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117 Cards in this Set

  • Front
  • Back
Neck injury in football player
do not remove helmet on field- remove helmet and shoulder pads in one maneuver
C-spine clearance in awake alert patient
no x-ray needed if no pain; if have pain, AP, Lat, open mouth.
C-spine clearance in patient with uncertain x-rays
CT, followed by ACTIVE flex/ext if CT equivocal, followed by MRI (if get MRI early that is adequate)
Highest death rate in spinal cord injury- when and why?
w/in first year; death by Pneumonia (#1), followed by infection, homicide, suicide
Neurogenic Shock
Hypotension, relative bradycardia. If suspect neurogenic shock, Swan Ganz and Pressors. Careful w/ fluids
Autonomic Dysreflexia
Symptoms: Headache, agitation, sweating, hypertension; Treatment: check Foley, disimpact
Foley Management in Spinal cord injury
Place Foley in OR in sterile condition; keep in three days, then remove and start intermitent catheterization
Anterior Cord injury
Profound Motor, worst prognosis
Central Cord injury
most common incomplete spinal cord injury: UE>LE
Brown-Sequard
Hemisection of cord; contralateral loss of pain and temerature, ipsalateral motor loss
Role of steroids in spinal cord injury
Overall, practice abandoned due to low functional benefit and increased risk of complications; but if you use, do w/in 8hrs of injury; contra-indications GSW, pregnancy, under 13.
Reduction of Fx/Dislocation of spine
if complete SCI, no MRI needed; if awake and alert w/ incomplete SCI, get MRI to make sure there is no HNP; in obtunded patient, get MRI first
Colonic injury GSW to spine
10 days Abx, don’t remove bullet unless bullet in canal (with cauda equina)
Occipital Condyle Fx
common to see Cranial Nerve Palsy; Rule out occipital-cervical dissociation and Tx w/ rigid orthosis
Occipital-Cervical Dissociation
Powers Ratio: Basion to post arch atlas - anterior arch atlas to opisthion; Harris Line: Basion to tip of dens >12mm=ant dislocation
Jefferson Fracture
bilat ant/post ring; if transverse ligament injury get >8mm spread lat masses; put in Halo whether or not ligament injured; if lig injured will eventually need C1-C2 fusion
Cervical Transverse Ligament Injury
Get MRI; Type I: mid substance: won’t heal, Type 2 avulsion, will heal; Tx: Type I will need C1-2 fusion.
Dens Fracture
Type I (tip) Tx: Halo, Type II (mid) Tx: surgery if displacement >6mm initially, late diagnosis, >50yrs, redisplacement, Type III (base) Tx: Halo
Surgery for Dens Fracture
Anterior osteosynthesis w/ 1 or 2 screws if early fracture, low BMI, fracture obliquity; C1-C2 fusion with wiring, transarticular screws, etc
Hangman’s Fracture
Traumatic spondylolisthesis of the axis (pars Fx C2 and tearing of PLL w/ anterior translatio of C2)
Hangman’s Fracture Types and treatment
Type I <3mm displacement, no angulatio; orthosis: Type II >3mm angulation; reduce then Halo, Type III: C2-3 facet dislocation: operative reduction and fusion C2-3
Burst Fracture C-spine with retropulsion
Decompression anterior for SCI <goal of root recovery>; consider posterior instrument/fusion if post lig injury
Cervical spine facet dislocation
unilateral - clasically 25% subluxation (harder to reduce b/c PLL intact); Bilateral- classically 50% subluxation; Tx: reduction by traction in neuro intact patient
Cervical spine facet dislocation if not neuro intact
if complete SCI, no MRI; if incomplete, get MRI. get MRI if obtunded/incooperative patient, neuro worsening.
Cervical spine facet dislocation with HNP
Do ACDF first, then posterior fusion instrumention
Thoracic cord trauma
narrow canal/cord ratio; watershed blood supply; more stable due to ribs and sternum
Thoracic cord trauma indications for fracture in Compression/Burst
>30 deg kyphosis, 50% collapse, if spinal cord injury, decompress Anteriorly if incomplete SCI, don’t decompress if complete SCI
Most common complication of thoracic pedicle screw placement
aortic injury
Thoracolumbar Trauma
T11-L2; Rigid thorax to mobile L-spine; coronal orientation thoracic facets, sagittal orientation lumbar
Stability in T-L spine injury
3 column: Middle column key to stability- if it is injured, needs treatment, though not necessarily surgical. Posterior ligamentous complex is disrupted, then typically it is unstable, if neuro defecit, typically unstable and needs surgery
T-L burst fractures
>25 deg kyposis, >50% collapse, >50% canal compromise
Canal remodeling
50% of retropulsed bone will remodel eventually
Non-operative treatment
Non-operative is first line of treatment.
