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6. Spine MCQs

Practice Set 106 of 379

This practice set contains high-yield board review questions covering key concepts in 6. Spine. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 2101

Topic: 6. Spine

Figures 23a and 23b show the MRI scans of a 50-year-old woman who has increasing gait disturbance. She reports three falls in the past week. Examination reveals hyperreflexia, motor weakness in the biceps and triceps, and a positive Hoffman’s sign. What is the most appropriate treatment plan? Review Topic

. Observation
. Physical therapy
. Epidural steroid injections
. Cervical laminectomy
. Anterior cervical diskectomy and fusion

Correct Answer & Explanation

. Observation

Explanation

The patient has obvious signs of progressive myelopathy. Based on her significant physical examination findings, nonsurgical management will not significantly impact her outcome. Cervical decompression alone is contraindicated in patients with cervical kyphosis such as seen here. Anterior cervical fusion is the best option.(SBQ12SP.77) A 68-year-old is undergoing lateral lumbar interbody fusion using the tranpsoas approach. Which of the following statements is true regarding the safe approach zone for this procedure as you move cranial to caudal in the lumbar spine?Review TopicSafe approach zone increases due to vessels moving more ventralSafe approach zone increases due to lumbar plexus moving more dorsalSafe approach zone decreases due to vessels moving more dorsalSafe approach zone decreases due to lumbar plexus moving more ventralSafe approach zone remains the same throughout the lumbar spineAs you move cranial to caudal in the lumbar spine, the safe approach zone for the lateral transpsoas approach decreases due to the more ventral position of the lumbar plexus.Lateral lumbar interbody fusion has become more common for degenerative spine disorders and adjacent segment degeneration. This transpsoas approach is typically useful for pathology from L1-L2 disc space to the L4-L5 disc space and places the lumbar plexus at risk. Working at the more caudal disc spaces is especially difficult given the more ventral position of the plexus, but the use of triggered EMG retractors and probes can help prevent nerve injuries. Surgical approach can be especially difficult in patients with rotational deformities.Benglis et al. did a cadaver study with specimens placed lateral to trace the course of the lumbar plexus. They found that the plexus move more ventral with respect to the disc space moving more caudal in the lumbar spine.Park et al. used 10 cadaver specimens to measure the distance of the lumbar nerve roots from the center of the disc space in the lateral approach. While disc space access was generally safe, there was less distance to the nerve root for more caudal disc levels.Regev et al. did a MRI study to evaluate the safe working corridor for the lateral approach. The safe zone narrows considerably in the L4-L5 disc space due to moreventral position of the nerve roots, and they recommend careful monitoring when addressing this level.Incorrect

Question 2102

Topic: 6. Spine

Immediately after undergoing lumbar instrumentation, a patient reports severe right leg pain and has 4+/5 weakness. Figure 24 shows an axial CT scan of L5. Exploratory surgery will most likely reveal

. transection of the L5 root.
. displacement of the L5 root.
. partial laceration of the L5 root.
. segmental artery injury.
. spinal fluid leakage.

Correct Answer & Explanation

. transection of the L5 root.

Explanation

DISCUSSION: The most common finding at exploration of an inappropriately placed pedicle screw is displacement of the nerve.  Pedicle breach is common, ranging from 2% to 20%, but most are asymptomatic.  All of the choices are possible, but in a large series conducted by Lonstein and associates, the authors reported that displacement of the root, most often medial, was the most common finding.  Laceration, contusion, or transfixion usually was not seen.  Spinal fluid leakage occurs less frequently and is not expected in the minimal broach illustrated.REFERENCES: Esses SI, Sachs BL, Dreyzin V: Complications associated with the technique of pedicle screw fixation: A selected survey of ABS members.  Spine 1993;18:2231-2238.Laine T, Lund T, Ylikoski M, et al: Accuracy of pedicle screw insertion with and without computer assistance: A randomised controlled clinical study in 100 consecutive patients.  Eur Spine J 2000;9:235-240.Lonstein JE, Denis F, Perra JH, et al: Complications associated with pedicle screws.  J Bone Joint Surg Am 1999;81:1519-1528.

