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Spine

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Describe the following Physical Exam test:
1. Adson's test
1. patient seated, arm dependent, neck toward side being tested and extended, deep breath. decreased pulse is positive = thoracic outlet syndrome
Describe the following Physical Exam test:
1. Babinski
1. stroking the bottom of the foot causes reflex toe extension = upper motor neuron lesion (normal in newborns)
Describe the following Physical Exam test:
1. Bowstring
1. Hip flexed to 90 degrees, knee flexed to reduce radicular symptoms, pressure placed on tibial nerve in popliteal area = reproduces radicular pain
Describe the following Physical Exam test:
1. Crossed straight leg raise
1. passive lifting of contralateral straight leg, flex hip w/straight knee = suggests herniated disc
Describe the following Physical Exam test:
1. Clonus
1. forced dorsiflexion of the foot = reflex rhythmic plantar flexion response > 4 beats
Describe the following Physical Exam test:
1. Femoral nerve traction test
1. place patient laterally on the unaffected side, examiner passively extends the hip and flexes the knee of the affected side = reproduces radicular pain
Describe the following Physical Exam test:
1. Hoffman's
1. Flicking distal interphalangeal joint (DIPJ) of middle finger causes involuntary flexion of the DIPH of index and IPJ of thumb = myelopathic sign/UMN lesion
Describe the following Physical Exam test:
1. Lhermitte's
1. forward flexion of neck causes lancinating pain down spinal cord = stenotic sign
Describe the following Physical Exam test:
1. Straight leg raise
1. passive lifting of straight leg, flex hip w/straight knee +/- dorsiflexion of foot (Lesegue maneuver) = reproduces radicular symptoms; dorsiflexion should reproduce symptoms at less hip flexion
Describe the following Physical Exam test:
1. Waddell's signs
1. -pain (out of proportion) to superficial touch (superficial tenderness)
- pain w/axial rotation of the pelvis and with axial loading on the top of the skull (simulation)
- sitting straight leg raise < lying SLR (distraction)
- nonanatomic weakness or sensory changes
- overreaction

= may indicate heavy psychosocial overlay (>3/5 signs present)
Describe the following for spinal cord level C5/6
1. motor exam
2. motor nerve
3. reflex
4. sensory area
5. sensory nerve
1. arm abduction (deltoid), elbow flexion (biceps)
2. axillary, radial
3. biceps
4. lateral arm, thumb & index finger
5. cutaneous nerve of arm, musculocutaneous
Describe the following for spinal cord level C6/7
1. motor exam
2. motor nerve
3. reflex
4. sensory area
5. sensory nerve
1. wrist extension (extensor carpi radialis)
2. radial
3. brachioradialis
4. lateral forearm, middle digit
5. lateral antebrachial cutaneous
Describe the following for spinal cord level C7/8
1. motor exam
2. motor nerve
3. reflex
4. sensory area
5. sensory nerve
1. elbow extension (triceps)
2. radial
3. triceps
4. middle digit, medial hand
5. median, radial
Describe the following for spinal cord level C8/T1
1. motor exam
2. motor nerve
3. reflex
4. sensory area
5. sensory nerve
1. grip (flexor digitorum profundus), finger abduction (interosseous)
2. ulnar
3. none
4. medial hand and forearm
5. ulnar, medial cutaneous nerve
Describe the following for spinal cord level L2/3
1. motor exam
2. motor nerve
3. reflex
4. sensory area
5. sensory nerve
1. hip flexion (iliopsoas)
2. femoral
3. cremasteric
4. anterior, superior thigh
5. genitofemoral, femoral
Describe the following for spinal cord level L3/4
1. motor exam
2. motor nerve
3. reflex
4. sensory area
5. sensory nerve
1. knee extension (quadriceps)
2. femoral
3. patellar quadriceps
4. mid medial thigh and calf
5. obturator
Describe the following for spinal cord level L4/5
1. motor exam
2. motor nerve
3. reflex
4. sensory area
5. sensory nerve
1. ankle dorsiflexion (hamstrings, tibialis anterior)
2. peroneal
3. none
4. medial and anterior calf
5. sural, dorsal cutaneous
Describe the following for spinal cord level L5/S1
1. motor exam
2. motor nerve
3. reflex
4. sensory area
5. sensory nerve
1. Knee flexion (hamstring), foot inversion (posterior tibialis), great toe extension (extensor hallucis longus)
2. peroneal, sciatic/tibial nerve
3. none
4. lateral calf and foot (medial L5, lateral S1)
5. sural, dorsal cutaneous
Describe the following for spinal cord level S1/2
1. motor exam
2. motor nerve
3. reflex
4. sensory area
5. sensory nerve
1. ankle plantar flexion (gastrocnemis)
2. sciatic/tibial nerve
3. achilles
4. foot, posterior
5. sural
Describe the following for spinal cord level S2-4
1. motor exam
2. motor nerve
3. reflex
4. sensory area
5. sensory nerve
1. rectal tone (bowel/bladder, anal sphincter)
2. pudendal
3. anal cutaneous, bulbocavernosus
4. perianal area
5. pudendal, coccygeal
describe acute spinal cord injury in terms of:
1. epidemiology
2. etiology
1. 50/1 million/year
M > F
20% of pt's w/SCI have >1 level affected
major causes of death are aspiration and shock