Approach for T-L spine trauma
Neuro defecit go anterior, if disruption of posterior lig complex, need to go post; if both, then do combined
L4-L5 Compression Fracture
Think post lig injury; ususally treated non-op
Chance Fracture
most common L3; Ant Long Ligament if center of rotation of injury; Associated abdominal injury; Tx: Bony- cast or brace; ligamentous- posterior instrumentation/fusion
Sacral Fracture
Zone I (lateral to foramen) 6% neuro injury, Zone II (through foramen) 28% neuro injury, Zone III (through canal) 50% neuro injury
Complete versus Incomplete SCI
complete- no sacral root sparing, incomplete: sacral sparing or posterior column sparing
Spinal shock
24-72 hour period of paralysis, hypotonia, areflexia. Return of bulbocavernosus reflex signifies end of spinal shock.
Which nerve root is involved in a given spinal segement - cervical spine
Always the lower root (example: C5-C6: C6 nerve root)
False positive MRI
under age 40: 14%, over age 40: 24%
Cervical Disk Disease: diagnosis
no EMG needed: MRI adequate
Cervical Disk DIsease: Management
collar, moist heat, physical therapy, traction, injections (facet, etc)
Cervical disk disease: Mangement in myelopathic patient
surgery
Cervical radiculopathy
>6 -8 weeks pain, coorelative MRI findings, OK to operate
Cervical Disk Replacement indications
indicated in myelopathy and radiculopathy (same indication as ACDF)
posterior Keyhole laminoforaminotomy C-spine
good for unilateral, one level radiculopathy, does not assess neck pain
Cervical myelopathy- causes
Stenosis, spondylosis, cervical kyphosis, OPLL
Cervical myelopathy: Signs and symptoms
gait deterioration, UE weakness/clumsiness, atrophic hand, UMN signs (20% negative)
Cervical Myelopathy: Natural history
All progress though at different rates, none really improve; all need non-urgent surgery
Cervical myelopathy: radiographic diagnosis
<13 mm sagittal diameter (17mm normal) indicative of stenosis, Pavlov’s ratio 1:1 <0.8 = stenosis; MRI test of choice
Indications for laminoplasty in cervical myelopathy
OPLL, multi-level disease (>3) preserved lordosis;
Most common complication in laminoplasty c-spine
C5 root palsy with severe deltoid weakness that typically resolves
Most common litigated complication in ACDF
recurrent laryngeal nerve injury (right > left); may be subtle voice change: Tx is observation x 6 weeks. If no resolution, refer to ENT
Rheumatoid Spine
pannus w/ ligamentous laxity (transverse ligament), can erode and destroy dens itself; C1-2 most common
Suprior migration of odontoid
McRae line: dens should not cross this line- it means Dens is in the skull
Anesthesis in patients with C1-2 instablity
unstable if >4mm motion; awake intubation, alert anesthetist
Operative indications C1-C2 instability Rheumatoid Spine
best predictor of impending neurologic injury PADI in FLEXION view <14mm, also anterior ADI >9-10mm
Surgical treatment of C1-C2 instability
Posterior fusion and wiring with Halo OR transarticular screws; Fuse to occiput if basilar invagination- when in doubt fuse to occiput
Rheumatoid C1-C2 instability: Cervico-medullary angle
should be greater than 135 degrees, if less than 135, fusion should include occiput (angle of spinal cord to brainstem)
Surgical indications for thoracic disk disease
myelopathy, progressive neuro deficit, intractible radicular pain not responsive to non-op Tx
Treatment for thoracic disc disease- Surgery
should almost never do in general, exhause non-op; no laminectomy indicated anymore, alternative approaches used because thecal sack should not ever be retracted/moved
Surgery for thoracic disk herniation: lateral herniation
Transpedicular
Surgery for thoracic disk herniation: paramedian heniation
Posterolateral (through costotransversectomy) can also do multiple levels
Surgery for thoracic disk herniation: Central herniation
Anterior approach with thoracotomy, VATS, remove rib head pedicle, create trough
Low back pain: conservative treatment
no more than 24-48 hrs bedrest; progressive increase activities, no x-rays x 4 weeks, minimize injections, physical therapy and chiropractic; No MRI unless pursuing diagnosis of tumor/infection
Lumbar disc disease- inflammatory mediators
TNF-alpha, inflammatory cytokines, phospholipase A2 concentrated in nerve root ganglion
Nerve involved in postero-lateral or paracentral HNP L-spine
get traversing/lower nerve root (example in L4-L5 get L5 nerve root)
Nerve involved in foraminal (far lateral )HNP L-spine
get exiting nerve root (L4-L5 get L4 nerve root)
Cauda equina- clinical findings
presentation with bilat LE pain/weakness, saddle anesthesia, inability to initiate urination with possible overflow incontinence
Cauda equina- urgency to decompress
best results if decompressed within 48hrs of presentation
Lumbar HNP tension signs
Straight leg raise only works for L5-S1 HNP, contralateral SLR highly specific
Lumbar HNP nateral history
80-90% improve w/o surgery (phys therapy, injections, rest, NSAIDS), most better 4-6 weeks; OK to operate as early as 6 weeks
Lumbar HNP indications for early surgery
cauda equina, progressive weakness, persistent, disabling pain (often pts with recurrent sciatica or superimposed stenosis)
Lumbar HNP indications for surgery
