Spine - Orthobullets

  1. Most common site of lumbar disc herniation
    L5/S1
  2. Lumbar disc herniation: Peak incidence
    gender
    Caused
    • 4th + 5th decade
    • Male 3:1
    • Recurrent torsional strain leads to tear of outer annulus > herniation of nucleus pulposus
  3. Lumbar disc herniation: disc with greatest resorbtion
    Mechanism
    • Sequestered disc
    • Macrophage phagocytosis
  4. Composition of Intervertebral disc
    • Annulus fibrosus
    • Nucleus polpous
  5. Annulus fibrosus: type of collagen
    Composition
    Mechanical properties
    • Type I
    • high collagen/low proteoglycan
    • Extensibility and tensile strenght
  6. Nucleus pulposus: collagen type
    Composition
    Mecahnical properties
    • Type 2
    • Low collagen/high proteoglycan
    • COmpressibility
  7. SPine: where do the nerve root exit
    • Cervical: above pedicle
    • Rest: below pedicle
  8. 4 types of herniations + what does it affect
    Central

    Posterolateral: at L4/L5 affects L5

    Foraminal: At l4/l5 affects l4

    Axillary: can affect both exiting and traversing roots
  9. Most common type of disc herniation + reason
    Posterolateral: PLL weakest here
  10. Define Disc protusion
    Extrusion
    Sequestered fragment
    Eccentric bulging with intact annulus

    disc material herniates through annulus but remains continuous with disc space

    Disc material herniates through annulus and is no longer continuous with disc space
  11. Physical exam for L5/S1 nerve root tension (5)
    • Straight leg raise
    • Contralateral SLR: more sensitive but less specific
    • Lesegue sign SLR aggravated by forced ankle dorsiflexion
    • Bowstring sign: SLR aggravated by compression popliteal fossa
  12. L5 weakness: gait
    Trendelenburg: glut medius innervated by L5
  13. Disc herniation: use of MRI arthro
    Distinguish between post surgical fibrosis ( enahnces) and recurrent disc (does not enhance)
  14. Describe non op management of disc herniation: first line 
    second line
    First line

    • Meds: NSAIDs, Muscle relaxant, steroid taper
    • PT: Extension exercice

    Second line: Selective nerve root injection with steroids
  15. 2 operative indications for disc herniation
    Persistent disabling pain lasting more than 6 weeks that have failed non op

    Progressive significant weakness

    Cauda equina
  16. Disc herniation surgery vs non op
    If done after 6 weeks

    Surgery better pain and function
  17. 4 positive predictive factors for good outcome disc herniation
    • Leg pain is chief complaint
    • Positive SLR
    • Weakness that correlates with nerve root impingement on MRI
    • Married
  18. Negative predictor factor for lumbar disc herniation surgery
    Workman compensation
  19. 4 complications of lumbar discectomy
    • Dural tear
    • Recurrence
    • Discitis
    • Vancular catastrophy
  20. Outcome of recurrent disc herniation vs primary surgery
    No diference
  21. SPORT study of lumbar disc improved outcomes if (8)
    • Age >41
    • No joint problems
    • High school education or less
    • no CSST
    • SYmptoms >6 months
    • Married
    • Worsening symptoms at baseline
    • MCS < 35
  22. Spinal cord injury: most common syndrome
    Most common location
    • Central cord
    • C spine
  23. 4 causes of secondary injury in spinal cord injury
    • Decreased perfusion
    • Lipid peroxidation
    • Free radicals/cytokines
    • Cell apoptosis
  24. 2 risk factors for vertebral artery injury in c spine trauma
    • Atlas fracture
    • facet dislocation
  25. Vertbral artery injury: symptoms
    Treatment
    • Basilar artery insufficiency
    • Stenting: only if symptomatic
  26. How to determine if patient is in spinal shock
    Abscence of bulbocavernosus reflex
  27. Neurogenic shock: Classic presentation
    Mechanism
    • Hypotension and tachycardia
    • Circulatory collapse from loss of sympathetic tone
  28. Steroids for Spinal cord injury: Indication
    Based on what
    Technique
    • Nonpenetrating SCI within 8 hours of injury
    • NASCIS III
    • 30mg/kg over 1st hour then 5.4 mg/kg/hr fro 23-47 hours
  29. 5 contraindications to steroids in Spinal cord injury
    • GSW
    • Pregancy
    • Under 13
    • >8 hours after injury
    • Brachial plexus injuries
  30. 7 non ortho complications of spinal cord injury
    • Skin problems
    • Venous thromboembolism
    • Urosepsis
    • Sinus tachycardia
    • Orthostatic hypotension
    • Autonomic dysreflexi: headache, hypertension, agitation
    • MDE: 11%
  31. Spinal cord injury patient function if: c1-c3
    c3-c4
    c5
    c6
    c7
    c8-t1
    T2-T6
    T7-T12
    L1-L5
    S1-S5
    • Vent dependent + Electric wheelchair with head or chin control
    • Can become vent independent + electric chair with head or chin control
    • Vent independent + electric wheelchair with hand control
    • Can feed themselves + manual wheelchair with sliding board transfers
    • Manual wheelchair + independent transfers
    • Tully independent tranfers
    • Wheelchair dependent
    • Can do unsupported seated activities
    • Variable ability to ambulate
    • Various amounts ofB/B function and sexual dysfuction
  32. Functional electrical stimulation is used in the rehabilitation of patients with spinal cord injuries. This rehabiliation method has the greatest functional effect on
    Skeletal muscle

    It stimulates skeletal muscle: for improved strenght
  33. 2 causes of cervical radiculopathy
    • Degenerative cervical spondylosis: discosteophyte complex
    • Disc herniation: posterolateral>>>btw posterior edge of uncinate and lateral edge of pll
  34. 2 key differences between cervical and lumbar nerve root anatomy
    Pedicle/nerve root mismatch: Root exits above in c spine and below in l spine

    HOrizontal vs vertical nerve root anatomy


    Vertical anatomy of lumbar nerve root > paracentral and foraminal disc affect different nerve roots

    Horizontal anatomy of cervical discs > central and foraminal nerve root affect same nerve root
  35. Describe the physical exam findings for the following radiculopathy:
    C5
    C6
    C7
    C8 
    T1
    C5: Deltoid and bicep weakness + diminished bicep reflex

