92 A Abos

Front 1

45yo F IV drug user presents to the ED c/o severe focal low back pain progressed over the past 10 days, dfficult for her to walk, night sweats, fluctuating fever, loss of appetite. PE shows exquisite pain with flex & ext lumbar spine. urinalysis ER + urinary tract infection. WBC=12,6 ESR= 78. lat xray Fig A. Which is the best choice in managt?

Back 1

1-D/C w/ PO Abx; 2-Admission hospital w/ immediate empirical IV Abx; 3-MRI of the lumbar spine w/ & w/out gadolinium;4- Nuclear medicine bone scan; 5. Renal ultrasound:::highly suspicious of vertebral osteo. MRI w/ & w/out gadolinium is the most appropriate next step managt=> blood cx, CT blood bx if Bd cx in (-), opn Bx then ABX 6-12.Ans3

Front 2

All of the following are characteristics of juvenile ankylosing spondylitis EXCEPT? 1-Spinal stiffness; 2-Sacroiliitis; 3-Urethritis; 4-Enthesitis; 5-Kyphosis

Back 2

sacroiliitis, spondylitis, enthesitis, HLA B-27, kyphosis, asymmetric lower extremity inflammatory arthritis, decreased chest expansion, and uveitis, but NOT Urethritis (which is typical of the triad of Reiter syndrome). Ans 3

Front 3

pt w/ ankylosing spondylitis & hip flex contracture undergoes uneventful R THR using a Kocher (posterior) app. This pt is at incr risk for which of the following complications post-op?

Back 3

1-Post hip dislctn; 2-Ant hip dislctn; 3-Deep infection; 4-Osteolysis; 5-Periprosthetic fx:::concomitant hip flex contracture inc post-op rates of ant hip dislctns. the relationship of the pelvis ->lumbar spine in the sag plane in order to avoid an excessively hyperextnd hip.Ans2

Front 4

32yo M c/o low back & hip pain-> gradually worsening x 1 yr. sx are worse in the AM. xrays Fig A. Lab studies (+) HLA-B27. What additional finding confirm the dx? 1-Erythema marginatum; 2-(+) HLA-DR3; 3-Uveitis; 4-(+) Rheumatoid Factor; 5-Elevated urine phosphoethanolamine

Back 4

Bilateral sacroiliitis & postive HLA-B27 is diagnostic of ankylosing spondylitis. negative RF titer. uveitis.HLA-DR3=SLE.Elevated urine phosphoethanolamine = hypophosphatasia.Erythema marginatum =major criteria for Acute Rheumatic Fever.RF =rheumatoid arthritis, Sjogren's, sarcoid, SLE.Ans3

Front 5

69yo M s/p fall on ice. On arrival in ER he is found to a 2 cm lac on the back of his head, c/o neck pain, but is oriented to place & time & neurologic exam = nl. Cervical & lumbar xrays no evidence of fx. What is the next step in tx.

Back 5

1-flex-ext xrays; 2-CT lumbar spine; 3-CT cervical spine; 4-technetium bone scan 5-treat w/ soft collar & d/c pt home::: increased risk for cervical fx->very difficult to see on xray->high mortality rate secondary to epidural hemorrhage->cervical spine should be immobilized until there is unequivocal evidence that there is no cervical spine injury.Ans3

Front 6

45yo M w/ ankylosing spondylitis c/o fixed sagittal imbalance & difficulty with horizontal gaze, kyphotic deformity is localized to the thoracolumbar spine. Which of the following procedures allows the most correction in the sagittal plane at a single level w/out having to resect the intevertebral disc?

Back 6

1-Smith-Petersen osteotomies; 2-Pedicle subtraction osteotomy (PSO); 3-Vertebral column resection (VCR); 4-Single-level opening wedge osteotomy; 5-Multi-level opening wedge osteotomies::: (PSO) provides > sagittal correction than: single-level opening wedge osteotomy, Smith-Petersen osteotomies, Multi-level opening wedge osteotomies. w/OUT resect the intevertebral disc.Ans2

Front 7

29yo M c/o numbness & tingling in his LE & gait instability x 2 wks. PE shows 3+ brisk patellar reflexes. MRI in Fig A. What is the most appropriate first line of tx? 1-Obser; 2-PT 3-Epidural injection; 4-Laminectomy; 5-Ant diskectomy

Back 7

thoracic disk herniation w/ spinal cord compression causing sx of thoracic myelopathy. This is an indication for surgery. Thoracic level disk herniations are tx'd w/ ant diskectomy w/or w/out fusion.Ans5

Front 8

64yo F s/p endocarditis x 6 mths tx'd w/ IV Abx. She c/o 3 mths of severe low back pain, progressive LE weakness, parathesias x 1 wk. WBC nl & afebrile. ESR & CRP are elevated. xray & MRI Fig A & B, What is the most appropriate next step in managmnt?

