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