1
Q
What is the difference between syringomyelia and syringobulbia?
A
Syringomyelia is spinal cord; syringobulbia is brain stem.
2
Q
What is the etiology of syringomyelia? (4)
A
- Cranocervical junction (Chiari malformities);
- spinal cord trauma;
- spinal cord tumors;
- post-infections
3
Q
What are associated conditions with syringomyelia?
A
- congenital scoliosis (25-80%);
- Klippel-Feil;
- Charcot joints
4
Q
What are the indications for an MRI with a patient with scoliosis? (5)
A
- abnormal curves - double apex (L);
- Neuro deficit/ABN reflexes;
- infantile/juvenile onset;
- Male;
- Kyphosis>30 degrees
5
Q
Why do we need to identify a syrinx if there is a scoliosis?
A
Increased risk of neurological deficit if fusion is done with an undiagnosed syrinx.
6
Q
What are the classifications of spinal cord tumors?
A
- Intradural - extramedullary;
- Intradural - intramedullary;
- Extradural
7
Q
What is the most common intradural extramedullary tumor?
A
Schwannoma
8
Q
What are the intradural extramedullary tumors?
A
- Schwannoma;
- Meningioma
9
Q
Schwannoma is associated with which NF gene?
A
NF type II
10
Q
What are 2 risk factors for spinal meningioma?
A
- NF II;
- Radiation
11
Q
What is the Tx of spinal meningiona?
A
If Sx, complete Sx resection, Tx recurrence with radiation therapy
12
Q
What are the 2 intramedullary intradural tumors?
A
- Astrocytoma;
- Ependymoma
13
Q
What is the most common intradural intramedullary CNS tumor?
A
Ependymoma
14
Q
How does one differentiate ependymoma from astrocytoma of CNS lesions?
A
- Astrocytoma - cerviothoracic, eosinophils on histology;
- Ependymoma - usually @ filium terminale, rosettes on hystology
15
Q
What is the most concerning extradural tumor?
A
Lymphoma
16
Q
What is the Tx of extradural lymphoma of the spine?
A
Chemo with methotrexate
17
Q
What are 5 indicators of high energy trauma when considering C-spine injuries?
A
- > 35 mph MVA;
- > 10 feet;
- closed head injuries;
- neurodeficit referrable to C-spine;
- pelvis and extremity #s
18
Q
What are 4 key history points for C-spine injuries?
A
- Ank. spond.;
- DISH;
- GLL/Marfans/ED;
- instrumentation/HW
19
Q
What are 4 complications of late C-spine collar clearance?
A
- aspiration;
- resp function;
- decubitus ulcers;
- increased ICP
20
Q
What is the immediate Tx of neurogenic shock?
A
- Swan-Ganz for fluid monitoring;
- pressors
21
Q
What are 3 characteristics of spinal shock?
A
- flaccid paralysis;
- Bradycardia hypotension;
- absent Bulbocavernosis reflex
22
Q
What are 5 contraindications to high dose methylprednisone?
A
- GSW;
- pregnancy;
- under 13 yoa;
- > 8 hours post injury;
- Bracial plexus injuries
23
Q
What are the indications for decompression and stabilization for SCI GSW?
A
- progressive neurological deficit with retained bullet;
- cauda equina;
- retained bullet fragment within thecal sac (CSF can lead to lead poisoning)
24
Q
What are the W/C functions of: 1. C3-C4; 2. C5; 3. C6; 4. C7
A
- C3-C4 - electric W/C with chin controls;
- C5 - electric W/C with hand controls;
- C6 - manual W/C with sliding board transfers;
- C7 - manual W/C with independent transfers
25
What is the most common incomplete cord injury?
Central cord
26
What are 4 key characteristics of central cord syndrome?
1. motor deficit more to u/e than l/e;
2. sacral sparing;
3. good prognosis;
4. often have permanent clumsy hands
27
What is the order of recovery for central cord syndrome?
1. l/e first;
2. bowel/bladder;
3. prox u/e;
4. distal u/e
28
What is the pathophys. of anterior cord syndrome?
1. direct compression;
2. anterior spinal artery injury
29
What are the key points for anterior cord syndrome?