Back 8

1-Intrathecal catheter placement w/ ABX x 6 wks
2-I & D, corpectomy, fusion; 3- PO prednisone regimen x 4 wks; 4-I & D via posterior approach;5-Initiation of multiagent abx regimen for TB x 6 mths:::extensive destruction of the lumbar spine extending >3 vertebral segments w/ associated epidural abcess necessitating surgical decompression & fusion, epidural abscess may present rapidly with neurological compromise, 23% of patients with paralysis completely recover after decompression.Ans2

Front 9

In pts w/ a stable thoracolumbar burst fx & no neurologic deficits, op tx has what long term outcome vs nonop managt? 1-Improved sagittal balance; 2-Dec pain scores; 3-Improved RTW status; 4-Improved function; 5-Incr disability & complications

Back 9

thoracolumbar burst fx w/out neurologic deficits, w/ intact two- and three-column-injured Denis-types A, B and C= NO advantages to surgical tx.Ans5

Front 10

32yo M s/p L4 burst fx in a MVA 5 days ago. On initial presentation= neurologically intact & tx in a thoracolumbar orthosis. In last 2 days he has inc'g difficulty voiding, dec perianal sensation, weakness to ankle PF. xrays, CT MRI Fig A-D. What is the next step in tx?

Back 10

1-EMG; 2-Spinal dose corticosteroids w/ in-pt obser; 3-decompressive lumbar lami w/out fusion; 4-Percut pos instrum stabilization L2 - L5 w/ indirect decomp via distraction 5-Ant decompresssion w/ strut graf followed by pos instrumentation::: pt w/ cauda equina syndrome following a lumbar burst fx, Surgery is indicated = unstable fx patterns &/or neurologic deficits, if progression. Urgent ant decompression w/ strut grafting is indicated followed by instrum stabilization, w/ pos instrumentation.Ans5

Front 11

32yoM in ED c/o L1 burst fx in a fall. neurologic exam= ASIA E. MRI - mild vertebral retropulsion w/ 10% central canal stenosis, no injury to the posterior ligament complex. Which of the following is true re surgical decomp & and fixation vs nonop tx w/bracing?

Back 11

1-Pts tx w/ surgery RTW earlier; 2-Pts txd w/ surgery have dec pain scores; 3-Pts txd w/ surgery have incr complic rates; 4-Pts txd w/ surgery have improved final SF-36 scores; 5-All of above::: Asia E=nl, stable thoracolumbar burst fx w/ no neurological deficit, NO major long-term advantage vs nonop tx, BUT does inc compli rate.Ans3

Front 12

A 29-year-old male presents with numbness and tingling in his lower extremities and gait instability for two weeks duration. Physical exam shows 3+ brisk patellar reflexes. Magnetic-resonance-imaging is shown in Figure A. What is the most appropriate first line of treatment?

Back 12

1. Observation 2. Physical therapy 3. Epidural injection 4. Laminectomy 5. Anterior diskectomy:::thoracic disk herniation with spinal cord compression causing symptoms of thoracic myelopathy. This is an indication for surgery. Thoracic level disk herniations are treated with anterior diskectomy with or without fusion.Ans5

Front 13

In pediatric discitis, which of the following is the most accurate description of the radiographic findings. 1. The earliest radiographic finding is loss of normal lumbar lordosis, followed by disc space narrowing and endplate erosion.
2. The earliest radiographic finding is disc space narrowing, followed by endplate erosion and loss or normal lumbar lordosis.

Back 13

3-The earliest radiographic finding is endplate erosion, followed by disc space narrowing and loss or normal lumbar lordosis; 4-The earliest radiographic finding is scalloping of the inferior endplate, followed by disc space narrowing and endplate erosion; 5-The earliest radiographic finding is vertebra magna, followed by disc space narrowing and endplate erosion:::Isolated disk space narrowing may be seen after 1 week. Endplate changes may be seen at 1-3 weeks. “Sawtooth” erosion of adjacent vertebral end plates may be seen at 3-4 weeks. Scalloping of the superior or inferior endplates may be seen with longstanding infections.Ans1