Question 2103

Topic: 6. Spine

A patient underwent an anterior cervical diskectomy and interbody fusion for a C5-6 herniated nucleus pulposus and left C6 radiculopathy 8 months ago. He now reports new onset of severe neck pain and left C6 radicular pain, with wrist extension weakness. The radiograph and CT scan shown in Figures 26a and 26b reveal pseudarthrosis at C5-6. The next step in management should consist of

. application of a neck brace for 6 to 12 weeks.
. revision anterior diskectomy and interbody fusion with autograft at C5-6.
. revision anterior diskectomy with interbody autograft and anterior plate fixation at C5-6.
. posterior fusion at C5-6.
. posterior foraminotomy at left C6 and posterior fusion at C5-6 with stabilization and autograft.

Correct Answer & Explanation

. application of a neck brace for 6 to 12 weeks.

Explanation

DISCUSSION: Brodsky and associates reviewed 34 cases of cervical pseudarthrosis after anterior fusion.  Seventeen were treated with revision anterior fusion and 17 with posterior foraminotomy and fusion.  Good results were seen in 75% of patients who underwent revision anterior surgery, but better results (94%) were seen with posterior surgery, including foraminotomy and stabilization.  Tribus and associates reported treatment of 16 patients with pseudarthrosis using revision anterior debridement of the fibrous tissue and fusion with autograft and plates.  There was improvement of the neck in 75% of the patients, nonunion in 19%, continued weakness in 28%, and dysphagia in 5%.  Farey and associates reported on 19 patients treated with posterior foraminotomy, stabilization, and fusion with a fusion rate of 100%, resolution of arm pain in 94%, resolution of weakness in 100%, and resolution of neck pain in 75%.  It would appear that posterior foraminotomy is more effective for relieving arm pain and neurologic deficits associated with pseudarthrosis.  Posterior fusion has the most reliable rate of arthrodesis in this setting.  Dysphagia is reported in some patients undergoing more extensive anterior dissections required for applying plates.  A neck brace is unlikely to aid in healing of pseudarthrosis in a patient who underwent surgery 8 months ago.  A neck brace would be most effective within the first 3 months if a delayed union is identified.REFERENCES: Brodsky AE, Khalil MA, Sassard WR, Neuman BP:  Repair of symptomatic pseudarthrosis of anterior cervical fusion: Posterior versus anterior repair.  Spine1992;17:1137-1143.Tribus CB, Corteen DP, Zdeblick TA: The efficacy of anterior cervical plating in the management of symptomatic pseudarthrosis of the cervical spine. Spine 1999;24:860-864.Farey ID, McAfee PC, Davis RF, Long DM: Pseudarthrosis of the cervical spine after anterior arthrodesis: Treatment by posterior nerve root decompression, stabilization, and arthrodesis.J Bone Joint Surgery Am 1990;72:1171-1177.

Question 2104

Topic: 6. Spine

A 67-year-old woman has persistent anterior thigh and knee pain after undergoing total knee arthroplasty 1 year ago. Examination and radiographs reveal no problems in the knee, mild hip flexor weakness (grade 4+), and decreased sensation over the anterior thigh including and proximal to the incision. MRI of the lumbar spine will most likely reveal which of the following findings?

. Posterolateral herniated nucleus pulposus at L3-4
. Posterolateral herniated nucleus pulposus at L4-5
. Degenerative disk disease at L3-4 and L4-5 with no significant facet hypertrophy
. Degenerative spondylolisthesis at L3-4 with central and foramenal stenosis
. Degenerative spondylolisthesis at L4-5 with central stenosis

Correct Answer & Explanation

. Posterolateral herniated nucleus pulposus at L3-4

Explanation

DISCUSSION: Degenerative spondylolisthesis at L3-4 is the most likely diagnosis.  This spondylolisthesis would result in foraminal stenosis affecting the third lumbar root and leading to anterior thigh and knee pain and hip flexor weakness.  L4-5 spondylolisthesis would impinge on the L4 root in the foramen.  Degenerative disk disease without hypertrophy is unlikely to have root impingement.  Posterolateral herniations typically affect the inferior root and are less common in this age group.REFERENCES: Hoppenfeld S:  Physical Examination of the Spine and Extremities.  Upper Saddle River, NJ, Prentice Hall, 1976, p 250.Lauerman WC, Goldsmith ME: Spine, in Miller MD (ed): Review of Orthopaedics, ed 3.  Philadelphia, PA, WB Saunders, 2000, pp 353-378.

