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87 Cards in this Set
- Front
- Back
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C3-C4 HNP
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C4 nerve root. Motor: scapula. Sensory: lateral neck/shoulder. Reflex: none
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C4-C5 HNP
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C5 nerve root. Motor: deltoid/biceps. Sensory: lateral arm. Reflex: biceps
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C5-C6 HNP
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C6 nerve root. Motor: wrist extensor/biceps/triceps. Sensory: radial forearm. Reflex: brachioradialis
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C6-C7 HNP
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C7 nerve root. Motor: Triceps/wrist flexors. Sensory: middle finger. Reflex: triceps
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C7-C8 HNP
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C8 nerve root. Motor: Finger flexors/interossei. Sensory: ulnar hand. Reflex: none
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C8-T1 HNP
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T1 nerve root. Motor: interossei. Sensory: ulnar forearm. Reflex: none
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SAC
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normal: 17mm. Compressed at 13mm
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Finger escape sign
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small finger spontaneous abduction due to intrinsic weakness
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Incidence of asymptomatic HNP
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Cervical: 25% @ age 40. Lumbar: 40% @ 40yo
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Pavlov-Torg ratio
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Canal width/ vertebral body width. Normal: 1.0. <0.8: risk factor for neuro involvement
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Classification of neuro impairement in RA
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Ranawat classification. I: subjective paresthesias. II: Subjective weakness, UMN findings. III: Objective weakness, UMN findings. IIIA: ambulatory. IIIB: non-ambulatory
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AA subluxation in RA
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Etiology: pannus formation C1/C2 destroys transverse ligament/dens/ring of C1. Dynamic XR: >3.5mm motion. PADI <14mm or >9mm motion is risk factor for neuro involvement. Tx: Indication: SAC<14mm/myelopathy/progressive instability. C1-C2 screw fixation. Occiput-C2 fusion +decompression if irreducible. Anterior cord compression often resolves after PSF. Odontoidectomy rarely needed.
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Dynamic radiographs in AA subluxation
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>3.5mm abnormal. >9-10mm: increased risk of neuro injury
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Magerl fixation
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Screw fixation from C1-C2. Must do preop CT to determine vertebral artery location.
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Basilar invagination
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Cranial migration of Dens 2/2 erosion and bone loss. Dx: Ranawat's line most reproducible. Tx: if >5mm or neuro compromise. Tx with occiput-C2 fusion. If significant brainstem compromise: transoral/retropharyngeal odontoid resection
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Subaxial subluxation (RA)
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2/2 joints of Luschka/facet joints. Multiple level involvement common. >4mm or >20% of body width indicates cord compression. Cervical height index (body height/width) less than 2.00 100% sens/spec for predicting neuro compromise
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ADI
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normal: 7-10mm
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Spinal Shock
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24-72hr period of paralysis, hypotonia, areflexia. When over, spasticity, hyperreflexia, clonus begin. Bulbocavernosus returns when spinal shock over (may not return if cauda equina/conus syndromes)
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Neurogenic shock
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hypotension in presence of relative bradycardia. Treatment with selective vasopressors.
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Functional recovery post complete SCI
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80% improve one level/ 20% improve 2 levels.
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Central Cord Syndrome
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Most common. Upper extremities more affected than lower. Motor more affected than sensory.
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Anterior cord syndrome
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Posterior columns spared (proprioception/vibratory sensation). Worst prognosis
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Brown-Sequard syndrome
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ipsilateral loss of motor/proprioception. Contralateral loss of pain/temperature sensation. Best prognosis
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Steroid therapy for SCI
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Bolus 30mg/kg then 5.4mg/kg/hr. Duration 23hrs if within 3hrs/ 47hrs if 3-8hrs. Contraindicated in: penetrating injuries, pregnancy, <13yo, infection, uncontrolled diabetes
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Cervical traction
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Gardner-Wells tongs. 5-10lbs initially then 5-7lbs per cervical level. Radiographs in between each weight addition.
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Frankel Classification
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A: complete. B: sensory only distally. C: motor grades 1-2/5 distal. D: motor grades 3-4/5 distal. E: normal distally
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GSW to spine
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OR if: progressive neuro deficit, Intraspinal bullet fragment. If concomitant GI perforation then give IV antibiotics x 7-14 days (no I/D needed)
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Autonomic dysreflexia
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Sx: pounding headache, anxiety, profuse sweating, blurred vision. Tx: urinary catheterization, rectal dispimpaction.