2. fractures, dislocation, distraction, mass (tumor, epidural abscess, epidural hematoma, etc.), penetrating (knives, bullets, shrapnel, etc..), ischemic
describe complete SCI
no residual function more than 3 levels below the injury
- only 3% of pt's will recover some function w/in 24hrs, after which the expectation is that all distal function is likely lost
describe incomplete SCI
any residual sensory or motor function below the injured level
ex, central cord syndrome, brown-sequard syndrome, anterior or posterior cord syndromes
what is sacral sparing?
sensation and voluntary rectal sphincter contraction (excluding,
Describe central cord syndrome
usually an extension injury w/underlying chronic cervical spondylosis, where the central region of the spinal cord is injured
Sx - disporportionately greater motor impairment in UE > LE
hand > upper extremity > lower extremity dysfunction, bladder dysfunction, variable sensory changes
Describe Brown-Sequard syndrome
spinal cord hemisection
Si/Sx - ipsilateral weakness (descending motor fibers), loss of contralateral pain/temp (spinothalamic), loss of ipsilateral vibration & proprioception (dorsal columns)
Describe muscle strength testing
0 - no movement
1 - visible contraction
2 - movement without gravity
3 - movement with gravity
4 - less than full strength
5 - full strength
Describe the Frankel Grade (ASIA)
A - complete paralysis
B - sensory function only below level of injury
C - incomplete motor function (grade 1-2/5) below level of injury
D - fair to good motor function (grade 3-4/5) below level of injury
E - normal function (5/5)
Describe Lumbar spinal stenosis
canal < 12mm
stenosis < 10mm AP diameter
lateral recess stenosis < 2mm
Describe the following for Cauda Equina Syndrome
1. Symptoms
2. Signs
3. Etiology
4. Radiology
5. Treatment
1. motor/sensory deficits corresponding to affected nerve roots (severe radiculopathy or myelopathy), bowel or bladder incontinence, perineal numbness (late)
2. pain out of proportion to exam, digital rectal exam w/decreased rectal tone, abnormal postvoid residual (> 200cc)
3. compressive lesion, usually from herniated disc, cancer trauma or infection
4. STAT MRI of thoracic and lumbar spine (compression can be anywhere from conus down to sacral region & is usually central)
5. Emergent surgical decompression
what are indications for emergent spine surgery?
Cauda Equina syndrome
Acute, severe neurological deficit (myelopathy of vital cervical root) - controversial
Mechanical instability, usually 2/2 trauma (ie nonreducible fracture-dislocation w/locked facets)
what are contraindications for emergent spine surgery?
complete spinal cord injury > 24hrs (not absolute), medically unstable (STEMI, coagulopathy, etc)
what is the initial management for acute SCI?
ATLS protocol
- intubation may be necessary if diaphragm paralyzed or altered LoC
- avoid neck extension & fibro-optically intubate if necessary
- maintain oxygenation & BP to ensure appropriate perfusion of spinal cord & to avoid exacerbation of injury
- additional injuries below level of injury may be missed d/t lack of si/sx & fixed bradycardia/hypotension from loss of sympathetic tone
- maintain immobilization & spine precautions until appropriate diagnostic procedures & evals can be done
what is the NEXUS criteria for cervical spine imaging in pediatric blunt trauma
midline tenderness
impaired consciousness, poor history
neurologic deficit
distractin/painful injury
intoxication
what is neurogenic shock
hypotension 2/2 interruption of sympathetics (loss of vascular tone) bradycardia from unopposed parasympathetics, relative hypovolemia d/t venous pooling from decreased muscle tone, & hypothermia
- generally above T6
- treat hypotension w/dopamine gtt (epi can exacerbate bradycardia)
what is spinal shock
transient flaccid paralysis and areflexia after acute SCI which transitions into spasticity in 1-2 weeks
describe the following for ischemic spinal cord injury
1. etiology
2. symptoms
3. treatment
1. arterial or venous; atherosclerosis, DM, aortic aneurysms or dissection, sickle cell, trauma, arteritis, AVF, hypercoagulable state or hypotension
- spinal cord has 1 ant, 2 post spinal arteries
- watershed area in mid-thoracic region is susceptible to ischemic injury in severe hypotension or vascular injjry to aorta
- artery of adamkiewicz leaves from around T9 & disruption may lead to Ant spinal cord syndrome
2. pain, weakness, paralysis, loss of sensation, incontinence
3. symptomatic, maintain BP to increase spinal cord perfusion
what is anterior spinal artery syndrome?
flaccid transitioning to spastic paralysis, hyperreflexia, loss of pain & temp, intact vibratory & proprioception (dorsal column function preserved)
Describe atlanto-occipital dislocation
severe hyperextension-distraction injury rupturing craniocervical ligaments (tectorial membrane, cruciate, apical, alar) and frequently resulting in fatal brain stem injury (respiratory arrest)
- basion-dental interval (inf tip of clivus to top of odontoid) > 12mm
- more common in children
- may be atraumatic in down syndrome, rheumatoid arthritis

