PHII - Neuro > CH32- TL > Flashcards

CH32- TL Flashcards

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1
Q

• Name the structures identified in this image. From bottom left up and around to bottom right (Pedicle)

A

• Transverse process
• Cranial articular process
• Vertebral foramen
• Mammary process of the articular process
• Spinous process
• Lamina
• Pedicle
• Spinous process
• Caudal articular process
• Acessory process
• Pedicle

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2
Q

• What are the joints called between the vertebrae?

A

• Zygapophyseal joints - articular processes join to form synovial joints

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3
Q

• What is the anticlinal vertebra and what does it indicate?

A

• T11
• Location where the spinous processes change from slanting caudally to slanting cranially

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4
Q

• Which direction do the transverse processes point?

A

• Lateral to craniolaterally

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5
Q

• What forms the vertebral foramen?

A

• The vertebral arch - two pedicles, lamina and spinous process
• The vertebral body

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6
Q

• What is the intervertebral foramen and where is it located in relation to the zygapophyseal joint?

A

• Opening between each pair of vertebra
• ventral and cranial to zyapophyseal joint

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7
Q

• What are the 3 components of an intervertebral disc and what are they composed of?

A

• Annulus fibrosis - collagen and
• Nucleus pulposus - glycosaminoglycans (chondroitin and keratin sulfate) and Type 4 collagen
• Cartilaginous end plates - allows nutrient entry to into the avascular disc

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8
Q
  • What are the passive stabilizers of the vertebral column?
A

Passive
* IVD - provides the most stability
* Tendons
* Ligaments
* Zygapophyseal joints

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9
Q
  • Name the ligaments of the spine (3 long and 3 short).
A

Long
* Supraspinous
* Dorsal and ventral longitudinal ligaments

Short
* Interspinous
* Intertransverse
* Yellow
* Intercapital ligament

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10
Q

• Identify the structures in these images.

A

• Dorsal and ventral longitudinal ligaments - dorsal and ventral to the vertebral discs Intercapital ligament - exists from T2 - T11 between the ribs ventral to the dorsal longitudinal ligament Yellow ligament

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11
Q

• What muscle is attached to the accessory process?

A

• Longissimus lumborum, from T11-L7

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12
Q

• Which vertebrae is the anticlinal vertebra, typically?

A

• T11

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13
Q

• NP contains what type of collagen?

A

• Type IV

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14
Q

• Name the anatomy in this image.

A

• Spinal branches of the intercostal a.
• Intercostal a.
• Azygous
• -> drains the intervertebral venous plexus

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15
Q
  • Describe the dorsal approach to the cranial Thoracic spine. (T1-T5)
A

To Really Swing Start Little League Swing to Major League

  • Trapezius
  • Rhomboideus
  • Splenius
  • Serratus dorsalis
  • Longissimus cervicis
  • Longissimus thoracis
  • Semispinalis
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16
Q

• Describe the approach to the TL spine. Major League

A

• Incise skin and dorsal thoracolumbar fascia
• Multifidus - spinous processes and joint
• Longissimus lomborum - accessory processes T11-T7

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17
Q

• Describe the lateral approach to the TL spine. To See It Look Cranial

A

• T9-L6 skin incision
• Dissect through epaxial m.
• Serratus dorsalis
• Iliocostalis
• Longissimus lomborum
• Annulus CRANIAL to transverse process or rib
• Retract spinal a/n/v CRAINIAL

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18
Q

• Describe the dorsolateral approach to the TL spine.

A

• Swing Starts Major League
• Spinalis
• Semispinalis
• Multifidus -> retract medially from transverse processes
• Longissimus lomborum -> retract laterally

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19
Q

• What is use of dorsal approach to the thoracic spine?

A

• T1-5,
• IVD, fracture repair, biopsy of neoplasia

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20
Q

• What is use of dorsal approach to the thoracolumbar spine?

A

• T6-L6
• IVD, hemi, dorsal laminectomy, pediculectomy, mini-hemi, IVD-fenestration, lateral corpectomy, and stabilization of fx

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21
Q

• What is use of lateral approach to the TL spine?

A

• T10-L5
• Lateral corpectomy
• Disc fenestration

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22
Q

• Indications for dorsolateral approach?

A

• Hemi, lateral disc fenestration, lateral corpectomy, pediculectomy, and mini-hemi
• T9-L7

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23
Q

• What 3 components contribute to jTL stability and what forces do they resist?