1. l/e more than u/e;
2. loss LCT (motor), LST (pain, temp);
3. preserved DC (vib, proprioception);
4. worst prognosis of ISCI
30
What is the pathophys. of Brown-Sequard syndrome?
penetrating trauma
31
What are the physical findings in Brown-Sequard syndrome?
1. ipsilateral - motor (LCST) - light touch, proprioception (DC);
2. contralateral - pain, temp, light touch (LSTT)
32
What is the prognosis of Brown-Sequard syndrome?
Excellent - 99% ambulatory @ final followup
33
What are the key points of posterior cord syndrome?
1. rare;
2. Dorsal column affected;
3. proprioception/vibration gone;
4. motor/pain/light touch preserved
34
What is the most common cause of cauda equina syndrome?
disc protrusion (herniation)
35
What are 4 complications of cauda equina syndrome?
1. sexual dysfunction;
2. urinary dysfunction;
3. chronic pain;
4. persistent leg weakness
36
What is the most common complication of cervical laminoplasty?
C5
37
What nationality has a high frequency of isthmic spondylothesis?
Eskimo - \> 50%
38
What 4 ligaments stabilize the occipitoatlantoaxial complex?
1. transverse ligaments;
2. paired alar ligaments;
3. apical ligament;
4. tectorial membrane
39
What is the Anderson and Montesano classification of the occipital condyle #s?
Type I - impact #, stable;
Type II - Basilar skull # with extension, stable;
Type III - avulsed alar ligament, can be unstable
40
What are the indications for operative management for OC #s?
1. Type III with instability;
2. neural compression;
3. associated atlantoaxial or atlas injuries; Tx with OC - C2 or C3 fusion
41
What are the classifications of occipitocervical D/L?
Type I - anterior;
Type II - longitudinal;
Type III - posterior
42
What is Powers Ratio and its importance?
diagram: Powers Ratio = CD/AB; normal = 1;
1. \> 1 concern for anterior D/L;
2. \<1 post D/L, dens #, atlas #
43
What is a major contraindication to traction in cervical spine injuries?
OC D/L due to high (10%) rate of neurologic injury
44
Where is the thickest portion of the occiput?
5 cm lateral to the external occipital protuberance
45
What is the major complication associated with OC-cervical fusion?
Damage to major dural venous sinus located just inferior external occipital protuberance
46
Where do you place screws for OC fusion?
Safe zone located 2 cm lateral to EOP + 2 cm inferior to the EOP (Danger is dural venous plexus)
47
What are 9 causes of atlanto-axial instability?
1. Down syndrome;
2. RA;
3. Os odontoideum;
4. Type I odontoid #s;
5. atlas #s;
6. transverse ligament injury;
7. JRA;
8. Morquio's;
9. rotary atlanto-axial subluxation
48
What is the most important stabilizer of C1-C2 stability?
transverse ligament
49
What ADI is considered unstable in adults?
3.5 mm
50
What ADI is Sx indication in RA?
\> 10 mm
51
What PADI or sac is indication for Sx in RA?
\<14 mm
52
What sum of lateral mass overhang indicates transverse ligament disruption?
8.1 mm
53
What is C1 # classification?
Type I - isolated anterior/posterior arch #s;
Type II - Jefferson-Burst #, bilateral ant/post arch #s;
Type III - unilateral lateral mass #
54
What are 3 non-op indications for C1 #s?
1. stable type I #s;
2. stable type II #s - \<3 m ADI or \<8.1 displacement;
3. stable type III #s \<8.1 mm displacement
55
What are the indications for C1-C2 fusion or OC C2-C3 fusion in C1 #s?
1. unstable type II #s;
2. unstable type III #s;
3. occipitocervical fusion if OC joint involved or poor purchase in C1
56
What are the options for fusing C1-C2?
1. C1 lateral mass, C2 pars;
2. C1 lateral mass, C2 pedicle;
3. transarticular with Gallie/Brook/bone graft enhancement
57
What is the blood supply to Dens/C2?
1. apex is carotid;
2. base is vert.
58
What is the Andonson and D'Azunzo classification of C2 #s?
Type I - tip avulsion #s;
Type II - waist #s;
Type III -# extends into body
59
What are the radiographic parameters for atlanto-axial instability in OS odontoideum?