Question 2105

Topic: 6. Spine

What is the advantage of percutaneous pedicle screw fixation over open instrumentation and fusion for a thoracolumbar burst fracture without neurologic deficit?

. Better clinical outcomes
. Less blood loss
. Less pseudarthrosis risk
. Lower revision surgery rate

Correct Answer & Explanation

. Better clinical outcomes

Explanation

DISCUSSIONA prospective randomized study on short-segment treatment of burst fractures with and without fusion demonstrated similar outcomes at 5 years with lower blood loss in the nonfusion group. There is by definition no fusion performed with percutaneous stabilization, so patients often develop hardware failure. Some surgeons routinely remove instrumentation following percutaneous stabilization, thus revision surgery is common. Clinical outcomes are not improved compared to open methods.RECOMMENDED READINGSKoreckij T, Park DK, Fischgrund J. Minimally invasive spine surgery in the treatment of thoracolumbar and lumbar spine trauma. Neurosurg Focus. 2014;37(1):E11. doi: 10.3171/2014.5.FOCUS1494. Review. PubMed PMID: 24981899.View Abstract at PubMedJindal N, Sankhala SS, Bachhal V. The role of fusion in the management of burst fractures of the thoracolumbar spine treated by short segment pedicle screw fixation: a prospective randomised trial. J Bone Joint Surg Br. 2012 Aug;94(8):1101-6. doi: 10.1302/0301-620X.94B8.28311. PubMed PMID: 22844053.View Abstract atPubMedDai LY, Jiang LS, Jiang SD. Posterior short-segment fixation with or without fusion for thoracolumbar burst fractures. a five to seven-year prospective randomized study. J BoneJoint Surg Am. 2009 May;91(5):1033-41. doi: 10.2106/JBJS.H.00510. PubMed PMID:

Question 2106

Topic: 6. Spine

When compared to smokers who do not quit, an improvement in the rate of lumbar fusion is seen in patients who cease smoking for at least how many months postoperatively?

. 1 month
. 2 months
. 4 months
. 6 months
. 12 months

Correct Answer & Explanation

. 1 month

Explanation

DISCUSSION: The effects of cigarette smoking and smoking cessation on spinal fusion have been studied extensively.  Although permanent smoking cessation is ideal, significant improvements in fusion rates are seen in patients who avoid smoking for greater than 6 months postoperatively.REFERENCE: Glassman SD, Anagnost SC, Parker A, et al: The effect of cigarette smoking and smoking cessation on spinal fusion.  Spine 2000;25:2608-2615.

Question 2107

Topic: 6. Spine

Figures 29a and 29b show the AP and lateral radiographs of a 30-year-old man who has increasingly worse back pain and stiffness. Examination shows painful, limited spinal range of motion. There is no neurologic deficit. What laboratory study would be most helpful in confirming the diagnosis?

. HLA-B27
. Prostate-specific antigen
. Rheumatoid factor
. Antinuclear antibody
. Serum protein electrophoresis

Correct Answer & Explanation

. HLA-B27

Explanation

DISCUSSION: The radiographs show ankylosing spondylitis with sclerosis of the sacroiliac joints and a “bamboo spine” in the lumbar region.  HLA-B27 is positive in 80% to 90% of patients with ankylosing spondylitis and in about 8% of the general population.  The findings do not represent diffuse idiopathic skeletal hyperostosis (DISH), which is a radiographic diagnosis in which there are three consecutive levels of nonmarginated osteophytes without disk degeneration.REFERENCES: Calin A: Ankylosing spondylitis.  Clin Rheum Dis 1985;11:41-60.Booth R, Simpson J, Herkowitz H: Arthritis of the spine, in Herkowitz HH (ed): The Spine, ed 4.  Philadelphia, PA, WB Saunders, 1992, p 431.van der Linden S, Valkenburg H, Cats A: The risk of developing ankylosing spondylitis in HLA-B27 positive individuals: A family and population study.  Br J Rheumatol 1983;22:18-19.