A

• Vertebral body - buttress, resists bending and axial
• IV disc - important stabilizer against rotation and lateral bending
• Articular process- resists all forces

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24
Q

• What are 3 landmarks for hemilaminectomy site

A

• Base of spinous process -> dorsal
• Ventral aspect of accessory process = ventral canal
• base of articular processes -> cranial and caudal aspects

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25
• What is a pediculectomy? How is it beneficial?
• Removal of the pedicle over the body of one vertebra • Better because it is faster, joint is preserved and the nerve, artery and vein are avoided
26
• What is a mini-hemiliaminectomy?
• Pediculectomy over multiple vertebral segments preserving the joint and lamina
27
• Describe this image. Explain each approach.
Funkquist type A • Articular process, half of the pedicles, lamina and spinous process Funkquist type B • Spinous process and lamina Deep dorsal laminectomy • Lamina, all of the pedicles, joint and spinous process
28
• What is a modified dorsal laminectomy?
• Spinous process, lamina and caudal articular process NOT cranial
29
• What is reported accuracy of rads to id single site herniated disc?
• 51-61%
30
• What are the common radiographic findings (6) in IVDD?
• Narrowing of the disc space • Wedging of the disc space • Increased articular process overlap • Mineralized material in the intervertebral foramen or canal • Reduced intervertebral foramen diameter • Vacuum phenomenon - gas in the IVD space due to degeneration
31
* What are 3 patterns of spinal cord change on myelography, and reported accuracy of ID disc
Intramedullary * Spinal cord swelling, ie edema/necrosis Extramedullary intradural * If disc penetrates the dura - rarely id’d Extradural * Most commonly recognized * (intraparenchymal - may suggest myelomalacia) * Sensitivity for ID disc is 74-98% * Accuracy for ID disc lateralization is 55-100%
32
• Prognostic factors for myelogram (consider length of intramedullary component)?
• If L2 vertebral ratio > 5, only 26% recovery • If L2 vertebral ratio
33
• List 3 myelogram artifacts
• Central canal filling • Epidural contrast • Subdural filling
34
• What are the adverse effects of myelography (7)?
• Seizures - heavier dogs receiving cisterna contrast (10-20%) • Myelopathy • Apnea • Cardiac arrhythmia • Meningitis • Subarachnoid hemorrhage • death
35
• What are the common findings on CT with disc herniation?
• Loss of epidural fat • Spinal cord compression • Mineral dense material in the canal - disc and hemorrhage
36
• What improves accuracy of CT in identifying IV-disc herniation?
• Multiplanar recon • Chronic history of IVD • Chondrodystrophic breed • Mineralized disc material
37
• What is the accuracy of CT at identifying site and side of herniated disc?
• 97-100%
38
• What are the types of disc herniation identified on MRI? 496
• Disc protrusion • Disc extrusion (dispersed and non-dispersed) • Disc bulge • Noncompressive nucleus propulsus extrusion • Acute noncompressive nucleus propulsus extrusion
39
• Describe this image. What is your diagnosis?
• T2W sagittal and transverse images. Numerous areas of decreased signal within the ventral canal. Hypointense smoothly marginated bulging of the dorsal aspect of the annulus fibrosis suggesting disc protrusion.
40
• Degenerate disk appears how on T1/T2, vs non-degenerate disk?
• Degenerate disk - hypointense on T1/2 weighted • Non-degenerate (more common in cervical region) - isointense on T1, hyperintense on T2
41
• Describe the images and the findings. What is your diagnosis?
• Image A is T2W transverse image • Image B is a T2* transverse image • Both show extradural compressive material in the right epidural space associated with compression. Due to the signal void on T2* it is likely it contains hemorrhage.
42
• What weighted image of MRI voids hemorrhage?
• T2* Gradient Echo
43
• What imaging sequences on MRI null fat OR fluid to help ID disc?
• STIR - nulls fat • FLAIR - nulls pure water
44
• How is T2W hyperintensity related to prognosis with L2 vertebral length ratio VS CSA %?
• CSA % > 90 = 86/96% sens/spec for poor long term outcome • CSA% <90 = 93% chance of returning to normal • No T2 hyperintense = all returned to ambulation • >3x L2 length = 20% recovery of ambulation • Decrease odds by 1.9 x per every unit of T2 hyperintensity