1. need flex-ex films;
2. ADI = \> 10 mm;
3. Sac or PADI \< 13 mm
60
What is the Tx algorithm for C2 #/instability?
1. OS odontoideum - observe;
2. type I - cervical orthoses, 6-12 weeks;
3. type II young - halo if RF (-), Sx if RF (+);
4. type II old - collar if not Sx candidate, Sx if candidate;
5. type III - hard cervical collar for 6-12 weeks
61
What are the indications for C2 osteosynthesis?
Type II C2 # with:
1. acceptable alignment;
2. # line perpendicular to screw trajectory;
3. body habitus allows trajectory
62
What are the risk factors for C2 type II non-union? (5)
1. \> 5 mm displacement;
2. # comminution;
3. \> 10 degrees angulation;
4. age \> 50;
5. delay in Tx \> 4 days
63
What is the order of ossification of the Dens?
Dens to base - about 6 yoa;
Tip to Dens - about 12 yoa;
Tip ossifies @ age 3
64
What is Levine and Edward's classification of C2 Hangman's #s?
1. Type I - \<3 mm displacement - not angulated;
2. Type II - \>3 mm displacement + angulated vertical # line;
3. Type IIA - same as above but horizontal # line;
4. Type III - Type I with B/L C2-C3 D/L
65
What is the Tx of type I Hangman's #?
rigid cervical collar X 4-6/52
66
What is the Tx of type II Hangman's #?
1. If \<5 mm - traction + halo;
2. If \>5 mm consider C1-C2 fusion
67
What is the Tx of type IIA Hangman's #?
AVOID TRACTION due to horizontal # line;
Reduction + halo X 6-12/52 weeks
68
What is the Tx of type III Hangman's #?
open reduction of facets with stabilization
69
What are the operative options for unstable Hangman's #?
1. Anterior C2-C3 interbody fusion;
2. posterior C1-C3 fusion;
3. B/L C2 pars osteosynthesis
70
How much displacement do UNI vs B/L facet dislocations lead to?
UNI - 25%;
B/L - 50%
71
What percentage of facet D/L will fail closed reduction?
26%
72
What lumbar Dx study leads to accelerated degenerative disc disease?
provocative discography
73
What is the congenital cause of spinal steiosis and why?
1. Achondoplasta;
2. due to short pedicles + medially based facets
74
What is Kemp sign?
a unilateral radiculopathy made worse by bending backwards
75
Vasc. vs Neuro claudication? (5)
Neuro IS + postural, standing stationary, going up stairs easier, stationary bike easier, pulses normal
76
What are the 7 steps of pedicle to pedicle decompression?
1. remove spine proc.;
2. remove lamina to LF;
3. preserve PARS int.;
4. decompress pedicle above;
5. decompress pedicle below;
6. decompress lateral recess;
7. ensure no disc remnant
77
When to instrument with ped-to-ped decomp. for spinal stenosis? (3)
With segmental instability:
1. spondy (isthmic);
2. spondy (degen.);
3. degen. scoliosis
78
What 2 factors create instability in L-spine?
1. complete laminectomy;
2. \> 50% facetectomy
79
What is the most common cause of persistent pain following decomp. for spinal stenosis?
inadequate foraminal stensis
80
What is the outcome of the Sport Trial?
Better function + pain scores @ 4 years
81
What is Wiltse classification of spondylolisthesis?
Type I - dyplastic (congenital);
Type II - A-isthmic (fatigue #); B-isthmic (elongated ); C-isthmic (acute #);
Type III - degenerative;
Type IV - traumatic, not pars;
Type V - neoplastic
82
What defines a motion segment instability on flex/ex L-spine?
1. 4 mm or \>;
2. 10 degrees \> movement than adjacent motion seg.
83
What are the Myerding classifications?
Type I - \<25%;
Type II - 25-50%;
Type III - 50-75%;
Type IV - 100%;
Type V - loptosis
84
Is degen. spondy of L-spine more common to men or women?
8X in women
85
What are the risk factors for degen. spondy? (3)
1. woman;
2. sacralization of L5;
3. horizontal facets
86
What is the procedure of choice for failed posterior decomp. and in-situ fusion for degen. spondy?