Rx = cervical fusion (historically halo rigid immobilization)
what is the clinical criteria to clear cervical spine
awake, alert, oriented
- no neck pain either to palpation or to active range of motion (flexion, extension & lateral rotation)
- not intoxicated
- no distracting injuries
- no focal neurological deficits

if pt cannot be clinically cleared, may require an MRI to r/o ligamentous injury. if pt has no evidence of fracture on a c-spine CT, but does have tenderness to palpation or pain w/ROM, a flex-ex film w/view of C7 is indicated
describe AtlantoDental Interval
distance on lateral x-ray between back of C1 anterior tubercle (atlas) to the ant aspect of odontoid (dens)
- normal for adult is up to 3mm, child up to 5mm (pseudosubluxation)
what is chamberlain's line?
posterior aspect of hard palate to posterior edge of foramen magnum or opisthion
- if the dens is > 6mm above this line, c/w vertical translocation
what is Fischgold's Digastric Line?
between the digastric notches
What is Fischgold's Bimastoid Line?
between tips of mastoid process
what is McGregor's Line?
dorsal edge of the hard palate to the caudal occiput
- if dens is > 4.5mm, c/w invagination
what is McRae's Line?
opening of the foragmen magnum
- tip of dens should not be above this line
what is Power's Ratio?
identify anterior subluxation
- ratio of BC (distance from basion to the the midvertical portion of the posterior laminar line of the atlas) over OA (opisthion to midvertical portion of posterior surface of anterior ring of atlas)
- anterior subluxation present if ratio > 1
what is Ranawat's line
center of the C2 pedicle to a line connecting the anterior and posterior C1 arches
< 13mm designates impaction
What is Redlund-Johnell measurement
from base of C2 to McGregor's line
- pathological when less than 34mm in men and 29mm in women
- designates basilar invagination
what is the rule of spence?
on odontoid view x-ray, if sum of C1 lateral mass overhang on C2 is 7mm, then this suggests transverse ligament instability
what is Wachenheim's line?
determines subluxation
line from posterior surface of clivus to odontoid tip
- constant in flexion-extension
should not be > 5mm
describe Type I (tip) odontoid fracture
stable fx
- avulsion of alar ligament insertion (connects dens to occiput)
- treat with collar
describe type II (base) odontoid fracture
most common dens fx
unstable d/t disruption of blood supply
nonunion in up to 50%, especially in elderly, increased translation or angulation
- required halo placement (younger, < 5mm translation) or surgical management such as an odontoid screw or historically a C1-2 posterior arthodesis w/wire (must have intact C1 posterior arch)
describe type III (body) odontoid fracture
stability depends upon degree of displacement, unless the fracture extends into facets
- heals with immobilization - collar in elderly or if stable, otherwise halo; if no fusion, then anterior odontoid screw
describe odontoid screw placement
goal is anterior, inferior, midline endplate of C2 in midline
- will maintain normal ROM when compared to posterior fusion, may reduce need for postop external orthosis immobilization (ie halo)
Describe Jefferson's fracture
comminuted C1 ring fx (b/l fx of anterior and posterior arches)
most common fx of C1
Fx from axial load of atlas via occipital condyles
neurological deficits rare, occasional injury to vertebral a.
treated w/hard collar if there is no disruption of the transverse atlantal ligament (TAL) and can be treated w/halo or surgical fusion if TAL is disrupted
- if TAL is intact is determined by ADI and rule of spence (C1 separated by dens > 7mm)
describe hangman's fracture
b/l C2 pars/pedicle Fx w/avulsion of C2/C3 endplates, slippage of C2 on C3; separation of posterior elements from the vertebral body
- the worse the angulation and slippage the worse the grade