45
• What is typically found (4) in CSF of IVDD dogs?
• Elevated protein < 35 mg/dL • Elevated WBCs < 50 • Neutrophils in acute injury • Lymphocytes after 7 days or in lumbar tap
46
• What are general success rates of medical management for non-ambulatory vs ambulatory dogs? Recurrence rate?
• Ambulatory - 82-88% • Non-ambulatory - 43-51% • *recurrence up to 31%
47
• List 3 alternative medications for use in medical management of IVD
• IV polyethelene glycol • N-acetylcysteine - antioxidant • Autologous olfactory glial cell spinal cord transplant
48
• What is a lateral corpectomy? What is it indicated for? Describe the procedure.
• Dorsal to dorsolateral approach. Formation of a slot centered over the vertebral body (¼ length of vertebra), ventral to the intervertebral foramen of the affected area. It is centered over the disk and the pedicle and lamina and articulation remain intact. Outcomes 91% dogs ambulatory at 6mo.
49
• What is percutaneous discectomy and how is it performed? What is it indicated to treat?
• Indicated for localized disc herniation and instead of fenestration • Fluoroscopic guided K-wire into the center of the disc. 5mm Michele trephine placed over the wire to remove a plug of IVD
50
• What are outcomes of dogs with normal nociception following surgery? Compared to loss of normal nociception?
• 72-100% for pain intact • 43-62% for deep pain negative
51
• Average time to ambulation in dogs that had voluntary motor vs dogs that did not?
• 7 d (motor) vs 16 d (no motor) • Prognostic indicators for disc herniations (name 3) • No difference in herniation location • NP extrusions have better outcome than annulus fibrosis protrusions • Younger dogs recover better than older dogs
52
• What are (3) negative prognostic factors for DP negative dogs following surgery?
• Greater than 2 weeks w/o regaining sensation • Extensive subdural hemorrhage • T2 hyperintensity length relative to L2 (> 5 times)
53
• Name these instruments.
• Kirby intracapsular lens retractor hook • Angled nerve hook • House curette • Curved dental tartar scraper • Angled ball probe
54
• How can you treat hemorrhage intra-operatively during hemilaminectomy?
• Gelfoam - remove before closing
55
• How can you prevent laminectomy membrane from forming?
• Fat graft • Cellulose membranes
56
• What is most common disc space affected by disc extrusion/protrusion in TL spine in dogs > 15 kg?
• L1-2
57
• What are recurrence rates for TL disc in surgically vs medically managed?
• 15-20% (surgically) • Up to 40% medically • Longo JVIM 2021 - Finding a completely degenerate disc in the T10-L3 region on MRI in addition to the surgery site associated with 2.92 hazard ratio for recurrence of clinical signs
58
• What is the association of mineralized discs on rads and risk of recurrent disc disease in non-chondrodystrophic breeds?
• 1.4x increased risk per mineralized disk
59
• What are two alternatives to fenestration for prophylactic treatment of degenerative discs?
• Chemonucleosis - chemical dissolution of the NP with chymopapain, collagenase and chondroitinase ABC • Laser disc fenestration - Ho: YAG laser, percutaneous placement with fluoroscopy. Laser energy dehydrates and chars the NP reducing its volume.
60
• Most common site of feline disc disease?
• Caudal lumbar • L4-5 associated with fatter cats
61
• Which nerve is involved with bladder nociception, and what spinal segments does it arise from?
• L1-4 • Hypogastric n.
62
• What nerve is involved in sympathetic stimulation of the bladder and where does it come from?
• Hypogastric n. • L1-L4 = STORE
63
• What nerve is involved in the parasympathetic stimulation to the bladder and where does it come from?
• Pelvic • S1-S3 = PEE
64
• What is the somatic stimulation the external sphincter and where does that nerve come from?
• Pudendal • S1-S3 • Pu -> U (choose when you want to pee)
65
• Describe what occurs in storing urine?
• Sympathetic = store = L1-L4 • Stimulation of B1 receptor on detrusor • = relaxation of bladder • Stimulation of alpha receptor on internal urethral sphincter = contraction • Pudendal nerve • ACh release on nicotinic receptors at external sphincter = contraction
66
• Describe what occurs during urination.
• Parasympathetic = PEE = S1-3 • Pelvic nerve causes contraction of detrusor muscle by muscarinic receptors • Inhibits pudendal nerve causing relaxation of external sphincter • Inhibits hypogastric n to relax internal sphincter