Question 2108

Topic: 6. Spine

A 42-year-old woman who has had an 18-month history of severe low back pain is referred to your office for surgical evaluation. She reports that the pain initially began with right lower extremity pain and management consisted of oral analgesics, nonsteroidal anti-inflammatory drugs, and muscle relaxants. She has seen a chiropractor as well as a pain management specialist and she is status-post epidural steroid injections. She has also completed exhaustive physical therapy, as she is a certified athletic trainer and runs a health fitness program at a community hospital. Currently, she denies lower extremity pain and her pain is isolated to her low back and is subjectively graded as 8/10, with 10 being the worst pain she has ever experienced. The pain is interfering with her activities of daily living and she is seeking definitive treatment. Figures 32a through 32c show current MRI scans. Based on the current available medical literature, what is the most appropriate treatment?

. Continued nonsurgical management to include long-acting narcotic analgesics
. Referral for vertebral axial decompression
. Referral to interventional pain management for a spinal cord stimulator
. Intradiskal electrothermal therapy (IDET) at L5-S1
. Lumbar spinal fusion at L5-S1

Correct Answer & Explanation

. Continued nonsurgical management to include long-acting narcotic analgesics

Explanation

DISCUSSION: The MRI scans reveal advanced degenerative disk disease at L5-S1.  Nonsurgical management has failed to provide relief and the patient is quite debilitated as a result of her back pain.  Fritzell and associates demonstrated that in a well-informed and selected group of patients with severe low back pain, lumbar fusion can diminish pain and decrease disability more efficiently than commonly used nonsurgical treatments.  In a recent updated Cochrane Review of surgery for degenerative lumbar spondylosis, it was noted that while Fritzell and associates appeared to provide strong evidence in favor of fusion, a more recent trial by Brox and associates demonstrated no difference between those patients undergoing lumbar fusion compared to those receiving cognitive intervention and exercise.  The Cochrane Review suggests that this may reflect a difference between the control groups.  Fritzell and associates compared lumbar fusion to standard 1990s “usual care,” whereas Brox and associates compared lumbar fusion to a “modern rehabilitation program.”  Bear in mind that this patient is a certified athletic trainer and runs a hospital health fitness department; therefore, at least for purposes of this question, it can be assumed that she has participated in a “modern rehabilitation program.”  The Cochrane Review goes on to state that preliminary results of three small trials of intradiskal electrotherapy suggest that it is ineffective and that preliminary data from three trials of disk arthroplasty do not permit firm conclusions.REFERENCES: Gibson JN, Waddell G: Surgery for degenerative lumbar spondylosis: Updated Cochrane Review.  Spine 2005;30:2312-2320.Fritzell P, Hagg O, Wessberg P, et al: 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: A multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group.  Spine 2001;26:2521-2532.Brox JI, Sorensen R, Friis A, et al: Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration.  Spine 2003;28:1913-1921.

Question 2109

Topic: 6. Spine
  • A 14-year-old patient who has homocystinuria and is Risser 3 is referred for surgical treatment of scoliosis. In addition to the usual risks associated with posterior spinal fusion, the family should be advised that the patient ‘s underlying condition significantly increases the perioperative risk of
. Spinal pseudoarthrosis
. Spinal cord traction injury with paralysis
. Arterial and venous thromboses
. Superior mesenteric artery syndrome
. Crankshaft phenomenon

Correct Answer & Explanation

. Spinal pseudoarthrosis

Explanation

Tendency towards venous and arterial thrombosis along with mental retardation, dislocation of the lens and skeletal changes resembling Marfan’s are all clinical features of homocystinuria. Homocysteine is toxic and causes endothelial cell damage. Increased platelet stickiness is also associated with the disease.1 and 2 are concerns during spinal fusion but are not specific to this disease. 4 may occur with homocystinuria but is not related to spinal fusion. 5 occurs with PSF in the younger population because of the growth potential remaining.

Question 2110

Topic: 6. Spine

A 69-year-old woman is seen in the emergency department with a bilateral C5-6 facet dislocation and complete quadriplegia after falling down a flight of stairs. After initial evaluation and treatment by the trauma service, she is moved to the intensive care unit. Examination reveals a blood pressure of 90/50 mm/Hg, a pulse rate of 50/min, a respiration rate of 12/min, and urine output of 1 mL/kg/h. Her hemodynamic status should be addressed by

. continued fluid bolus.
. methylprednisolone.
. insertion of a Swan-Ganz catheter.
. immediate intubation.
. beta blockers to decrease peripheral resistance.