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Prognosis nonoperative tx acute back pain
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>1/2 recover by 1wk/ 90% by 3mo. If no improvement @6wks then further workup indicated
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Intraoperative pulsatile bleeding tx
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Rapid wound closure, IV fluids, transfusion, laparotomy to identify and stop bleeding. Mortality >50%
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Scar vs recurrent HNP
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MRI diagnostic: scar enhances with contrast/ disc non-enhancing
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"Instability catch"
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Sudden painful catch when extending from flexed position. Indicates segmental instability
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Dynamic radiographs in lumbar segmental instability
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>10deg angular change/ >3mm translational change (20deg and 6mm at L5-S1)
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Incidence of adjacent segment disease after lumbar fusion
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15% @5yrs/ 40% @10yrs
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Definition of spinal stenosis
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Cross-sectional area <100mm2 or <10mm AP diameter
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Vascular claudication
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Distal-proximal pain pattern. Worse with uphill, better with rest. Symptomatic with bicycling/ better when lying flat.
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Neurogenic Claudication
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Proximal-distal pain pattern. Better with uphill, no symptoms with bicycling. May develop when lying flat.
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Disc position and affected nerve root
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Subarticular: traversing nerve root. (L5 root at L4-L5). Foraminal: exiting root. (L4 root at L4-L5)
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Extraforaminal nerve root compression
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Involves L5 root between sacral ala and L5 TP. RAD: Ferguson view (25deg caudo-cephalic view), axial imaging
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Natural history spondylolisthesis
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Unilateral doesn't progress. Bilateral: rate of progression slows over time
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Type I spondylolisthesis
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I: Dysplastic- congenital dysplasia of S1 superior facet
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Type II spondylolisthesis
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II: Isthmic- most common- predisposition leading to elongation/fracture of L5-S1 pars
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Type III spondylolisthesis
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III: Degenerative- >40yo- facet arthrosis leading to subluxation of L4-L5. Causes central/lateral recess stenosis and L5 radiculopathy.
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Type IV spondylolisthesis
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IV: traumatic: acute fracture other than pars
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Type V spondylolisthesis
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V: Pathologic: incompetence of bony elements
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Type VI spondylolisthesis
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VI: postsurgical: excessive resection of neural arches/facets
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Return to play in spondylolisthesis
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Grade I: return to full sporting if asymptomatic. Grade II: no gymnastics/football/etc… even if asymptomatic
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Risk factors for childhood spondylolisthesis progression
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Young age, female gender, >10 deg slip angle, high grade slip, dome shaped sacrum, >30deg sacral tilt, dysplastic type
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Pars defect repair
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Lag screw (Buck) or tension band (Bradford). Young patients with grade I and pars defect above L4
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Radiculopathy in spondylolisthesis
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L5 (S1 in HNP @ L5-S1)
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Treatment high grade spondylolisthesis
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In situ fusion indicated after 50% slip- L4-S1 fusion
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Reduction of spondylolisthesis
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Indication: sig cosmetic deformity, significant kyphosis (places construct on tension). 20-30% risk of L5 nerve root injury
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Gill procedure
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Excision of loose elements in spondyloptosis without fusion
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Burst fracture non-op treatment
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<20deg kyphosis, no neuro compromise
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Burst fractures fixation
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Posterior sufficient at midlumbar levels. Fuse 3 levels above to 2 levels below
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DISH
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non-marginal syndesmophytes. Can occur anywhere in spine, most in T spine R>L. No relationship with spinal pain. Associated with extra-spinal ossifications
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Ankylosing spondylitis
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HLA B27 associated. Marginal syndesmophytes. SI joint destruction. Concern for fractures with minor trauma.
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Effects of adult scoliosis
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Thoracic curve >60-65--> compromise pulmonary function. >90--> increased mortalitiy
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Indications for surgical treatment adult scoliosis
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symptomatic curve >50 in young adult, older patient w/ curve >90, progressive curves, cardiopulmonary compromise, spinal stenosis
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Adding fusion to sacrum in treating adult scoliosis
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Higher complication rate: pseudoarthrosis, hardware failure, loss of lordosis, pain. Improves stability. Adding anterior fusion to sacrum improves fusion rates
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Efficacy of bisphosphonates for prevention of vertebral fractures
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65% reduction @ 1yr, 40% @ 3yrs
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Surgical treatment adult kyphosis
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Posterior instrumentation and fusion of entire segment w/ compression implant. Anterior fusion if curve doesn't correct to <55deg on hyperextension radiographs
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Pedicle subtraction osteotomy correction
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30deg correction per level
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SI joint pain
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Elicited by FABER test. Can do diagnostic/therapeutic injection. Trochanteric cinch= orthotic of choice. Fusion not indicated except in infection.