Revision decomp. + fusion with anterior support (ALIF)
87
What are the risk factors for adjacent segment disease post decomp./fusion in L-spine? (4)
1. age;
2. increased levels you do;
3. adjacent laminectomy;
4. increases above L3
88
What effect has pedicle screws had on lumbar fusion?
decreased rates of pseudarthrosis
89
What is the most reliable predictor of clinical outcome of adult spinal deformity?
Sagittal balance
90
How much correction can you get with a SPO (Smith Pete Osteotomy)?
up to 10 degrees
91
How much correction can you get from a PSO (pedicle subtraction osteotomy)?
30-50 degrees
92
How much correction can you get from a VCR?
up to 45 degrees usually in rigid thoracic kyphosis/scoliosis
93
What are the indications for anterior procedures in adult spinal deformity? (4)
1. curves \> =70 degrees;
2. rigid curves;
3. isolated lumbar;
4. L5/S1 ALIF when fusing to S1
94
What are the risk factors for pseudarthrosis? (7)
1. age \> 55;
2. kyphosis \> 20 degrees;
3. (+) sagittal balance \> 5 cm;
4. hip OA;
5. smoking;
6. thoraco abdominal approach;
7. incomplete lumbo pelvic fixation
95
What are the indications for posterior C1-C2 fusion in RA? (3)
1. ADI =\> 10 mm;
2. PADI/SAC - \<14mm;
3. progressive myelopathy
96
What is the most reliable measurement of basilar invagination?
Ranawat classification \<15 mm arch C1 to pedicule C2
97
What is cervico-medullary angle and what is its meaning?
CMA \<135 degrees suggest impending neuro impairment
98
What are the risk factors for subaxial instability? (4)
1. steroids;
2. males;
3. seropositive RA;
4. nodules present
99
What is the most reliable radiographic measurement to predict post-op neural recovery in RA C-spine Sx?
PADI \>= 14 mm
100
What are the diagnostic criteria of ANK sponds?
1. bilateral sacroiliitis;
2. +/- uveitis; 3. HLA B27 (+)
101
What are the key physical exam tests for ANK sponds?
1. chest wall expansion;
2. Schober's test;
3. chin brow to vertical angle;
4. hip flexion contraction;
5. Faber test (sacroiliitis)
102
What is the most sensitive test to Dx #s in ANK sponds?
CT scan
103
What is definition of DISH?
non-marginal syndesmophytes @ 4 contiguous levels (Forestier disease)
104
What are the risk factors for DISH? (3)
1. gout;
2. hyperlipidemia;
3. DM
105
Why is DISH preserved in L thoracic spine?
pulse of aorta is protective in that region
106
What do you need to counsel DISH patients undergoing THA?
HO (30-50%) \<20 without DISH
107
What is the most common demographic with OPLL?
Asians
108
What is the surgical treatment for OPLL?
1. anterior corpectomy +/- OPLL resection: a) kyphotic spine; b) OPLL falls within gap;
2. posterior laminectomy + fusion - Lordotic spine
109
Where and at what age are C-spine injuries more common? ie. upper/lower spine
1. above C3 8 years old;
2. below C3 \> 8 year old
110
What are the risk factors for C-spine injuries in children?
1. head size;
2. horizontal facets;
3. lig. laxity;
4. weaker muscles Number 2 through 4 increase physical motion
111
How far can peds spinal cord stretch without rupture?
5 cm
112
What are the differences in C-spine between adults and peds?
1. ADI 5 mm (N);
. C3 vertebrae wedge;
3. loss of lordosis;
4. C2-C3 or C3-C4 pseudosubluxation (N) posterolaminar line \<4 mm (N)
113
How do you determine how much cut-out is needed on a peds spine board?
Shoulders should be in-line with exterior auditory meatus
114
What is the most common associated injury with peds C-spine injury?
head injury
115
What are 4 reasons for increased mobility of peds C-spine compared to adults?
1. increased ligament laxity;
2. immature supporting structures;
3. horizontal/shallow facets;
4. NP has increased H2O content allowing movement
116
What are the indications for TLSO in peds? (3)
1. comp. #s \<50% anterior height loss;
2. Burst # with no neuro + \<50% retropulsion;
3. purely osseous flex/dist injury
117
How do you differentiate pseudosubluxation form true C-spine subluxation in peds?