Correct Answer & Explanation

. continued fluid bolus.

Explanation

DISCUSSION: The patient’s heart rate is not responding to hypotension with tachycardia, as would be expected in the event of hypovolemic shock.  Additionally, the adequate urineoutput suggests proper fluid resuscitation.  Instead, she is bradycardic, possibly indicating neurogenic shock and loss of sympathetic tone to the heart.  A Swan-Ganz catheter should be used to help differentiate these problems and guide appropriate fluid resuscitation and use of vasopressor agents.REFERENCES: Hadley MN: Management of acute spinal cord injuries in an intensive care unit or other monitored setting.  Neurosurgery 2002;50:S51-S57.VaccaroAR, An HS, Betz RR, et al: The management of acute spinal trauma: Prehospital and in-hospital emergency care.  Instr Course Lect 1997;46:113-125.

Question 2111

Topic: 6. Spine

A 68-year-old woman undergoes a complicated four-level anterior cervical diskectomy and fusion at C3-7 with iliac crest bone graft and instrumentation for multilevel cervical stenosis. Surgical time was approximately 6 hours and estimated blood loss was 800 mL. Neuromonitoring was stable throughout the procedure. The patient’s history is significant for smoking. The most immediate appropriate postoperative management for this patient should include

. normal postoperative orders with frequent neurologic evaluations for the first 24 hours.
. administration of IV steroids and placement of a soft cervical collar for 24 hours.
. placement of both deep and superficial surgical drains prior to wound closure.
. administration of IV mannitol and placement of a soft collar.
. maintaining intubation for up to 24 to 48 hours.

Correct Answer & Explanation

. normal postoperative orders with frequent neurologic evaluations for the first 24 hours.

Explanation

DISCUSSION: Airway complications after anterior cervical surgery can be a catastrophic event necessitating emergent intubation for airway protection.  Multilevel surgeries requiring long intubation and prolonged soft-tissue retraction as well as preexisting comorbidities may predispose a patient to postoperative airway complications.  Sagi and associates reported that surgical times greater than 5 hours, blood loss greater than 300 mL, and multilevel surgery at or above C3-4 are risk factors for airway complications.  In surgical procedures with the aforementioned factors, serious consideration should be given to elective intubation for 1 to 3 days to avoid urgent reintubation.REFERENCES: Sagi HC, Beutler W, Carroll E, et al: Airway complications associated with surgery on the anterior cervical spine.  Spine 2002;27:949-953.Epstein NE, Hollingsworth R, Nardi D, et al: Can airway complications following multilevel anterior cervical surgery be avoided?  J Neurosurg 2001;94:185-188.Emery SE, Smith MD, Bohlman HH: Upper-airway obstruction after multi-level cervical corpectomy for myelopathy.  J Bone Joint Surg Am 1991;73:544-551.

Question 2112

Topic: 6. Spine

What spinal nerves in the cauda equina are primarily responsible for innervation of the bladder?

. L1, L2, and L3
. L4 and L5
. L5 and S1
. S2, S3, and S4
. Filum terminale

Correct Answer & Explanation

. L1, L2, and L3

Explanation

DISCUSSION: The spinal nerves primarily responsible for bladder function are the S2, S3, and S4 nerve roots.  With significant compression of the cauda equina by either disk herniation, tumor, or degenerative stenosis, bladder dysfunction may result.REFERENCES: Hoppenfeld S: Physical Examination of the Spine and Extremities.  Norwalk, CT, Appleton-Century-Crofts, 1976, p 254.Pick TP, Howden R (edS): Gray’s Anatomy.  New York, NY, Bounty Books, 1977, p 1004.

Question 2113

Topic: 6. Spine

A 40-year-old woman has had sciatic pain on the left side for the past 8 weeks. She reports that the pain radiates to her posterior thigh, lateral calf, and into the dorsum of her left foot. Neurologic examination shows weakness of the left extensor hallucis longus. Axial T 2 -weighted MRI scans through L4-L5 are shown in Figure 14. Management should consist of

. CT-guided needle biopsy at L4-L5.
. a bone survey.
. anterior interbody fusion.
. left L4-L5 microdiskectomy.
. left L4-L5 hemilaminectomy and partial facetectomy.