mechanism: hyperextension, compression (axial loading) & distraction
- may present w/instant death d/t spinal cord transection or no neuro deficits
describe grade 1 hangmans fracture
minimal distraction (<3mm), anterior longitudinal ligament torn
stable, treat w/collar
describe grade 2 hangmans fracture
moderate distraction/angulation (> 4mm), ALL and PLL torn, disk herniation
unstable, treat w/halo
describe grade 3 hangmans fracture
significant distraction, torn ligamentous complex, epidural/spinal cord hematoma, locked facets, vertebral artery injury, disc herniation
flexion injury that may result in locked facets or subluxation of C2 on C3
unstable, treat w/surgery
describe compression fracture
compression of anterior spinal column elements
describe burst fracture
compression of anterior and middle spinal column elements
describe seat-belt fracture
compression or no fx of ant column, distraction injury middle, distraction posterior column
describe fracture/dislocation
compression +/- rotation/shear injury ant; distraction +/- rotation/shear injury middle and posterior columns
what are criteria for stale spine fracture
no transiet or persistent neurological injury
acceptable alignment
at least 1 column intact
no signif ligamentous disruption
describe cervical facet dislocation in terms of:
1. pathophys
2. complications
3. treatment
1. flexion/rotation injury -> unilateral
flexion/distraction -> bilateral
- disruption of ALL and PLL w/facet articular capsule tears -> sliding superior facet forward on the inferior facet
- superior vertebral body displaces anteriorly, disc may herniate posteriorly
2. ipsilateral vertebral artery injury, PLL injury, canal stenosis, cord compression
- bilateral facet injuries generally have corresponding complete SCI
3. posterior, posterior or combined cervical decompression, reduction and stabilization w/or w/o diskectomy
describe facet orientation:
1. cervical
1. posteromedial
describe facet orientation:
1. upper thoracic
1. coronal (resistance to anterior translation but not rotation)
describe facet orientation:
1. lower thoracic
1. sagittal (less resistance to anterior translation)
describe teardrop fracture
flexion-compression injury
- vertebral body with > 50% original height
- injury to the PLL
- unstable
describe a wedge fracture
fracture of the anterior column
- stable if < 50% loss of height -> can observe w/brace
describe a spinous process fracture
stable in siolation
- when ocurring at C7, is referred to as a clay-shoveler's fracture
describe a burst fracture
fracture of the ant & middle columns from axial compression injury
- usually between T10 & L2
- can be treated w/brace or surgery depending on the complexity
- surgery if > 50% canal compromise or > 50% vertebral body height loss or with facet fx or dislocations
- may lead to retropulsion of bony fragments into the spinal canal w/devastating neurological compromise
what are criteria that make a burst fracture unstable?
height < 50%
angulation > 20 degree
canal compromise > 50%
scoliosis > 10 degree
neurologic injury
-> early operative stabilization
describe fracture dislocation
disruption of the anterior, middle and posterior columns
- almost always requires surgery
describe a chance fracture
flexion-distraction fracture through all 3 spine columns (including disruption of PLL, shearing of pedicle/vertebral body)
- dislocation of facet joint leading to a "naked" facet
- may have associated spinal cord injury or hematoma
- usually in the thoracic spine of a person who had a lap belt on and was in a MBA
-d/t etiology of injury up to 30% will have associated abdominal organ injury
what are schmorl's nodes
herniation of the nucleus pulposus into the end plate
- ass'd w/endplate fx
- T7-L2
describe the following for Halo placement
1. indication
2. contraindication
3. procedure
4. complications
1. treatment of cervical spine trauma, preoperative reduction for spinal deformity, postop stabilization
2. open wounds or infection at proposed pin sites, cranial fracture (relative contraindications include obesity, elderly, barrel shaped chest, severe chest trauma)
3. see book
4. pin site infection, skull fx, pin loosening, skin break-down, inadequate healing requiring surgical intervention, pain, resp distress
describe atlantoaxial impaction (basilar invagination) and platybasia
1. symptoms
2. pathophys
3. treatment
subluxation of the dens (odontoid process) thru the foramen magnum leading to brainstem compression

1. myelopathy, headache, nystagmus, cranial neuropathies
2. bony erosion between occiput and dens (ie rhuematoid arthritis); also ass'd w/chiari malformation, syringomyelia, klippel-feil sundrome
3. occiput to C2 fusion, possible transoral decompression
describe a radiculopathy
a nerve root or lower motor neuron injury potentially causing unilateral dermatome pain and weakness as well as decreased reflexes
describe myelopathy
a spinal cord or UMN injury causing bilateral symptoms and can manifest as neck pain, weakness/numbness in extremities, hyperreflexia, gait instability & urinary incontinence
what is the treatment for nonurgen, stable disk herniation?
nonop management should be tried for at least 2 months

-natural history of many disk herniation, especially in the lumbar spine, is spontaneous resolution
- may undergo open or minimally invasive techniques for surgical removal or herniated disc
what are non-surgical therapies for disk herniation?
physical therapy, epidural steroid injections, selective nerve root blocks, acupuncture, radiofrequency ablation, intradiskal electrothermal treatment, chiropractic, OMT
what is failed back syndrome?
patients who have had multiple revision spine surgeries and have no clear pain generators at this point
- may be treated by pain pumps and spinal cord stimulators
what is ossification of the PLL
usually occurs in the cervical spine
segmental, continuous, or mixed
can be treated w/laminectomy, laminoplasty, or corpectomy w/instrumentation
ACDF for this procedure frequently results in a CSF leak since the ligament is adherent to the dura
usually occurs on the posterior portion of the vertebral body in the cervical spine wheras ankylosing spondylitis has heterotopic ossificaiton anterior and posterior to the vertebral body that can happen all along the spine
describe cervical disk herniation
affects the nerve root of the lower vertebral body (ie C6 nerve root would be affected in a C5/6 disk herniation)
- most herniations occur at C5/6, followed by C6/7
- treat w/anterior cervical decompression and fusion or if a posterolateral soft disc herniation, in singers or athletes, may do a posterior foraminotomy
describe thoracic disk herniation
rare
- most common at T11/12
- should not be treated w/laminectomy alone as risk for neurological injury or no improvement reaches 45%
- approaches include transpedicular, transfacet, transthoracic or lateral extracavitary
describe lumbar disk herniation
affects the nerve root of the lower vertebral body (ie L4 would be affected in an L3/4 central or paracentral disk herniation)
describe a far-lateral lumbar disk herniation
affects the nerve root of the higher vertebral body
- ie L3 would be affected in L3/4 far-lateral disk herniation
describe spinal stenosis
space available for the cord (SAC) = spinal canal diameter
-central stenosis is a narrowing of the SAC from bone, disk, ligament or foreign body encroachment
-foraminal stenosis is a narrowing of the neural foramen where the nerve root exits and can be bilateral or unilateral
describe Spondylosis
1. pathophys
2. symptoms
3. treatment
1. degenerative changes of the spine including facet hypertrophy, lamina and ligamentous hypertrophy, degeneration of the intervertebral disc, formation of osteophytes, autofusion of vertebral levels & loss of cervical and lumbar lordosis
- annular tears of the intervertebral disc occurs from collagen deposition, loss of water & proteoglycan from nucleus pulposus
- spondylosis may lead to neural foramina narrowing, central spinal stenosis, decreased mobility & kyphosis