1. \<8 yoa pseudo;
2. C2 on C3 pseudo;
3. reduced with extension xray;
4. C2 within 1.5 mm of Swischuk"s line;
5. no Hx/PE trauma
118
What are the common causes of atlanto-axial rotary displacement (AARD)? (6)
1. trauma;
2. Grisel's disease (retropharyngeal irritation);
3. Down syndrome;
4. RA;
5. tumor;
6. congenital
119
What is the Fielding classification of AARD?
Type I - uni facet subluxation;
Type II - uni facet with 5 mm anterolisthesis;
Type III - B/L facet with \>5 mm anterolisthesis;
Type IV - posterial C1 displacement
120
What is the gold standard test for AARD?
Dynamic CT
121
What is the Tx algorithm for AARD?
subluxation:
\<1 week - soft collar, NSAIDS, physio;
\> 1 week - head halter traction - 5 lbs;
\> 1 month - halo traction; \> 3 months or neuro - posterior C1-C2 fusion
122
What are associated conditions in Klippel-Feil syndrome? (10)
1. congen. scoliosis;
2. Sprengel's;
3. renal aplasia;
4. synkinesis;
5. heart disease
6. basilar invagination;
7. AA instability (C1-C2);
8. cervical stenosis;
9. brainstem anomolies;
10. adjacent level disease
123
What is the classic triad of Klippel-Feil syndrome?
1. low posterior hair line;
2. short webbed neck;
3. decreased cervical ROM; Classic triad is seen in fewer than 50%
124
What are the surgical indications for Klippel-Feil syndrome?
1. basilar invagination;
2. chronic pain;
3. myelopathy;
4. C1-C2 instability;
5. adjacent level disease
125
What tests must be ordered in Klippel-Feil syndrome? (2)
1. cardiac U/S;
2. renal ultrasound
126
What makes the decision whether or not Klippel-Feil patients can play contact sports?
cervical spine fusion above C3
127
What are the physical exam findings in congenital muscular torticollis?
head tilts toward affected side + rotates away
128
What is the imagine modality of choice to differentiate congenital torticollis from severe pathology?
U/S
129
What is the Tx algorithm for congenital muscular torticollis?
1. If \<1 year + \<30 degrees - stretching (90% success);
2. If \>1 year - a) botox, b) Z-plasty, c) bipolar 5 cm release
130
What is the most common curve type for AIS?
right thoracic
131
What are the risk factors for curve progression in AIS? (8)
1. magnitude \> 25 degrees before skeletal maturity;
2. \<12 yoa;
3. Tanner \<3 (females);
4. Risser 0-1;
5. open triradiate;
6. before menarche;
7. thoracic \>lumbar curves;
8. double \> single
132
What are the key physical findings for AIS? (scoliosis) (7)
1. Adams forward bend;
2. skin defects (spina bifida);
3. shoulder height differences;
4. cafe-au-lait;
5. foot deformities (Cavovarus);
6. asymmetric abdominal reflexes;
7. thorough NV exam
133
How can you measure coronal balance?
C7 plumb to CSVL (diagram)
134
What are the indications for MRI in AIS (scoliosis)? (8)
1. L thoracic curve;
2. rapid progression;
3. excessive kyphosis;
4. structure anomolies (congenital);
5. neuro Sx or pain;
6. foot deformities;
7. asymmetric ABDO reflexes;
8. short angular curve
135
What are the indications for observation, bracing and Sx for AIS? (scoliosis)
1. obs. - \<25 degrees;
2. brace - 25-50 degrees, flexible curves, Risser 0,1,or 2;
3. Sx - Cobb \>45 degrees
136
What are the indications for anterior/posterior Sx for AIS? (scoliosis)
1. \> 75 degrees;
2. young age - girls \<10, boys \<13, Risser 0; prevent crankshaft
137
How do you define skeletal maturity for patient for AIS?
1. Risser 4;
2. 2 year post menarchal;
3. \<1 cm growth over 2 visits 6 months apart
138
What is stable vertebrae in scoliosis?
most cephalad vertebrae that is bisected by CSVL
139
Where should you stop proximal fusion in AIS Sx? (scoliosis)
1 or 2 levels above stable vertebrae
140
What is the risk of fusing to L4 or L5 in AIS Sx? (scoliosis)
increased incidence of low back pain as described by Cochrane
141
What is the definition of intra-op neuro event as defined by SSEP's/MEP's during spine manipulation?
a drop in amplitude \> 50%
142
What is the algorithm for intra-op neuro event? (6)
1. check technical error;
2. check for low BP + Tx;
3. check for low Hgb + Tx;
4. lessen/reverse correction;
5. remove instrumentation;
6. implement wake up test
143
What is the most common bug for late spine infections?
P. Acnes (just like shoulder)
144
What are 2 medical complications of scoliosis Sx?
1. staph.;
2. superior mesenteric artery syndrome
145
What is the #1 risk factor for pseudarthrosis following scoli corrective Sx?
thoracic hyperkyphosis
146
List 6 neural axis abnormalities in idiopathic scoliosis.
1. syringomyelia;
2. Chiari;
3. tethered cord;
4. diastematomyelia;
5. dysraphism;
6. spinal cord tumor
147
What are the indications for an MRI in juvenile idiopathic scoliosis?
1. age \<10;
2. curve \>20 degrees
148
What is the Tx algorithm for juvenile idiopathic scoliosis?
skeletally immature patient, growing rods for curves \> 50 degrees, then PSF +/- ASF once reaches skeletal maturity
149
What is the inheritance pattern of infantile idopathic scoliosis?
autosomal dominant
150
What should one look for on xrays in infantile idiopathic scoliosis?
1. Cobb angle;
2. vertebrae rib overlap;
3. RVAD (rib vertebrae angle difference) - \> 20 degrees has an increased risk of progression, \< 20 degrees associated with spontaneous recovery
151
What are the indications for Mehta casting or TLSO in infantile idiopathic scoliosis?
1. phase II ribs;
2. RVAD \> 20 degrees;
3. Cobb \> 25-30 degrees;
4. flexible curves
152
What are the indications for growing rod construction in infantile idiopathic scoliosis?
1. Cobb \> 50 degrees;
2. failed Mehta casting/bracing
153
What are the indications for Sx in neuro scoliosis in CP?
1. curve \> 50 degrees;
2. pelvic obliquity with sitting imbalance
154
In what 2 neuro scoliosis is bracing contraindicated?
1. muscular dystrophy;
2. spina bifida
155
What are the indications for scoliosis correction in muscular dystrophy?
1. curve \> 20 degrees;
2. progressive curve;
3. Tx before respiratory decline
156
What are the causes (syndromes) for neuro scoliosis? (5)
1. CP;
2. SMA;
3. muscular dystrophy;
4. spina bifida/trauma;
5. polio
157
What type of CP is most at risk of developing scoliosis?
spastic quadriplegia
158
When should one extend to pelvis in CP scoliosis? Why?
1. If pelvic obliquity \> 15 degrees;
2. to prevent pseudoarthrosis
159
What are the key components of pre-op assessment of CP scoliosis patient?
1. multi-disciplinary;
2. nutritional status \> 3.5 g/dl albumin;
3. respiratory status;
4. GI evaluation (GERD = aspiration);
5. neuro function (seizure disorder) If valproic acid, then increased bleeding risk
160
What are the common causes of pathologic scoliosis?
1. osteoid osteoma;
2. osteoblastoma
161
What are 2 positive prognostic factors for spontaneous resolution of scoliosis following osteoid osteoma resection?
1. child \<10 yoa;
2. resection occurred within 15 months of onset of scoliosis
162
What are the syndromes associated with congenital scoliosis?
1. VACTERL;
2. Goldenhar;
3. Jarcho-Levin;
4. Klippel-Feil;
5. Alagille syndrome
163
Which vertebrae morphology is associated with the highest progression of curve in congenital scoliosis?
unilateral unsegmented BAR with contralateral hemivertebrae
164
Which vertebrae morphology is least likely to cause curve progression in congenital scoliosis?
block vertebrae
165
What are 3 mandatory tests in congenital scoliosis?
1. MRI spine;
2. echocardiogram;
3. renal U/S
166
What neural axis defects are found in congenital scoliosis?
1. syrinx;
2. diastematomyelia;
3. tethered cord;
4. Chiari;
5. intradural lipoma
167
What are the indications for scoliosis corrective Sx in congenital scoliosis?