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Timing kyphoplasty/vertebroplasty
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Best in active healing phase. Best demonstrated by MRI
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Idiopathic coccodynia
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May occur after pregnancy/ minor trauma +/- associated fracture. Self-limiting but may take 1-2 years. Surgery with high failure and complication rate.
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Tumors of posterior elements of spine
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ABC, osteoblastoma, osteoid osteoma
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MRI of spinal tumors
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Low intensity T1/ High T2. Gadolinium increases sensitivity
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Location of vertebral tumors
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Lumbar>Thoracic>cervical. Vertebral body more common
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Bone destruction required for lesions to be visible on plain radiographs
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30%
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Radiosensitivity of mets
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Prostate/lymphoid radiosensitive, breast 70% sensitivie, GI/renal radioresistant
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Vertebroplasty for spine mets
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Useful for myeloma/breast mets without instability/ neuro compromise
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Osteoid osteoma of spine
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Sx: painful scoliosis. Dx: bone scan/ thin cut CT. Tx: NSAIDS/resection. Scoliosis usually resolves after resection if <11yo
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Osteoblastoma of spine
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Posterior elements. Older patients. Usually have neuro compromise. Tx: resection/ stabilization
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ABC of spine
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2nd decade. Posterior elements>anterior elements. Tx: excision and/or XRT
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Hemangioma of spine
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Sx: usually asymptomatic. XR: "jail-house striations". CT: "spikes of bone". Vertebrae not expanded. Tx: Observation/ XRT if persistent pain after pathologic fracture. Anterior resection/fusion for pathologic collapse/neural compression. Caution: excessive bleeding
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Eosinophilic granuloma of spine
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Sx: Progressive back pain. Age <10yo. XR: vertebra plana. Dx: usually req biopsy. Tx: Observation +/- bracing. Chemo for systemic form. XRT if neuro deficits. 1/2 vertebral height expected to return
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Giant Cell Tumor of Spine
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Onset: 4th-5th decades. RAD: expansile destruction of vertebral body. Tx: Excision/ bone grafting. NO XRT. High recurrence rate expected.
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Multiple myeloma of spine
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Osteopenic lytic lesions. Tx: XRT with 3000-4000cGy +/- chemo. Surgery if instability/neuro symptoms.
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Chordoma
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Slow-growing lytic lesion in midline of anterior sacrum/base of skull. Possible in C-spine. Sx: intra-abdominal complaints + presacral mass. Tx: XRT + surgery. May excise up to 1/2 of sacral roots and still maintain continence. Cure is rare/ recurrence expected.
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Most common axial location for GCT
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sacrum
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Spine deformity associated with fibrous dysplasia
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scoliosis
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Vertebral appearance with lymphoma
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"ivory vertebrae"
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Discitis
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Sx: pain/tenderness, inability to sit/walk/stand. Lab: often nml. RAD: disc space narrowing, end plate erosion- appear at 10-21 days. MRI: diagnostic test o fchoice. Tx: bedrest, immobilization, antibiotics
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Pyogenic vertebral osteomyelitis
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Hx: Debilitated patients/ IVDU more common. H/o PNA/UTI/skin infection, immune compromise. Micro: hematogeneous spread- S. aureus. Fungal if immunocompromised. Sx: pain. Dx: osteopenia, soft tissue swelling, disc destruction (distinguishes from neoplasm). Gad enhances sensitivity. Tissue Dx mandatory. Tx: 6-12 weeks IV abx. Anterior debridement + strut grafting for refractory cases. Posterior surgery usually ineffective.
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Spinal Tb
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Most common extra-pulmonary site of Tb. Inc risk in HIV (CD4 50-200). Starts in body then spreads under ALL-->continguous levels or skip lesions. XR: anterior vertebral body destruction, disc preservation (distinguishes from pyogenic infection). Tx: antibiotics. OR for advanced disease with caseation/fibrosis/avascularity. Radical anterior debridement + uninstrumented autogenous strut grafting
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Calve disease
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vertebra plana
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