Correct Answer & Explanation

. CT-guided needle biopsy at L4-L5.

Explanation

DISCUSSION: The MRI scans show hypertrophy of the left L4-L5 facet joint and ligamentum flavum, with a synovial cyst.  Appropriate surgical management consists of a hemilaminectomy and direct decompression of the neural elements.  Fusion, in addition to the decompression, may be considered, particularly in patients with an associated spondylolisthesis.REFERENCES: Epstein NE: Lumbar laminectomy for the resection of synovial cysts and coexisting lumbar spinal stenosis or degenerative spondylolisthesis: An outcome study.  Spine 2004;29:1049-1055.Shah RV, Lutz GE: Lumbar intraspinal synovial cysts: Conservative management and review of the world’s literature.  Spine J 2003;3:479-488.

Question 2114

Topic: 6. Spine

What is one of the principle concerns when a fracture such as the one seen in Figure 18 is encountered?

. Fractures of the lower extremities
. Paroxysmal hypertension
. Infection
. Epidural hematoma
. Gastrointestinal bleeding

Correct Answer & Explanation

. Fractures of the lower extremities

Explanation

DISCUSSION: The injury shown is a fracture-dislocation and it is highly unstable.  In addition to this concern, spinal epidural hematomas have a much higher incidence in people with ankylosing spondylitis following knee fracture.  It is felt to be due to disrupted epidural veins, with hypervascular epidural soft tissue in the setting of a rigid spinal canal.  Patients with ankylosing spondylitis may have other significant comorbidities, especially cardiac and pulmonary, and these should be carefully assessed.REFERENCES: Ludwig S, Zarro CM: Complications encountered in the management of patients with ankylosing spondylitis, in Vaccaro AR, Regan JJ, Crawford AH, et al (eds): Complications of Pediatric and Adult Spine Surgery.  New York, NY, Marcel Dekker, 2004,pp 279-290.Wu CT, Lee ST: Spinal epidural hematoma and ankylosing spondylitis: Case report and review of the literature.  J Trauma 1998;44:558-561.

Question 2115

Topic: 6. Spine

A 35-year-old woman undergoes an L4-5 anterior fusion via a left retroperitoneal approach. Postoperative examination reveals that her right foot is cool and pale. Her neurologic examination is normal, and her pedal pulses are asymmetric. What is the most likely reason for the right foot finding?

. Injury to the lumbar sympathetic chain
. Injury to the parasympathetic nerve
. Immune response to the allograft bone
. Occlusion of the left iliac vein
. Prolonged retraction of the left iliac artery

Correct Answer & Explanation

. Injury to the lumbar sympathetic chain

Explanation

DISCUSSION: The lower extremity symptoms are consistent with a sympathectomy that is the result of an injury to the sympathetic chain, ipsilateral to the approach along the anterior border of the lumbar spine.  This results in a warm, red foot, which creates the appearance that the normal cooler foot may have compromised circulation.  The latter generally attracts greater attention because of the risks associated with limb ischemia.  The condition usually is self-limited and does not require any specific treatment.REFERENCES: Rothman RH, Simeone FA (eds): The Spine, ed 4.  Philadelphia PA, WB Saunders, 1999, p1550.Benzel EC (ed): Spine Surgery Techniques, Complication Avoidance and Management.  New York, NY, Churchill Livingstone, 1999, p 190.

Question 2116

Topic: 6. Spine

A 69-year-old patient with diabetes has had acute-onset back pain and difficulty with ambulation for several hours. Evaluation reveals a temperature of 38.3°C, a white blood cell (WBC) count of 14000/µL (reference range [rr], 4500-11000/µL), C-reactive protein (CRP) level of 120 mg/L (rr, 0.08-3.1 mg/L), erythrocyte sedimentation rate of 130 mm/h (rr, 0-20 mm/h), normal rectal examination findings, and normal sensation to light touch. Motor function testing of the lower extremities reveals 3/5 ankle dorsiflexion and 4/5 plantar flexion strength bilaterally. An MR image reveals a large epidural abscess from L1-5. What is the most appropriate treatment at this time?

. Medical management with intravenous (IV) antibiotics and observation
. CT-guided aspiration of the abscess before initiating antibiotics
. Surgical decompression and IV antibiotics
. Blood cultures and re-evaluation in 24 hours

Correct Answer & Explanation

. Medical management with intravenous (IV) antibiotics and observation

Explanation

DISCUSSIONEpidural abscess is a serious and potentially disastrous condition. Although medical management is effective in some situations, surgical decompression is considered urgent with the presence of a neurological deficit. Medical management can be considered in the case of a neurologically intact patient, particularly when the microorganism has been identified. If medical management is chosen, careful observation and serial examination for neurologic deterioration is required. Surgical decompression is indicated if a patient's neurologic status worsens or if medical management failure is noted. Additionally, diabetes, a CRP level higher than 115 mg/L, WBC higher than 12500/µL , and bacteremia have proven predictive of medical treatment failure. This patient would be a better candidate for urgent surgical decompression and subsequent IV antibiotics than for medical management.RECOMMENDED READINGSPatel AR, Alton TB, Bransford RJ, Lee MJ, Bellabarba CB, Chapman JR. Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases. Spine J. 2014 Feb 1;14(2):326-30. doi: 10.1016/j.spinee.2013.10.046. Epub 2013 Nov 12. PubMed PMID: 24231778.ViewAbstract at PubMedKim SD, Melikian R, Ju KL, Zurakowski D, Wood KB, Bono CM, Harris MB. Independent predictors of failure of nonoperative management of spinal epidural abscesses. Spine J. 2014 Aug 1;14(8):1673-9. doi: 10.1016/j.spinee.2013.10.011. Epub 2013 Oct 30. PubMed PMID:

Question 2117

Topic: 6. Spine

A 25-year-old athletic woman has a 16-week history of left lower-extremity radiating pain in an S1 distribution. MR images obtained by her family physician reveal a large L5-S1 paracentral disk herniation impinging on the left S1 nerve root. You suggest a left-sided L5-S1 microdiskectomy and tell her that when comparing tubular diskectomy and open procedures

. there are no differences in functional outcome.
. open diskectomy is associated with superior functional outcomes.
. tubular diskectomy is associated with superior short- and long-term results.
. tubular diskectomy is associated with inferior short-term results but superior long-term outcomes.

Correct Answer & Explanation

. there are no differences in functional outcome.

Explanation

DISCUSSIONSeveral comparative studies have reported no difference in functional outcomes between tubular diskectomy and microsurgical lumbar diskectomy. A recent systematic review by Kamper and associates in which conventional microdiskectomy and minimally invasive approaches were compared revealed that there was no difference between the procedures in terms of clinical outcomes, complication risk, or rate of revision surgery.RECOMMENDED READINGSKamper SJ, Ostelo RW, Rubinstein SM, Nellensteijn JM, Peul WC, Arts MP, van Tulder MW. Minimally invasive surgery for lumbar disc herniation: a systematic review and meta-analysis. Eur Spine J. 2014 May;23(5):1021-43. doi: 10.1007/s00586-013-3161-2. Epub 2014 Jan 18.PubMed PMID: 24442183.View Abstract at PubMedDasenbrock HH, Juraschek SP, Schultz LR, Witham TF, Sciubba DM, Wolinsky JP, Gokaslan ZL, Bydon A. The efficacy of minimally invasive discectomy compared with open discectomy: a meta-analysis of prospective randomized controlled trials. J Neurosurg Spine. 2012 May;16(5):452-62. doi: 10.3171/2012.1.SPINE11404. Epub 2012 Mar 9. PubMed PMID:

Question 2118

Topic: 6. Spine

A high school athlete reports the sudden onset of low back pain while performing a dead lift. Examination reveals a lumbar paraspinal spasm and a positive straight leg raising test. The deep tendon reflexes, motor strength, and sensation in the lower extremeties are normal. The radiographs are normal. If symptoms persist for more than a few weeks, management should consist of

. an electromyogram and nerve conduction velocity studies.
. an MRI scan.
. a bone scan.
. physical therapy.
. bed rest.

Correct Answer & Explanation

. an electromyogram and nerve conduction velocity studies.