1. significant progression;
2. neuro deficits;
3. respiratory failure;
4. failure of formation with contralateral failure of segmentation
168
How does one decide on posterior or anterior + posterior scoliosis correction in congenital scoliosis?
1. AGE - \<12 boys and \<10 girls - anterior/posterior, +/- growing rods; \>12 boys and \>10 girls post insitu;
2. failure of formation with failure of segmentation = ant/post +/- vertebrectomy
169
What are the indications for hemiepiphysiodesis in congenital scoliosis? (3)
1. patient \<5 yoa;
2. intact discs/growth plates on concave side;
3. curve \<40-50 degrees
170
What is the definition of Scheuermann's kyphosis?
1. \> 45 degrees;
2. anterior wedge of \> 5 degrees across 3 vertebrae
171
What is the inheritance pattern of Scheuermann's kyphosis?
autosomal dominant
172
What is the normal thoracic kyphosis range?
25-45 degrees T5-T12
173
What is the Tx algorithm for Scheuermann's kyphosis?
1. observe if \<60 degrees;
2. brace and observe if 60-80 degrees + Risser \<3;
3. PSF with rods +/- interbody fusion a)kyphosis \>75 degrees and rigid, b) neuro deficit, c) cord compression, d) severe pain in adults
174
What is the mechanism of spondy in adolescents?
repetitive micro #s due to hyperextension stress (gymnast, lineman, weight lifter)
175
What is a listhetic crisis in peds spondy?
1. severe back pain - worse with extension and relieved by rest;
2. neuro deficit;
3. hamstring spasm
176
What are the special physical exam tests for peds spondylolisthesis?
1. single limb stance;
2. popliteal angle for hamstring tightness;
3. detailed neuro exam
177
What is the first investigation to do when lumbar pain in adolescent?
xrays
178
What is the next investigation to do in lumbar pain in peds if xrays are negative?
SPECT
179
Can kids with spondylolisthesis participate in contact sports?
1. Asymptomatic low grade (ie. I or II) - Yes;
2. Symptomatic low grade (ie. I or II) - No
180
What is the Sx and Tx algorithm for spondylolisthesis in peds?
1. low grade failed cons. management - L5-S1 in situ fusion;
2. high grade failed cons. mangement - L4-S1 in situ fusion
181
What is the most common nerve root injury with spondylolisthesis reduction?
L5
182
What is the most common location for discitis inpeds?
L-spine
183
What is the earliest xray finding in peds discitis?
loss of lumbar lordosis
184
What is the Tx algorithm for peds discitis?
First, Tx IV antibiotics X 4-6 weeks;
Follow ESR/CRP if:
a) positive response then continue;
b) abcess/neuro go to surgical decompression;
c) negative response then CT guidedbiopsy R/O TB
185
What are the indications for closed cervical traction? (5)
1. subaxial C-spine with malalignment;
2. facet D/L;
3. displaced odontoid;
4. some Hangman's #s;
5. C1-C2 rotatory subluxation
186
What are 4 suspicious factors (red flags) for mets in vertebrae compression #s?
1. #s above T5;
2. atypical;
3. constitutional Sx;
4. younger patient with no fall
187
What are the components of spien PLC?
1. supraspinous ligament;
2. interspinous ligament;
3. ligamentum flavum;
4. facet joint capsules
188
What are the risk factors for degenerative disc disease?
1. obesity;
2. smoking;
3. gender;
4. lifting;
5. vibration;
6. prolonged sitting;
7. job dissatisfaction
189
What are the Waddell signs?
1. non-anatomical tenderness;
2. pain with axial compression of the spine;
3. reduced pain of SLR with distraction;
4. non-dermatomal/myotomal ;
5. over reaction to P/E
190
What is the most common level of disc herniation?
L5-S1
191
What is the mechanism of disc herniation reabsorption?
macrophage phagocytosis
192
How does one differentiate between recurrent disc and fibrosis post lumbar disc Sx?
MRI with GAD
1. fibrosis enhances with GAD;
2. recurrent disc does not enhance with GAD
193
What are the positive predictors post lumbar disc Sx?
1. leg pain as chief component;
2. + SLR;
3. weakness correlated with MRI;
4. married
194
What is the most influential negative predictor post lumbar disc Sx?
WSIB
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