2. back pain, radicular pain, myelopathy
- in lumbar region can lead to neurogenic claudication, cauda equina syndrome

3. non-op management 1st -> analgesics, anti-inflammatory, muscle relaxants, PT, epidural steroid injections
- cervical nerve root compression can be treated w/dorsal foraminotomies
- central cervical stenosis = ACDF
- lumbar central stenosis = decompressive laminectomy
- lumbar foraminotomy = foraminotomy
what is lateral recess syndrome?
compression of nerve root in lateral recess between hypertrophied superior articular facet, pedicle, & inferior vertebral body
- treat w/laminectomy & medial facetectomy (1/3 of facet, more is destabilizing & may require fusion)
describe spondylolisthesis
one vertebral body slips over another
- commonly in lumbar spine (95% at L5) & is usually ass'd w/bilateral pars interarticularis (spondylolysis) fractures but can be congenital, traumatic or degenerative
- leads to foraminal stenosis commonly, but canal rarely compromised
- pathologic process separates the spine into anterior (vertebral body, pedicles, transverse process, superior facet) and posterior (inferior facet, laminae, spinous process)
M > F
many spontaneously resolve, so treat conservatively first
describe the degree of slippage for spondylolisthesis
1. Grade I
2. Grade II
3. Grade III
4. Grade IV
1. 25%
2. 25-50%
3. 50-75%
4. 75-100%
what are indications for surgery for spondylolisthesis?
progressive spondylolisthesis, radiographic instability on flexion/extension films with corresponding mechanical pain, progressive neurological deficit or medically refractory pain
describe isthmic spondylolisthesis
abnormality of the pars interarticularis
- degenerative (facet joint motion -> intersegmental instability), traumatic (fx of pedicle, articular process) or pathologic (generalized disease process, ie Paget's)
describe dysplastic spondylolisthesis
usually L5-S1
- facet joint subluxation
describe spondyloptosis
100% subluxation; synonymous w/pars interarticularis defect or fx
- occurs in up to 20% of the population..
describe the following term:
- laminectomy
bilateral or unilateral removal of spinal lamina processes
describe the following term:
- laminotomy
partial removal of lamina to decompress or facilitate access to a microdiskectomy
describe the following term:
- diskectomy
can refer to a partial or "microdiskectomy" or can be total removal of disk material that may require a spacer and possible instrumentation
describe the following term:
- foraminotomy
decompression of an existing nerve root by removal of bone and ligament around the foramen
describe the following term:
- interspinous process device (ISPD)
sits between the spinous processes mechanically expanding the neural foramen at that level
describe Class I spondylolysis and spondylolisthesis in terms of:
1. type
2. age
3. pathology/other
1. congenital
2. child
3. dysplastic S1 superior facet
describe Class II spondylolysis and spondylolisthesis in terms of:
1. type
2. age
3. pathology/other
1. isthmic
2. 5-50
3. elongation/fracture of L5 S1 pars
describe Class III spondylolysis and spondylolisthesis in terms of:
1. type
2. age
3. pathology/other
1. degenerative
2. older
3. subluxation d/t facet (L4 L5) arthrosis
describe Class IV spondylolysis and spondylolisthesis in terms of:
1. type
2. age
3. pathology/other
1. traumatic
2. young
3. acute fracture (not pars)
describe Class V spondylolysis and spondylolisthesis in terms of:
1. type
2. age
3. pathology/other
1. pathologic
2. any
3. bony elements destroyed/incompetent
describe Class VI spondylolysis and spondylolisthesis in terms of:
1. type
2. age
3. pathology/other
1. postsurgical
2. adult
3. over resected arches/facets
describe spondylolysis
defect in pars interarticularis
most common cause of low back pain in kiddos
fatigue fx (gymnastics, football linemen)
80% visible on plain films, 15% on obliques (scottie dog collar)
Rx = symptomatic, avoid extension
casting for more severe or symptomatic cases
describe ACDF in terms of:
1. indications
2. outcome
3. complications
1. persistent radiculopathy/myelopathy or neuro deficit attributable to clear anterior pathology on MRI (ie single or 2 level herniated cervical disk), w/normal spinal lordosis; destabilizing trauma
2. although fusion rate for single level ACDF is quite high (95%) every level of surgery added increase the risk of nonunion.
surgeon preference dictates if a rigid collar is required or not
3. injury to pharynx, esophagus or trachea, vocal paresis (injury of recurrent laryngeal nerve/vagus; 11% temporary, 4% permanent), vertebral artery, carotid artery, CSF leak, Horner's syndrome, injury to spinal cord/nerve root, inability to fuse, infection, and hematoma.
immobility at levels of fusion may increase stress on adjacent levels leading to progressive degenerative dz
describe the indications for posterior cervical laminectomy +/- fusion
-Multiple cervical disc dz and myelopathy (w/neutral or lordotic sagittal alignment)
-Severe cervical stenosis w/ posterior compression
-OPLL
-previous anterior approach
-individuals where risk of vocal cord paralysis is intolerable
- can be supplemented w/lateral mass fusion
describe the Magerl technique for lateral mass screw fixation
screw should be placed using an entry point 1mm medial to dead center of lateral mass and the trajectory should be to the upper outer quadrant to minimize vertebral a. & nerve root injury
describe the Roy-Camille technique for lateral mass screw fixation
aim 'straight thru' the lateral mass
describe cervical laminoplasty
designed to preserve motion, hinges on one side of the posterior elements (lamina), then held open w/instrumentation
what are complications from lateral mass screw fixation?
-progressive kyphotic deformity
-vertebral artery injury
-CSF leak
-injury to spinal cord/nerve root
-inability to fuse
-infection
-hematoma
describe thoracic fusion
1. description
2. approaches
3. complications
1. the thoracic spine is technically challenging d/t proximity of the cord, difficulty of access, critical vascular & pulmonary structures, & small pedicles for instrumentation (ie ankylosing spondylitis) as unistrumented laminectomies for decompression may result in complete paraplegia
2. laminectomy, transpedicular, costotransversectomy, transthoracic
3. radicular a. injury leading to spinal cord ischemia
-pneumothorax
-CSF-pleural fistula
-pneumonia
-vascular injury (aorta/vena cava)
-CSF leak
-injury to spinal cord/nerve root
-inability to fuse
-infection
-hematoma
give an overview of lumbar fusion
depending on the approach, may involve laminectomy, discectomy, placement of bone graft, & instrumentation.
a general rule about lumbar pedicle screw placement is that as you progress down the levels, you should "medialize" the screw trajectory between 15 & 30 degrees
(15 at L1 to 30 at L5)
- the entry point is usually at the transverse process/facet junction
- complications depend on the approach utilized, but generally include:
-durotomy
-neurological injury
-infection
-implant migration
caution in osteopenia/osteoporosis
describe Anterior Lumbar Interbody Fusion (ALIF)
good for L5/S1 or revision cases where you do not want to go thru a posterior approach (avoids removal of posterior musculature). Cannot decompress from this approact, so must be combined w/a posterior approach if stenosis is present
at some institutions, the approach is performed by vascular or general surgery
anterolateral approach is for L2-5 and is 30 degrees lateral to the direct anterior approach (L5/S1)