    C6: brachioradialis and wrist extension weakness + diminished brachioradialis reflex + thumb parasthesia

    C7: Tricep and wrist flexion weakness + diminished tricep reflex + thumb parasthesi

    C8: Weakness distal phalanx flexion of middle and index finger + parasthesia little finger
  36. Describe the following tests: spurling
    Spurling: Simultaneous extension, rotation to affected side, lateral bend, vertical compression reproduces symptoms
  37. How to do cervical ct myelography
    Injection at C1-2
  38. percentage of cervical radiculopathy that improve with non op
    75%
  39. Indication for a posterior foraminotomy
    Formainal disc herniation causing single level radiculopathy
  40. Gold standard treatment for cervical radiculopathy
    Sigle level ACDF
  41. 3 risk factors for pseudoarthrosis after ACDF
    • Smoking 
    • Diabeted
    • Multi level fusion
  42. 7 causes of cervical myelopathy + most common
    • Degenerative cervial spondylosis: MOst common...casued by degenerative change
    • Congenital stenosis
    • OPLL
    • Tumor
    • Epidural abcess
    • Trauma
    • Cervical kyphosis
  43. 5 classic symptoms of cervical myelopathy
    • Neck pain or stiffness
    • Extremity parasthesias
    • Weakness and clumsiness
    • Gait instability
    • Urinary retention
  44. Finger escape sign: test for
    how to do it
    • Cervical myelopathy
    • Hold fingers extended and adducted> small finger has spontaneous abduction due to weak intrinsics
  45. 5 physical exam findings of upper motor neuron signs
    Hyperreflexia

    Inverted radial: tapping brachioradialis > finger flexion

    Hoffman

    Sustained clonus: > 3beats

    Babinski
  46. 2 physical exam tests for gait and balance
    • Toe heel walk
    • romberg: arms held forward and eyes closed > loss of balance
  47. Pavlov ratio: is
    values
    Ratio of canal to vertebral body <0.8 suggest a congenital narrow canal
  48. What is compression ratio in cervical stenosis and what is the value
    Smallest AP diameter of cord/largest transverse diameter of the cord

    if <0.4 poor prognosis
  49. ACDF: approach
    Indication
    • Smith robertson
    • 1-2 level disease or fixed kyphosis >10 degrees
  50. 4 advantages of AACDF vs PSF
    • Lower infection
    • Less blood loss
    • Less post op pain
  51. Contraindication to cervical PSF
    FIxed kyphosis >13 degrees: will not adequately decompress due to bowstriging
  52. Indication for laminoplasty
    Multilevel compression in OPLL: less complication vs anterior
  53. Post op C5 nerve palsy: incidence
    ?mechanism
    Prognosis
    • 5%
    • Tethering of cord anteriorly if doing post decompression
    • Good
  54. Recurrent laryngeal injury: at risk with what approach
    what side
    management
    • Smith robertson
    • Right side: more aberrant path

    Watch and refer to ENT if no improvement in 6 weeks..

    If revision do same side as palsy
  55. fasciculations: sign of
    Lower motor neuron disorder
  56. 6 anatomic structures that can cause lumbar spinal stenosis
    • Facet osteophytes
    • Uncinate spurs
    • Spondylolisthesis
    • Herniated disc
    • Ligamentum flavum hypertophy or buckling
    • Synovial facet cysts
  57. Cross sectional area definition of lumbar spinal stenosis
    <100mm2

    or <10mm AP diameter
  58. What is the primary culprit for lateral recess stenosis
    Overgrowth of superior articular facet
  59. What nerve root is affected in lumbar spie if: Central stenosis
    Lateral recess stenosis
    Foraminal stenosis
    Extraforaminal stenosis
    • non specific symptoms of lower nerve root
    • Descending nerve root
    • Exiting nerve root
    • Exiting nerve root
  60. kemp sign: is
    Unilacular radicular pain from foraminal stenosis made worse by extension of back
  61. Differences btw vascular and neurogenic claudication 5
    Postural changes: worsen neurogenic, no difference in vascular

    Standing stationary: causes neurogenic, relief vascular

    Stair climbing: Up easier neurogenic, down easier vascular

    Stationary bike: Reliefs symptoms neurogenic, causes symptoms vascular

    Pulses: normal neurogenic, abnormal vascular
  62. 2 indications for surgical management of lumbar spinal stenosis
    Failed conservative x 6 months

    Progressive neuro deficit: weakness or bowel/bladder
  63. Most common cause of failed lumbar spinal stenosis surgery
    Recurrence of disease above or below decompressed level
  64. Single level decompression and fusion risk of adjacent level disease
    30% at 10 years
  65. 2 surgical variables that increase the rate of infection in lumbar spinal stenosis surgery
    Use of microscope: doubles it to 1.4%

    Instrumentation: as high as 10 %
  66. Demographics of degenrative spondy: 3 populations increased risk
    • African americans
    • Diabetics
    • WOman over 40
  67. 2 risk factors for degenerative spondy
    • Sacralization of L5
    • Sagitally oriented facet joints
  68. In degenerative spondy what nerve roots are affected
    If L4/L5

    • L5 at the level of the lateral recess
    • L4 from foraminal stenosis
  69. Myerding classification: for
    Is
    Spondylolisthesis

    • I: <35%
    • II: 25-50%
    • III: 50-75:
    • IV: 75-100%
    • V: spondyloptosis
  70. How do you define instability in flexion extension x rays of the lumbar spine
    4mm translation or >10 degrees agulation
  71. What is a negative prognostic factor for spinal decompression and fusion in degen spondy
    Smoking
  72. Injury to what nerve structure causes retrograde ejaculation
    Superior hypogastric plexus
  73. risk factors for adjacent level disease in lumbar spinal fusion (3)
    • Multi level
    • Age >60
    • Adjacent level laminectomy
  74. Ank spond: Gene
    RF
    Primarily affects
    • HLA-B27
    • RF negative
    • Axial spine
  75. 3 diagnostic criteria for Ank spond
    • Bilateral sacroiliitis
    • +/- uveitis
    • HLA b27 positive
  76. 6 systemic manifestations of ank spond
    • Acute uveitis
    • Heart disease: conduction abnormalities
    • Pulm fibrosis
    • Renal amyloidosis
    • Ascending aorta conditions
    • Klebsielle synovitis
  77. 4 ortho manifestations of ank spond
    • Bilateral sacroiliitis
    • Progressive spine kyphotic deformity
    • Cervical spine fractures
    • Large joint arthritis
  78. Limitation of chest wall expansion > 2cm: dx
    ank spond
  79. X ray for si joint
    Ferguson pelvic tilt view: x ray directed 10-15 degrees cephalad
  80. Compare DISH from ank spond (DISH/ANK SPOND): Sydesmophytes
    x ray classic sign
    Disc space
    OSteopenia
    HLA
    age group
    SI joint
    Diabetes
    • Nonmarginal/marginal
    • flowing candle wax/ bamboo spine
    • Preserved/ossicified
    • NO/yes
    • older/younger
    • No/bialteral sacroiliitis
    • yes/no
  81. 3 DMARDs for ank spond
    Infliximab, etanercept/adalimumab: TNF alpha blocking
  82. Ank spond spine fractures: look for
    location
    mechanism
    • Epidural hematoma
    • Midcervical and cervicothoracic jct
    • Extension type: involve all 3 columns
  83. 4 complications in ank spond spine surgery
    • Progressive deformity
    • nonunion
    • hardware failure
    • infection
  84. AS and chin on chest deformity: surgery
    C7-T1 cervicalthoracic osteotomy: vert is external to transverse foramen + large canal diameter
  85. Ank spond and THA: increased risk of what complication
    Anterior dislocation: vertically oriented nd anteverted acetabulum
  86. Definition of sagital plane inbalance in spinal deformity
    >5cm
  87. Most common location of: AIS
    Deden scoli
    • Thoracic
    • Lumbar
  88. 4 factors that contribute to development of degen scoli
    • Osteoporosis
    • Pre existing scoli
    • Iatrogenic instability
    • DDD
  89. 2 factors that lead to worse prognosis in Spinal degen scoli cases
    • Symptoms on convex side of curve
    • Sagital plane inbalance
  90. 4 causes of de novo ASD
    • Degenerative changes
    • iatrogenic
    • paralytic
    • post traumatic
  91. Degenerative scoliosis: what curve affects PFT
    What curve affects mortality
    • > 60 degrees thoracic
    • > 90 degrees
  92. 3 types of spine osteotomy and degree of correction
    Smith petersen: 10 degree per level...need normal disc..correct through the disc

    PSO: 30 degrees per level..correct through vertebral body

    Vertebral column resection: up to 45 degrees
  93. Adult spine deformity psudoarthrosis: 2 common locations

    7 risks
    L5-S1 + thoracolumbar junction

    • Age >55
    • kyphosis > 20
    • positive sagital balance >5
    • hip OA
    • smoking
    • Thoracoabdominal approach
    • Incomplete lumbopelvic fixation
  94. Burst #: definition
    Mechanism
    • Vertebral fracture that involves the anterior and middle column
    • Axial load with fleion
  95. Burst fracture what happens to retropulsed fragments over time
    usually resorb and do not cause neuro deficits
  96. Name the components of: anterior column (2)
    Middle column (2)
    Posterior column (6)
    • ALL
    • Ant 2/3 vertebral body

    • PLL
    • Posterior 1/3 vertebral body

    • Pedicles
    • Lamina
    • Facets
    • LF
    • SP
    • Posterior ligament complex
  97. How to identify middle column spine fracture on x ray (2)
    • Widening of interpedicular distance on AP
    • Loss of height of posterior cortex on lateral
  98. 4 components of posterior ligamentous complex spine
    • Supraspinous ligament
    • Infraspinous ligament
    • Ligamentum flavum
    • Facet capsule
  99. 4 signs of instability of posterior ligamentous complex in the spine
    • Bony chance
    • Widening of interspinous space
    • Progressive kyphosis with non op Mgmt
    • Facet diastasis
  100. TLICS score: 4 components

    treatment implications
    • Injury morphology
    • Neuro status
    • PLC integrity

    • <4: non op
    • 4: uncertain
    • >4 operative
  101. 4 indications of non op managament of burst #
    Neuro intact +

    • PLC presrved
    • kyphosis < 30 (controversial)
    • Vertebral body height loss < 50% (controversial)
    • TLICS<4
  102. Outcomes of bracing for TL burst #
    No difference to no brace

    May help patient for pain control
  103. burst fracture: 2 ways to achieve decompression of canal
    Direct: transpedicular removal of retropulsed fragment

    Indeirect: ligamentotaxis
  104. Treatment of neuro intact patients with thoracolumbar burst #
    Non op


    Operative has been associated with higher complication and revision surgery rates with no benefit in functional outcome
  105. Odontoid # 2 mechanisms
    Hyperflexion: anterior displacement > associated with transverse ligament failure and atlantoaxial instability

    Hyperextension: casued by direct impact of posterior arch of atlas
  106. How many ossicifaction centers for the odontoid
    5
  107. Occiput-c1-c2 instability 3 components
    • Transverse ligaments:limit anterior translation
    • Apical ligaments: Limit rotation
    • Alar ligaments: limit rotation
  108. Odontoid blood supply: 2 main
    watershed
    • Apex: internal carotid
    • BasE: Vertebral artery

    Watershed at location of type 2 #
  109. Odontoid # classification
    • Type 1: oblique avulsion # tip odontoid
    • Type 2: waist > high non union rates
    • type 3: into cancellous body and involves c1-c3 joint
  110. What defines instability in flex ext views cervical spien 2
    • ADI >10mm
    • < 13mm Space available for cord (PADI)
  111. Treatment of odontoid #
    • Type 1: collar
    • Type 2 young: halo if no risk factors no union or PSF if risk factors present
    • Type 2 elderly: collar if not surgical candidates
    • Type 3: collar
  112. COntraindication to halo fixation for odontoid #
    elderly patient: do not tolerate > aspiration
  113. 6 risk factors for no union in type 2 odontoid #
    • >6mm displacement
    • Age >50
    • Fx comminution
    • Angulation >10 degrees
    • Delay in treatment
    • Smoker
  114. Location of vertebral artery
    In foramen c6-c2

    At C2 deviates laterally to pass C1 foramen then wraps medially on top of arch of C1
  115. C1-C2 transarticular screws: structure at risk
    Vert
  116. IV disc responsible for what % of spinal column height
    25%
  117. Innervation of IV disc
    Sinuvertebral nerve from dorsal root ganglion: superficail fibers of annulus
  118. With IV disc aging what happens to water content
    It is replaced by fibrocartilage: change in properties
  119. In IV disc what  happens to keratans ulfate to chondroitin sulfate ratio with aging
    It increases
  120. Most common fragility fracture
    vertebral compression fracture
  121. Strongest predictor of future vertebral fractures in postmenopausal women
    Hx f 2 VCF
  122. BMD peak: women
    Men
    • 33-44
    • 19033
  123. 1 year mortality of vertebral compression fracture
    15%
  124. Medication to reduce pain acutely in vertebral compression fractures
    Calcitonin: within 5 days
  125. AAOS recommendaton on: vertebroplasty
    kyphoplasty
    AAOS: recommend strongly against

    AAOS: May be used but limited recommendation strenght
  126. L5-S1 spondy: nerve root affected
    L5
  127. How to calculate: PI
    PT
    SS
    • PI = PT  + SS
    • PT = line from center S1endplate to center of femoral head + vertical line
    • SS = Horizontal line + line parallel to sup endplate of S1
  128. L5-S1 fusion for spondy + reduction: risk
    benefit
    • L5 nerve root neuropraxia
    • Improved sagital alignment
  129. Critical physical exam finding to differentiate complete vs incomplete SCI
    Sacral sparing: presence of voluntary anal contraction
  130. Most common incomplete spinal cord injury
    central cord syndrome
  131. Spinal cord anatomy: 5 tracts
    • Descending (motor)
    • Lateral corticospinal
    • Ventral corticospinal

    • Ascending
    • Dorsal column: deep touch, vibration, propioception
    • Lateral spinothalamic tract: pain temperatire
    • Ventral spinothalamic tract: light touch
  132. 4 types of incomplete SCI
    • Anterior cord syndrome
    • Brown sequard
    • Central cord
    • Posterior cord
  133. Central cord syndrome: what tract affected
    physical exam
    recovery pattern
    • Lateral corticospinal
    • UE > LE weakness: hands and upper extremity more central in corticospinal tract

    Lower extremity > bladder and bowel > proximal upper extremity >hands
  134. 2 causes of anterior cord syndrome
    • Direct compression: disc or bony
    • Anterior spinal artery injury: 2/3 spine supplied by it
  135. Anterior cord syndrome: Physical exam
    Loss 
    preserved
    Lower extremity more affected than UE

    • Loss
    • Lateral corticospinal:motor
    • Lateral spinothalamic: pain and temperature

    • Preserved
    • Dorsal column: Propioception and vibration
  136. Worst prognosis in incomplete spinal cord injury
    Anterior cord syndrome
  137. Brownsequard syndrome: caused by
    prognosis

    Physical exam
    Transection half cord: penetrating trauma

    excellent prognosis

    Ipsilateral deficits: Motor (LCS), vibration/proprioception (dorsal column)

    Contralateral: Pain and temperature (LST)
  138. Where do spinothalamic tracts cross
    2 levels below the
  139. 3 contraindications to halo fixation
    • Cranial fracture
    • Infection
    • Severe sof t tissue injury
  140. Adult halo technique: torque
    Location
    8 lb/inch

    Total 4

    2 anterior pins: safe zone 1 cm above lateral 1/3 eyebrow...lateral to supraorbital nerve and anterior to temporalis

    2 posterior pins: opposite form anterior pins
  141. Pediatric halo technique: torque
    pin #
    Pin location
    • 2-4 lbs
    • 6-8

    • Anterior pins
    • Lateral 1/3 eyebrow and 1 cm above: safe zone 1 cm above lateral 1/3 eyebrow...lateral to supraorbital nerve and anterior to temporalis

    Posterior pins: Exactly opposite to anterior
  142. Most common nerve palsy with halo traction
    Abducens: diplopia and loss of lateral gaze
  143. Halo pins: at risk if pins too lateral
    pins too medial
    • Supraorbital nerve
    • Supratrochlear nerve
  144. Halo complications in kids vs adults
    • kids 70%
    • adults 35%
  145. Halo vest: controls what motion best
    Rotation C1-C1
  146. Most common level of thoracic disc herniation
    T11-t12
  147. 1 risk factor for thoracic disk
    Underlying scheuermanns disease
  148. Thoracic disc: what location can give you horners
    T2-T5
  149. Best approach for thoracic disc
    Lateral thorugh costotransversectomy
  150. Most common complication from VATS for antererior thoracic discectomy
    Intercoastal neuralgia
  151. 3 types of spinal cord monitoring
    • EMG
    • SEP: 25% sensitive + 100% specific
    • MEP: 100% sensitive + 100% specific
  152. 2 spinal cord pathways
    • Afferent (sensory)
    • Dorsal column
    • Spinothalamic tract

    • efferent (motor)
    • Lateral corticspinal
    • Ventral corticospinal
  153. Sensory evoked potentials: technique
    Record brain: somatosensory cortex

    Lower extremity: stimulate posterior tibial nerve

    Upper extrimity: stimulate uknar nerve
  154. Sensory evoked potentials: Advantage
    Disadvantage
    Unaffected by anesthetics

    No reliable for monitorng anterior spinal cord (motor)
  155. Motor evoked potentials: what part of spinal cord do they monitor

    Technique
    Ventral and lateral corticospinal cord: motor

    • Initiate signal at brain
    • Record signal at lower extremity
  156. Motor evoked potential: advantage
    Disadvantage
    • Detect ischemia of anterior cord
    • Unreliable due to anestheisa
  157. Typical location of comus medullaris
    T12-L1
  158. External sphincter of bladder controlled by what nerve
    Pudendal nerve
  159. Cauda equina time to surgery and outcomes
    Better bowel and bladder symptom resolution if performed within 48 hours
  160. % subluxation on x ray if: unilateral facet dislocation
    Bilateral facet dislocation
    • 25%
    • 50%
  161. Facet fractures: what structure most commonly injured
    Location most common
    mechanism
    Superior facet

    Subaxial c spine c2-c7

    Flexion distraction
  162. Unilateral facet dislocation: location of symptoms
    Exiting nerve root below level ie if C6/7 C7 affected
  163. Which type of cervical facet dislocations are easier to reduce and why
    Bilateral easier than unilateral: PLL torn >>also makes them less tabe
  164. outcome of LBP treated with conservative mgmt
    90% resolves within 1 year
  165. How to evaluate for malingering in spine exam
    Wadell signs: 3 positive is clinically significant

    • Superficial non anatomic tenderness
    • Pain with axial compression or simulated rotation of spine
    • Negative SLR when distracted
    • Non dermatomal distribution
    • Overreaction to physical exam
  166. What is the strongest negaive predictor to good outcome for non op LBP mgmt
    High VAS scale prior to treatment
  167. Adult vertebral osteo lcoation
    • Lumbar: 50-60
    • Thoracic: 30-40
    • Cervical: 10
  168. 9 risk factors for adult vertebral osteo
    • IV drugs
    • diabetes
    • recent systemic infection
    • obesity
    • malignancy
    • immunosuppresed
    • Malnutrition
    • Trauma
    • smoking
  169. Most common pathogen of vertebral osteo
    Staph aureus
  170. 3 mechanisms of innoculation of vertebral osteo
    Hematogenous spread: end plates are area of low flow vascular anastamosis > easier to seed

    Direct: penetrating trauma or procedure

    Contiguous spread: Retropharyngeal or retroperitoneal abcess
  171. Gold standard for diagnosis of vertebral oste
    MRi with gado: disc and endplate enhancement with gado
  172. Labs to order if suspecting vertebral osteo
    • CBC: WBC only elevated in 50%
    • ESR: elevated 90%
    • CRP: elevated 90%
    • Blood cultures: least invasive form to obtain organism
  173. 3 indications for surgery in bacterial vertebral osteo
    • Refractory to Abx
    • euro deficits
    • Progressive deformity and instability
  174. Atlas fracture: 2 assocaited injuries
    • C2
    • Spine injury
  175. Atlas: ossification centers
    Anatomic variant
    • 3
    • Incomplete fusion of posterior arch
  176. C1 fracture classification
    Type 1: isolated anterior or posterior arch fracture

    Type 2: Jefferson...bilateral fracture of posterior and anterior arch from axial loading....Stability determined by integrity of transverse ligament

    Type 3: Unilateral mass fracture >>stability determined by integrity of transverse ligement
  177. ADI: normal
    Injury to to transverse
    Injury to transverse, alar, tectorial membrane
    • <3mm
    • 3-5mm
    • >5mm
  178. Measurement on open mouth odontoid
    Sum of lateral mass displacement: if>7mm transverse ligament rupture and considered unstable
  179. 3 types of screws you can use for c1-c2 fusion
    • C1 lateral mass
    • C2 pedicle
    • C1-2 transarticular screw
  180. 1 possible indication for lumbar disc replacement
    Single level disease with no adjacent level disease
  181. Outcomes of adjacent level disease in total disc replacement vs fusion
    Total disc lower level of adjacent level disease
  182. negative effects of provocative discography (2)
    Accelerated disc degeneration and reactive endplate changes
  183. Most common location of lumbar facet cyst
    L4-5
  184. What procedure for lumbar synovial cyst give the lowest risk of persistent back pain and cyst recurrence
    Facetectomy and instrumented fusion
  185. Lumbar lordosis: average
    Apex
    • 60
    • L3
  186. Mammillary process: what do they separate
    location
    • Separate ossification centers
    • Project superiorly from superior articular facet
  187. Facet orientation as you move down the spine
    Become more coronal
  188. Blood supply to lumbar vertebrae
    Segmental arteries
  189. 3 patterns of instability for RA
    • Atlantoaxial subluxation
    • Basilar invagination
    • Subaxial subluxation
  190. Ranawat classification: for
    Myelopathy

    • Class I: pain no neuro
    • Class II: subjective weakness, hyperreflexia, dyesthesias
    • Class IIIA: Objective weakness + UMN + ambulatory
    • Class IIIB:: objective weakness + UMN + non ambulatory
  191. Most common instability in RA: is
    caused by
    • Atlantoaxial subluxation: 50-80% RA
    • Pannus btw dens and ring of c1>destruction of transverse ligament
  192. Indications for surgery in C1-C2 instability in RA (2)
    >10 mm ADI 

    <14mm PADI/SAC
  193. Most important radiographic finding that my predict complete neural recovery after decompression in c1-c2 instability
    >13mm of SAC/PADI
  194. When can you not perform C1-C2 fusion iin c1/c2 instability in RA 2
    Canot reduce c1/c2: means that you need to decompress> loss stability

    Basilar invagination
  195. Basilar invagination4 radiographic measurements
    Ranawat C1-C2 index

    • Draw line from posterior to anterior c1 arch
    • Draw perpendicular from center of C2 pedicle >>if this line is <15mm it is abnormal

    • McGregors line
    • Posterior edge of hard palate to caudal posterior occipital curve
    • Basialr invagination if tip of dens >4.5cm above this line

    • Chamberlain's line
    • Line from dorsal margin f hard palate to posterior edge os foramen magnum
    • If tip dens >5mm above it is abnormal

    McRae's line

    • Line across foramen magnum
    • Helps rule out basilar invagination if dens is below it
  196. 3 indication for C2-occiput fusion in basilar invagination
    • Progressive cranial migration >5mm
    • Neuro compromise
    • Cervicomedullary angle <135 on MRI
  197. RA and subaxial instability: best predictor of neuro compromise
    Cervical height to width ratio <2 is almost 100% sensitive and specific
  198. Dish: definition
    Most common location
    Presence of non marginal syndesmophytes at 3 succesive levels

    Thoracic spine (right side) > cervical > lumbar
  199. 3 risk factors for DISH
    • Gout
    • DLP
    • DM
  200. DISH and HO after TH
    30-50% in DISH: more than normal
  201. Most common extrapulmonary site of TB
    Thoracic spine
  202. How to distinguish TB from Discitis/osteo
    TB has contiguous multilevel involvement that skips the disc
  203. 4 spine at risk signs in TB
    • Retropulsion
    • Subluxation
    • lateal translation
    • Toppling
  204. % PPD positive in TB spine
    80%
  205. TB medical managament
    RHZE: for 2 months then RH for 9-18 months

    • Rifampin
    • Isoniazid
    • Ethambutol
    • Pyrazanamide
  206. 6 indications for surgical management of TB spine
    • Neuro deficit
    • Spinal stability
    • Kyphosis correction: >60 degrrees in adult
    • Advanced disease with caseation
    • Failed non op
    • Panvertebral lesion
  207. POtt's paraplegia: what is it
    SPinal cord injury caused by abcess/bony sequestrum
  208. Population with high incidence of pott disease
    HIV
  209. Histologic composition of ligamentum flavum
    Mostly elastin 

    Rest of ligaments in spine are collagen
  210. Normal range for: Cervical lordosis
    Thoracic kyphosis
    Lumbar Lordosis
    • 20-40
    • 20-50: 35
    • 20-80: 60
  211. Where can you put pedicle screws in cervical spine
    C2 and C7

    or the rest, pedicles are too small so use lateral mass screws
  212. Location of conus: at birth
    At maturity
    • L3
    • L1
  213. Which sympathetic ganglion is at risk during ACDF + what does it cause
    Middle ganglion t the level of C6: close to medial border of longus coli

    Leads to horners
  214. Histologic origin of vertebral bodies
    Notocord
  215. Primary blood supply to dorsal sensory column
    Posterior spinal artery
  216. Largest anterior segmental artery: name
    Arises from
    location
    • Artery of adamkiewicz
    • Left posterior intercoastal
    • 75% left side btw T8 and L1
  217. CSF: where is it produces
    rate of formation
    Choroid plexus in third, fourth, lateral ventricles

    500 mL/day
  218. Define: syringomyelia
    Syringobulbia
    Syrinx within the spinal cord that expands > neuro deficits

    Syrinx in the brain stem
  219. Syrinx can be caused by 4 main things
    Chiari malformation: 50% have syrinx

    Spinal cord trauma

    Spinal cord tumor

    Post infectious
  220. Syringomyelia: 3 associated conditions
    • Developmental scoli
    • Klippel-feil
    • Charcot joints
  221. Syrinx and scoliosis: what to fix first
    Fix syrinx first then fusion 3-6 months later
  222. Chance fracture: mechanism
    Flexion / distraction
  223. Chance fracture 2 types and which one is more difficult to heal without surgery
    Bony

    Ligamentous: Harder to heal
  224. Discitis: Location
    Gender
    Age
    Pathogenesis
    • Lumbar spine
    • Male
    • <5

    In kids blood vessels reach the nucleus polpusus> direct onoculation
  225. 3 indications for surgical managemnt of discitis
    • Late intection
    • Paraspinal abcess and neuro deficits
    • Limited response to non op
  226. 3 radiographic changes in ped discitis from soonest to latest to appear
    Loss of lordosis

    Disc space narrowing

    Endplate erosion
  227. 6 risk factors for epidural abcess
    • IV drug user
    • Immunodeficiency
    • Malignancy
    • HIV
    • Immunosuppresive meds
    • Recent spinal procedure
  228. Epidural abscess most common pathogen
    Staph aureus
  229. Epidural abscess most important indicator of clinical outcome
    Preop degree of neuro deficits
  230. Gold standard for Dx of epidural abcess
    MRI with GADO
  231. 4 indications for surgery in epidural abscess
    • Neuro deficits
    • Spinal cord compression on imaging
    • Failed conservative
    • Progressive deformity or instability
  232. AARD: 3 causes
    • Infection: grisel disease
    • Trauma
    • Recent head and neck surgery
  233. 4 associated conditions to AARD
    • Downs
    • RA
    • TUmor
    • Congenital anomalies
  234. AARD: physical exam 3
    Gold standard for dx
    • Chin rotated to the opposite side of subluxation
    • Spastic contralateral SCM
    • reduced ROM: rotation

    Dynamic CT: will see fixed c1/c2 subluxation
  235. AARD Management: <1 week
    1 week to 1 month
    > 1 month
    > 3 months
    NSAID's, soft collar

    Head-halter: 5lb then hardcollar x 3 months

    Halo vest x 3 months


    Postrior C1-C2 fusion
  236. definition of scheurmann's kyphosis(3)
    • > 45 degreed
    • Anterior wedging >5 degrees of 3 consecutive vertebrae
    • Rigid kyphosis
  237. scheurmann's kyphosis: most common location
    Genetics
    • Thoracic
    • Autosomal dominant
  238. scheurmann's kyphosis: 3 ortho associated conditions
    1 non ortho condition
    • Hyperlordosis
    • SPondylolysis
    • Scoliosis

    Pulmonary issues if curve > 100 degrees
  239. scheurmann's kyphosis: curve < 60
    curve 60-80
    curve >75
    Stretching and observation

    Bracing if growth remaining: can stop progression

    PSF with smith pete osteotomy +/- anterior release
  240. Cervical spine levels with bifid spinous process
    C2-C6
  241. Vertebrae with no Vertebral artery
    C7
  242. what level in c spine: palpable carotid tubercle
    Non bifid spinous process
    • C6
    • C7
  243. 3 erector spinae muscles + relationship to each other
    • SPinalis:most medial >>SP to SP
    • Longissimus in the middle >> TP to TP
    • Iliocostalis: most lateral
  244. Cause of congenital torticollis
    SCM contracture:
  245. COngenital torticollis: associated condition
    Physical exam (2)

    Describe non op management

    Indications/describe surgical management
    Packaging disorders

    • Head tilt towards affected side chin rotates away from affected side
    • Palpable neck mass

    Condition < 1 year,limitation < 30 degrees: Stretching > 90% response

    Failed stretching 1 year or limitation > 30 degrees: SCM lenghtening or release
  246. OPLL: population at risk
    Gender
    Location
    • Asian
    • Men
    • C spine: C4-6
  247. 4 associated factors to OPLL
    • DM
    • Obesity
    • High salt/low sodium
    • Poor calcium absorption
  248. 2 techniques for OPLL myelopathy
    Anterior corpectomy: either remove OPLL or let it fall into void

    Posterior laminoplasty: Need spine lordois..considered safer
  249. Most common location of cervical spondylosis
    C5/6 + C6/7: because site of most flexion
  250. 4 risk factors for cervical spondylosis
    • Excessive driving
    • Smoking
    • Lifting
    • Professional athletes
  251. Cause of cervical spondylosis
    Degeneration of the discand 4 joints in c spine


    • 2 facet joints
    • 2 uncovertebral joints
  252. Definition of absolute and relative cervical stenosis
    • Canal diameter < 10
    • Canal diameter 10-13
  253. thoracolumbar # dislocations: Most common location 
    Mechanism of injury
    • thoracolumbar junction
    • Acceleration > deceleration injuries
  254. Type of subaxial cervical spine fracture associated with complete/incomplete SCI
    Burst
  255. Explain what a flexion teardrop injury is + managment
    In c spine Anterior column fails in flexion/compression

    Posterior column fails in tension

    Posterior portion of verebrae retropulsed

    Usually unstable
  256. Quadrangular fracture of spine: dc
    Flexion teardrop #
  257. Extension teardrop fracture:characterized by
    Management
    • Small fleck of bone avulsed of anterior endplate
    • Usually stable:treat wwith collar
  258. 3 subaxial cervical spine # patterns that need surgery
    • Compression# with 11 degrees of angulation or 25% loss of height
    • Unstable burst
    • Unstable flexion Tear drop with cord compression
  259. Associated condition to occipitocervical instability
    Down syndrome
  260. measurements used to diagnose occipitocervical dislocation (2)
    Powers Ratio

    Basion-posterior arch / opistheon to anterior arch

    • If > 1 anterior dislocation
    • If <1 posterior dislocation

    • Harris rule of 12
    • Bastion to tip of dens >12mm abnormal
    • Basion posterior axial interval > 12mm abnormal

    Posterior axial interval is vertical line drain down posterior aspect of odontoid
  261. Use of traction in occipitocervical dislocation
    AVOID: can pop the head off ifligaments compromised
  262. Structure at risk when placing screws in skull for occipito cervical fusion
    Major dural venous sinus
  263. Klippel feil: definition
    More symptomatic if
    Less symptomatic if
    Cannot play sports if
    Congenital fusion of 2 or more cervical vertebrae

    • Fusion above c3
    • Fusion below C3

    Fusion involving C2
  264. Klippel feil: classic triad
    • Low posterior hairline
    • Short webbed neck
    • Limited cervical ROM
  265. Klippel feil: associated with
    • heart
    • Kidney
    • Sprengel deformity
  266. nerve responsible for bowel and bladder function
    S3-4
  267. Lateral mass fracture separation: Location 
    Mechanism
    Management
    C6 >5>7>4>3

    Hyperextension, lateral compression, rotation

    mostly surgical because high association with ligamentous injuries >>>use posterior approach because that is the location of the pathology
  268. Kotani classification: What is it for
    4 classes
    Lateral mass #

    Type A: separation.. 2 fracture lines of unilateral lamina and pedicle

    Type B: Comminuted >>multiple fracture lines with lateral wedging

    Type C: split >> vertical fracture in coronal plane with invagination of superior articular process 

    Type D: Bilateral horizontal # of pars >>separation of anterior and posterior elements
  269. Hangman fracture: definition
    Mechanism
    Bilateral pars # of C2

    • Hyperextension: # pars
    • Secondary flexion: tears PLL
  270. Hangman # classification / mentio mechanism for each

    Which ones require surgery
    Type I: < 3mm horizontal displacement ...axial compression and hyperextension...C2/3 disc are intact

    Type 2: > 3mm horizontal displacement...hyperextension>>axial load >>>rebound flexion.....C2/3 disc +  PLL disrupted

    Type 2A: Flexion distraction>>no horizontal displacement...significant angulation

    Type 3: flexion distraction then hyperextension...same as type 1 but with facet dislocation
  271. Hangman # types that need surgery
    Type II: if displaced > 5mm

    Type III: for reduction of facet
  272. Hangman fracture: avoid traction if
    Type 2A #

    Has horizontal line...treatment is compression halo vest
  273. 5 reasons why thoracic spine has increased stiffness
    • Articulate with ribs
    • Facet joints oriencted in coronal plane
    • Disks are thin
    • Kyphosis concentrates axial load on anterior column
  274. 3 approaches to thoracic spine
    Posterior

    Costotransverse

    Transthoracic
  275. 3 conditions associated with sacroiliitis
    • Ank spond
    • Reiter syndrome
    • Pregnancy
  276. Sacroiliitis physical exam manouver
    FABER produces pain
  277. Most common location c spine injuries in: <8 years
    > 8 years
    • 83% above C3
    • Lower cervical
  278. 4 reasons why patients below 8 have upper c spine injuries
    • Bigger head
    • Ligamentous laxity
    • Horizontal facet joints
    • Weak muscles
  279. How much can the spinal cord stretch before rupture in children
    5 cm
  280. Normal amount of prevertebral soft tissue swelling in children
    <2/3 of adjacent vertebral width
  281. Optimal position of head immobilization for c spine fracture
    In line cervical stabilization with ears in line with shoulders
  282. Pseudosubluxation c spine in kids: normal amount
    Age
    Most common location
    Caused by
    Classic x ray findings (2)
    • <4mm or 40% width or vertebrae
    • Children <8
    • C2 on 3
    • Horizontal nature of facet joints

    • Reduction of subluxation on extension views
    • Absence of prevertebral soft tissue swelling
  283. Swischuks line: For 
    Is
    Normal range
    • Assesmen of pseudosubluxtion
    • Line from spino laminar poin on C1 to spinolaminar point on C3

    Spinolaminar point on C2 should be within 1.5mm of this point
  284. 4 causes of adult atlantoaxial instability
    • Downs
    • RA
    • Os odontoideum
    • Trauma: transverse ligament injuries
  285. 4 causes of pediatric atlantoaxial instability
    • JRA
    • Morquio
    • Downs
    • Trauma: AARD
  286. What joint provides 50% rotation of c spine
    Atlantoaxial joint
  287. ADI: normal range in adults
    Considered unstable
    Indication for surgery in RA
    • < 3mm
    • > 3.5
    • > 10mm
  288. PADI/SAC associated with increased risk of neuro injury
    <14: therefore indication for surgery
  289. Spinal cord injury in kids: more lethal if
    Better prognosis for recovery
    • < 8 years 
    • > 8 years
  290. Highest risk of scoliosis: what type of CP
    • Spastic quad
    • If bedridden: 100%
  291. 5 features of scoliosis in CP different from AIS
    • Start at younger age
    • long stiff c shaped
    • Greater sagital plane deformity
    • Associated with pelvic obliquity
    • More likely to progress
  292. CP scoliosis: when to extend to pelvis
    Pelvic obliquity >15 degrees
  293. spondylolysis: Definition 
    Mechanism
    % associated with spondylolisthesis
    • Defect in pars interarticularis
    • Repetitive hyperextension
    • 15%
  294. Spondyolisthesis 2 things that increase risk of progression
    • Larger slip
    • Dysplastic type
  295. Describe wiltse classification
    • Dysplastic
    • Isthmic: pars elongatiom
    • Isthmic: pars acute fracture
    • Isthmic: pars stress fracture
    • Traumatic
    • Neoplastic
  296. X ray to order of looking for spondylolysis + name of sign
    Spine oblique

    Scotty dig sign
  297. Best diagnostic test for spondylolisis if plain x rays are negatine
    SPECT
  298. Indication for par interartecularis repair
    L1-L4 isthmic defect that failed non op
  299. When to use TLSO for spondy
    Positive SPECT: suspected stress or acute isthmic spondy
  300. 2 main causes of pathologic scoliosis
    • Osteoid osteoma: apex of concavity
    • Osteoblastoma: pain less severe
  301. Osteoid osteoma scoliosis will resolve if (2)
    Removal of tumor before 18 months of onset of scoli

    Child is <11 years old
  302. 6 causes of neuromuscular scoliosis
    • CP: UMN
    • Rett: UMN
    • SMA: Muscle weakness
    • Muscular dystrophy: Muscle weakness
    • Spina bifida/SCI: Paralytic
    • Polio: Paralytic
  303. 2 types of neuromuscular scoli where bracing is contraindicated
    • Muscular dystrophy
    • SPina bifida/SCI
  304. When to treat a duschene scoliosis
    20-30 degrees: after this they get pulmonary deterioration
  305. Adolescent idiopathic scoli: Gender
    Curve pattern
    Cardiopulmonary dysfunction if
    • Female 10x
    • Right thoracic
    • Curve >90 degrees
  306. Risk factors for curve progresson AIS 3
    • Curve magnitude: >50 thoracic, >40 lumbar
    • Remaining skeletal growth
    • Curve type: thoracic > lumbar...double>single
  307. 5 ways to assess remaining skeletal growth + risk of scoli
    • Younger age: <12
    • Tanner stage: <3
    • Risser stage: 0-1
    • Peak growth velocity: if curve > 30 before peak growth velocity.....likely to need surgery
  308. Describe lenke classification

    MOdifiers (2)

    Structural if (3)
    • I: Main thoracic
    • II: Double Thoracic
    • III: Double Major (T>L)
    • IV: Triple Major
    • V: Thoracolumbar/Lumbar
    • VI: Double Major (L>T)

    Sagital from t5-t12: If <10 kyphosis (-)...if >40 (+)

    Lumbar modifier (CSVL relationship to pedicles of apical vertebrae): 

    • A: BTW pedicles
    • B: touches Pedicle
    • C: Does not touch pedicle


    Structural if

    • >25 degrees on standing AP and does not bend to < 25 on bending films
    • >20 in sagital plane
    • Biggest curve
  309. How to do screening with scoliometer
    If 7 degrees on scoliometer corresponds to 20 degree curve
  310. Define: Stable vertebrae
    Neutral vertebrae
    End Vertebrae
    Apical vertebrae
    • Stable vertebrae: Most proximal vertebrae that is bisescted by CVSL
    • Neutral vertebrae: Rotationally neutral
    • End Vertebrae: Vertebre that s most tilted from horizontal
    • Apical vertebrae: Deviates furthest from midline
  311. Indications for bracing in AIS
    • Cobb angle 25-45
    • Risser 0-2
  312. 5 factors for poor prognosis with brace
    • Poor in brace correction
    • Hypokyphosis
    • Male
    • Obese
    • noncompliant
  313. Type of brace if: curve above t7
    Curve below T7
    • Milwakee: extends to neck
    • Boston
  314. MOst common organism for delayed infection in AIS
    P acnes
  315. SMA syndrome: Definition
    SMA arises from
    Treatment

    3 risk factors
    • Compression of 3rd part of duodemun due to narrowing of space btw aorta and SMA
    • Aorta at the level of L1
    • NG and IVF

    • Height <50th percentile
    • weight <25th percentile
    • Sagital kyphosis
  316. What gestational age does the vertebrae develop
    4-6 weeks of gestation
  317. Maternal exposure to 4 things increase risk congenital scoli
    • DIabees
    • Alcohol
    • Valproic acid
    • Hyperthermia
  318. 5 syndromes associated with congenital scoliosis
    • VACTERL
    • Gondenhar: hemifacial microsomia
    • Jarcho-Levin: 
    • Klippel-feil: 
    • Alagille: peripheral pulm stenosis, cholestasis
  319. Congenital scoli top 3 risk of progression
    Unilateral unsegmented bar + contralateral hemi

    Unilateral unsegmented bar

    Fully segmented hemiverterbrae
  320. 3 gross categories of congenital scoliosis
    • Failure of formation
    • Faiure of segmentation
    • Mixed
  321. 5 things to look for in MRI for congenital scoli
    • Tethered cord
    • Chiari
    • Syrinx
    • Diastematomyelia
    • Intradural lipoma
  322. What x ray finding makes you concerned with thoracic insufficiency syndrome + what to do
    fusion > 4 ribs

    Osteotomy btw ribs
  323. Juvenile idiopathic scoliosis: definition
    Curve type
    • Age 4-10
    • Right main thoracic
  324. Associated conditions to juvenile idiopathic scoli 5
    • Syringomyelia
    • Chiari syndrome
    • Tethered cord
    • Dysraphism
    • Spinal cord tumor
  325. Infantile idiopathic scoli: age
    gender
    Curve type
    Progression
    • < 3 years
    • Male> female
    • Left thoracic
    • Most resolve
  326. Infantile idiopathic scoli 4 associated condition
    • Plagiocephaly
    • COngenital defects
    • Neural axis
    • Thoracic insufficiency
  327. 3 mehta predictors of progression
    For infantile scoli

    • Cobb > 20
    • RVAD > 20
    • phase 2 ribs
  328. RVAD: what is it
    Progression
    Recovery
    • Rib vertebral angle difference
    • >20 degrees: Progression
    • <20 degrees: recovery
  329. Indications for growing rod construct in infantile scoli (2)

    when to do it
    • CObb>50/60
    • Failed Mehta casting or bracing

    If fusion < 10 >>>pulmonary compromis
Author
egusnowski
ID
345819
Card Set
Spine - Orthobullets
Description
Spine orthobullets
Updated