Explanation

DISCUSSION: In adolescents, a lumbar herniated disk is characterized by a paucity of clinical findings; a positive straight leg raising test may be the only consistent positive finding.  This may result in a long period of nonsurgical management that fails to provide relief.  Activities that place a significant shear load on the lumbar spine, such as the dead lift, are associated with an increased risk of central disk herniation.  When an adolescent who lifts weights has a history of low back pain that fails to respond to a short period of active rest, an MRI scan is the study of choice to evaluate for a lumbar herniated disk.REFERENCES: Epstein JA, Epstein NE, Marc J, Rosenthal AD, Lavine LS:  Lumbar intervertebral disk herniation in teenage children:  Recognition and management of associated anomalies.  Spine 1984;9:427-432.Hashimoto K, Fujita K, Kojimoto H, Shimomura Y: Lumbar disc herniation in children.  J Pediatr Orthop 1990;10:394-396.

Question 2119

Topic: 6. Spine

Figures 48a and 48b are the axial and sagittal T1-weighted MR images of the L4-5 disc level of a 38-year-old man. He is symptomatic from the pathology shown. A surgeon would expect the neurological findings to include

. Right extensor hallucis longus (EHL) weakness, anterior shin numbness, and diminished patella reflex
. Right quadriceps weakness, anterior shin pain, and diminished patella reflex
. Right dorsal foot first web numbness, EHL weakness, and normal reflexes
. Left quadriceps weakness, anterior shin pain, and diminished patella reflex

Correct Answer & Explanation

. Right extensor hallucis longus (EHL) weakness, anterior shin numbness, and diminished patella reflex

Explanation

DISCUSSIONThe pathology shown in the MR images is a right-sided far lateral herniated nucleus pulposus at L4-5, which, if symptomatic, would cause a radiculopathy of the exiting root, L4. A more common posterolateral herniation at L4-5 would cause irritation of the traversing root, L5. The L4 root has a sensory distribution over the anterior thigh that extends along the anterior shin but does not tend to reach the toes. The motor distribution is to the quadriceps and anterior tibialis muscles, with the predominant reflex effect being the patella reflex. The L5 root has a sensory distribution to the first dorsal web space of the foot, motor distribution to the EHL, and no specific reflex.RECOMMENDED READINGSStandaert CJ, Herring SA, Sinclair JD. The patient history and physical examination: Cervical, thoracic, and lumbar. In: Herkowitz HN, Garfin SR, Eismont FJ, Bell GR, Balderston RA, eds. Rothman-Simeone The Spine. Vol 1. 5th ed. Philadelphia, PA: Saunders Elsevier; 2006:171-186.Bono CM, Wisneski R, Garfin SR: Lumbar disc herniations. In: Herkowitz HN, Garfin SR, Eismont FJ, Bell GR, Balderston RA, eds. Rothman-Simeone The Spine. Vol 1. 5th ed. Philadelphia, PA: Saunders Elsevier; 2006:967-991.

Question 2120

Topic: 6. Spine

A 27-year-old woman reports the acute atraumatic onset of burning pain in her right shoulder followed a week later by significant weakness and the inability to abduct her shoulder. One week prior to this incident she had recovered from a flu-like syndrome. Examination reveals full passive motion of the shoulder and the inability to actively raise the arm. Sensation in the right upper extremity is normal. Cervical spine examination is normal. Radiographs of the shoulder and cervical spine are normal. What is the most likely diagnosis?

. Calcific tendinitis
. Poliomyelitis
. Diskogenic cervical spine disease
. Impingement
. Brachial neuritis

Correct Answer & Explanation

. Calcific tendinitis

Explanation

DISCUSSION: The patient has symptoms and examination findings of acute brachial neuritis which is often a diagnosis of exclusion.  The recent viral flu-like symptoms have shown a correlation with the development of this disorder.  The acute, severe shoulder weakness excludes calcific tendinitis, impingement, and poliomyelitis.  A normal cervical spine examination makes cervical disk disease unlikely.REFERENCES: Turner JW, Parsonage MJ: Neuralgic amyotrophy (paralytic brachial neuritis).  Lancet 1957;2:209-212.Omer GE, Spinner M, Van Beek AL (eds): Management of Peripheral Nerve Problems, ed 2.  Philadelphia, PA, WB Saunders, 1998, pp 101-104.

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