complications: injury to abdominal vessels or bowel, ileus, retrograde ejaculation (relative contraindication in young, male pt's), abdominal hernia
describe Lateral interbody fusion
tubular dilators are inserted via a flank incision & EMG monitoring thru the psoas helps to avoid nerve root injury
generally restricted to levels L3-5 as one is limited cadually by the iliac crest and rostrally by the ribs

complications:
psoas muscle weakness (generally transient) & injury to nerves running on or thru the psoas muscle
describe posterior lumbar interbody fusion
full laminectomy and diskectomy is done w/an interbody graft placed into the disk space from either side. this construct is then usually supplemented w/pedicle screws.
can only be done at lower levels b/c req's signif retraction on the dural sac
epineural fibrosis may lead to chronic radiculopathy
describe transforaminal lumbar interbody fusion
similar to PLIF, but more lateral approach allowing for less retraction on the dural sac.
approach is from one side and the facet is taken down allowing access to the tisk space for the diskectomy
a single banana-shaped interbody graft is slid across the midline and the construct is usually supplemented w/pedicle screws
- puts greater tension on the nerve root so runs higher risk of neuropathy
describe the frequency of the diff types of spinal cord tumors
extradural 55%
intradural extramedullary 40%
intramedullary 5%
give a brief overview of extradural spinal cord tumors
outside the spinal cord & dura (ie epidural or in the vertebral body)
- frequently metastatic lesions in the adult & neuroblastoma or Ewings sarcoma in kids
what are the commoner metastatic extradural spinal cord tumors?
lymphoma, lung, breast, prostate -> destructive
prostate, breast -> osteoblastic
what are the types of primary extradural spinal cord tumors?
chordoma, neurofibroma, osteoid osteoma, osteoblastoma, aneurysmal bone cyst, chondrosarcoma, osteochondroma, vertebral hemangioma, giant cell tumor of bone, osteosarcoma
how does osteoid osteoma often present
benign, posterior lumbar spine nocturnal pain improved w/aspirin, lytic lesion w/calcifications
describe perineural (Tarlov) cyst
occurs at the junction of the dorsal nerve roots & ganglia most commonly @ the sacrum
- between endoneurium & perineurium
- may present w/pain (sciatica) urinary incontinence, sexual dysfunction, weakness
- spontaneous rupture may lead to HA from intracranial hypotension from CSF leak from cyst
F > M
Rx = cyst drainage (usually recur), steroid injection, microsurgical resection
describe eosinophilic granuloma
lytic lesion w/o surrounding sclerosis
- classic cause of single collapsed vertebral body in pediatric pt, if no evidence of trauma
- bright on T2, enhances w/contrast
describe Aneurysmal Bone Cysts in terms of:
1. epidemiology
2. Radiology
1. < 20yo
ass'd w/eosinophilic granuloma, fibrous dysplasia, giant cell tumor, benign
2. posterior cervical, thoracic area
- CT shows lytic lesion w/surrounding cortical bone
MRI shows lobulated fluid-fluid levels from blood degradation products
describe epidermal lipomatosis in terms of:
1. pathogenesis
2. presentation
3. Rx
1. chronic hypercortisolemia, obesity, idiopathic
2. radicular, myelopathic si/sx of thoracic, lumbar region
3. conservative; wt loss; decreased steroid dose; decompressive laminotomy
what are the types of intradural extramedullary spinal cord tumors?
= in the nerve root or leptomeninges

