Orthopedic Spine Review | Dr Hutaif Spine Surgery Revie -...

Scientific References

: Jimenez R, Lewis VO (eds): Culturally Competent Care Guidebook. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007.**
**www.watchtower.org. Official Web Site of Jehovah’s Witnesses. Link verified as active as of August 8, 2008.**
**3****. Which of the following is a contraindication to laminoplasty in a patient with cervical spondylotic myelopathy?
1- Space available for the cord of less than 8 mm
2- Ossification of the posterior longitudinal ligament
3- Fixed cervical kyphosis
4- Previous posterior surgery
5- Concomitant cervical radiculopathy
PREFERRED RESPONSE: 3**
**DISCUSSION: Laminoplasty or any posterior decompressive procedure is contraindicated in patients with cervical spondylotic myelopathy and cervical kyphosis. The residual kyphotic posture of the cervical spine results in persistent spinal cord compression. The other choices are not contraindications for laminoplasty. Concomitant cervical radiculopathy can be addressed at the time of laminoplasty with a keyhole foraminotomy.**
**REFERENCES: Emery SE: Cervical spondylotic myelopathy: Diagnosis and treatment. J Am Acad Orthop Surg 2001;9:376-388.**
**Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 235-247.**
**4****. A 44-year-old man reports persistent left leg pain following a L5-S1 hemilaminotomy and partial diskectomy. Examination shows a grade 4 weakness of the left extensor hallucis longus and a positive left straight leg raise. A radiograph is shown in Figure 1a, and sagittal and axial MRI scans are shown in Figures 1b and 1c. Nonsurgical management consisting of medication, physical therapy, and injections has failed to provide relief. Surgical management should consist of
1- revision L5-S1 hemilaminotomy.
2- L5-S1 total disk arthroplasty.
3- L5 Gill laminectomy.
4- posterior foraminal decompression and fusion at L5-S1 with instrumentation and bone graft.
5- stand-alone posterior lumbar interbody fusion.
PREFERRED RESPONSE: 4**
**DISCUSSION: The patient has a grade I isthmic spondylolisthesis at L5-S1. He has an L5 radiculopathy with foraminal stenosis. Any further treatment needs to include an arthrodesis and foraminal decompression. Isolated interbody fusion is contraindicated in patients with spondylolisthesis, as is total disk arthroplasty. Therefore, the best procedure is a posterior fusion with instrumentation and bone graft along with a foraminal decompression.**
**REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 311-317.**
**Moller H, Hedlund R: Instrumented and noninstrumented posterolateral fusion in adult spondylolisthesis: A prospective randomized study: Part 2. Spine 2000;25:1716-1721.**
**5****. Bisphosphonates are indicated in the treatment of osteoporosis in patients who have a DEXA T-score of
1- between 0 and 1.
2- between 0 and -1.
3- -3.5 and are already on teriparatide.
4- within one standard deviation from the mean.
5- less than -1.
PREFERRED RESPONSE: 5**
**DISCUSSION: Bisphosphonates are indicated in the treatment of osteoporosis. They have been shown to reduce the incidence of vertebral and extremity fractures in patients with a T-score of less than -1.**
**REFERENCE: Gass M, Dawson-Hughs B: Preventing osteoporosis-related fractures: An overview. Am J Med 2006;119:S3-S11.**
**6****. A 45-year-old man reports that he awoke 2 weeks ago with severe pain in his right arm. Examination reveals weakness in the biceps, brachialis, and wrist extensors. There is decreased sensation in the thumb and index finger and a diminished brachioradialis reflex. Assuming this patient has a posterolateral herniated nucleus pulposus, what level is involved?
1- C2-3
2- C3-4
3- C4-5
4- C5-6
5- C6-7
PREFERRED RESPONSE: 4**
**DISCUSSION: This is a classic C6 nerve injury, and it is most likely the result of a herniated nucleus pulposus at C5-6. The C5 nerve root controls the elbow flexors, shoulder abductors, and external rotators. The C7 nerve root controls the elbow extensors, wrist pronators, and the triceps reflex.**
**REFERENCES: Standaert CJ: The patient history and physical examination: Cervical, thoracic and lumbar, in Herkowitz HN, Garfin SR, Eismont FJ, et al (eds): Rothman-Simeone The Spine, ed 5. Philadelphia, PA, Saunders Elsevier, 2006, vol 1, pp 171-186.**
**Bates B: A Guide to Physical Examination and History Taking, ed 5. Philadelphia, PA,
JB Lippincott, 1991.**
**7****. A 42-year-old woman underwent an instrumented posterior spinal fusion at L3-S1 with transforaminal lumbar interbody fusion. She had an excellent clinical result with complete resolution of leg pain. Three months later she now reports increasing back pain and weakness in her legs. Examination reveals weakness in the quadriceps and tibialis anterior. Radiographs show no interval changes in the position of the hardware. MRI scans are shown in Figures 2a through 2c. What is the next most appropriate step in management?
1- Observation
2- Oral antibiotics only
3- IV antibiotics only
4- Irrigation and debridement of the surgical site
5- Irrigation and debridement of the surgical site with hardware removal
PREFERRED RESPONSE: 4**
**DISCUSSION: The MRI scans reveal a postoperative infection. Observation and antibiotics are not appropriate choices. There is a large fluid collection and this requires decompression because the patient has neurologic changes. There is considerable debate regarding the removal of hardware. Many contend that biofilm on the implants can harbor the infection. However, these complications usually can be treated with serial irrigations, debridements, and IV antibiotics. The incidence of infection has been widely studied with varying rates in fusions with instrumentation. Rates appear to be increased with instrumentation, yet these infections usually can be managed without hardware removal.**
**REFERENCES: Glassman SD, Dimar JR, Puno RM, et al: Salvage of instrumental lumbar fusions complicated by surgical wound infection. Spine 1996;21:2163-2169.**
**Fang A, Hu SS, Endres N, et al: Risk factors for infection after spinal surgery. Spine 2005;30:1460-1465.**
**8****. What is the primary reason for including the ilium in the distal fixation of long instrumentation constructs in adult scoliosis?
1- Better coronal balance
2- Better pelvic balance
3- Reduced fretting and corrosion
4- Improved curve correction
5- Improved fusion success
PREFERRED RESPONSE: 5**
**DISCUSSION: Studies have shown that when compared with fixation to the sacrum alone, the success rate of fusion across the lumbosacral junction increases when both the sacrum and ilium are included in the posterolateral construct. Curve correction, coronal balance, and pelvic balance are all attended to within the thoracolumbar spine and are not directly related to the pelvic fixation. Fretting and corrosion are a byproduct of metal-to-metal connections.**
**REFERENCES: Islam NC, Wood KB, Transfeldt EE, et al: Extension of fusions to the pelvis in idiopathic scoliosis. Spine 2001;26:166-173.**
**Emami A, Deviren V, Berven S, et al: Outcome and complications of long fusions to the sacrum in adult spine deformity: Luque-Galveston, combined iliac and sacral screws, and sacral fixation. Spine 2002;27:776-786.**
**9****. A 60-year-old man is evaluated in the ICU after a rollover motor vehicle accident 3 days ago. He has multiple upper and lower extremity trauma and was found unresponsive at the accident scene. Surgery is planned for the extremity trauma once the patient is medically stable. He remains intubated and the cervical spine is immobilized in a semi-rigid collar. Examination reveals mild erythema in the posterior occipital cervical region. Initial AP and lateral radiographs of the cervical spine have not revealed any obvious fracture. What is the most appropriate treatment option at this time?
1- Continued semi-rigid immobilization until the extremity surgeries are completed
2- Halo skeletal fixation prior to the extremity surgery
3- Definitive clearance of the cervical spine with CT and/or MRI
4- Removal of the semi-rigid collar and physical examination when the patient is responsive
5- Soft collar immobilization and local wound care
PREFERRED RESPONSE: 3**
**DISCUSSION: Ackland and associates demonstrated that the failure to achieve early spinal clearance in an unconscious blunt trauma patient predisposed the patient to increased morbidity secondary to the prolonged used of cervical immobilization. They demonstrated that the four significant predictors of collar-related ulcers were ICU admission, mechanical ventilation, the necessity for cervical MRI, and the time to cervical spine clearance and collar removal. The risk of pressure-related ulceration increased by 66% for every 1-day increase in Philadelphia collar time and this highlights the need for definitive C-spine clearance.**
**REFERENCES: Ackland HM, Cooper DJ, Malham GM, et al: Factors predicting cervical collar-related decubitus ulceration in major trauma patients. Spine 2007;32:423-428.**
**Hewitt S: Skin necrosis caused by semi-rigid cervical collar in a ventilated patient with multiple injuries. Injury 1994;25:323-324.**
**10****. A 46-year-old woman who was involved in a motor vehicle accident reports a 4-month history of right-sided lower back pain and pain radiating into the right thigh. The patient underwent an extensive 3-month course of physical therapy and now is dependent on narcotic medication for pain control. Epidural injection therapy has failed to improve her symptoms. Examination is significant for weakness of hip flexion in the seated position and for decreased sensation to light touch in the medial anterior thigh region. Straight leg raise is negative, but the femoral stretch test reproduces anterior thigh pain. A CT myelogram image, at L3-L4, is shown in Figure 3. What is the most appropriate management at this time?
1- Repeat epidural steroid injections
2- Wide lumbar laminectomy
3- Microdiskectomy from either a midline approach or far lateral approach
4- Referral to pain management
5- Minimally invasive posterior lumbar interbody fusion
PREFERRED RESPONSE: 3**
**DISCUSSION: The CT scan reveals a right-sided lateral disk protrusion at L3-4 that has been symptomatic for more than 4 months despite appropriate nonsurgical management. Relative surgical indications include persistent radiculopathy despite an adequate trial of nonsurgical management, recurrent episodes of sciatica, persistent motor deficit with tension signs and pain, and pseudoclaudication caused by underlying stenosis. Whereas studies have shown improvement in patients with sciatica from a lumbar disk herniation treated either nonsurgically or surgically, those undergoing surgical treatment had an overall greater improvement of symptoms.**
**REFERENCES: Weinstein JN, Lurie JD, Tosteson TD, et al: Surgical vs nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006;296:2451-2459.**
**Yorimitsu E, Chiba K, Toyama Y, et al: Long-term outcomes of standard discectomy for lumbar disc herniation: A follow-up study of more than 10 years. Spine 2001;26:652-657.**
**11****. A 73-year-old woman reports a 4-month history of severe left-sided posterior buttock pain and left leg pain. The leg pain radiates into the left lateral thigh and posterior calf with cramping. Examination reveals mild difficulty with a single-leg toe raise on the left side and a diminished ankle reflex. There is also a significant straight leg raise test at 45 degrees which exacerbates symptoms. An MRI scan is shown in Figure 4. What is the most appropriate treatment at this time?
1- Lumbar laminectomy with synovial cyst excision
2- Repeat epidural steroid injection
3- Microdiskectomy at L4-5
4- Nonsteroidal medication and outpatient physical therapy
5- Left-sided facet blocks at L4-5 and L5-S1
PREFERRED RESPONSE: 1**
**DISCUSSION: Lumbar spinal stenosis with lumbar radiculopathy can be commonly caused by a synovial cyst arising from the facet joints. Lyons and associates reported on the surgical treatment of synovial cysts in 194 patients. Of the 147 with follow-up data, 91% reported good pain relief and 82% had improvement of their motor deficits. Epstein reported a 58% to 63% incidence of good/excellent results and a 38 to 42 point improvement on the SF-36 Physical Function Scale. It was also suggested that since the presence of a synovial cyst indicates facet pathology, possible fusion should be considered in these patients, especially those with underlying spondylolisthesis.**
**REFERENCES: Lyons MK, Atkinson JL, Wharen RE, et al: Surgical evaluation and management of lumbar synovial cysts: The Mayo Clinic Experience. J Neurosurg
2000;93:53-57.**
**Khan AM, Synnot K, Cammisa FP, et al: Lumbar synovial cysts of the spine: An evaluation of surgical outcome. J Spinal Disord Tech 2005;18:127-131.**
**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.**
**12****. Osteoporotic vertebral compression fractures are associated with
1- neurologic deterioration in 33% of patients.
2- osteomalacia in 50% of patients.
3- a further fracture risk rate of 20%.
4- chronic pain in 75% of patients.
5- a 2-year mortality rate that is less than that associated with hip fractures.
PREFERRED RESPONSE: 3**
**DISCUSSION: Osteoporotic vertebral compression fractures are associated with neurologic complications in less than 1% of patients. After the initial fracture however, patients have a 20% risk of further fractures. The mortality rate of patients with vertebral fractures exceeds that of patients with hip fractures when they are followed beyond 6 months.**
**REFERENCES: Gass M, Dawson-Hughs B: Preventing osteoporosis-related fractures: An overview. Am J Med 2006;119:S3-S11.**
**Lindsay R, Silverman SL, Cooper C, et al: Risk of new vertebral fracture in the year following a fracture. JAMA 2001;285:320-323.**
**Kado DM, Duong T, Stone KL, et al: Incident vertebral fractures and mortality in older women: A prospective study. Osteoporos Int 2003;14:589-594.**
**13****. 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- 1 month
2- 2 months
3- 4 months
4- 6 months
5- 12 months
PREFERRED RESPONSE: 4**
**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.**
**14****. A 19-year-old woman reports persistent neck pain for 2 years. Pain is relieved with aspirin. A bone scan shows intense uptake in the superior, posterior portion of the C3 vertebral body. A sagittal CT reconstruction is shown in Figure 5. Treatment should consist of
1- radiation therapy.
2- en bloc excision.
3- posterior fusion at C2-C3 with instrumentation.
4- CT-guided aspiration followed by IV antibiotics.
5- radiofrequency ablation.
PREFERRED RESPONSE: 2**
**DISCUSSION: The CT scan shows an osteoblastic nidus pathognomic for an osteoid osteoma. Surgical treatment should include an en bloc excision of the lesion. Surgical treatment is not mandatory because the lesion often becomes asymptomatic over time. This lesion is not amenable to radiofrequency ablation due to its proximity to the spinal cord. A complete corpectomy is not necessary to adequately resect the lesion, as only the nidus needs to be removed. Radiation therapy and antibiotics are not appropriate treatments for an osteoid osteoma. Posterior C2-C3 fusion will not address the pathology.**
**REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 351-366.**
**Hadjipavlou AG, Lander PH, Marchesi D, et al: Minimally invasive surgery for ablation of osteoid osteoma of the spine. Spine 2003;28:E472-E477.**
**15****. A 56-year-old man with a history of chronic lower back pain from lumbar spondylosis reports a 2-day history of acute incapacitating back pain. He denies any history of acute trauma, although he reports the pain starting after a coughing spell. He also reports difficulty urinating and some fecal incontinence. Examination reveals generalized lower extremity weakness, saddle paresthesia, hyporeflexia in the lower extremities, and loss of rectal tone. What is the most appropriate management at this time?
1- Immediate MRI of the lumbar spine
2- General reassurance, anti-inflammatory drugs, and an early home exercise program
3- Immediate radiographs of the lumbar spine and pain medications with 2 days of bed rest if the radiographs are normal
4- Office caudal epidural steroid injection with follow-up in 1 week
5- Outpatient MRI of the lumbar spine with follow-up in 1 week for test results
PREFERRED RESPONSE: 1**
**DISCUSSION: Cauda equina syndrome is a medical emergency that must be quickly diagnosed and treated to avoid long-term complications. Cauda equina syndrome typically presents with low back pain, unilateral or usually bilateral sciatica, saddle sensory disturbances, bladder and bowel dysfunction, and variable lower extremity motor and sensory loss. Although a number of pathologies can cause cauda equina syndrome, in a patient with a history of chronic back pain, disk pathology is the most common cause of acute onset cauda equina syndrome. Whereas radiographs may be useful in a traumatic onset of symptoms, MRI is the most appropriate study. Cauda equina syndrome should be evaluated on an emergent basis and admission for work-up is appropriate.**
**REFERENCES: Ahn UM, Ahn NU, Buchowski JM, et al: Cauda equina syndrome secondary to lumbar disc herniation: A meta-analysis of surgical outcomes. Spine 2000;25:1515-1522.**
**Small SA, Perron AD, Brady WJ: Orthopedic pitfalls: Cauda equina syndrome. Am J Emerg Med 2005;23:159-163.**
**16****. A 55-year-old woman with a long history of low back and left lower extremity pain has failed to respond to exhaustive nonsurgical management. MRI scans show bulging and degeneration at L3-4 and L4-5 as well as a normal disk at L2-3 and L5-S1. She undergoes provocative lumbar diskography at L3-4, L4-5, and L5-S1. Post-diskography axial CT images of L3-4 and L4-5 are shown in Figures 6a and 6b, respectively. The injections at L3-4 and L4-5 produce no pain. The injection at L5-S1 produces 10/10 concordant back pain with radiation to the lower extremity. What is the most appropriate recommendation at this time?
1- Consider fusion surgery
2- Intradiskal ozone therapy
3- Lumbar laminectomy
4- Vertebral augmentation
5- Cognitive intervention and exercise
PREFERRED RESPONSE: 5**
**DISCUSSION: The results of this patient’s lumbar diskography are equivocal at best. The two disks most likely to be her pain generators, based on their MRI appearance, produced 10/10 pain, however it was nonconcordant and did not reproduce any of her typical left-sided radicular symptoms. The only disk that produced concordant back pain was the normal disk at the L5-S1 level and it reproduced radicular symptoms on the side opposite of her typical pain. Based on these findings, it would be difficult to select a level or levels to include in a lumbar fusion. As such, continued nonsurgical management is the safest treatment option at the current time. Brox and associates reported on a randomized clinical trial comparing lumbar fusion to cognitive intervention and exercise and found similar results in both groups, with significantly less risk in the latter.**
**REFERENCES: 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.**
**Carragee EJ: Clinical practice: Persistent low back pain. N Engl J Med 2005;352:1891-1898.**
**17****. A 36-year-old woman is brought to the emergency department intubated and sedated following a motor vehicle accident. She is moving her upper and lower extremities spontaneously. She cannot follow commands. CT scans are shown in Figures 7a through 7c. The initial survey does not reveal any other injuries. Initial management of the cervical injury should consist of immediate
1- immobilization with a halo ring and vest with reduction when medically stable.
2- closed traction reduction using Gardner-Wells tongs.
3- posterior open reduction, stabilization, and fusion.
4- cervical MRI followed by reduction.
5- anterior open reduction, stabilization, and fusion.
PREFERRED RESPONSE: 4**
**DISCUSSION: The patient has a bilateral facet dislocation of C6-C7 with preservation of at least some neurologic function. Urgent reduction is necessary. However, because she is sedated and unable to follow commands, an MRI scan is necessary before any closed or open posterior reduction to look for an associated disk herniation. If a disk herniation is present, it must be removed prior to any reduction maneuver to prevent iatrogenic neurologic injury. It is very unlikely that this injury can be reduced with an open anterior procedure alone.**
**REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 189-199.**
**Kwon BK, Vaccaro AR, Grauer JN, et al: Subaxial cervical spine trauma. J Am Acad Orthop Surg 2006;14:78-89.**
**18****. A 51-year-old woman with no preoperative neurologic deficit is undergoing elective anterior cervical diskectomy and fusion (ACDF) with plating and fusion for a C5-6 disk herniation with right-sided neck pain. Thirty minutes into the surgery the neurophysiologic monitoring shows a rapid drop and then loss of amplitude in the right cortical somatosensory-evoked potential waveform. All other waveforms remained normal and unchanged, including right-sided cervical (subcortical) and peripheral (Erb’s point), and those from the left-sided upper extremity and both lower extremities. What is the most likely cause of the change?
1- Electrode placement
2- Stimulation failure
3- Anesthetic effect
4- Cord ischemia from retraction
5- Cerebral ischemia from retraction
PREFERRED RESPONSE: 5**
**DISCUSSION: The change noted is focal and confined to the cortex, sparing the opposite side, both lower extremities, and the subcortical waveforms, making all the choices unlikely with the exception of carotid compression with focal cortical ischemia. This may be associated with poor collateral flow from the opposite hemisphere due to an incomplete circle of Willis.**
**REFERENCES: Drummond JC, Englander RN, Gallo CJ: Cerebral ischemia as an apparent complication of anterior cervical discectomy in a patient with an incomplete circle of Willis. Anesth Analg 2006;102:896-899.**
**Yeh YC, Sun WZ, Lin CP, et al: Prolonged retraction on the normal common carotid artery induced lethal stroke after cervical spine surgery. Spine 2004;29:E431-E434.**
**19****. 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
1- normal postoperative orders with frequent neurologic evaluations for the first 24 hours.
2- administration of IV steroids and placement of a soft cervical collar for 24 hours.
3- placement of both deep and superficial surgical drains prior to wound closure.
4- administration of IV mannitol and placement of a soft collar.
5- maintaining intubation for up to 24 to 48 hours.
PREFERRED RESPONSE: 5**
**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.**
**20****. A 22-year-old woman reports a 4-year history of worsening low back and left lower extremity pain following a motor vehicle accident. Management consisting of physical therapy, chiropractic manipulation, and interventional pain management, including sacroiliac joint injections and epidural steroid injections, has failed to provide relief. A sagittal T** 2**-weighted MRI scan is shown in Figure 8. No nerve root compression is seen on axial images. She is currently working and lives with her fiancé. She smokes half a pack of cigarettes per day and reports depression on her health history. She is being maintained on narcotic analgesics and is having increasing difficulty performing her activities of daily living secondary to pain. What is the most appropriate management at this time?
1- Provocative lumbar diskography
2- Laboratory studies, including a complete blood cell (CBC) count, erythrocyte sedimentation rate (ESR), and urinalysis
3- Cognitive intervention, exercise, and smoking cessation
4- Bilateral lower extremity electromyography and nerve conduction velocity studies
5- Lumbar myelogram with a postmyelography CT scan of the lumbar spine
PREFERRED RESPONSE: 3**
**DISCUSSION: The MRI scan reveals a rudimentary disk at the L5-S1 level, suggesting transitional anatomy. There is a posterior disk bulge at L3-4. At L4-5, there is disk desiccation and loss of disk height, with a posterior disk bulge and a high intensity zone in the posterior annulus, suggesting an annular tear. While these and similar radiographic findings have been associated with the severity of a patient’s pain, they are also commonly found in cross-sectional studies of asymptomatic subjects. Carragee and associates found 59% of symptomatic patients undergoing diskography have high intensity zones as compared to 25% of asymptomatic subjects of a similar patient profile. Diskographic injections provoked pain in disks with high intensity zones approximately 70% of the time whether the individual was previously symptomatic or not. This patient’s non-specific pain pattern does not require further work-up as she is not a surgical candidate.**
**REFERENCES: Carragee EJ, Paragioudakis SJ, Khurana S: 2000 Volvo Award winner in clinical studies: Lumbar high-intensity zone and discography in subjects without low back problems. Spine 2000;25:2987-2992.**
**Pneumaticos SG, Reitman CA, Lindsey RW: Diskography in the evaluation of low back pain.
J Am Acad Orthop Surg 2006;14:46-55.**
**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.**
**Carragee EJ: Clinical practice: Persistent low back pain. N Engl J Med 2005;352:1891-1898.**
**21****. A 42-year-old man with a history of renal cell carcinoma has progressive weakness in the lower extremities for the past 3 weeks. The patient desires intervention. A sagittal T** 2**-weighted MRI scan is shown in Figure 9a, and a sagittal contrast enhanced T** 1**-weighted MRI scan is shown in Figure 9b. He currently ambulates minimal distances with a walker. His life expectancy is 8 months. Treatment of the spine lesion should consist of
1- radiation therapy.
2- posterior laminectomy.
3- anterior corpectomy and reconstruction.
4- posterior laminectomy and fusion.
5- kyphoplasty.
PREFERRED RESPONSE: 3**
**DISCUSSION: The MRI scans show a metastatic lesion in two contiguous vertebral bodies in the lower thoracic spine. Posterior laminectomy is not indicated because this does not adequately decompress the neural elements and will lead to progressive kyphosis. A posterior fusion may prevent progressive kyphosis but will not decompress the spinal cord. Renal cell carcinoma is not radiosensitive; therefore, radiation therapy would not be helpful in relieving neurologic compression. The lesion should be treated by an anterior corpectomy and reconstruction. This will allow for complete decompression as well as reconstruction of the anterior column. Kyphoplasty is not indicated in a lesion with disruption of the posterior cortex and neurologic impairment.**
**REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 351-366.**
**White AP, Kwon BK, Lindskog DM, et al: Metastatic disease of the spine. J Am Acad Orthop Surg 2006;14:587-598.**
**22****. A 40-year-old man has intractable pain following 2 years of nonsurgical management for high-grade spondylolisthesis. What is the best surgical option?
1- Posterolateral fusion
2- Posterolateral fusion with instrumentation
3- Circumferential fusion
4- Transforaminal lumbar interbody fusion
5- Anterior lumbar interbody fusion
PREFERRED RESPONSE: 3**
**DISCUSSION: Circumferential fusion is the preferred choice for patients undergoing revision surgery following failed posterolateral fusions for isthmic spondylolisthesis as well as for those patients having primary surgery for high-grade isthmic spondylolisthesis.**
**REFERENCE: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 311-317.**
**23****. An adult patient with a grade I isthmic spondylolisthesis at L5-S1 is most likely to have weakness of the
1- anterior tibialis.
2- quadriceps.
3- gastrocsoleus.
4- extensor hallucis longus.
5- iliopsoas.
PREFERRED RESPONSE: 4**
**DISCUSSION: Adult patients with isthmic spondylolisthesis most commonly have neurologic symptoms due to foraminal stenosis at the level of the spondylolisthesis. In this scenario, the patient is most likely to have weakness of the L5 myotome, which would cause weakness of the extensor hallucis longus.**
**REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 311-317.**
**Lauerman WC, Cain JE: Isthmic spondylolisthesis in the adult. J Am Acad Orthop Surg 1996;4:201-208.**
**24****. When performing a long fusion to the sacrum in an osteopenic patient in whom optimal sagittal balance is restored, which of the following is a benefit of extending the distal fixation to the pelvis, rather than the sacrum alone?
1- Decreased risk of sacral fractures
2- Decreased risk of proximal functional kyphosis
3- Easier contouring of the instrumentation
4- Reduced risk of late pubic ramus fractures
5- Improved coronal plane correction
PREFERRED RESPONSE: 1**
**DISCUSSION: In osteopenic individuals, even those with excellent obtained or maintained balance, long instrumented fusions to the sacrum impart a high degree of strain, and the sacrum may fail in a transverse fracture or fracture-dislocation pattern. The risk of proximal functional kyphosis is unrelated to distal fixation as are coronal plane correction and rod contouring. Pubic ramus fractures have been shown to be associated with both fixation to the sacrum alone as well as to the ilium.**
**REFERENCE: Hu SS, Berven SH, Bradford DS: Adult spinal deformity, in Frymoyer JW, Wiesel SW (eds): The Adult and Pediatric Spine, ed 3. Philadelphia, PA, Lippincott Williams and Wilkins, 2004, pp 465-477.**
**25****. Which of the following statements describing chordomas is false?
1- Treatment consisting of complete surgical resection with clean margins offers the best survival.
2- They occur in the clivus and sacrum and occur only 15% of the time in the rest of the spine.
3- They are locally aggressive and invasive tumors.
4- They are highly radiosensitive.
5- They have the ability to become malignant.
PREFERRED RESPONSE: 4**
**DISCUSSION: Casali and associates provided a recent review of the treatment options for chordomas. These tumors are not radiosensitive; however, modern intensity modulated radiosurgery techniques may be of value. The combination of surgery and radiotherapy compared to surgery alone results in the same disease-free survival time. Complete surgical resection of the chondroma with clean margins offers the best survival; however, its location may make total removal impossible. Thus subtotal resection followed by radiotherapy results in better survival despite the tumor’s lack of radiosensitivity.**
**REFERENCE: Casali PG, Stacchiotti S, Sangalli C, et al: Chordoma. Curr Opin Oncol 2007;19:367-370.**
**26****. A previously healthy 35-year-old man was involved in a rollover motor vehicle accident 2 days ago. He was placed in a semi-rigid cervical orthosis. He now reports mostly axial neck pain with attempted range of motion. Examination reveals the mechanical neck pain but no obvious neurologic deficits. AP, flexion, and extension radiographs are shown in Figures 10a through 10c, and sagittal and coronal CT scans are shown in Figures 10d and 10e. What is the most appropriate management at this time?
1- Continued immobilization in a semi-rigid cervical orthosis for 6 to 8 weeks
2- Posterior occipital-cervical fusion with iliac crest bone graft
3- Open reduction and internal fixation of the odontoid process with an anterior odontoid screw
4- Resection of the odontoid process through a transoral approach
5- Reduction with Gardner-Wells tong traction and 6 weeks of skeletal traction
PREFERRED RESPONSE: 3**
**DISCUSSION: Odontoid fractures can be classified based on the anatomic position of the fracture within the dens itself. Type I is an oblique fracture through the upper part of the odontoid process. Type II is a fracture that occurs at the base of the odontoid as it attaches to the body of C2; type III occurs when the fracture line extends through the body of the axis. Type 1 fractures typically can be treated nonsurgically with 6 to 8 weeks of immobilization with a semi-rigid cervical orthosis. Nondisplaced, deep type III fractures generally are treated with skeletal halo fixation. Deep, displaced, and angled type III fractures can be treated with closed reduction and skeletal halo fixation. Shallow type III fractures are sometimes amenable to anterior odontoid screw fixation. Type II fractures can be managed nonsurgically or surgically. Treatment options include halo immobilization, internal fixation (odontoid screw fixation), and posterior atlantoaxial arthrodesis. Management with the halo vest usually is considered if the initial dens displacement is less than 6 mm, the reduction is performed within 1 week of the injury and is able to be maintained, and the patient is younger than age 60 years. Halo vest immobilization can lead to a healing rate of more than 90%. Posterior surgical fusion techniques provide high fusion success rates but do so at the expense of cervical rotation. Up to 50% of rotation is lost with these techniques. Anterior odontoid single screw fixation is often tolerated better than skeletal halo fixation and also is noted to preserve the normal rotation at C1/C2. Studies have shown less of a malunion and nonunion rate in the treatment of type II odontoid fractures with anterior odontoid screw fixation. Osteoporosis, short neck and barrel-chested anatomy, and fractures that are more than 4 weeks old preclude anterior odontoid fixation.**
**REFERENCES: Shilpakar S, McLaughlin MR, Haid RW Jr, et al: Management of acute odontoid fractures: Operative techniques and complication avoidance. Neurosurg Focus 2000;8:e3.**
**Subach BR, Morone MA, Haid RW Jr, et al: Management of acute odontoid fractures with single-screw anterior fixation. Neurosurgery 1999;45:812-819.**
**Fountas KN, Kapsalaki EZ, Karampelas I, et al: Results of long-term follow-up in patients undergoing anterior screw fixation for type II and rostral type III odontoid fractures. Spine 2005;30:661-669.**
**27****. Which of the following palpable bony landmarks is correctly matched with its corresponding vertebral level?
1- Angle of the mandible and the C2-C3 interspace
2- Hyoid bone and C6
3- Carotid tubercle and C6
4- Superior portion of the thyroid cartilage and the C3 vertebral body
5- Cricoid cartilage and C7-T** 1
**PREFERRED RESPONSE: 3**
**DISCUSSION: The carotid tubercle is usually located at the level of C6. The angle of the mandible is at C1-C2; the hyoid is at C4; the superior portion of the thyroid cartilage is C4-C5; and the cricoid cartilage is at C6.**
**REFERENCES: Smith GW, Robinson RA: The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and interbody fusion. J Bone Joint Surg Am 1958;40:607.**
**An HS: Surgical Exposure and Fusion Techniques of the Spine: Principles and Techniques of Spine Surgery. Baltimore, MD, Williams and William, 1998, pp 31-62.**
**28****. What root is most commonly involved with a segmental root level palsy after laminoplasty?**
1- C3
2- C4
3- C5
4- C6
5- C7
**PREFERRED RESPONSE: 3**
**DISCUSSION: The postoperative incidence of C5 root palsy after laminoplasty ranges from 5% to 12%. Other roots also may be affected. The palsies tend to be motor dominant, although sensory dysfunction and radicular pain are also possible. The palsy may arise during the immediate postoperative period or up to 20 days later. C5 may be preferentially involved because it is at the apex of the cervical lordosis. Recovery usually occurs over weeks to months.**
**REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 235-249.**
**Uematsu Y, Tokuhashi Y, Matsuzaki H: Radiculopathy after laminoplasty of the cervical spine. Spine 1998;23:2057-2062.**
**29****. Up to what time frame are the risks minimized in anterior revision disk replacement surgery?
1- 3 days
2- 1 week
3- 10 days
4- 2 weeks
5- 6 weeks
PREFERRED RESPONSE: 4**
**DISCUSSION: Revision anterior exposure within 2 weeks of total disk replacement incurs relatively little additional morbidity because adhesion formation is minimal. Surgeons should have a low threshold for revising implants that are clearly dangerously malpositioned or show early migration within this 2-week window. Beyond this time period, a revision strategy must be individualized to the particular clinical situation. A posterior fusion with instrumentation with or without a laminectomy is currently the most effective salvage procedure.**
**REFERENCE: Tortolani JP, McAfee PC, Saiedy S: Failures of lumbar disc replacement. Sem Spine Surg 2006;18:78-86.**
**30****. Which of the following best describes the use of epidural morphine and steroid paste after laminectomy?
1- Associated with an 11% rate of postoperative surgical site complications
2- Associated with a less than 1% rate of surgical site infections
3- Associated with a decreased rate of postoperative urinary retention
4- Considered the standard for outpatient microdiskectomy
5- Should only be used in the absence of radiculopathy
PREFERRED RESPONSE: 1**
**DISCUSSION: Kramer and associates conducted a retrospective review during an “epidemic” period to identify the risk factors associated with a sudden increase in the rate of surgical site infections. They found in a multivariate analysis that the use of morphine nerve paste resulted in a 7.6-fold increase in postoperative surgical wound debridement, and an 11% rate of surgical site complications.**
**REFERENCES: Kramer MH, Mangram AJ, Pearson ML, et al: Surgical-site complications associated with a morphine nerve paste used for postoperative pain control after laminectomy. Infect Control Hosp Epidemiol 1999;20:183-186.**
**Lowell TD, Errico TJ, Eskenazi MS: Use of steroids after discectomy may predispose to infection. Spine 2000;25:516-519.**
**31****. Figures 11a and 11b show the T** 2**-weighted MRI scans of the lumbar spine of a 53-year-old woman who has low back and right lower extremity pain. What structure is the arrow pointing to in Figure 11a?
1- Ligamentum flavum
2- Lumbar synovial cyst
3- Tarlov cyst
4- Pseudomeningocele
5- Herniated nucleus pulposus
PREFERRED RESPONSE: 2**
**DISCUSSION: The arrow is pointing to a cystic-appearing structure with high signal intensity on T** 2**-weighted image sequencing. It appears to be contiguous with the hypertrophied right facet joint, which appears to also have high signal intensity. The mass significantly narrows the right lateral recess. The high signal intensity suggests that this is a fluid-filled mass. In addition, the facet joints are degenerative and there is a very mild degree of anterolisthesis on the sagittal image. These findings make a lumbar synovial cyst the most likely diagnosis. Most lumbar juxtafacet cysts are observed at the L4-5 level, extradurally and adjacent to the degenerative facet joint. They may contain synovial fluid and/or extruded synovium. Presentation is indistinguishable from that of a herniated disk. The etiology of spinal cysts remains unclear, but there appears to be a strong association between their formation and worsening spinal instability. They occasionally regress spontaneously and may respond to aspiration and injection of corticosteroids, though there is a high recurrence rate with nonsurgical management. Synovial cysts resistant to nonsurgical management should be treated surgically. If the patient’s symptoms can be attributable to radicular findings, a microsurgical decompression that limits further destabilization should suffice. However, if there is significant low back pain attributable to spinal instability, decompression and fusion remains an appropriate option.**
**REFERENCES: Banning CS, Thorell WE, Leibrock LG: Patient outcome after resection of lumbar juxtafacet cysts. Spine 2001;26:969-972.**
**Deinsberger R, Kinn E, Ungersbock K: Microsurgical treatment of juxta facet cysts of the lumbar spine. J Spinal Disord Tech 2006;19:155-160.**
**Khan AM, Synnot K, Cammisa FP, et al: Lumbar synovial cysts of the spine: An evaluation of surgical outcome. J Spinal Disord Tech 2005;18:127-131.**
**32****. A 38-year-old man reports a 2-week history of acute lower back pain with radiation into the left lower extremity. There is no history of trauma and no systemic signs are noted. Examination reveals a positive straight leg test at 35 degrees on the left side and a contralateral straight leg raise on the right side. Motor testing demonstrates mild weakness of the gluteus medius and weakness of the extensor hallucis longus of 3+/5. Sensory examination demonstrates decreased sensation along the lateral aspect of the calf and top of the foot. Knee and ankle reflexes are intact and symmetrical. Radiographs demonstrate no obvious abnormality. MRI scans show a posterolateral disk hernation. The diagnosis at this time is consistent with a herniated nucleus pulposus at
1- L1-2.
2- L2-3.
3- L3-4.
4- L4-5.
5- L5-S1.
PREFERRED RESPONSE: 4**
**DISCUSSION: The patient’s history and physical examination findings are consistent with a lumbar disk herniation at the L4-5 level. Weakness of the extensor hallucis longus and gluteus medius are consistent with an L5 lumbar radiculopathy. Nerve root tension signs are also consistent with sciatica from a lumbar disk herniation. The MRI scans confirm a posterolateral disk herniation at L4-5, which typically affects the exiting L5 nerve root.**
**REFERENCES: Hoppenfeld S: Orthopedic Neurology. Philadelphia, PA, JB Lippincott, 1977, pp 45-74.**
**Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 43-56.**
**33****. A 42-year-old woman is brought to the emergency department following a motor vehicle accident. She has sustained multiple injuries, and she is intubated and pharmacologically paralyzed. Sagittal cervical CT scans through the right cervical facets, the left cervical facets, and the midline are shown in Figures 12a through 12c, respectively. Definitive management of her cervical injury should consist of
1- anterior diskectomy and fusion at C4-C5.
2- immobilization in a Philadelphia collar and voluntary flexion and extension radiographs when awake.
3- occipital-cervical fusion with instrumentation.
4- halo immobilization for 12 weeks.
5- left C6 superior facetectomy and posterior fusion at C6-C7 with instrumentation.
PREFERRED RESPONSE: 3**
**DISCUSSION: The CT scans reveal an occipital-cervical dissociation with subluxation of the occipitocervical joints bilaterally. Definitive management should consist of an occipital-cervical fusion with instrumentation. Immobilization in a Philadelphia collar is inadequate for this highly unstable injury, and halo immobilization, while affording adequate temporary immobilization, is not appropriate definitive management for this ligamentous injury. The patient does not have an injury at C4-C5 or C6-C7.**
**REFERENCES: Jackson RS, Banit DM, Rhyne AL III, et al: Upper cervical spine injuries.
J Am Acad Orthop Surg 2002;10:271-280.**
**Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.**
**34****. A 32-year-old motorcycle rider is involved in a motor vehicle accident and radiographs show a burst fracture at L2 with 20 degrees of kyphosis. The neurologic examination is consistent with unilateral motor and sensory involvement of the L5, S1, S2, S3, and S4 nerve roots. He has no other injuries. CT demonstrates 20% anterior canal compromise with displaced laminar fractures at the level of injury. What is the best option for management of this patient?
1- Bed rest for 6 weeks, followed by mobilization in a thoracolumbosacral orthosis until the fracture has healed
2- Anterior corpectomy with strut grafting and placement of an anterior plate spanning L1 to L3
3- Anterior corpectomy with strut grafting, followed by posterior spinal fusion and instrumentation
4- Posterior spinal fusion and instrumentation from T11 to L4
5- L2 laminectomy and posterior spinal fusion and instrumentation from T11 to L4
PREFERRED RESPONSE: 5**
**DISCUSSION: The patient has a burst fracture with probable unilateral entrapment of the cauda equina within the elements of the fractured lamina. A dural tear is likely in this scenario as well. It is recommended that this type of burst fracture be treated surgically with laminectomy, freeing of the entrapped nerve roots, and dural repair followed by stabilization of the fracture by either a posterior or combined approach. The degree of kyphosis and the extent of anterior canal compromise does not warrant corpectomy in this patient. Therefore, after completing the laminectomy and dural repair, posterior fusion and instrumentation should be sufficient to stabilize the fracture.**
**REFERENCES: Cammisa FP Jr, Eismont FJ, Green BA: Dural laceration occurring with burst fractures and associated laminar fractures. J Bone Joint Surg Am 1989;71:1044-1052.**
**Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.**
**35****. A patient who underwent a L4-L5 hemilaminotomy and partial diskectomy for radiculopathy 8 weeks ago now reports increasing low back pain without neurologic symptoms. A sagittal T** 2**-weighted MRI scan is shown in Figure 13a, and a contrast enhanced T** 1**-weighted MRI scan is shown in Figure 13b. What is the most appropriate management for the patient’s symptoms?
1- Physical therapy
2- CT-guided needle biopsy and IV antibiotics
3- Revision laminotomy and diskectomy
4- L4-L5 anterior debridement and fusion
5- Open repair of the L4-L5 pseudomeningocele
PREFERRED RESPONSE: 1**
**DISCUSSION: The MRI scans show Modic changes in the L4-L5 vertebral bodies due to spondylosis. There is no increased fluid signal or enhancement in the L4-L5 disk to suggest infection or any other pathologic process. Therefore, the patient’s pain should be treated with a course of physical therapy and rehabilitation. There is no infection; therefore, IV antibiotics and debridement are not indicated. Similarly, a pseudomeningocele is not present. A revision diskectomy is useful for recurrent radiculopathy but would not be helpful for degenerative low back pain.**
**REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 319-329.**
**Shen FH, Samartzis D, Andersson GBJ: Nonsurgical management of acute and chronic low back pain. J Am Acad Orthop Surg 2006;14:477-487.**
**36****. What is the heaviest weight that can be safely applied to the adult cervical spine via Gardner-Wells tong traction?
1- 40 pounds
2- 50 pounds
3- 75 pounds
4- 100 pounds
5- Greater than 100 pounds
PREFERRED RESPONSE: 5**
**DISCUSSION: Cotler and associates reported on the use of awake skeletal traction to reduce facet fracture-dislocations in 24 patients. Seventeen patients required more than 50 pounds of traction (the “traditional” limit) to achieve reduction. More than 100 pounds of traction was safely used in one-third of the patients in this study. A cadaver study has supported the safe use of traction with weights in excess of 100 pounds.**
**REFERENCES: Cotler JM, Herbison GJ, Nasuti JF, et al: Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds. Spine 1993;18:386-390.**
**Anderson DG, Vacccaro AR, Gavin K: Cervical orthoses and cranioskeletal traction, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005,
pp 110-121.**
**37****. A 68-year-old man reports a 4-week history of progressive left-sided lower back and hip pain. The pain is in the posterior buttock region with radiation to the groin and to the left anterior knee region. The pain is aggravated with walking and improves with rest. There is no history of previous trauma. Radiographs are seen in Figures 14a and 14b, and MRI scans are seen in Figures 14c through 14e. What is the most appropriate treatment option at this time?
1- Epidural steroid injection at L4-5
2- Outpatient physical therapy for the lower back
3- Non-weight-bearing of the left lower extremity
4- Home exercise program, analgesics, and limited use of muscle relaxants
5- Cortisone injection of the left greater trochanter region
PREFERRED RESPONSE: 3**
**DISCUSSION: Although the imaging reveals generalized lumbar spondylosis and stenosis, in particular at L4-5, the MRI scan of the left hip clearly reveals a stress fracture of the femoral neck. Therefore, the treatment of choice is non-weight-bearing of the left lower extremity. During the evaluation of acute back pain, clinicians must include other possibilities within the differential diagnosis that may mimic mechanical axial back pain; thus, potential complications from a missed diagnosis can be avoided.**
**REFERENCES: Wong DA, Transfeldt E: Macnab’s Backache, ed 4. Philadelphia, PA, Lippincott Williams and Wilkins, 2007, pp 339-361.**
**Spivak JM, Connolly PJ (ed): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 43-56.**
**38****. A 79-year-old woman reports a history of left leg pain with walking. Her pain is exacerbated with walking and stair climbing, and her symptoms are improved by standing after she stops walking. Lumbar flexion does not provide any significant improvement of the symptoms and sitting does not significantly change symptoms. Her leg pain is worse at night and she obtains relief by hanging her leg over the side of the bed. The neurologic examination is essentially normal. Examination of the lower extremities demonstrates mild early trophic changes, and her pulses distally are palpable but are diminished bilaterally. Radiographs are shown in Figures 15a and 15b. What is the next most appropriate step in management?
1- Decompression and posterior fusion at L4-L5
2- Epidural steroid injection at L4-5
3- Nonsteroidal medications and physical therapy for 6 weeks
4- Measurement of the ankle-brachial index
5- CT myelogram
PREFERRED RESPONSE: 4**
**DISCUSSION: The patient has symptoms that are more consistent with vascular claudication than with the pseudoclaudication anticipated from lumbar spinal stenosis. Therefore, the patient is a candidate for further vascular work-up. The radiographs reveal early spinal stenosis and spondylolisthesis at L4-5 but also show significant calcification of the iliac arteries, suggestive of peripheral vascular disease. Vascular claudication is a manifestation of peripheral vascular disease and presents with crampy leg pain that is exacerbated by physical exertion. The pain is easily relieved by standing still or sitting. Unlike pseudoclaudication, a forward-flexed posture and/or sitting does not improve the symptoms. Night pain is common in vascular claudication due to the elevation of the extremities and patients often report pain improvement by hanging their extremities in a dependent position. In evaluation of a patient with suspected vascular claudication, the five “P’s” of vascular insufficiency should be monitored, including pulselessness, paralysis, paresthesia, pallor, and pain. While pain and paresthesias can be common in both vascular claudication and pseudoclaudication, the presence of any of the remaining symptoms is suggestive of vascular disease.**
**REFERENCES: Aufderheide TP: Peripheral arteriovascular disease, in Rosen P, Barkin R (eds): Emergency Medicine: Concepts and Clinical Practice, ed 4. St Louis, MO, Mosby, 1998,
pp 1826-1844.**
**Mirkovic S, Garfin SR: Spinal stenosis: History and physical examination. Instr Course Lect 1994;43:435-440.**
**39****. Figure 16 shows the MRI scan of a 43-year-old man who has had worsening low back pain for the past 4 months. What is the most likely diagnosis?
1- Osteochondroma
2- Posttraumatic kyphosis
3- Staphylococcus aureus osteomyelitis
4- Ankylosing spondylitis
5- Tuberculosis
PREFERRED RESPONSE: 5**
**DISCUSSION: Tuberculosis of the spine is seen in 50% to 60% of skeletal disease and is most commonly found in the lower thoracic or upper lumbar spine. Typically two or more adjacent bodies are involved as seen in this MRI scan. The disk space is narrowed but still relatively preserved as opposed to pyogenic infections (black arrow). Epidural extensions often spread from vertebrae to vertebrae (white arrow); however, the posterior elements are not frequently involved (arrowhead). Tumors rarely spread to adjacent vertebrae. The anterior and posterior spread of the infectious process rules out trauma.**
**REFERENCES: Boachie-Adjei O, Squillante RG: Tuberculosis of the spine. Orthop Clin North Am 1996;27:95-103.**
**Currier BL, Eismont FJ: Infections of the spine, in Rothman RH, Simeone FA (eds): The Spine. Philadelphia, PA, WB Saunders, 1992, p 2614.**
**40****. In patients without spondylolisthesis or scoliosis undergoing laminectomy for lumbar spinal stenosis, spinal fusion is generally recommended if
1- a dural tear is repaired.
2- more than one level requires decompression.
3- less than one half of each facet is removed bilaterally.
4- the pars interarticularis is fractured.
5- the patient is a smoker.
PREFERRED RESPONSE: 4**
**DISCUSSION: With the notable exception of fusion for degenerative spondylolisthesis and scoliosis, there is a paucity of evidence on the indications for spinal fusion in patients undergoing laminectomy for spinal stenosis. However, it is generally recommended that if the spine is destabilized (for example by removal of one complete facet joint or by an iatrogenic pars fracture), spinal fusion should be considered. Although fusion can be considered for a very long laminectomy, a two-level laminectomy does not represent, by itself, a clear indication for the addition of a spinal fusion. The repair of a dural tear and the use of nicotine by the patient play no role in the determination of whether or not to add fusion to a laminectomy procedure.**
**REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 299-409.**
**Fischgrund JS, Mackay M, Herkowitz HN, et al: 1997 Volvo Award winner in clinical studies. Degenerative lumbar spondylolisthesis with spinal stenosis: A prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine 1997;22:2807-2812.**
**41****. An 18-year-old collegiate basketball player has had a 3-month history of activity-related back pain. She describes isolated low back pain without radiation that increases with training and playing basketball. Her pain resolves with rest. Physical therapy for 6 weeks has failed to provide relief. An axial CT scan is shown in Figure 17a, and Figures 17b and 17c show sagittal CT reconstructions through the right and left lumbar facets, respectively. Further management should consist of which of the following?
1- CT-guided needle biopsy followed by radiation therapy
2- L5-S1 fusion with instrumentation
3- L5-S1 hemilaminotomy and partial diskectomy
4- Activity restriction and bracing
5- L5-S1 total disk arthroplasty
PREFERRED RESPONSE: 4**
**DISCUSSION: The sagittal and axial CT scans show a bilateral spondylolysis at L5. The defect is in the pars interarticularis on the right side but at the base of the pedicle on the left. Having failed a trial of physical therapy with only a 3-month history of pain, the next most appropriate step in management should consist of activity modification and bracing in an antilordotic lumbosacral orthosis. Surgical intervention is reserved for patients who have failed to respond to a trial of bracing and activity restriction.**
**REFERENCES: Debnath UK, Freeman BJ, Grevitt MP, et al: Clinical outcome of symptomatic unilateral stress injuries of the lumbar pars interarticularis. Spine 2007;32:995-1000.**
**Bono CM: Low-back pain in athletes. J Bone Joint Surg Am 2004;86:382-396.**
**42****. Radiating pain associated with a posterolateral thoracic disk herniation typically follows what pattern?
1- Extending down the spine into the lumbosacral region
2- Down the inner aspect of either upper extremity
3- Cephalad up to the cervicothoracic junction
4- Around or through the chest to the anterior wall
5- Down the contralateral lower extremity
PREFERRED RESPONSE: 4**
**DISCUSSION: Although symptomatic thoracic disk herniations can affect more caudal structures, even to the point of paralysis, the pattern of radiating pain has been described as either following the dermatomal band around the chest or feeling to the patient as if the pain passes straight anteriorly to the chest wall.**
**REFERENCE: Skubic JW, Kostuik JP: Thoracic pain syndromes and thoracic disc herniation, in Frymoyer JW (ed): The Adult Spine: Principles and Practice. New York, NY, Raven Press, 1991, pp 1443-1464.**
**43****. A 53-year-old man reports a 5-week history of worsening low back pain accompanied by bilateral knee and ankle pain and swelling. He also reports a lesser degree of neck and left elbow pain. He denies any history of trauma or provocative episodes. His medical history is significant for Reiter’s syndrome more than 25 years ago, with no subsequent exacerbations. Furthermore, he has recently returned from a vacation in Costa Rica and noted the development of infectious gastroenteritis with diarrhea within 1 week of his return. This was treated with a 10-day course of oral antibiotics and has since resolved. He denies any significant bowel or urinary symptoms at this time. His neurologic examination is essentially within normal limits, but is somewhat limited by his low back and leg pain. What further investigation is most appropriate at this time?
1- Radiographs of the lumbar spine and bilateral knees and ankles
2- MRI of the lumbar spine with and without gadolinium contrast
3- Synovial fluid analysis of the involved joints for crystals and bacteria
4- Laboratory tests including a CBC count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP)
5- Laboratory tests including CBC count, rheumatoid factor (RF), antinuclear antibodies (ANA), and human leukocyte antigen-B27 (HLA-B27)
PREFERRED RESPONSE: 4**
**DISCUSSION: The patient has pain involving the cervical and lumbar spine as well as pain and swelling in both the knees and ankles. As such, this can be classified as polyarticular arthritis. The presence of multiple joint symptoms in the lower extremities, the absence of a history of trauma, and the multiple joints involved direct attention away from the spine as the etiology of this patient’s pain. Radiographs of the involved joints are not likely to yield much useful information to assist with a diagnosis. Likewise, an MRI scan of the lumbar spine is not likely to provide much information regarding the etiology of the patient’s condition. When a rheumatologic illness is suspected, the selective use of confirmatory laboratory testing can aid in arriving at a correct diagnosis. A presumed case of gout or chondrocalcinosis can be confirmed by the presence of the appropriate crystals in a joint-fluid aspiration. Because of the patient’s recent trip to Costa Rica and the subsequent gastroenteritis, a CBC count, ESR, and CRP should be ordered to rule out infectious and inflammatory versus noninflammatory conditions. Rheumatoid factor (RF) in general should only be ordered for patients with polyarticular joint inflammation for more than 6 weeks. The presence of rheumatoid factor does not indicate rheumatoid arthritis. Antinuclear antibodies (ANA) should be ordered when a connective tissue disease such as systemic lupus erythematosus (SLE) is suspected on the basis of specific history and physical examination findings, such as inflammatory arthritis. Human leukocyte antigen-B27 (HLA-B27) should be ordered only when the patient’s history is compatible with ankylosing spondylitis or Reiter’s syndrome and this patient had a history of Reiter’s syndrome.**
**REFERENCES: Gardner GC, Kadel NJ: Ordering and interpreting rheumatologic laboratory tests. J Am Acad Orthop Surg 2003;11:60-67.**
**Shojania K: Rheumatology: 2. What laboratory tests are needed? CMAJ 2000;162:1157-1163.**
**44****. The 5-year outcome for patients with sciatica secondary to lumbar disk herniation shows which of the following results?
1- Patients have the same likelihood of receiving disability whether treated with or without surgery.
2- Sixty percent of surgically treated patients undergo at least one more operation within 5 years.
3- Only 20% of patients treated with surgery report improved symptoms of back and/or leg pain.
4- A smaller portion of surgical patients, compared to nonsurgically treated patients, report improvement.
5- Fifty percent of patients treated nonsurgically seek surgery within 5 years.
PREFERRED RESPONSE: 1**
**DISCUSSION: Atlas and associates, in the Maine Lumbar Spine Study, reported that overall, patients treated initially with surgery reported better outcomes. By 5 years, 19% of surgical patients had undergone at least one additional lumbar spine operation, and 16% of nonsurgical patients had opted for at least one lumbar spine operation. At the 5-year follow-up, 70% of patients initially treated surgically reported improvement in their predominant symptom (back or leg pain) versus 56% of those initially treated nonsurgically. They also noted that there was no difference in the proportion of patients receiving disability compensation at the 5-year follow-up.**
**REFERENCE: Atlas SJ, Keller RB, Chang Y, et al: Surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: Five-year outcomes from the Maine Lumbar Spine Study. Spine 2001;26:1179-1187.**
**45****. What is one of the principle concerns when a fracture such as the one seen in Figure 18
is encountered?
1- Fractures of the lower extremities
2- Paroxysmal hypertension
3- Infection
4- Epidural hematoma
5- Gastrointestinal bleeding
PREFERRED RESPONSE: 4**
**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.**
**46****. Retrograde ejaculation is most commonly associated with what surgical approach?
1- Anterior retroperitoneal approach to L5-S1
2- Anterior transperitoneal approach to L5-S1
3- Anterior retroperitoneal approach to L4-5
4- Minimally invasive lateral trans-psoas approach to L4-5
5- Open lateral approach to L4-5
PREFERRED RESPONSE: 2**
**DISCUSSION: Retrograde ejaculation is the sequela of an injury to the superior hypogastric plexus. This structure needs protection, especially during anterior exposure of the lumbosacral junction. Although the superior hypogastric plexus can be injured with anterior or anterolateral spine surgery at any lumbar level, it is most at risk with anterior transperitoneal approaches to the lumbosacral junction. To avoid this complication, the use of monopolar electrocautery should be avoided during deep dissection in this region. The ideal anterior exposure starts with blunt dissection just to the medial aspect of the left common iliac vein sweeping the prevertebral tissues toward the patient’s right side.**
**REFERENCES: Flynn JC, Price CT: Sexual complications of anterior fusion of the lumbar spine. Spine 1984;9:489-492.**
**Watkins RG (ed): Surgical Approaches to the Spine. New York, NY, Springer-Verlag, 1983,
p 107.**
**An HS, Riley LH III: An Atlas of Surgery of the Spine. New York, NY, Lippincott Raven, 1998, p 263.**
**47****. What nerve is most likely to be injured during the anterior exposure of C2-3?
1- Facial
2- Superior laryngeal
3- Vagus
4- Hypoglossal
5- Phrenic
PREFERRED RESPONSE: 4**
**DISCUSSION: The hypoglossal nerve exits from the ansa cervicalis at approximately the C2-3 level and can be injured during retraction up to the C2 level. The superior laryngeal nerve lies at about C4-5. The facial nerve is much higher. The vagus nerve runs with the internal jugular and carotid much more laterally. The phrenic nerve exits posteriorly.**
**REFERENCES: Chang U, Lee MC, Kim DH: Anterior approach to the midcervical spine, in Kim DH, Henn JS, Vaccaro AR, et al (eds): Surgical Anatomy and Techniques to the Spine. Philadelphia, PA, Saunders Elsevier, 2006, pp 45-54.**
**Netter GH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy Corporation, 1989.**
**48****. A 24-year-old man sustains the injury shown in Figures 19a through 19e in a paragliding accident. He is neurologically intact. He also sustained fractures of his left femur and right distal radius. Which of the following represents the best option for management of the spinal injury?
1- Bed rest for 6 weeks, followed by mobilization in a thoracolumbosacral orthosis (TLSO) until the fracture has healed
2- Immediate mobilization in a TLSO, continuing until the fracture has healed
3- Anterior corpectomy with strut grafting and placement of anterior fixation
4- Anterior corpectomy and strut grafting followed by posterior spinal fusion and instrumentation
5- Posterior spinal fusion and instrumentation
PREFERRED RESPONSE: 5**
**DISCUSSION: The injury pattern is that of a burst fracture at L1 contiguous with a compression fracture at T12. There is associated kyphosis and slight spondylolisthesis of T12 on L1. Treatment of this type of burst fracture in neurologically intact patients is somewhat controversial, with at least one study demonstrating equal long-term results comparing nonsurgical treatment to surgical treatment. In this study, however, body casts were used initially in the nonsurgical group. Moreover, because this patient has multiple fractures, spinal fracture stabilization should be considered to facilitate early mobilization. Surgical stabilization and fusion via a posterior approach is the best treatment option in this patient. Anterior decompression is not necessary since the patient is neurologically intact.**
**REFERENCES: McLain RF, Benson DR: Urgent surgical stabilization of spinal fractures in polytrauma patients. Spine 1999;24:1646-1654.**
**Wood K, Butterman G, Mehbod A, et al: Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: A prospective, randomized study.
J Bone Joint Surg Am 2003;85:773-781.**
**Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.**
**49****. An 82-year-old man is seen in consultation after being admitted for a fall from ground level. There was no loss of consciousness and the patient recalls striking his head and sustaining a hyperextension-type injury to the cervical spine. Examination reveals an
8-cm head laceration with only mild axial neck tenderness. He has generalized weakness throughout the upper extremities and maintained motor function of the lower extremities. There are no obvious sensory deficits, and the bulbocavernous reflex and deep tendon reflexes are maintained. What is the most appropriate diagnosis at this time?
1- Anterior cord syndrome
2- Central cord syndrome
3- Posterior cord syndrome
4- Brown-Séquard syndrome
5- Spinal shock
PREFERRED RESPONSE: 2**
**DISCUSSION: Incomplete cord syndromes have variable neurologic findings with partial loss of sensory and/or motor function below the level of injury. Incomplete cord syndromes include the anterior cord syndrome, the Brown-Séquard syndrome, central cord syndrome, and posterior cord syndrome. Central cord syndrome is characterized with greater motor weakness in the upper extremities than in the lower extremities. The pattern of motor weakness shows greater distal involvement in the affected extremity than proximal muscle weakness. Anterior cord syndrome involves a variable loss of motor function and pain and/or temperature sensation, with preservation of proprioception. The Brown-Séquard syndrome involves a relatively greater ipsilateral loss of proprioception and motor function, with contralateral loss of pain and temperature sensation. Posterior cord syndrome is a rare injury and is characterized by preservation of motor function, sense of pain, and light touch, with loss of proprioception and temperature sensation below the level of the lesion. Spinal shock is the period of time, usually 24 hours, after a spinal injury that is characterized by absent reflexes, flaccidity, and loss of sensation below the level of the injury.**
**REFERENCES: Penrod LE, Hegde SK, Ditunno JF: Age effect on prognosis for functional recovery in acute, traumatic central cord syndrome. Arch Phys Med Rehab 1990;71:963-968.**
**Harrop JS, Sharan A, Ratliff J: Central cord injury: Pathophysiology, management, and outcomes. Spine J 2006;6:198S-206S.**
**50****. Kyphosis from a vertebral osteoporotic compression fracture often results in progressive kyphosis due to
1- progressive increase in lumbar lordosis.
2- load transfer to the superior adjacent vertebra.
3- normalization of load transfer with working kyphosis.
4- reduced strain at the occipito-cervical junction.
5- reduced strain at the apex of the deformity.
PREFERRED RESPONSE: 2**
**DISCUSSION: Kayanja and associates, in a number of biomechanical studies, showed that in a kyphotic spine the strain is located at the apex of the deformity, the force is transmitted to the superior adjacent vertebrae, and that realignment and cement augmentation effectively normalize the load transfer.**
**REFERENCES: Kayanja MM, Ferrara LA, Lieberman IH: Distribution of anterior cortical shear strain after a thoracic wedge compression fracture. Spine J 2004;4:76-87.**
**Kayanja MM, Togawa D, Lieberman IH: Biomechanical changes after the augmentation of experimental osteoporotic vertebral compression fractures in the cadaveric thoracic spine. Spine J 2005;5:55-63.**
**Kayanja MM, Schlenk R, Togawa D, et al: The biomechanics of 1, 2, and 3 levels of vertebral augmentation with polymethylmethacrylate in multilevel spinal segments. Spine 2006;31:769-774.**
**Kayanja M, Evans K, Milks R, et al: The mechanics of polymethylmethacrylate augmentation. Clin Orthop Relat Res 2006;443:124-130.**
**51****. A 58-year-old woman with rheumatoid arthritis has progressive neck pain, upper extremity and lower extremity weakness, and difficulty with fine motor movements. Examination reveals hyperreflexia with mild to moderate objective weakness but the patient has no difficulty with ambulation for short distances. What is the most important preoperative imaging finding that predicts full neurologic recovery with surgical stabilization?
1- Basilar invagination of less than 1 cm
2- Anterior atlanto-dens interval of 4 mm
3- Posterior atlanto-dens interval of greater than 14 mm
4- Rotatory subluxation of less than 10 degrees
5- Subaxial subluxation of less than 3.5 mm
PREFERRED RESPONSE: 3**
**DISCUSSION: Boden and associates’ article presents compelling evidence that patients with rheumatoid arthritis and neurologic deterioration in C1-2 instability are more likely to achieve some improvement if the posterior atlanto-dens interval is greater than 10 mm on preoperative studies. All the patients in their series who had neurologic deterioration and a preoperative posterior atlanto-dens interval of greater than 14 mm achieved complete motor recovery.**
**REFERENCES: Boden SD, Dodge LD, Bohlman HH, et al: Rheumatoid arthritis of the cervical spine: A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am 1993;75:1282-1297.**
**Boden SD, Clark CR: Rheumatoid arthritis of the cervical spine, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 755-764.**
**Monsey RD: Rheumatoid arthritis of the cervical spine. J Am Acad Orthop Surg 1997;5:240-248.**
**52****. Figures 20a through 20d show the radiographs and MRI scans of a 59-year-old woman who has had symptoms consistent with progressive neurogenic claudication and back pain for the past 9 months. In the last 6 months, nonsurgical management consisting of nonsteroidal anti-inflammatory drugs, physical therapy, and a series of epidural steroid injections have been used; however the injections, while beneficial, have provided only temporary relief of her symptoms. What is the most appropriate management at this time?
1- Repeat trial of epidural steroid injections
2- Pain management referral for narcotic management of symptoms
3- Lumbar laminectomies at L4-5
4- Lumbar laminectomies and fusion at L4-5
5- Bilateral lumbar laminotomies at L3-4 and L4-5
PREFERRED RESPONSE: 4**
**DISCUSSION: Patients with a degenerative spondylolisthesis and severe stenosis who have failed appropriate nonsurgical management are candidates for surgical intervention. Most studies show good to excellent results in more than 85% of patients after lumbar decompression for stenosis. Atlas and associates found that at 8- to 10-year follow-up, leg pain relief and back-related functional status were greater in those patients opting for surgical treatment of the stenosis. Similarly, the decision to fuse a spondylolisthetic segment has been supported in the literature. Herkowitz and Kurz compared decompressive laminectomy alone and decompressive laminectomy with intertransverse arthrodesis in 50 patients with single-level spinal stenosis and degenerative spondylolisthesis. They demonstrated good to excellent results in 90% of the fused group compared to 44% in the nonfusion group. The decision to include instrumentation during the fusion is more controversial. Whereas the use of instrumentation has shown to improve fusion rates, it has not been conclusively shown to improve the overall clinical outcomes of patients.**
**REFERENCES: Atlas SJ, Keller RB, Wu YA, et al: Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the Maine lumbar spine study. Spine 2005;30:936-943.**
**Herkowitz HN, Kurz LT: Degenerative lumbar spondylolisthesis with spinal stenosis: A prospective study comparing decompression with decompression and intratransverse process arthrodesis. J Bone Joint Surg Am 1991;73:802-808.**
**Fischgrund JS, Mackay M, Herkowitz HN, et al: 1997 Volvo Award winner in clinical studies. Degenerative lumbar spondylolisthesis with spinal stenosis: A prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine 1997;22:2807-2812.**
**53****. A 29-year-old man reports a 2-week history of severe neck pain after being struck sharply on the back of the head and neck while moving a refrigerator down a flight of stairs. Initial evaluation in the emergency department revealed no obvious fracture and he was discharged in a soft collar. Neurologic examination is within normal limits, and radiographs taken in the office are shown in Figures 21a through 21c. Subsequent MRI scans show intra-substance rupture of the transverse atlantal ligament. What is the most appropriate treatment option at this time?
1- Discontinue use of the soft collar and encourage range of motion
2- Semi-rigid collar immobilization for 6 to 8 weeks
3- Surgical stabilization
4- Halo skeletal fixation
5- Outpatient physical therapy with isometric neck exercises
PREFERRED RESPONSE: 3**
**DISCUSSION: Dickman and associates classified injuries of the transverse atlantal ligament into two categories. Type I injuries are disruptions through the substance of the ligament itself. Type II injuries render the transverse ligament physiologically incompetent through fractures and avulsions involving the tubercle of insertion of the transverse ligament on the C1 lateral mass. Type I injuries are incapable of healing without supplemental internal fixation. Type II injuries can be treated with a rigid cervical orthosis with a success rate of 74%. Surgery may be required for type II injures that fail to heal with 3 to 4 months of nonsurgical management.**
**REFERENCES: Findlay JM: Injuries involving the transverse atlantal ligament: Classification and treatment guidelines based upon experience with 39 injuries. Neurosurgery 1996;39:210.**
**Dickman CA, Mamourian A, Sonntag VK, et al: Magnetic resonance imaging of the transverse atlantal ligament for the evaluation of atlantoaxial instability. J Neurosurgery 1991;75:221-227.**
**54****. Figure 22 reveals what anatomic variant of the lumbar spine?
1- Spina bifida occulta
2- Unilateral sacralization
3- An aplastic or hypoplastic pedicle
4- Lumbarization
5- Facet tropism
PREFERRED RESPONSE: 2**
**DISCUSSION: Unilateral sacralization of the fifth lumbar vertebra was first described by Bertolotti in 1917. Bertolotti’s syndrome is present in 12% to 21% of the population. The altered biomechanics have been postulated to cause low back pain by placing increased stress on the adjacent cephalad disk, thus contributing to accelerated degenerative disk disease at this level. It has also been found that the neoarticulation between the enlarged transverse process and the sacrum and/or ilium may be a source of neural impingement on the exited L5 nerve root and results in radicular pain syndrome. Brault and associates reported on a case treated surgically at the Mayo Clinic, in which the pain generator was found to be the contralateral facet joint.**
**REFERENCES: Brault JS, Smith J, Currier BL: Partial lumbosacral transitional vertebra resection for contralateral facetogenic pain. Spine 2001;26:226-229.**
**Quinlan JF, Duke D, Eustace S: Bertolotti’s syndrome: A cause of back pain in young people.
J Bone Joint Surg Br 2006;88:1183-1186.**
**Whelan MA, Feldman F: The variant lumbar pedicle. Neuroradiology 1982;22:235-242.**
**55****. Posterior lumbar spine arthrodesis may be associated with adjacent segment degeneration cephalad or caudad to the fusion segment. Which of the following is the predicted rate of symptomatic degeneration at an adjacent segment warranting either decompression and/or arthrodesis at mid-range follow-up (5-10 years) after lumbar fusion?
1- 2%
2- 10%
3- 25%
4- 50%
5- 80%
PREFERRED RESPONSE: 3**
**DISCUSSION: The rate of symptomatic degeneration at an adjacent segment warranting either decompression or arthrodesis was predicted to be 16.5% at 5 years and 36.1% at 10 years based on a Kaplan-Meier analysis.**
**REFERENCE: Ghiselli G, Wang J, Bhatia NN, et al: Adjacent segment degeneration in the lumbar spine. J Bone Joint Surg Am 2004;86:1497-1503.**
**56****. A 24-year-old man who was involved in a high speed motor vehicle accident is transferred for definitive care after having been diagnosed with an acute spinal cord injury from a fracture-dislocation at C6-7. He has a complete C6 neurologic level and it is now approximately 10 hours from his injury. What is the most appropriate pharmacologic treatment at this time?
1- No pharmacologic intervention is recommended at this time
2- Administration of methylprednisolone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 24 hours
3- Administration of methylprednisolone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 48 hours
4- Administration of naloxone with an initial bolus of 30 mg/kg followed by
5.4 mg/kg for 24 hours
5- Administration of naloxone with an initial bolus of 30 mg/kg followed by
5.4 mg/kg for 48 hours
PREFERRED RESPONSE: 1**
**DISCUSSION: The standard practice in the pharmacologic treatment of a spinal cord injury in the United States has been the administration of methylprednisolone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 24 hours, in accordance with the findings of the second and third National Acute Spinal Cord Injury Studies (NASCIS). Although the studies have subsequently drawn criticism for their methodology and outcomes, it has been generally accepted that beneficial neurologic outcomes were anticipated in patients who were able to start the protocol within 8 hours of their initial injury. Further improvement was noted in patients receiving the methylprednisolone within 3 hours of their injury and continuing an infusion for
48 hours. In this patient, who is outside the 8-hour treatment window, no studies have supported starting the methylprednisolone protocol at this time.**
**REFERENCES: Braken MB, Shepard MJ, Holford TR, et al: Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury: Results of the third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA 1997;277:1597-1604.**
**Kwon BK, Tetzlaff W, Grauer JN, et al: Pathophysiology and pharmacologic treatment of acute spinal cord injury. Spine J 2004;4:451-464.**
**57****. 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?
1- Observation
2- Physical therapy
3- Epidural steroid injections
4- Cervical laminectomy
5- Anterior cervical diskectomy and fusion
PREFERRED RESPONSE: 5**
**DISCUSSION: 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.**
**REFERENCES: Emery SE, Bohlman HH, Bolesta MJ, et al: Anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy: Two to seventeen-year follow-up. J Bone Joint Surg Am 1998;80:941-951.**
**Ferguson RJ, Caplan LR: Cervical spondylotic myelopathy. Neurol Clin 1985;3:373-382.**
**Herkowitz HN: A comparison of anterior cervical fusion, cervical laminectomy, and cervical laminoplasty for the surgical management of multiple level spondylotic radiculopathy. Spine 1988;13:774-780.**
**58****. What structure (arrow) is shown in Figure 24?
1- Ilioinguinal nerve
2- Sympathetic chain
3- Ureter
4- Iliac vein
5- L5 nerve
PREFERRED RESPONSE: 2**
**DISCUSSION: The structure illustrated is the sympathetic chain viewed from an anterolateral view of the lower lumbar spine. It descends along the anterolateral aspect of the spine into the pelvis closely adherent to the vertebral column. The spinal nerves, including L5, can be seen exiting from the foramen. The ureters descend from the kidneys and cross anterior to the iliac vessels to the bladder.**
**REFERENCES: Onibokun A, Khoo LT, Holly L: Anterior retroperitoneal approach to the lumbar spine, in Kim DH, Henn JS, Vaccaro AR, et al (eds): Surgical Anatomy and Techniques to the Spine. Philadelphia, PA, Saunders Elsevier, 2006, pp 101-105.**
**Netter GH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy Corporation, 1989.**
**59****. The best patient-related outcomes, following the surgical treatment of cauda equina syndrome secondary to a large L5-S1 disk herniation, are most closely related to which of the following?
1- Extent of bowel and bladder dysfunction
2- Extent of the motor deficit
3- Extent of the perianal saddle anesthesia
4- Timing of surgery
5- Location of the herniation
PREFERRED RESPONSE: 4**
**DISCUSSION: The most predictable positive outcome from spinal surgery due to a cauda equina syndrome is early surgical intervention before any significant neurologic deficit develops. Meta-analysis studies demonstrate that surgical intervention more than 48 hours after the onset of cauda equina syndrome show an increased risk for poor outcomes.**
**REFERENCES: Ahn UM, Ahn NU, Buchowski JM, et al: Cauda equina syndrome secondary to lumbar disc herniation: A meta-analysis of surgical outcomes. Spine 2000;25:1515-1522.**
**Kohles SS, Kohles JD, Karp AP, et al: Time-dependent surgical outcomes following cauda equina syndrome diagnosis: Comments on meta-analysis. Spine 2004;29:1281-1287.**
**60****. A 45-year-old man undergoes an anterior cervical diskectomy and fusion at C5-6 and
C6-7 with instrumentation. During the first postoperative visit at 1 week, the patient reports difficulty swallowing and mild anterior cervical tightness. The anterior wound is benign and the patient denies any dyspnea or shortness of breath. A postoperative radiograph is seen in Figure 25. What is the most appropriate management at this time?
1- Admit for observation and reassurance
2- Surgical exploration and removal of the anterior instrumentation
3- Esophageal swallowing study
4- Soft cervical collar and early range-of-motion exercises
5- CT of the cervical spine
PREFERRED RESPONSE: 1**
**DISCUSSION: The radiograph shows significant prevertebral soft-tissue swelling following a two-level anterior cervical diskectomy and fusion. The incidence of dysphagia 2 years after anterior cervical spine surgery is 13.6%. Risk factors for long-term dysphagia after anterior cervical spine surgery include gender, revision surgeries, and multilevel surgeries. The use of instrumentation, higher levels, or corpectomy versus diskectomy did not significantly increase the prevalence of dysphagia. Lee and associates demonstrated that while dysphagia after anterior cervical spine surgery is a common early finding, it generally decreases significantly by
6 months with nonsurgical management. A minority of patients experience moderate or severe symptoms by 6 months after the procedure. Female gender and multiple surgical levels have been identified as risk factors for the development of postoperative dysphagia.**
**REFERENCES: Lee MJ, Bazaz R, Furey CG, et al: Risk factors for dysphagia after anterior cervical spine surgery: A two-year prospective cohort study. Spine J 2007;7:141-147.**
**Bazaz R, Lee MJ, Yoo JU: Incidence of dysphagia after anterior cervical spine surgery:
A prospective study. Spine 2002;27:2453-2458.**
**61****. Steroids are thought to prevent neurologic deterioration after traumatic spinal cord injury by which of the following mechanisms?
1- Maintains calcium influx into damaged cells
2- Destabilizes lysosomal membranes in the zone of injury
3- Reduces TNF-alpha expression
4- Increases NF-kB binding capacity
5- Maintains free radical oxidation
PREFERRED RESPONSE: 3**
**DISCUSSION: The proposed mechanisms by which steroids such as methylprednisolone are thought to prevent neurologic deterioration by limiting secondary insult, include: decreasing the area of ischemia in the cord, reducing TNF-alpha expression and NF-kB binding activity, decreasing free radical oxidation and thus stabilizing cell and lysosomal membranes, and checking the influx of calcium into the injured cells, thus reducing cord edema.**
**REFERENCES: Slucky AV: Pathomechanics of spinal cord injury. Spine: State Art Rev 1999;13:409-417.**
**Torg JS, Thibault L, Sennett B, et al: The Nicolas Andry Award. The pathomechanics and pathophysiology of cervical spinal cord injury. Clin Orthop Relat Res 1995;321:259-269.**
**62****. Which of the following mechanisms of inhibition has been linked to cigarette smoking and lumbar spinal fusion?
1- Diminished revascularization of cancellous bone graft
2- Increased activity of osteoblasts
3- Increased activity of osteocytes
4- Antibody-induced necrosis
5- Inhibition of prostaglandins
PREFERRED RESPONSE: 1**
**DISCUSSION: Cigarette smoking has been directly linked to pseudarthrosis in spinal fusions. The direct mechanism of action is diminished revascularization of cancellous bone graft. Additionally, a smaller area of revascularization is seen in these grafts, as well as an increased area of necrosis. Increased activity of osteoblasts would result in more bone production. Increased activity of osteocytes would not affect the fusion because osteocytes are mature bone cells.**
**REFERENCE: Daftari TK, Whitesides TE Jr, Heller JG, et al: Nicotine on the revascularization of bone graft: An experimental study in rabbits. Spine 1994;19:904-911.**
**64****. A previously healthy 29-year-old man reports a 2-day history of severe atraumatic lower back pain. He denies any bowel or bladder difficulties and no constitutional signs. Examination is consistent with mechanical back pain. No focal neurologic deficits or pathologic reflexes are noted. What is the most appropriate management?
1- Radiographs, including anterior, lateral, and oblique views
2- MRI of the lumbar spine and follow-up at the clinic in 1 week
3- Caudal epidural steroid injection
4- Reassurance, limited analgesics, and early range of motion as tolerated
5- Immediate MRI of the lumbar spine and possible urgent surgical decompression
PREFERRED RESPONSE: 4**
**DISCUSSION: In general, a previously healthy patient with an acute onset of nontraumatic lower back pain does not need diagnostic imaging before proceeding with therapeutic treatment. In the absence of any “red flags” during the history and physical examination, such as trauma or constitutional symptoms (ie, fevers, chills, weight loss), the appropriate treatment for acute onset lower back pain is purely symptomatic treatment including limited analgesics and early range of motion. Diagnostic imaging is not necessary unless the initial treatment is unsuccessful and symptoms are prolonged. Miller and associates suggested that the use of radiographs can lead to better patient satisfaction but not necessarily better outcomes.**
**REFERENCES: Miller P, Kendrick D, Bentley E, et al: Cost effectiveness of lumbar spine radiographs in primary care patients with low back pain. Spine 2002;27:2291-2297.**
**Wong DA, Transfeldt E: Macnab’s Backache, ed 4. Philadelphia, PA, Lippincott Williams and Wilkins 2007, pp 298-338.**
**65****. Sacral fractures are most likely to be associated with neurologic deficits when they involve what portion of the sacrum?
1- Zone 1 (the ala)
2- Zone 2 (the foramina)
3- Zone 3 (the central canal)
4- Zones 1 and 2
5- The sacral laminae
PREFERRED RESPONSE: 3**
**DISCUSSION: Denis divided the sacrum into three zones: zone 1 represents the lateral ala, zone 2 represents the foramina, and zone 3 represents the central canal. A fracture is classified according to its most medial extension. Those in zone 3 are typically bursting-type fractures or fracture-dislocations and are most prone to neurologic sequelae.**
**REFERENCES: Denis F, Davis S, Comfort T: Sacral fractures: An important problem.
A retrospective analysis of 236 cases. Clin Orthop Relat Res 1988;227:67-81.**
**Wood KB, Denis F: Fractures of the sacrum and coccyx, in Vacarro AR (ed): Fractures of the Cervical, Thoracic and Lumbar Spine. New York, NY, Marcel Dekker, 2003, pp 473-488.**
**66****. Which of the following is associated with the use of bisphosphonates in the setting of metastatic breast cancer to the spine?
1- Reduction in skeletal-related events by 30% to 40%
2- Jaw osteonecrosis in 15% of patients
3- Pain improvement in only 30% of patients
4- Improvement in serum hypocalcemia in 40% of patients
5- Accelerated bone destruction in 10% of patients
PREFERRED RESPONSE: 1**
**DISCUSSION: The indications of bisphosphonate therapy in breast cancer patients range from the correction of hypercalcemia to the prevention of cancer treatment-induced bone loss. Bisphosphonates reduce metastatic bone pain in at least 50% of patients and can reduce the frequency of skeletal-related events by 30% to 40%. Osteonecrosis of the jaw could occur in up to 2.5% of breast cancer patients during long-term bisphosphonate therapy.**
**REFERENCE: Body JJ: Breast cancer: Bisphosphonate therapy for metastatic bone disease. Clin Cancer Res 2006;12:6258s-6263s.**
**67****. A 67-year-old retired steelworker was involved in a motor vehicle accident and sustained a midcervical spinal cord injury. Radiographs and MRI scans reveal severe cervical stenosis and spondylosis without fractures or dislocations. Neurologic examination reveals an ASIA C spinal cord impairment with greater motor involvement of the upper extremities than the lower extremities. What is the probability that the patient eventually will become ambulatory?
1- 2% to 5%
2- 15% to 20%
3- 35% to 45%
4- 60% to 70%
5- Greater than 90%
PREFERRED RESPONSE: 3**
**DISCUSSION: The patient sustained an incomplete spinal cord injury known as central cord syndrome. Central cord syndrome characteristically has disproportionate involvement of the upper extremities with the lower extremities being relatively spared. It is most commonly seen after cervical injuries in elderly patients with spondylosis and spinal stenosis, often without fracture. Penrod and associates noted that 23 of 59 patients with central cord syndrome
(ASIA C and D) ultimately walked. The poorest prognosis, however, was in ASIA C patients older than age 50, in which only 40% walked. **
**REFERENCES: Penrod LE, Hegde SK, Ditunno JF Jr: Age effect on prognosis for functional recovery in acute, traumatic central cord syndrome. Arch Phys Med Rehab 1990;71:963-968.**
**Northrup BE: Acute injuries to the spine and spinal cord: Evaluation and early treatment, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005, p 735.**
**68****. A 20-year-old man involved in a motor vehicle accident is brought to the emergency department with a C6-7 unilateral facet dislocation. His neurologic examination reveals
a focal left-sided C7 nerve root palsy. He is awake and cooperative with questioning
and has no other obvious traumatic injuries. What is the most appropriate treatment at this time?
1- Further imaging studies, including MRI
2- An awake closed reduction with Gardner-Wells traction with neurologic examination
3- Immobilization in a halo skeletal fixation for definitive treatment
4- Closed reduction under general anesthesia
5- Immediate open reduction and internal fixation in the surgical suite
PREFERRED RESPONSE: 2**
**DISCUSSION: In the patient who is neurologically intact or has an incomplete injury from a cervical facet dislocation, a closed reduction with weighted tong traction is appropriate when the patient is awake, alert, and cooperative. Although there is a risk that a cervical facet dislocation could occur with an underlying cervical disk herniation, Vaccaro and associates have shown that closed reduction can be safely carried out in the awake, responsive patient. Closed reduction can be performed in the emergency department with traction with skull tongs or a halo ring. A slow stepwise application of weight is added until a reduction is achieved. Any worsening of the neurologic status of the patient requires immediate termination of the closed reduction and further diagnostic imaging before proceeding with further treatment.**
**REFERENCES: Vaccaro AR, Falatyn SP, Flanders AE, et al: Magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine dislocations. Spine 1999;24:1210-1217.**
**Hart RA: Cervical facet dislocation: When is magnetic resonance imaging indicated? Spine 2002;27:116-117.**
**Cotler JM, Herbison GJ, Nasuti JF, et al: Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds. Spine 1993;18:386-390.**
**69****. A 66-year-old man reports a 2-week history of worsening low back and leg pain. He reports that his pain is aggravated by lying down and relieved by standing and walking. He notes that he has been losing weight recently and that his pain has been awakening him during the night. His medical history is significant for hypertension, coronary artery disease, and prostate cancer. His physical examination is essentially unremarkable. Lumbar radiographs are within normal limits. What is the most appropriate management for this patient?
1- MRI of chest
2- Laboratory studies, including a complete blood cell (CBC) count, erythrocyte sedimentation rate (ESR), and urinalysis, PSA, CEA
3- Activity alterations to avoid undue back irritation
4- Comfort measures, including medications
5- Spinal manipulative therapy within the first 6 weeks
PREFERRED RESPONSE: 2**
**DISCUSSION: In the initial assessment of acute low back pain in adults, no diagnostic testing is indicated during the first 4 weeks in the absence of “red flags” for a serious underlying condition. The purpose of the initial assessment of acute low back pain in adults is to rule out serious underlying conditions presenting as low back pain. The Agency for Healthcare Policy and Research, in its 1994 clinical practice guideline, identified four serious conditions that may present with low back pain, including fracture, tumor, infection, and cauda equina syndrome. This patient has five “red flags” for a spinal tumor as a possible etiology of his low back pain, including age of older than 50 years, constitutional symptoms (recent weight loss), pain worse when supine, severe nighttime pain, and a history of cancer. Of these, his history of cancer is most significant, as greater than 90% of spinal tumors are metastatic. In order of frequency, breast, prostate, lung, and kidney make up approximately 80% of all secondary spread to the spine. In the presence of “red flags” for tumor or infection, it is recommended that the clinician obtain a CBC count, ESR, and a urinalysis. If these are within normal limits and suspicions still remain, consider consultation or seek further evidence with a bone scan, radiographs, or additional laboratory studies. Negative radiographs alone are insufficient to rule out disease. If radiographs are positive, the anatomy can be better defined with MRI.**
**REFERENCES: Agency for Health Care Policy and Research, Bigos SJ (ed): Acute Low Back Problems in Adults. Rockville, MD, US Department of Health and Human Services, AHCPR Publication 95-0642, Clinical Practice Guideline #14, 1994.**
**Gertzbein SD: Metastatic spine tumors, in Herkowitz HN, Dvorak J, Bell G, et al (eds): The Lumbar Spine, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 792-802.**
**70****. Which of the following increases radiation exposure to patients and personnel during surgery?
1- Orienting the beam in the opposite direction of the working team and keeping the team outside a 6-foot radius of the fluoroscopy machine
2- Orienting the cathode ray tube beneath the patient with the image intensifier receptor as close to the patient as possible
3- Limiting the beam on time to only what is clinically important
4- The use of continuous fluoroscopy whenever possible to ensure proper placement of implants
5- The use of lead glasses, a thyroid shield, and a lead apron with an equivalent lead thickness of 0.25 mm
PREFERRED RESPONSE: 4**
**DISCUSSION: Continuous fluoroscopy and cine radiography expose the patient and personnel to markedly increased levels of direct and scatter radiation exposure. Continuous fluoroscopy should be limited to only what is absolutely needed for safe completion of the procedure. By orienting the cathode ray tube beneath the patient and placing the image intensifier as close as clinically possible to the patient, scatter radiation exposure to the personnel is minimized.**
**REFERENCE: Wagner L, Archer B: Minimizing Risks from Fluoroscopic X-rays: A Credentialing Program for Anesthesiologists, Cardiologists, Surgeons, Radiologists, and Urologists, ed 3. The Woodlands, TX, Partners in Radiation Management, 2000.**
**71****. A 78-year-old woman undergoes her third lumbar decompression and fusion from L3 to L5 without complication. On the morning of postoperative day 3, examination reveals painless, flaccid weakness of both lower extremities. She also has an absent bulbocavernous reflex and a mild saddle paresthesia. MRI scans of the lumbar spine are shown in Figures 26a and 26b. What is the most appropriate management at this time?
1- Continued serial neurologic examinations
2- CT with a myelogram of the lumbar spine
3- Immediate surgical exploration and hematoma drainage
4- Electromyography of bilateral lower extremities
5- IV antibiotics for 24 hours, followed by surgical exploration if symptoms persist
PREFERRED RESPONSE: 3**
**DISCUSSION: The MRI scans reveal a large postoperative hematoma causing significant thecal compression. An epidural hematoma with neurologic deficit is a surgical emergency requiring immediate evacuation of the hematoma. Although the incidence of postoperative epidural hematomas is rare, the consequences of a missed diagnosis can be catastrophic. Early recognition and evacuation are essential in preserving or restoring neurologic function. Uribe and associates attributed delayed postoperative hematomas to previous multiple lumbar surgeries as a possible contributing factor.**
**REFERENCES: Yi S, Yoon do H, Kim KN, et al: Postoperative spinal epidural hematoma: Risk factor and clinical outcome. Yonsei Med J 2006;47:326-332.**
**Uribe J, Moza K, Jimenez O, et al: Delayed postoperative spinal epidural hematomas. Spine J 2003;3:125-129.**
**72****. Figures 27a through 27c show the radiographs and CT scan of a 27-year-old man who sustained a low-velocity gunshot wound to the neck. He is quadriplegic (ASIA A), hemodynamically stable, and does not have drainage from his wound. After initial resuscitation and stabilization, the cervical spine and spinal cord injuries are best managed by
1- wound debridement, anterior corpectomy, spinal cord decompression, dural repair, and anterior fusion with strut graft and anterior plating.
2- wound debridement, anterior corpectomy, spinal cord decompression, dural repair, anterior fusion with strut graft and anterior plating followed by posterior laminectomy, and spinal cord decompression and dural repair with excision of the bullet fragment.
3- wound debridement, anterior corpectomy, spinal cord decompression, dural repair, anterior fusion with strut graft and anterior plating followed by laminectomy and posterior fusion, and spinal cord decompression and dural repair with excision of the bullet fragment.
4- laminectomy and posterior fusion, and spinal cord decompression and dural repair with excision of the bullet fragment.
5- surgical treatment based on extraspinal pathology with orthotic treatment of the spinal fractures.
PREFERRED RESPONSE: 5**
**DISCUSSION: Although the spinal canal has been penetrated, the lateral masses are intact bilaterally with only partial destruction of the vertebral body and penetration of the lamina on one side, thus the cervical spine is not unstable and surgical stabilization is not indicated. Dural repair is not indicated since there is no external cerebrospinal fluid leakage. Surgical treatment should be based on the need to treat extraspinal pathology only.**
**REFERENCES: Bono CM, Heary RF: Gunshot wounds to the spine. Spine J 2004;4:230-240.**
**Punjabi MM, Jue JJ, Dvorak J, et al: Cervical spine kinematics and clinical instability, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005,
pp 55-87.**
**73****. Which of the following is a true statement regarding thoracic disk herniations?
1- Are most commonly discovered during the fifth to seventh decades of life
2- Occur with similar frequency as cervical disk herniations
3- Occur most commonly in the midthoracic or apical region of the spine
4- Can be found in 40% of asymptomatic individuals
5- Are best treated surgically with posterior laminectomy and excision
PREFERRED RESPONSE: 4**
**DISCUSSION: Symptomatic herniations of the thoracic spine are much less common than those of the cervical or lumbar region. They tend to occur most commonly during the third to fifth decades of life and although they can be found at all levels, they are most common in the lower third near the thoracolumbar region. Posterior laminectomy and disk excision has the highest rate of neurologic deterioration and is not recommended. Multiple studies have shown that herniated thoracic disks can be found at one or more levels in 40% of asymptomatic individuals.**
**REFERENCES: Shah RP, Grauer JN: Thoracoscopic excision of thoracic herniated disc, in Vaccaro AR, Bono CM (eds): Minimally Invasive Spine Surgery. New York, NY, Informa Healthcare, 2007, pp 73-80.**
**Bohlman HH, Zdeblick TA: Anterior excision of herniated thoracic discs. J Bone Joint Surg Am 1988;70:1038-1047.**
**74****. A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. What is the most common sentinel event related to spine surgery?
1- Surgery on the wrong patient
2- Surgery on the wrong side
3- Incorrect procedure performed
4- Intraoperative death
5- Surgery on the wrong level
PREFERRED RESPONSE: 5**
**DISCUSSION: Patient safety and prevention of medical errors is a major focus of recent national advocacy groups. Analysis has shown that the most common sentinel event in spine surgery is surgery on the wrong level. Therefore, it is recommended that every patient have the surgical site signed, the level of surgery marked intraoperatively, and a radiograph taken. Surgery on the wrong level is most likely to occur in single-level decompressive procedures.**
**REFERENCES: Wong DA, Watters WC III: To err is human: Quality and safety issues in spine care. Spine 2007;32:S2-S8.**
**Wong DA: Spinal surgery and patient safety: A systems approach. J Am Acad Orthop Surg 2006;14:226-232.**
**75****. What structure is most at risk with anterior penetration of C1 lateral mass screws?
1- Vertebral artery
2- External carotid artery
3- Internal carotid artery
4- Pharynx
5- Glossopharyngeal nerve
PREFERRED RESPONSE: 3**
**DISCUSSION: Posterior screw fixation of the upper cervical spine has gained a great deal of popularity due to its stable fixation, obviating the use of halo vest immobilization, and its high fusion rates. The use of screws in this location, however, has introduced a whole new set of potential complications. Vertebral artery injury is one of the most feared complications associated with screws in the C1/C2 region. This structure, however, is lateral and posterior at the C2 level and then penetrates the foramen transversarium of C1 to lie cephalad to the arch of C1 before entering the foramen magnum. It is the internal carotid artery that lies immediately anterior to the arch of C1 that is particularly at risk by anterior penetration of C1 lateral mass or C1-C2 transarticular screws as demonstrated by Currier and associates. The internal carotid artery lies posterior to the pharynx. The external carotid artery and the glossopharyngeal nerve are not at risk with this method of fixation.**
**REFERENCES: Currier BL, Todd LT, Maus TP, et al: Anatomic relationship of the internal carotid artery to the C1 vertebra: A case report of cervical reconstruction for chordoma and pilot study to assess the risk of screw fixation of the atlas. Spine 2003;28:E461-E467.**
**Grant JC: Grant’s Atlas of Anatomy, ed 6. Baltimore, MD, Williams & Wilkins, 1972.**
**Harms J, Melcher RP: Posterior C1-C2 fusion with polyaxial screw and rod fixation. Spine 2001;26:2467-2471.**
**76****. During the application of halo skeletal fixation, the most appropriate position for the placement of the anterior halo pins is approximately 1 cm above the superior orbital
rim and
1- lateral placement, directly within the temporalis muscle.
2- lateral to the medial third of the orbit.
3- lateral to the lateral aspect of the orbit.
4- above the medial third of the orbit.
5- lateral between the temporalis muscle and zygomatic temporal nerve.
PREFERRED RESPONSE: 2**
**DISCUSSION: Halo fixation is the most rigid form of cervical orthosis, but complications can arise from improper placement of the initial halo ring. A relatively safe zone for anterior pin placement is located 1 cm above the orbital rim and superior to the lateral two thirds of the orbit. This position avoids the supraorbital and supratrochlear nerves and arteries over the medial one third of the orbit. The more lateral positions in the temporal fossa have very thin bone and can interfere with the muscles of mastication. Posterior pin site locations are less critical; positioning on the posterolateral aspect of the skull, diagonal to the contralateral anterior pins, is generally desirable.**
**REFERENCES: Botte MJ, Byrne TP, Abrams RA, et al: Halo skeletal fixation: Techniques of application and prevention of complications. J Am Acad Orthop Surg 1996;4:44-53.**
**Garfin SR, Botte MJ, Nickel VL: Complications in the use of the halo fixation device. J Bone Joint Surg Am 1987;69:954.**
**77****. Figures 28a and 28b show the sagittal and axial lumbar MRI scans of a 72-year-old man who reports dull aching back pain that spreads to his legs, calves, and buttocks. He has had the pain for several years and it is precipitated by standing and walking and relieved by sitting. His symptoms have been worsening over the past year and he notes that he is leaning forward while walking to help relieve his symptoms. He has had no treatment to date. What is his prognosis if he chooses to pursue nonsurgical management for this condition?
1- He can expect complete resolution of his symptoms during the first month.
2- All patients experience relief within 3 months and continue to improve over the next 4 years.
3- Most patients experience some pain relief within the first 3 months.
4- He may experience some improvement but if he requires surgery at a later date he will have a poorer result because of the delay.
5- The patient requires immediate surgery to avoid permanent nerve damage.
PREFERRED RESPONSE: 3**
**DISCUSSION: The patient has lumbar spinal stenosis and the MRI scans reveal the pathology at L4-5, which is secondary to posterior disk bulging and hypertrophy and infolding of the ligamentum flavum, as well as degenerative facet arthrosis. The degree of spinal stenosis is moderate and his symptoms are positional in nature. Tadokoro and associates reported on a prospective study of 89 patients older than 70 years of age who underwent nonsurgical management for lumbar spinal stenosis. They found the prognosis to be relatively good with patients scoring at “excellent” or “good” for activities of daily living at final follow-up. However, they did note that patients with a complete block on myelography did not respond favorably to nonsurgical management. Amundsen and associates reported on a 10-year prospective study comparing surgical care to nonsurgical management. They concluded that, while the long-term results largely favored surgical treatment, more than half of the nonsurgically managed patients had a satisfactory outcome. They also concluded that a delay of surgery for some months did not worsen the prognosis. Therefore, their recommendation was for an initial primarily nonsurgical approach.**
**REFERENCES: Amundsen T, Weber H, Nordal HJ, et al: Lumbar spinal stenosis: Conservative or surgical management? A prospective 10-year study. Spine 2000;25:1424-1435.**
**Hilibrand AS, Rand N: Degenerative lumbar stenosis: Diagnosis and management. J Am Acad Orthop Surg 1999;7:239-249.**
**Tadokoro K, Miyamoto H, Sumi M, et al: The prognosis of conservative treatments for lumbar spinal stenosis: Analysis of patients over 70 years of age. Spine 2005;30:2458-2463.**
**78****. Which of the following vertebrae has the smallest pedicle isthmic width in a nondeformity patient?**
1- T10
2- T11
3- T12
4- L1
5- L2
**PREFERRED RESPONSE: 4**
**DISCUSSION: The smallest pedicle isthmic width is at L1, whereas T12 has the largest pedicle width in the upper lumbar and lower thoracic spine. Although smaller in diameter than T12, both T10 and T11 have larger pedicle widths than L1.**
**REFERENCE: Ofiram E, Polly DW, Gilbert TJ Jr, et al: Is it safe to place pedicle screws in the lower thoracic spine than in the upper lumbar spine? Spine 2007;32:49-54.**
**79****. Which of the following represents a contraindication for interspinous process decompression for the treatment of lumbar spinal stenosis?
1- Grade I degenerative spondylolisthesis
2- Inability to walk at least 100 feet
3- Cauda equina syndrome
4- Fixed sensory deficit
5- Intermittent foot drop
PREFERRED RESPONSE: 3**
**DISCUSSION: Kondrashov and associates noted stable good outcomes at 4 years in 14 of 18 patients treated with X-STOP interspinous process decompression as defined as an improvement over preoperative Oswestry scores of 15 points or more. Similar results were seen after 1 year in a European study by Siddiqui and associates. Exclusion and inclusion criteria for these studies varied somewhat, but cauda equina syndrome was the only exclusion criteria listed in both studies. All of the other choices did not represent exclusion criteria in either study.**
**REFERENCES: Kondrashov DG, Hannibal M, Hsu KY, et al: Interspinous process decompression with the X-STOP device for lumbar spinal stenosis: A 4-year follow-up study.
J Spinal Disord Tech 2006;19:323-327.**
**Siddiqui M, Smith FW, Wardlaw D: One-year results of X Stop interspinous implant for the treatment of lumbar spinal stenosis. Spine 2007;32:1345-1348.**
**80****. Which of the following statements about hoarseness due to vocal cord paralysis after anterior cervical diskectomy and fusion is most accurate?
1- Vocal cord paralysis is three times as likely with a right-sided approach as compared to a left-sided approach.
2- Vocal cord paralysis is twice as likely with a right-sided approach as compared to a left-sided approach.
3- Vocal cord paralysis is equally likely with either a right-sided or a left-sided approach.
4- Vocal cord paralysis is three times as likely with a left-sided approach as compared to a right-sided approach.
5- Vocal cord paralysis is twice as likely with a left-sided approach as compared to a right-sided approach.
PREFERRED RESPONSE: 3**
**DISCUSSION: It has been traditionally taught that a left-sided approach to the anterior cervical spine is associated with a lower incidence of injury compared to the right-sided approach. This is due in part to the anatomic differences in the path the recurrent laryngeal nerve (RLN) takes on the right as compared to the left. Both nerves ascend in the tracheoesophageal groove after branching off the vagus nerve in the upper thorax. The left-sided RLN loops around the aortic arch and stays relatively medial as compared to the right-sided RLN which loops around the right subclavian artery and is somewhat more lateral at this point, and therefore is theoretically more vulnerable as it ascends toward the larynx before becoming protected in the tracheoesophageal groove. