-
Most common site of lumbar disc herniation
L5/S1
-
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
-
Lumbar disc herniation: disc with greatest resorbtion
Mechanism
- Sequestered disc
- Macrophage phagocytosis
-
Composition of Intervertebral disc
- Annulus fibrosus
- Nucleus polpous
-
Annulus fibrosus: type of collagen
Composition
Mechanical properties
- Type I
- high collagen/low proteoglycan
- Extensibility and tensile strenght
-
Nucleus pulposus: collagen type
Composition
Mecahnical properties
- Type 2
- Low collagen/high proteoglycan
- COmpressibility
-
SPine: where do the nerve root exit
- Cervical: above pedicle
- Rest: below pedicle
-
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
-
Most common type of disc herniation + reason
Posterolateral: PLL weakest here
-
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
-
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
-
L5 weakness: gait
Trendelenburg: glut medius innervated by L5
-
Disc herniation: use of MRI arthro
Distinguish between post surgical fibrosis ( enahnces) and recurrent disc (does not enhance)
-
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
-
2 operative indications for disc herniation
Persistent disabling pain lasting more than 6 weeks that have failed non op
Progressive significant weakness
Cauda equina
-
Disc herniation surgery vs non op
If done after 6 weeks
Surgery better pain and function
-
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
-
Negative predictor factor for lumbar disc herniation surgery
Workman compensation
-
4 complications of lumbar discectomy
- Dural tear
- Recurrence
- Discitis
- Vancular catastrophy
-
Outcome of recurrent disc herniation vs primary surgery
No diference
-
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
-
Spinal cord injury: most common syndrome
Most common location
-
4 causes of secondary injury in spinal cord injury
- Decreased perfusion
- Lipid peroxidation
- Free radicals/cytokines
- Cell apoptosis
-
2 risk factors for vertebral artery injury in c spine trauma
- Atlas fracture
- facet dislocation
-
Vertbral artery injury: symptoms
Treatment
- Basilar artery insufficiency
- Stenting: only if symptomatic
-
How to determine if patient is in spinal shock
Abscence of bulbocavernosus reflex
-
Neurogenic shock: Classic presentation
Mechanism
- Hypotension and tachycardia
- Circulatory collapse from loss of sympathetic tone
-
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
-
5 contraindications to steroids in Spinal cord injury
- GSW
- Pregancy
- Under 13
- >8 hours after injury
- Brachial plexus injuries
-
7 non ortho complications of spinal cord injury
- Skin problems
- Venous thromboembolism
- Urosepsis
- Sinus tachycardia
- Orthostatic hypotension
- Autonomic dysreflexi: headache, hypertension, agitation
- MDE: 11%
-
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
-
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
-
2 causes of cervical radiculopathy
- Degenerative cervical spondylosis: discosteophyte complex
- Disc herniation: posterolateral>>>btw posterior edge of uncinate and lateral edge of pll
-
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
-
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
-
Describe the following tests: spurling
Spurling: Simultaneous extension, rotation to affected side, lateral bend, vertical compression reproduces symptoms
-
How to do cervical ct myelography
Injection at C1-2
-
percentage of cervical radiculopathy that improve with non op
75%
-
Indication for a posterior foraminotomy
Formainal disc herniation causing single level radiculopathy
-
Gold standard treatment for cervical radiculopathy
Sigle level ACDF
-
3 risk factors for pseudoarthrosis after ACDF
- Smoking
- Diabeted
- Multi level fusion
-
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
-
5 classic symptoms of cervical myelopathy
- Neck pain or stiffness
- Extremity parasthesias
- Weakness and clumsiness
- Gait instability
- Urinary retention
-
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
-
5 physical exam findings of upper motor neuron signs
Hyperreflexia
Inverted radial: tapping brachioradialis > finger flexion
Hoffman
Sustained clonus: > 3beats
Babinski
-
2 physical exam tests for gait and balance
- Toe heel walk
- romberg: arms held forward and eyes closed > loss of balance
-
Pavlov ratio: is
values
Ratio of canal to vertebral body <0.8 suggest a congenital narrow canal
-
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
-
ACDF: approach
Indication
- Smith robertson
- 1-2 level disease or fixed kyphosis >10 degrees
-
4 advantages of AACDF vs PSF
- Lower infection
- Less blood loss
- Less post op pain
-
Contraindication to cervical PSF
FIxed kyphosis >13 degrees: will not adequately decompress due to bowstriging
-
Indication for laminoplasty
Multilevel compression in OPLL: less complication vs anterior
-
Post op C5 nerve palsy: incidence
?mechanism
Prognosis
- 5%
- Tethering of cord anteriorly if doing post decompression
- Good
-
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
-
fasciculations: sign of
Lower motor neuron disorder
-
6 anatomic structures that can cause lumbar spinal stenosis
- Facet osteophytes
- Uncinate spurs
- Spondylolisthesis
- Herniated disc
- Ligamentum flavum hypertophy or buckling
- Synovial facet cysts
-
Cross sectional area definition of lumbar spinal stenosis
<100mm2
or <10mm AP diameter
-
What is the primary culprit for lateral recess stenosis
Overgrowth of superior articular facet
-
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
-
kemp sign: is
Unilacular radicular pain from foraminal stenosis made worse by extension of back
-
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
-
2 indications for surgical management of lumbar spinal stenosis
Failed conservative x 6 months
Progressive neuro deficit: weakness or bowel/bladder
-
Most common cause of failed lumbar spinal stenosis surgery
Recurrence of disease above or below decompressed level
-
Single level decompression and fusion risk of adjacent level disease
30% at 10 years
-
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 %
-
Demographics of degenrative spondy: 3 populations increased risk
- African americans
- Diabetics
- WOman over 40
-
2 risk factors for degenerative spondy
- Sacralization of L5
- Sagitally oriented facet joints
-
In degenerative spondy what nerve roots are affected
If L4/L5
- L5 at the level of the lateral recess
- L4 from foraminal stenosis
-
Myerding classification: for
Is
Spondylolisthesis
- I: <35%
- II: 25-50%
- III: 50-75:
- IV: 75-100%
- V: spondyloptosis
-
How do you define instability in flexion extension x rays of the lumbar spine
4mm translation or >10 degrees agulation
-
What is a negative prognostic factor for spinal decompression and fusion in degen spondy
Smoking
-
Injury to what nerve structure causes retrograde ejaculation
Superior hypogastric plexus
-
risk factors for adjacent level disease in lumbar spinal fusion (3)
- Multi level
- Age >60
- Adjacent level laminectomy
-
Ank spond: Gene
RF
Primarily affects
- HLA-B27
- RF negative
- Axial spine
-
3 diagnostic criteria for Ank spond
- Bilateral sacroiliitis
- +/- uveitis
- HLA b27 positive
-
6 systemic manifestations of ank spond
- Acute uveitis
- Heart disease: conduction abnormalities
- Pulm fibrosis
- Renal amyloidosis
- Ascending aorta conditions
- Klebsielle synovitis
-
4 ortho manifestations of ank spond
- Bilateral sacroiliitis
- Progressive spine kyphotic deformity
- Cervical spine fractures
- Large joint arthritis
-
Limitation of chest wall expansion > 2cm: dx
ank spond
-
X ray for si joint
Ferguson pelvic tilt view: x ray directed 10-15 degrees cephalad
-
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
-
3 DMARDs for ank spond
Infliximab, etanercept/adalimumab: TNF alpha blocking
-
Ank spond spine fractures: look for
location
mechanism
- Epidural hematoma
- Midcervical and cervicothoracic jct
- Extension type: involve all 3 columns
-
4 complications in ank spond spine surgery
- Progressive deformity
- nonunion
- hardware failure
- infection
-
AS and chin on chest deformity: surgery
C7-T1 cervicalthoracic osteotomy: vert is external to transverse foramen + large canal diameter
-
Ank spond and THA: increased risk of what complication
Anterior dislocation: vertically oriented nd anteverted acetabulum
-
Definition of sagital plane inbalance in spinal deformity
>5cm
-
Most common location of: AIS
Deden scoli
-
4 factors that contribute to development of degen scoli
- Osteoporosis
- Pre existing scoli
- Iatrogenic instability
- DDD
-
2 factors that lead to worse prognosis in Spinal degen scoli cases
- Symptoms on convex side of curve
- Sagital plane inbalance
-
4 causes of de novo ASD
- Degenerative changes
- iatrogenic
- paralytic
- post traumatic
-
Degenerative scoliosis: what curve affects PFT
What curve affects mortality
- > 60 degrees thoracic
- > 90 degrees
-
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
-
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
-
Burst #: definition
Mechanism
- Vertebral fracture that involves the anterior and middle column
- Axial load with fleion
-
Burst fracture what happens to retropulsed fragments over time
usually resorb and do not cause neuro deficits
-
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
-
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
-
4 components of posterior ligamentous complex spine
- Supraspinous ligament
- Infraspinous ligament
- Ligamentum flavum
- Facet capsule
-
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
-
TLICS score: 4 components
treatment implications
- Injury morphology
- Neuro status
- PLC integrity
- <4: non op
- 4: uncertain
- >4 operative
-
4 indications of non op managament of burst #
Neuro intact +
- PLC presrved
- kyphosis < 30 (controversial)
- Vertebral body height loss < 50% (controversial)
- TLICS<4
-
Outcomes of bracing for TL burst #
No difference to no brace
May help patient for pain control
-
burst fracture: 2 ways to achieve decompression of canal
Direct: transpedicular removal of retropulsed fragment
Indeirect: ligamentotaxis
-
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
-
Odontoid # 2 mechanisms
Hyperflexion: anterior displacement > associated with transverse ligament failure and atlantoaxial instability
Hyperextension: casued by direct impact of posterior arch of atlas
-
How many ossicifaction centers for the odontoid
5
-
Occiput-c1-c2 instability 3 components
- Transverse ligaments:limit anterior translation
- Apical ligaments: Limit rotation
- Alar ligaments: limit rotation
-
Odontoid blood supply: 2 main
watershed
- Apex: internal carotid
- BasE: Vertebral artery
Watershed at location of type 2 #
-
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
-
What defines instability in flex ext views cervical spien 2
- ADI >10mm
- < 13mm Space available for cord (PADI)
-
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
-
COntraindication to halo fixation for odontoid #
elderly patient: do not tolerate > aspiration
-
6 risk factors for no union in type 2 odontoid #
- >6mm displacement
- Age >50
- Fx comminution
- Angulation >10 degrees
- Delay in treatment
- Smoker
-
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
-
C1-C2 transarticular screws: structure at risk
Vert
-
IV disc responsible for what % of spinal column height
25%
-
Innervation of IV disc
Sinuvertebral nerve from dorsal root ganglion: superficail fibers of annulus
-
With IV disc aging what happens to water content
It is replaced by fibrocartilage: change in properties
-
In IV disc what happens to keratans ulfate to chondroitin sulfate ratio with aging
It increases
-
Most common fragility fracture
vertebral compression fracture
-
Strongest predictor of future vertebral fractures in postmenopausal women
Hx f 2 VCF
-
-
1 year mortality of vertebral compression fracture
15%
-
Medication to reduce pain acutely in vertebral compression fractures
Calcitonin: within 5 days
-
AAOS recommendaton on: vertebroplasty
kyphoplasty
AAOS: recommend strongly against
AAOS: May be used but limited recommendation strenght
-
L5-S1 spondy: nerve root affected
L5
-
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
-
L5-S1 fusion for spondy + reduction: risk
benefit
- L5 nerve root neuropraxia
- Improved sagital alignment
-
Critical physical exam finding to differentiate complete vs incomplete SCI
Sacral sparing: presence of voluntary anal contraction
-
Most common incomplete spinal cord injury
central cord syndrome
-
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
-
4 types of incomplete SCI
- Anterior cord syndrome
- Brown sequard
- Central cord
- Posterior cord
-
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
-
2 causes of anterior cord syndrome
- Direct compression: disc or bony
- Anterior spinal artery injury: 2/3 spine supplied by it
-
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
-
Worst prognosis in incomplete spinal cord injury
Anterior cord syndrome
-
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)
-
Where do spinothalamic tracts cross
2 levels below the
-
3 contraindications to halo fixation
- Cranial fracture
- Infection
- Severe sof t tissue injury
-
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
-
Pediatric halo technique: torque
pin #
Pin location
- 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
-
Most common nerve palsy with halo traction
Abducens: diplopia and loss of lateral gaze
-
Halo pins: at risk if pins too lateral
pins too medial
- Supraorbital nerve
- Supratrochlear nerve
-
Halo complications in kids vs adults
-
Halo vest: controls what motion best
Rotation C1-C1
-
Most common level of thoracic disc herniation
T11-t12
-
1 risk factor for thoracic disk
Underlying scheuermanns disease
-
Thoracic disc: what location can give you horners
T2-T5
-
Best approach for thoracic disc
Lateral thorugh costotransversectomy
-
Most common complication from VATS for antererior thoracic discectomy
Intercoastal neuralgia
-
3 types of spinal cord monitoring
- EMG
- SEP: 25% sensitive + 100% specific
- MEP: 100% sensitive + 100% specific
-
2 spinal cord pathways
- Afferent (sensory)
- Dorsal column
- Spinothalamic tract
- efferent (motor)Lateral corticspinal
- Ventral corticospinal
-
Sensory evoked potentials: technique
Record brain: somatosensory cortex
Lower extremity: stimulate posterior tibial nerve
Upper extrimity: stimulate uknar nerve
-
Sensory evoked potentials: Advantage
Disadvantage
Unaffected by anesthetics
No reliable for monitorng anterior spinal cord (motor)
-
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
-
Motor evoked potential: advantage
Disadvantage
- Detect ischemia of anterior cord
- Unreliable due to anestheisa
-
Typical location of comus medullaris
T12-L1
-
External sphincter of bladder controlled by what nerve
Pudendal nerve
-
Cauda equina time to surgery and outcomes
Better bowel and bladder symptom resolution if performed within 48 hours
-
% subluxation on x ray if: unilateral facet dislocation
Bilateral facet dislocation
-
Facet fractures: what structure most commonly injured
Location most common
mechanism
Superior facet
Subaxial c spine c2-c7
Flexion distraction
-
Unilateral facet dislocation: location of symptoms
Exiting nerve root below level ie if C6/7 C7 affected
-
Which type of cervical facet dislocations are easier to reduce and why
Bilateral easier than unilateral: PLL torn >>also makes them less tabe
-
outcome of LBP treated with conservative mgmt
90% resolves within 1 year
-
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
-
What is the strongest negaive predictor to good outcome for non op LBP mgmt
High VAS scale prior to treatment
-
Adult vertebral osteo lcoation
- Lumbar: 50-60
- Thoracic: 30-40
- Cervical: 10
-
9 risk factors for adult vertebral osteo
- IV drugs
- diabetes
- recent systemic infection
- obesity
- malignancy
- immunosuppresed
- Malnutrition
- Trauma
- smoking
-
Most common pathogen of vertebral osteo
Staph aureus
-
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
-
Gold standard for diagnosis of vertebral oste
MRi with gado: disc and endplate enhancement with gado
-
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
-
3 indications for surgery in bacterial vertebral osteo
- Refractory to Abx
- euro deficits
- Progressive deformity and instability
-
Atlas fracture: 2 assocaited injuries
-
Atlas: ossification centers
Anatomic variant
- 3
- Incomplete fusion of posterior arch
-
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
-
ADI: normal
Injury to to transverse
Injury to transverse, alar, tectorial membrane
-
Measurement on open mouth odontoid
Sum of lateral mass displacement: if>7mm transverse ligament rupture and considered unstable
-
3 types of screws you can use for c1-c2 fusion
- C1 lateral mass
- C2 pedicle
- C1-2 transarticular screw
-
1 possible indication for lumbar disc replacement
Single level disease with no adjacent level disease
-
Outcomes of adjacent level disease in total disc replacement vs fusion
Total disc lower level of adjacent level disease
-
negative effects of provocative discography (2)
Accelerated disc degeneration and reactive endplate changes
-
Most common location of lumbar facet cyst
L4-5
-
What procedure for lumbar synovial cyst give the lowest risk of persistent back pain and cyst recurrence
Facetectomy and instrumented fusion
-
Lumbar lordosis: average
Apex
-
Mammillary process: what do they separate
location
- Separate ossification centers
- Project superiorly from superior articular facet
-
Facet orientation as you move down the spine
Become more coronal
-
Blood supply to lumbar vertebrae
Segmental arteries
-
3 patterns of instability for RA
- Atlantoaxial subluxation
- Basilar invagination
- Subaxial subluxation
-
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
-
Most common instability in RA: is
caused by
- Atlantoaxial subluxation: 50-80% RA
- Pannus btw dens and ring of c1>destruction of transverse ligament
-
Indications for surgery in C1-C2 instability in RA (2)
>10 mm ADI
<14mm PADI/SAC
-
Most important radiographic finding that my predict complete neural recovery after decompression in c1-c2 instability
>13mm of SAC/PADI
-
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
-
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 linePosterior edge of hard palate to caudal posterior occipital curve
- Basialr invagination if tip of dens >4.5cm above this line
- Chamberlain's lineLine 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
-
3 indication for C2-occiput fusion in basilar invagination
- Progressive cranial migration >5mm
- Neuro compromise
- Cervicomedullary angle <135 on MRI
-
RA and subaxial instability: best predictor of neuro compromise
Cervical height to width ratio <2 is almost 100% sensitive and specific
-
Dish: definition
Most common location
Presence of non marginal syndesmophytes at 3 succesive levels
Thoracic spine (right side) > cervical > lumbar
-
-
DISH and HO after TH
30-50% in DISH: more than normal
-
Most common extrapulmonary site of TB
Thoracic spine
-
How to distinguish TB from Discitis/osteo
TB has contiguous multilevel involvement that skips the disc
-
4 spine at risk signs in TB
- Retropulsion
- Subluxation
- lateal translation
- Toppling
-
% PPD positive in TB spine
80%
-
TB medical managament
RHZE: for 2 months then RH for 9-18 months
- Rifampin
- Isoniazid
- Ethambutol
- Pyrazanamide
-
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
-
POtt's paraplegia: what is it
SPinal cord injury caused by abcess/bony sequestrum
-
Population with high incidence of pott disease
HIV
-
Histologic composition of ligamentum flavum
Mostly elastin
Rest of ligaments in spine are collagen
-
Normal range for: Cervical lordosis
Thoracic kyphosis
Lumbar Lordosis
-
Where can you put pedicle screws in cervical spine
C2 and C7
or the rest, pedicles are too small so use lateral mass screws
-
Location of conus: at birth
At maturity
-
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
-
Histologic origin of vertebral bodies
Notocord
-
Primary blood supply to dorsal sensory column
Posterior spinal artery
-
Largest anterior segmental artery: name
Arises from
location
- Artery of adamkiewicz
- Left posterior intercoastal
- 75% left side btw T8 and L1
-
CSF: where is it produces
rate of formation
Choroid plexus in third, fourth, lateral ventricles
500 mL/day
-
Define: syringomyelia
Syringobulbia
Syrinx within the spinal cord that expands > neuro deficits
Syrinx in the brain stem
-
Syrinx can be caused by 4 main things
Chiari malformation: 50% have syrinx
Spinal cord trauma
Spinal cord tumor
Post infectious
-
Syringomyelia: 3 associated conditions
- Developmental scoli
- Klippel-feil
- Charcot joints
-
Syrinx and scoliosis: what to fix first
Fix syrinx first then fusion 3-6 months later
-
Chance fracture: mechanism
Flexion / distraction
-
Chance fracture 2 types and which one is more difficult to heal without surgery
Bony
Ligamentous: Harder to heal
-
Discitis: Location
Gender
Age
Pathogenesis
In kids blood vessels reach the nucleus polpusus> direct onoculation
-
3 indications for surgical managemnt of discitis
- Late intection
- Paraspinal abcess and neuro deficits
- Limited response to non op
-
3 radiographic changes in ped discitis from soonest to latest to appear
Loss of lordosis
Disc space narrowing
Endplate erosion
-
6 risk factors for epidural abcess
- IV drug user
- Immunodeficiency
- Malignancy
- HIV
- Immunosuppresive meds
- Recent spinal procedure
-
Epidural abscess most common pathogen
Staph aureus
-
Epidural abscess most important indicator of clinical outcome
Preop degree of neuro deficits
-
Gold standard for Dx of epidural abcess
MRI with GADO
-
4 indications for surgery in epidural abscess
- Neuro deficits
- Spinal cord compression on imaging
- Failed conservative
- Progressive deformity or instability
-
AARD: 3 causes
- Infection: grisel disease
- Trauma
- Recent head and neck surgery
-
4 associated conditions to AARD
- Downs
- RA
- TUmor
- Congenital anomalies
-
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
-
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
-
definition of scheurmann's kyphosis(3)
- > 45 degreed
- Anterior wedging >5 degrees of 3 consecutive vertebrae
- Rigid kyphosis
-
scheurmann's kyphosis: most common location
Genetics
- Thoracic
- Autosomal dominant
-
scheurmann's kyphosis: 3 ortho associated conditions
1 non ortho condition
- Hyperlordosis
- SPondylolysis
- Scoliosis
Pulmonary issues if curve > 100 degrees
-
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
-
Cervical spine levels with bifid spinous process
C2-C6
-
Vertebrae with no Vertebral artery
C7
-
what level in c spine: palpable carotid tubercle
Non bifid spinous process
-
3 erector spinae muscles + relationship to each other
- SPinalis:most medial >>SP to SP
- Longissimus in the middle >> TP to TP
- Iliocostalis: most lateral
-
Cause of congenital torticollis
SCM contracture:
-
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
-
OPLL: population at risk
Gender
Location
-
4 associated factors to OPLL
- DM
- Obesity
- High salt/low sodium
- Poor calcium absorption
-
2 techniques for OPLL myelopathy
Anterior corpectomy: either remove OPLL or let it fall into void
Posterior laminoplasty: Need spine lordois..considered safer
-
Most common location of cervical spondylosis
C5/6 + C6/7: because site of most flexion
-
4 risk factors for cervical spondylosis
- Excessive driving
- Smoking
- Lifting
- Professional athletes
-
Cause of cervical spondylosis
Degeneration of the discand 4 joints in c spine
2 facet joints - 2 uncovertebral joints
-
Definition of absolute and relative cervical stenosis
- Canal diameter < 10
- Canal diameter 10-13
-
thoracolumbar # dislocations: Most common location
Mechanism of injury
- thoracolumbar junction
- Acceleration > deceleration injuries
-
Type of subaxial cervical spine fracture associated with complete/incomplete SCI
Burst
-
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
-
Quadrangular fracture of spine: dc
Flexion teardrop #
-
Extension teardrop fracture:characterized by
Management
- Small fleck of bone avulsed of anterior endplate
- Usually stable:treat wwith collar
-
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
-
Associated condition to occipitocervical instability
Down syndrome
-
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 12Bastion to tip of dens >12mm abnormal
- Basion posterior axial interval > 12mm abnormal
Posterior axial interval is vertical line drain down posterior aspect of odontoid
-
Use of traction in occipitocervical dislocation
AVOID: can pop the head off ifligaments compromised
-
Structure at risk when placing screws in skull for occipito cervical fusion
Major dural venous sinus
-
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
-
Klippel feil: classic triad
- Low posterior hairline
- Short webbed neck
- Limited cervical ROM
-
Klippel feil: associated with
- heart
- Kidney
- Sprengel deformity
-
nerve responsible for bowel and bladder function
S3-4
-
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
-
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
-
Hangman fracture: definition
Mechanism
Bilateral pars # of C2
- Hyperextension: # pars
- Secondary flexion: tears PLL
-
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
-
Hangman # types that need surgery
Type II: if displaced > 5mm
Type III: for reduction of facet
-
Hangman fracture: avoid traction if
Type 2A #
Has horizontal line...treatment is compression halo vest
-
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
-
3 approaches to thoracic spine
Posterior
Costotransverse
Transthoracic
-
3 conditions associated with sacroiliitis
- Ank spond
- Reiter syndrome
- Pregnancy
-
Sacroiliitis physical exam manouver
FABER produces pain
-
Most common location c spine injuries in: <8 years
> 8 years
- 83% above C3
- Lower cervical
-
4 reasons why patients below 8 have upper c spine injuries
- Bigger head
- Ligamentous laxity
- Horizontal facet joints
- Weak muscles
-
How much can the spinal cord stretch before rupture in children
5 cm
-
Normal amount of prevertebral soft tissue swelling in children
<2/3 of adjacent vertebral width
-
Optimal position of head immobilization for c spine fracture
In line cervical stabilization with ears in line with shoulders
-
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
-
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
-
4 causes of adult atlantoaxial instability
- Downs
- RA
- Os odontoideum
- Trauma: transverse ligament injuries
-
4 causes of pediatric atlantoaxial instability
- JRA
- Morquio
- Downs
- Trauma: AARD
-
What joint provides 50% rotation of c spine