schwannoma/neurofibroma (homogenously enhancing dumbbell shaped tumor that extends thru neural foramen; usually can spare the nerve in a schwannoma since the nerves do not run in the tumor as with neurofibromas)
meningioma (classically well circumscribed, homogenously enhancing; 15% are extradural)
paraganglioma (usually occur in the cauda equina region)
cysts (arachnoid, dermoid/epidermoid, & neurenteric)
lipoma
what are the types of intramedullary spinal cord tumors?
ependymoma (40%)
astrocytoma (40%)
20% - dermoid, epidermoid, teratoma, lipoma, hemangioblastoma, neuroma, lymphoma, oligodendroglioma, cholesteatoma, intramedullary mets
describe ependymoma intramedullary spinal cord tumor
cellular type occurs in the cervical region wehereas the myxopapillary type occurs at the conus. these can usually be separated out since there is often a well-definied plane between tumor & spinal cord.
goal is gross total resection
describe astrocytoma intramedullary spinal cord tumor
most common intramedullary spinal cord tumor in children
usually in the cervical region and can have an ass'd syrinx
these tumors are more difficult to get a gross total resection & may req postsurgical adjuvant therapy
whats the DDx for cauda equina tumors
myxopapillary ependymoma, schwannoma, paraganglioma, meningioma, drop mets, lymphoma, hemangioblastoma (esp w/VHL)
describe type I spinal AVM
Dural AV fistula
- extramedullary, no nidus, low flow, simple dorsal venous drainage, lower thoracic/conus
- most common in adults (85% of spinal AVMs)
- present w/progressive neurological deficits 2/2 venous congestion

Rx = coagulate feeder vessel as it enters nerve root sleeve vs embolize, curative
describe type II spinal AVM
Glomus
- intramedullary, may present w/hemorrhage, high flow, cervicothoracic junction

Rx = surgical excision after embolization
describe type III spinal AVM
Juvenile
intra- and extradural but w/intramedullary nidus, high flow, cervical/upper thoracic
- very rare, marked propensity to bleed, multiple feeders over multiple segments, present w/progressive neuro deficits
- prognosis poor, 2/2 size, vascular complexity & intervening normal spinal cord tissue
describe type IV spinal AVM
Perimedullary dural AV fistula w/extramedullary AVM nidus
-> progressive neurological deterioration
Rx: coagulate vessel as it enters nerve root sleeve vs embolize vs radiosurgery; trap nidus feeder vessels w/temporary clips & check for neuromonitoring before cauterizing permanently
subtypes:
I - single feeder, low flow
II - multiple feeders, increased venous engorgement
III - giant multiple feeders, high flow, vascular steal
describe Foix-Alajouanine syndrome
thrombosis of spinal cord AVM
presents as subacute myelopathy
occurs lower thoracic, lumbar, sacral
path = necrosis of gray > white matter
describe syringomyelia
a syrinx or intramedullary cavity formation w/in the spinal cord (distance from the central canal) that fills w/CSF
- syrinx can be ass'd w/Chiari malformation, trauma, spinal cord tumor or anything affecting flow of CSF thru the spinal cord
- can treat syrinx w/shunt or midline myelotomy, but it's best to try to remove the source of the syrinx
Si/Sx: transient pain, dissociated sensory loss (loss of pain & temp) in the upper extremities, motor disturbances, spastic paraparesis; may lead to neuropathic arthropathy = charcot or neurotrophic joint (loss of proprioception & deep sensation leads to recurrent trauma & destruction of the joint)
if in cervical region -> poss resp compromise
what is syringobulbia
syrinx extending into the medulla
si/sx = those of syringomyelia, but also include bulbar signs (weakness of tongue, pharynx, larynx)
what is hydromyelia
dilation of the central canal, has ependymal lining
etiology = congenital, postraumatic, tumor
describe Transverse Myelitis in terms of:
1. etiology
2. presentation
3. DDx
4. workup
5. Rx
sudden onset of autoimmune demyelination or inflammation across one spinal cord segment
1. lupus, postinfectious viral or bacterial, vaccinations, Behcet's, idiopathic, MS
2. sensory level, weakness, pain, paralysis, urinary incontinence
3. infarct, lymphoma, MS
4. CSF cytology & protein, MS panel, MRI brain
5. steroids
describe Subacute Combined Degeneration in terms of:
1. etiology
2. symptoms
3. pathology
symmetric spinal cord demyelination from B12 deficiency
1. B12 deficiency from pernicious anemia
2. lower extremity parasthesias, sensory loss, spastic paraparesis, ataxia, confusion, dementia, peripheral neuropathy, megaloblastic anemia
3. wallerian degeneration
- vacuolar disturbance of myelin sheath
-cervical, thoracic > lumbar
- posterior columns, spinocerebelar tracts, corticospinal tracts
describe the presentation of vit E deficiency
ataxia, decreased reflexes, acanthocytosis, hemolytic anemia, peripheral neuropathy, spinocerebellar tract degeneration, weakness, loss of proprioception & vibratory sense
describe Os Odontoideum
absent, hypoplastic or unfused dens
- may be a congenital lack of fusion but generally considered to be post traumatic
- generally stable & incidentally found
- may present w/neck pain
- no edema & ossified margins differentiate it from an acute fracture
describe Klippel-Feil syndrome in terms of:
1. etiology
2. Grading
3. Si/Sx
4. Associations
5. Rx
congenital fusion of 2 or more cervical vertebrae (usually involves C2-3)
1. ass'd w/mutation on ch 8
- failure of cervical vertebral (somite) segmentation

2. type I - fusion of cervical & upper thoracic vertebra w/synostosis
type II - isolated cervical spine fusion
type III - cervical vertebra ass'd w/lower thoracic or upper lumbar fusion

3. short/webbed neck, decreased cervical spine ROM, low hairline
- may be incidental or w/torticollis, neck webbing, facial asymmetry

4. sprengel's deformity (congenital elevation of scapula, occurs in 30%), chiari I, scoliosis, spina bifida, basilar impression, GU, cranial, facial & cardiac abnormalities
- can lead to traumatic quadriplegia after minor treatment

5. medical management of multiple comorbidities
- for spinal instability external immobilization (halo) vs surgical fusion
describe pediatric spinal cord injuries in general terms
children are more likely to have ligamentous injury rather than bony fx d/trelatively large size of head & ligamentous laxity
- synchondroses may be mistaken for a fx line, pseudospread of the atlas misdiagnosed for a Jefferson fx & pseudosubluxation

rare (<5% of SCI occur in kids), tend to involve the cervical spine, higher fatality rate than w/adults
- more susceptible to SCIWORA
describe SCIWORA in kids
1. pathophys
2. imaging
3. si/sx
4. Rx
5. prognosis
1/5 of all peds SCI
- > 80% involve cervical cord
most occur & are the most severe in kids < 8 Yo

1. pediatric spine is inherently elastic, permitting self-reduction but severe intersegmental displacement

2. immediate CT normal, MRI normal in 1/2

3. pure sensory 44%, pure motor 31%, mixed 25%

4. supportive care, steroid rx (controversial), bracing may not be necessary

5. may recover if initial MRI is neg
- > 50% have delayed onset of neurological deficit (may have paresthesias at time of accident), which is rapid & may lead to a complete lesion
define sagittal balance
global balance of head, cervical, thoracic, lumbar spine & pelvis on sagittal view when the pt is standing w/his or her knees straight. best assessed w/36" standing scoliosis films
define Cantilever forces
a beam supported on only one end that allows for overhanging structures w/o external bracing. ex is the forces experienced by a pedicle screw from the attached rod construct
define posterior tension band
stabilizing forces in the posterior elements that inhibit forward flexion. usually ligamentous forces & can be simulated w/posterior wiring techniques in case of disruption
define pull-out strength
intrinsic resistance to a screw or screw construct from backing out of the bone. this is usually enhanced by "medializing" or "lateralizing" the screw trajectory & adding a cross-link to make it a solid wedge of bone between the screws
define 3-point bending
term applied usually to a construct involving 3 adjacent vertebral bodies where the middle one is misaligned & the flanking ones allow for support to pull it back. usually in cases of spondylolisthesis
define glacial instability
similar to global vertebral body instability that can result in mechanical or axial back pain
define anterior column reconstruction
important when trying to regain normal lordosis for kyphotic deformity correction. usually requires an anterior approach
define axial loading
downward forces applied to the spine along its axis. can be chronic, acute, or traumatic. traumatic axial loading can result in spine fractures such as a Jefferson fx
define dynamic stabilization
spine instrumentation that allow for some preservation of motion such as an artificial disk, load sharing rods, etc
define ligamentotaxis
this is when spine constructs are used to manipulate bone structures in such a way as to move bone that is attached to ligaments. an ex would be pedicle screw distraction of a lumbar burst fx to move the retropulsed fragment out of the canal