67
• What is an UMN bladder
• L1-L2 (hypogastric nerve is damaged) but S1-S3 is intact so pudendal and pelvic nerves are intact • This causes the detrusor muscle to contract due to the pelvic nerve but also causes the external sphincter to contract because there is no UMN to inhibit it = LARGE FIRM BLADDER
68
• What is an LMN bladder
• Damage to the S1-S3 nerves causes loss of detrusor muscle tone and loss of external sphincter tone = LARGE FLOPPY BLADDER EASILY EXPRESSED
69
* What are the drugs used to treat UMN bladder and what do they target? What are their side effects?
Internal sphincter * Phenoxybenzamine -> alpha blocker to relax IUS * Prazosin -> alpha blocker (alpha 1 specific) -> relax IUS External sphincter * Diazepam -> benzodiazepine to relax external sphincter Bladder atony * Bethanechol -> parasympathomimetic -> increase detrusor contraction SLUDD = salivation, lacrimation, urination, diarrhea, vomiting
70
• What is a consideration for a dog post-op with urinary incontinence that had an indwelling catheter and is female that has developed fever, anorexia, vomiting, lethargy and abdominal pain in the post-operative period with BW consistent with neutrophilic leukocytosis, azotemia, pyuria and isosthenuria?
• Pyelonephritis from undiagnosed UTI postop
71
• What is risk of swelling and discharge for TL spinal surgery?
• 7.5 and 5.3% of cases
72
• Describe the findings. What is your diagnosis?
• T2W sagittal image • Compression of the spinal cord caused by hemivertebra
73
• What is a hemivertebra and how is it caused?
• Incompletely formed vertebra that is wedge-shaped. Caused by failure of one or more sclerotomes to form during embryogenesis
74
• What are the clinical signs of hemivertebrae?
• Kyphosis, scoliosis, lordosis
75
• What is a risk factor for frenchies developing L1-5 disc extrusion?
• kyphosis
76
• What breed has a heritable form of thoracic hemivertebrae?
• German short haired pointer
77
• What are the three types of vertebral malformations and what do they look like?
• Hemivertebra - wedge-shaped vertebra • Block vertebra - failure of disc space to develop between the vertebral bodies • Butterfly vertebrae - sagittal cleft within the vertebral body
78
• What is spina bifida?
• Failure of the lamina to fuse dorsally associated with neural tube malformations
79
• What 2 neural tube abnormalities is spina bifida also associated with?
• Meningocele - meninges herniated through the bony defect • Meningomyelocele - meninges and spinal cord herniated through the bony defect
80
• What are the 3 types of spina bifida?
• SB oculta • Subtle, may not be accompanied by any other changes • SB cystica • Concurrent w/meningocele, meningomyelocele • SB apera • Lesions open, threatening to be open into the environment
81
• What is pilonidal (dermoid) sinus?
• Failure of the skin to separate from the neural tube causing a sinus that communicates from the skin to the spinal cord
82
• What are most common locations for dermoid sinus or Pilonoidal sinus, to occur
• Cervicothoracic vs sacrococcygeal
83
• What breed has genetic connection to development of dermoid sinus?
• Rhodesian ridgeback
84
• How is an epidermoid cyst created, what does it contain, and where is it reported to occur?
• Failure of ectoderm to separate from neuroectoderm - late in process • Invagination of ectodermal cells in CNS; generate cyst that contains keratinocytes, keratinaceous material, and cholesterol • Intracranial > spinal cord
85
• What is a subarachnoid diverticulum?
• Focal accumulation of CSF within the arachnoid membrane or subarachnoid space
86
• What breeds are most susceptible to subarachnoid diverticula?
• Pugs, rotties, < 18 mo, males more • Marsupialization of arachnoid outpouch/diverticula -> suture to surrounding fascia
87
• Is acute hemorrhage and mineralized disk hyper or hypoattenuating compared to spinal cord on CT?
• Hyperintense - metal in acute hemorrhage, mineral in disk
88
• In dogs with TL disc extrusions >20 kg, what was the success rate of NP extrusion vs AF protrusion?
• NP - 78% success return to ambulation • AF - 22% success
89
Bladder expression types and acceptable post-evacuation bladder size.
* Indwelling catheter, repeat catheterization, expression (every 6- 8 hrs) * Diameter * < 3cm for < 30 kg * 4-5cm > 30 kg
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