Abos Day #96 A

Front 1

57yo F w/ PMH-DM & arrythmias requirg pacemaker c/o severe b/l LU x 12 mths, sx> w/prolonged walking & improved with sitting, stationary bicycle no sx. On PE is neurologically intact LE, ABI of 0.95. A flex & ext xray Fig A. An axial CT myelogram @ L4/5 level Fig. Extensive nonop tx w/ PT & epidural steroid inj have failed to provide any relief. What next step in txt?

Back 1

1- Obtain MRI; 2-Refer to a vascular surgeon for tx of PVD; 3-lumb decomp; 4-lumb decomp & instrum fusin
5-lumb decomp & uninstrumented fusn::: neurogenic claudication due to grade I degen spondylolisthesis @ L4/5. successful arthrodesis occurred in 82% of the instrum vs. 45% of the noninstrum cases, pedicle screws may lead to a > fusion rate.Ans4

Front 2

49yo M c/o L arm pain x 4 wks. T2-MRI Fig. Which most accurately describe his dx and PE findings? 1-C5 radiculopathy w/ deltoid & biceps weak. 2-C5 radiculopathy w/ brachioradialis & wrist ext weak; 3-C5 radiculopathy w/ triceps & wrist flex weak; 4-C6 radiculopathy w/ brachioradialis & wrist ext weak 5-C6 radiculopathy w/ finger flex weak

Back 2

posterolateral HNP@ C5/6, C6 radiculopathy= dermatomal arm pain, paresthesias in the thumb, weak to brachioradialis, wrist ext, diminished brachioradialis reflex. C6 nerve root exits at the C5-C6 disk space, and a C5-C6 disk herniation typically leads to C6 radiculopathy.Ans4

Front 3

57yo c/o w/ R arm pain x 4 wks.c/o pain began following a tennis match & has not improved w/time, aching sensation that affects his lat forearm that improves when abd shoulder, sensation of numbness R thumb. Reflex exam= 1+ right biceps reflexes and 2+ right triceps reflexes which symmetric, Sensory exam paresthesias in the distribution of the right thumb. Motor exam shows no evidence of radial deviation w/ active wrist ext. Motor exam on the R shows 5/5 deltoid, 5/5 elbow flex w/ the palms facing upward, 4/5 wrist ext, 5/5 elbow ext, 5/5 wrist flex. What is etiology of his sx?

Back 3

1-Tendinosis & inflam @ origin of ECRB; 2-Compres of the PIN by the proximal edge of supinator; 3-Compr of the ulnar nerve in Guyon's canal; 4-paracentral cervical HNP@ C5/6; 5-foraminal HNP@ C6/7::: C6 radiculopathy. cause by a a paracentral cervical disc herniation at C5/6.ANs4

Front 4

38yo M c/o cervical HNP @ C7/T1 level w/ ass foraminal stenosis, but no significant central stenosis. What would be the expected sx and PE findings? 1-Numb lat shoulder & deltoid weak; 2-Numb 2nd & 3rd fingers & triceps weak; 3-Numb thumb w/ weak wrist ext 4-Numb 5th finger w/ weak to long flex func in all digits & thumb; 5-Numb med elbow & weak to long finger flex 4th & 5th digits

Back 4

HNP @ C7/T1 level will affect C8 nerve root. A C8 radiculopathy presents w/ sensory sx in the med border of the forearm & hand, weak in long flex func in all digits & thumb. differentiate a C8 radiculopathy from a peripheral ulnar neuropathy which also presents with sensory symptoms in the ulnar hand and finger.Ans4

Front 5

pt w/ arm pain & paresthesias, which sx or PE findings supports a cervical radiculopathy NOT peripheral neuropathy? 1-Relief of pain when holding the arm above the head; 2-Reproduction of pain w/ tilting head to affected side and rotating head to contralateral side
3-Compensatory inter-phalangeal joint flex of the thumb when attempting to pinch; 4-Pt is unable to make "A OK" sign w index finger & thumb 5-Forearm pain w/ resisted wrist ext

Back 5

Relief of pain when holding the arm above the head is indicative of a cervical radiculopathy instead of a peripheral neuropathy, maneuver seems to occur by decreasing tension on the nerve root.Ans1

Front 6

FigA CT 27yo M that suffered a fall from a significant height. Which of the following xray meas would best indicate disruption of the transverse lig? 1-(ADI) =3mm; 2-Pos atlanto-dens interval (PADI) = 16mm
3-C2 pars horizontal displac=3 mm; 4- Combined lateral mass displac= 8.2mm; 5-Power's ratio of 1.2

Back 6

Jefferson fx=fx of the ant & pos arch of the atlas, Tx 1- intact transverse ligament represents a stable injury-> cervical orthosis. A ruptured transverse ligament represents an unstable fracture pattern that should be treated w/ halo immobilization or a C1-C2 posterior cervical fusion. Two parameters (+) ruptured transverse ligament are 1) a sum of lateral mass displacement over articular surface of C2 is 8.1mm or greater, and 2) an atlantodental interval (ADI) of 6mm or greater.Ans4

Front 7

A Gallie C1-2 fusion w/ sublaminar wiring of C1 to the spinous process of C2 is a valid tx option for which injury patterns? 1-occipital-cervical dissociation; 2- comminuted C1 burst fx; 3-type I odontoid fx; 4-type III odontoid fx; 5-transverse lig disruption

Back 7

C1-2 fusn w/sublaminar wiring or modern screw-rod constructs is indicated in transverse ligament injuries, “Recurrence of the [atlanto-axial] displacement following disruption of the transverse ligament can be prevented by fastening the two vertebrae together by fine steel wire passed around the laminae or spines. And the risk of late recurrence can be eliminated by bone grafts laid in the spines or on the laminae and articular facets."Ans5

Front 8

Biomechanical studies have shown that an atlanto-dens interval of >7mm is likely associated with? 1-an intact transv lig, w/ rup alar & apical lig;
2-rup transv lig w/ intact alar & apical lig 3-rup transv & apical lig, w/ intact alar lig 4-rup trans & alar lig w/ intact apical lig 5-rup transverse & alar lig & a rup tectorial memb

Back 8

intrinsic lig, located within the spinal canal, provide most of the lig stability. transverse atlantal lig is the strongest component, connecting the post odontoid to the ant atlas arch, inserting laterally on bony tubercles. odontoid lig (alar and apical ligaments) are the most ventral lig structures. The paired alar lig connect the odontoid to the occipital condyles. lig form 3 layers ant to the dura. ADI is < 3mm & < 5mm in children.Ans5

Front 9

51yo M w/ a pacemaker reports difficulty w/ urination & numbness in his b/l buttock. sx began 12 hrs ago. What is appropriate step in managt? 1-MRI lum spine
2-CT myelogram lum spine; 3-Epidural steroid inj; 4- Emergent lum decomp; 5-High dose methylprednisone

Back 9

most important next step is identifying a source of compression in the lum spine. The study of choice is an MRI, however in patient who cannot have an MRI-pacemakers, a CT myelogram done, Cauda equina is an ABSOLUTE indication for surgical tx.Ans2