Abos Day 93 A

Front 1

27yo F w/ Down's c/o neck pain, progressive gait instability, and loss of fine motor dexterity in her hands. Flex & ext x-rays Fig A & B ->demonstrate occipitocervical instability. When performing an occipitocervical fusion, what location in Fig is best placement of an 8mm unicortical screw?

Back 1

1-A; 2-B; 3-C; 4-D; 5-E::: the safe zone for screw placement in the occiput for occipitocervical fusion is in a triangular region created by connecting 2 dots 2cm lat to the EOP and a pt 2 cm inf to the EOP. The thickest region of the occiput is at a pt 5 cm lateral to the EOP.Ans2

Front 2

(mnemonic - Waddel signs

Back 2

(mnemonic - ROADS) 3 of 5
R-Regenial inconsisteant mortor or sensory findings which do not follow dermatomal pattern
O-Overreaction to PE w/ facial expressions, tremor, verbalization, muscle tension or fainting.
A-non Anatomic pain - Tender crosses multiple somatic boundaries w/out any anatomic distribution.
D-Distraction - negative straight-leg raise with patient distraction
S-Stimulation, pain with axial compression or simulated rotation of the spine

Front 3

pts w/ symptomatic lum disc hern failed nonop managt, which of the following pt characteristics are assoc w/ improved tx effects w/ surgery? 1. Duration of sx > 6 mos, improving symptoms at baseline, Mental Component Score (MCS) > 35

Back 3

2. Duration of symptoms < 6 mos, worsening sx at baseline, Mental Component Score (MCS) > 35; 3-Age > 41 yrs, divorced, presence of worker comp claim; 4-Age < 31 yrs, absence of jnt problems, no workers comp; 5-Age > 41 yrs, absence of jnt problems, married status::: (>90%) improve w/ nonop tX w/in 3 mths.Ans5

Front 4

33yo F c/o pain down her R leg & numbnss dorsum R ft x 3 mths ago during a bowel movement. Prior she had had 1 mth of low back pn, had a lmbr microdiscmy L4/5 3 yrs ago which was successful. PE= difflt DF R foot @ ankle (4/5). MRI Fig A. After a failure of nonop tx, which of the following is the most appropriate surgical tx?

Back 4

1-L4/5 microdiskectmy midline apprch; 2-L4/5 microdiskectmy w/ far latl Wiltse apprch; 3-L4/5 Decomp, TLIF, instrumntd fusn; 4-L4/5 Decomp, PLIF, instrum fusn; 5-L4/5 Ant Lum Interbdy Fusn:::dx= recurr lum disc hern, revsn microdiskctm (laminotomy & discectomy ), midline for poslat or central, no sign of instability or spondylolisthesis.=no fusn.Ans1

Front 5

35yo M c/o pn radiating down L leg, worse in the anterior leg distal-> knee. PE, unable to go from a sitting ->standing position w/ a single leg on L, whereas he has no difficulty on R. His patellar reflex=0 on L, and 2+ on R. Which of the following clinical scenarios would best produce this pattern of sx?

Back 5

1-L L2-3 foraminal HNP; 2-L L4-5 central HNP; 3-L L4-5 paracentral HNP; 4 L L4-5 foraminal NHP; 5-L L5-S1 paracentral HNP:::L4 radiculopathy, dec patellar reflex & quadriceps weakness, L4-5 foraminal (far lateral) HNP.Ans4

Front 6

pt C/O far lat HNP L4-5 disc. Which of the following findings is most likely to be present? 1-lat foot numb; 2-ant thigh numb; 3-ankle DF weak; 4-ankle PF weak
5-EHL weak:::

Back 6

L4 nerve root is =exiting root, Ant thigh numb=L2 or L3 nerve-NOT, EHL weak= L5 palsy-NOT, Lat foot numb &PF weak S1 palsy-NOT, ankle DF weak 2^ weak, and quad is 1^ weak therefore. Ans3

Front 7

foraminal of far lateral disc herniation affects the exiting nerve root, while a paracentral or posterolateral disc herniation affects the traversing nerve root
L5 radiculopathy caused by a right paracentral disc herniation at L4/5 which is compressing the L5 nerve root. A L4/5 paracentral disc involves the L5 nerve root. The muscles innervated by L5 nerve root include EHL and tibialis anterior, and therefore these patients may present with a "foot drop". While EHL is usually innervated by L5 alone, tibialis anterior has variable innervation by L4 and L5.

Back 7

L4 radiculopathy. This is supported by his decreased patellar reflex and quadriceps weakness. A L4-5 foraminal (far lateral) herniated nucleus pulposis would most likely cause symptoms in the L4 distribution as foraminal herniations most commonly affect the exiting upper nerve root at a given lumbar level.

Rainville et al performed a study to identify the most sensitive physical exam test to detect quadriceps weakness caused by either an L3 or L4 radiculopathy. They found in L3 and L4 radiculopathies, unilateral quadriceps weakness was detected by the single leg sit-to-stand test in 61%,

Front 8

In pts w/ lum HNP resulting in sign unilatl leg pain but no func limiting weak, surgical decom has what long term effects when compared to nonop managt? 1- Worse outcomes in pain, physical function, RTW @ 4 yrs; 2-Equivalent outcome in

Back 8

pain & physical func @ 4 yrs; 3-Improved outcome in pain & physical function @ 4 yrs; 4-Improved outcome in RTW only @ 4 yrs; 5-Worse outcome in RTW w/ equivalence in pain & physical function @ 4 yrs:::Recent evidence now supports that pts who undergo surgery for lumb HNP have signifily > improvement in pain, function, satisfaction, & self-rated progress @ 4 yrs compared to pts tx'd non-op.Ans3

Front 9

34yo M c/o 7 mths R-sided radiclr pain to his AM shin & med ankle which has failed non-op Tx, PE=foot drop & decr patellar reflexes, MRI fig A & B. Op tx is: 1-ant- retroperitoneal approach w/ ant- lum interbody fusn (ALIF); 2-ant transperitoneal app w/ discectomy only;

Back 9

3-pos midline lum lami, decom & fusn w/ pedicle screw fixn; 4-pos midline hemilami w/ discectomy
5-paraspinal mus-splitting app to the intertransverse space & discectomy R-sided far lat disc HNP @ L4/5:::far lat disc HNP @ L4/5, affect the L4 nerve, Wiltse paraspinal approach preserves segment stability by avoiding injury lamina & facet jnts. potential compn is DRG injury ->dysesthesias.Ans5

Front 10

27yo M is an unrestrained pass in MVA, stabilized in the ER. CT scans Fig A & B. He is neurologically intact, placed in a halo fixator prior to surg Tx What is the MC neurologic compln w/ halo traction?

Back 10

1-Weak in biting &chewing strengt; 2-Deficit in med & downward eye movmt; 3-Deficit in lat eye movmt
4-Inability to close eyes against resistance; 5-Tongue deviation toward the affected side::: pt w/ Type II odontoid fx. CN VI palsy (abducens N-lat rectus) MC nerve palsy assoc w/ halo cervical traction.Ans3

Front 11

The halo vest is most effective at controlling which of the following spinal motions? 1-Rotation @ atlantoaxial jnt; 2-Flex & ext the subaxial cervical spine; 3-Rotation subaxial cervical spn

Back 11

4-Lateral bend subaxial cervical spn; 5-Fle & ext at the cervicothoracic junctn::: intercalated paradoxical motion in the subaxial cervical spine, and is therefore less ideal for lower cervical spine injuries.lat bending was incr @ C6-7 w/ loose superstructure.Ans1