Atlantoaxial joint
-
ADI: normal range in adults
Considered unstable
Indication for surgery in RA
-
PADI/SAC associated with increased risk of neuro injury
<14: therefore indication for surgery
-
Spinal cord injury in kids: more lethal if
Better prognosis for recovery
-
Highest risk of scoliosis: what type of CP
- Spastic quad
- If bedridden: 100%
-
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
-
CP scoliosis: when to extend to pelvis
Pelvic obliquity >15 degrees
-
spondylolysis: Definition
Mechanism
% associated with spondylolisthesis
- Defect in pars interarticularis
- Repetitive hyperextension
- 15%
-
Spondyolisthesis 2 things that increase risk of progression
- Larger slip
- Dysplastic type
-
Describe wiltse classification
- Dysplastic
- Isthmic: pars elongatiom
- Isthmic: pars acute fracture
- Isthmic: pars stress fracture
- Traumatic
- Neoplastic
-
X ray to order of looking for spondylolysis + name of sign
Spine oblique
Scotty dig sign
-
Best diagnostic test for spondylolisis if plain x rays are negatine
SPECT
-
Indication for par interartecularis repair
L1-L4 isthmic defect that failed non op
-
When to use TLSO for spondy
Positive SPECT: suspected stress or acute isthmic spondy
-
2 main causes of pathologic scoliosis
- Osteoid osteoma: apex of concavity
- Osteoblastoma: pain less severe
-
Osteoid osteoma scoliosis will resolve if (2)
Removal of tumor before 18 months of onset of scoli
Child is <11 years old
-
6 causes of neuromuscular scoliosis
- CP: UMN
- Rett: UMN
- SMA: Muscle weakness
- Muscular dystrophy: Muscle weakness
- Spina bifida/SCI: Paralytic
- Polio: Paralytic
-
2 types of neuromuscular scoli where bracing is contraindicated
- Muscular dystrophy
- SPina bifida/SCI
-
When to treat a duschene scoliosis
20-30 degrees: after this they get pulmonary deterioration
-
Adolescent idiopathic scoli: Gender
Curve pattern
Cardiopulmonary dysfunction if
- Female 10x
- Right thoracic
- Curve >90 degrees
-
Risk factors for curve progresson AIS 3
- Curve magnitude: >50 thoracic, >40 lumbar
- Remaining skeletal growth
- Curve type: thoracic > lumbar...double>single
-
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
-
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
-
How to do screening with scoliometer
If 7 degrees on scoliometer corresponds to 20 degree curve
-
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
-
Indications for bracing in AIS
- Cobb angle 25-45
- Risser 0-2
-
5 factors for poor prognosis with brace
- Poor in brace correction
- Hypokyphosis
- Male
- Obese
- noncompliant
-
Type of brace if: curve above t7
Curve below T7
- Milwakee: extends to neck
- Boston
-
MOst common organism for delayed infection in AIS
P acnes
-
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
-
What gestational age does the vertebrae develop
4-6 weeks of gestation
-
Maternal exposure to 4 things increase risk congenital scoli
- DIabees
- Alcohol
- Valproic acid
- Hyperthermia
-
5 syndromes associated with congenital scoliosis
- VACTERL
- Gondenhar: hemifacial microsomia
- Jarcho-Levin:
- Klippel-feil:
- Alagille: peripheral pulm stenosis, cholestasis
-
Congenital scoli top 3 risk of progression
Unilateral unsegmented bar + contralateral hemi
Unilateral unsegmented bar
Fully segmented hemiverterbrae
-
3 gross categories of congenital scoliosis
- Failure of formation
- Faiure of segmentation
- Mixed
-
5 things to look for in MRI for congenital scoli
- Tethered cord
- Chiari
- Syrinx
- Diastematomyelia
- Intradural lipoma
-
What x ray finding makes you concerned with thoracic insufficiency syndrome + what to do
fusion > 4 ribs
Osteotomy btw ribs
-
Juvenile idiopathic scoliosis: definition
Curve type
- Age 4-10
- Right main thoracic
-
Associated conditions to juvenile idiopathic scoli 5
- Syringomyelia
- Chiari syndrome
- Tethered cord
- Dysraphism
- Spinal cord tumor
-
Infantile idiopathic scoli: age
gender
Curve type
Progression
- < 3 years
- Male> female
- Left thoracic
- Most resolve
-
Infantile idiopathic scoli 4 associated condition
- Plagiocephaly
- COngenital defects
- Neural axis
- Thoracic insufficiency
-
3 mehta predictors of progression
For infantile scoli
- Cobb > 20
- RVAD > 20
- phase 2 ribs
-
RVAD: what is it
Progression
Recovery
- Rib vertebral angle difference
- >20 degrees: Progression
- <20 degrees: recovery
-
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
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