sciatica, abnormal neuro finding, positive tension sign, confirmatory MRI, failure of at least 6 weeks non-op
Discogenic back pain- gold standard diagnostic study
coorelative discogram, with at least one control (non-painful level), that coorelates with MRI findings and patients symptoms
Discogenic back pain- treatment
cannot do posterior fusion alone- disk is pain generator; options are ALIF, TLIF, A/P fusion, disk replacement (single level)
Lumbar disc replacement- most common complication
transient leg pain
Congenital lumbar stenosis
Short pedicles, medially placed facets, trefoil canal (achondroplastics)
Central lumbar stenosis
caused by lig flavum, inferior facet
Lateral recess lumbar stenosis
postero-lateral bulging disk, overgrowth superior facet, thickening of facet capsule <gets traversing nerve root>
Foraminal lumbar stenosis
Facet enlargement, uncinate spur <gets exiting nerve root>
Lumbar stenosis signs and symptoms
more comfortable in flexion; leg pain, neurogenic claudication; limited spine extension with pain; SLR rarely positive
Straight leg raise
positive in HNP, usually negative in spinal stenosis
Thecal sack area under which diagnostic of central lumbar stenosis
Thecal sac < 100mm squared in axial view diagnostic of spinal stenosis (more a research tool)
Spinal Stenosis: indications for fusion
degenerative spondylolisthesis, >50% facet resection, degenerative scoliosis
Spondylolysis
fatigue fx pars interarticularis; L5 most common; 75% of these are present at age 6
Adult isthmic spondylolisthesis
L5 pars defect, extension catch, sometimes L5 weakness/radiculopathy. Often patient has long history of pain
Adult isthmic spondylolisthesis- indications for fusion
progressive slip, progressive motor defecit, symptoms greater than six months; decompression if significant LE symptoms
Adult idiopathic scoliosis: risk and rate of progression
don’t progress if curve <30 degrees, progress if curve >50 deg (R thoracic); progress at rate of 3.3 degrees/year
Adult idiopathic scoliosis: indications for surgery
documented curve progression, intractable pain (usually at concavity), Cosmesis
Adult scoliosis: complications
most common is pseudarthrosis T12-L1 (not necessarily indication for surgery- can observe)
Adult kyphosis: osteoporotic
treat non-operatively at all costs- bisphosphonates, most are below T5; if above T5 think tumor
Vertebroplasty
transpedicular cement injection; done only in acute, painful fracture (increased signal T2, decreased on T1, edema on STIR sequences!!)
Kyphoplasty
done only in acute, painful Fx; goal is to reverse kyphosis with balloon, inject PMMA- ability to improve kyphosis questionable
Adult Scheuermann’s
significant pain rare unless curve > 66 degrees; largely a cosmetic deformity
Pedicle subtraction osteotomy
30-40 degree correction
Most common places for pseudarthrosis
L12-L1, and L5-S1
Spine infection organisms
Mostly S. aureus, Gram (-) increasing, pseudomonas in IVDA
Tagged WBC scan utility in spine infections
not sensitive in spine infections - 17 % sensitivity only
Osteomyelitis spine
no empiric Abx- need Cx; IV Abx x 6-12 weeks, follow ESR and CRP, especially after Abx stopped
Surgical indication for spine infection
if any neurologic involvement, if significant destruction or deformity, epidural or paraspinal abscess if neurologic embarassment, to get tissue for Dx, failure of Abx alone
Surgery for anterior spine infection
anterior debridement and decompression, placement of autologous strut or titanium cage
Tuberculosis of spine- treatment
9 mos chemotherapy unless surgery indicated (neuro involvement, deformity, failed med mgt)
Post-op spine infection
standard management needle biopsy disk space and start Abx- give Abx even if negative; aggressively debride and retain instrumentation
Posterior epidural abscess
surgical emergency, do laminectomy to decompress; sometimes get after epidural injections
Posterior column tumor spine
think benign
Anterior column tumor spine
think malignant: Ewings, osteosarcoma, lymphoma
Chordoma
unresponsive to chemo or radiotherapy, surgical resections; local manifestation is what kills patients
Myeloma of Spine
Number one primary malignancy of spine, chemo and RT, even if neuro impaired; if collapse or kyphosis consider surgery; vertebroplasty/kyphoplasty options
Metastatic spine disease- diagnosis
winking owl (loss of pedicle); 90% start in body and spread to spine. Age >50, pain at rest, Hx CA, ; MRI test of choice
MRI spine tumor
disc sparing on each cut, marrow replacement
Treatment metastatic spine disease
Chemotherapy, hormonal, Radiotherapy, bracing, bisphosphonates- depends on primary
Surgical indications spine malignancy
Instability (multiple column involvement, >50% vertebral destruction), radioresistant tumor, if need tissue for diagnosis
c-cpine injury in ankylosing spondylitis
be more aggressive with surgical treatment, use Halo instead of rigid cervical orthosis
Role of excisional biopsy in soft tissue sarcoma
Never do excisional biopsy in STS. Do incisional biopsy to secure diagnosis, then proceed with definitive treatment (except when you think it is lipoma vs low grade liposarcoma)
What is the most accurate form of neuromonitoring when reducing Grade III spondylolisthesis?
EMG. not SSEP or MEP.