neck
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Higher levels of stimulation to diaphragm are required in the (sitting or supine) position with phrenic n. stimulation
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sitting (due to shorter diaphragm length). Can be reduced by abdominal binder
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Why is MRI contraindicated in phrenic n. pacing?
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magnets can lead to phrenic n. injury
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Why do children require a much longer period of conditioning after phrenic n. pacer placement?
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diaphragm in children has a small % of type 1, fatigue resistant fibers.
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NMES converts type IIa fibers to what?
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type IIb (intermediate fatigability) and type I (Fatigue resistant)
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What are more energy efficient: rigid or folding frames?
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rigid
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ultralightweight wheelchairs weigh less than this
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30lbs
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axonal variety of GBS associated with infection with this organism
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campylobacter jejuni
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CSF findings in GBs
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elevated protein, normal pressure, few or no cells
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pathologic findings with GBS
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perivascular mononuclear cell inflammation,demyelination and edema
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treatment for GBS
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plasmapheresis and IVIG
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treatment of CIDP
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steroids
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cranial n. most commonly involved in GBS
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CN7
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2 factors linked to ventilatory dependence in GBS
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cranial n involvement and dysautonomia
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mechanism of action of florinef
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enhances renal Na conservation, increases sensitivity of arterioles to NE
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mechanims of action of ephedra
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releases stored catecholamines, direct action on adrenoreceptors
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resting metabolic rate in tetraplegic
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22.7kcal/kg/day
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resting metabolic rate for paraplegic
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27.9kcal/kg/day
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Jewett brace is most effective in preventing flexion/extension at these levels
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T6 and L1
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greatest risk periods for kidney stones
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first 3 months
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alkaline urine predisposes to formation of these 2 types of stones
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magnesium ammonium phosphate and calcium phosphate
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What is a craig-scott orthosis?
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doube metal upright KAFO but without thigh and calf bands (easier to don and doff)
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Where are the bands located on a Craig Scott orthosis?
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has a rigid posterior thigh band and rigid anterior tibial band.
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type of knee used in craig scott orthosis
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bail lock which allows the lock to be disengaged by posterior pressure such as the edge of a seating surface
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Where are the electrodes placed on a parastep?
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quadriceps, peroneal n, gluteal muscles
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minimum width of a ramp
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3ft 6inches
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house entranceway width should be at least how many inches
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32inches (34 inches if powerchair); 36 inches if turn is involved
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minimum dimensions of an accessible bathroom
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8ft x 10ft
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height of kitchen counters
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30inches with 24inches beneath for knee clearance
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minimum turning space for power chair
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6ft x 6ft
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max height for light switches
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36inches
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risk factors for depression specific to SCI
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complete neurologic injury and medical comorbidity of TBI
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leading cause of death in SCI individual <55
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suicide
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average peak cough flow in tetraplegic
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220L/min (non SCI = 300-700)
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Vital capacity decreases by this much in sitting vs supine in tetraplegia
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50% (best to wean tetra from ventilator in supine position)
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Which type of SCI do better without abdominal binders for respiration?
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central cord when there is preservation o fthe intercostals but paralysis of diaphragm
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initial ventilator tidal volume and flow rate in tetra
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12-15ml/kg of IBW, 70 L/min
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In the ventilator protocol for tetra, if peak pressure <40, the tidal volume should be increased by how much?
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100ml/day (50ml if patient<5ft 6inches)
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What is the maximum tidal volume?
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25ml/kg IBW
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Most common location for HO
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HKES
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most common location for HO in hip
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anteromedial aspect of hip
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recommended dose of etidronate to treat HO
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20mg/kg for 2 weeks followed by 10mg/kg per day for 3 months
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most frequent location of artery of adamkewics
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T11 on left
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what is the watershed in the spinal cord?
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upper/mid thoracic area
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is location of pain a reliable guide for to site of vascular malformation
|
no
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CSF findings in MS
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oligoclonal bands and increased IgG
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15% of cases of ALS are attributed to this gene defects
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antioxidant enzyme Cu/Zn superoxide dismutase
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mechanism of action of riluzole
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inhibits presynaptic release of glutamate
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What are the 2 types of LMNs?
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alpha and gamma
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gamma motor neurons project to this type of muscle fiber
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intrafusal (alpha projects to extrafusal)
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mechanism of action of diazepam
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GABA- A receptor agonist which facilitates Cl conductance and hyperpolarizes the membrance
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enlargement of the central canal within the spinal cord
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communicating syringomyelia
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type of syrinx that develops within the gray matter of the spinal cord
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noncommunicating
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SCI patients with more than 15 degrees of kyphosis and more than 25% canal stenosis are twice as likely to develop this
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posttraumatic syrinx
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chiari I malformation
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downward displacement of cerebellar tonsils
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Chiari II malformation
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downward displacement of the cerebellar vermis, pons and medullar into foramen magnum
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Most common cause of syringomyelia
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chiari I malformation
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Which 2 traits carry the highest risk of OSA in sCI?
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obestiy and use of antispasticity medications
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Are ASIA scores and PFTs predictive of OSA?
|
no
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level of injury that should avoid succinylcholine during anesthesia?
|
thoracolumbar with LMN injureis
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components of anterior column
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anterior vertebral body, anterior longitudinal ligament and anterior half of annulus fibrosis
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components of middle colums
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posterior vertebral body, posterior longitudinal ligament and posterior half of annulus fibrosis
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If motor strength was grade 2/ 5 at the zone of injury 1 week after injury, then there is ?% chance that patient would regain functional strength at the next neurologic level
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80
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if grade 1 or 2 at the ZOI 1 week after injury, ?% would recover to next neurologic level within 3-6months
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80%
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4 MRI characteristics with siginificatn negative prognostication of neurologic recovery and independent from initial clinical exam
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presence of spinal cord hemorrhage, length of hemorrhage, length of edema, and spinal cord compression
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Can the H reflex be elicited during spinal shock?
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yes (unless it is a LMN injury)
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Can the F reflex be elicited during spinal shock?
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no
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The heart and blood vessels for the entire body are supplied by sympathetic outlfow from levels?
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T1-T7 (heart is T1-T4)
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The splanchnic vasculature receives innervation from which levels?
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T5-T7
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classic triad of neurogenic shock
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hypotension, bradycardia and hypothermia
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excitatory parasympathetic transmission to the bladder is mediated through ACh action at this receptor
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M3 muscarinic receptor
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parasympathetic inhibitory input to the urethra sphincter is medicated by release of this substnace
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nitrous oxide
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Excitatory input from somatic efferent fibers of the pudendal n. to the urethral sphincter are mediated by this receptor
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nicotonic receptors
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2 types of afferent nerves of the bladder
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A-delta (tension), C fibers - inflammation, pain
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micturition part of the thalamus
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ventral posterior nucleus of the thalamus
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most common form of bladder cancer seen in SCI
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squamous cell CA
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diaphragm function is responsible for this amount of the vital capacity
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60%
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most common NLOIs
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C5, C4, C6
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order of recovery in central cord syndrome
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legs, then bladder, then proximal arms, then hands
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order of recovery in brown-sequard
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recovery takes place in the ipsilateral proximal extensors and then the distal flexors
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What are the advantages of early vs late spinal surgery after SCi?
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shorter LOS and less pulmonary complications (no difference in neurologic or functional improvement)
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drug of choice for hypotension with bradycardai
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dopamine (alpha and beta agonist)
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Why is phenylephrine not recommended in neurogenic shock?
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alpha stimulation may lead to reflex bradycardia, worsening the already present bradycardia
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Peak airway pressure should be under this
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40cm of H20
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2 medications that increase surfactant
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B agonists and theophyllines
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What was the conclusion of NASCIS III?
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initiation of high dose MP within 3 hours is optimal and should be continued for 24h. If given 3-8h, 48h of MP should be given
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What is the Walking Index for SCI
|
WISCI 21 level scale of walking, based on physical assistance and need of braces/devices
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|
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What is the quadriplegia index of function scale?
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scale for evaluating UPPER extremity function
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|
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What is the MOA of etidronate?
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prevents conversion of amorphous calicum phosphate to hydroxyapatite (also has antiinflammatory effect)
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neuroblastoma tumors in children are almost always located at this level in the spinal cord
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thoracic
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pediatric spinal cord tumor that typically is painless
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neuroblastoma
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When should vaccines be given to patient with MS when they are currently in a relapse?
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wait 4-6 weeks until relapse has resolved (Except for tetanus that can be given emergently for a wound)
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sympathetic efferents to adrenal medulla
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mostly T5-T9 (but can range from T3-L3)
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|
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Lesions above this level will have impared adrenal response to exercise
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T9
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MAP should be kept above this after acute SCI
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85mmHG for 5-7days
|
|
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definition of spinal shock
|
loss of all or most sympathetic mediated physiologic reflexes below the level of injury
|
|
|
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first reflex to appear after spinal shock
|
deep plantar reflex (pathologic reflex that eventually disappears)
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last reflex to return after spinal shock
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knee jerk
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6 components of braden scale
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sensory perception, moisture, activity, mobility, nutrition, friction/shear
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|
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most common type of bladder cancer
|
squamous cell (transitional cell is more common in able bodied population)
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|
|
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risk factors for bladder cancer (3)
|
indwelling foley, bladder stones, frequent UTIs
|
|
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What is the union rate for type III fractures?
|
approaches 100% due to larger surface area and more vascular bone
|
|
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How are type II odontoid fractures treated if <10deg angulation and <5mm of displacement?
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with halo (if greater displacement, may need traction first; if severely displaced may need arthrodesis)
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|
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describe type IIA odontoid frx and what are their treatment?
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have signficant angulation but minimal translation, traction is CONTRAINDICATED - halo is treated
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|
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treatment of spinal aneurysmal bone cysts
|
exchsional bioopsy (needle biopsy may lead to hemorrhage and neurologic deterioration)
|
|
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these tumors frequently involve the neural arch and are expansile osteolytic cavities that often contain fine strands of bone (like an eggshell)
|
aneurysmal bone cyst
|
|
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most common location for degenerative spondylolisthesis
|
L4-L5
|
|
|
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which malignancies most commonly metastasize to the spine?
|
breast, lung, prostate, renal, GI, thyroid
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|
|
|
IV drug users have a high incidence of this bug in osteomyelitis
|
pseudomonas
|
|
|
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which 2 organisms are most common in chronic biofilms?
|
s.aureus and proteus aeruginosa
|
|
|
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VAC pressure setting for kids up to 2 years
|
50-75
|
|
|
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Major problem with use of mitoxantrone (novantrone) - antineoplastic agent used predominately for secondary progressive MS
|
cardiotoxic effects (need regular monitoring with echos and MUGA scans)
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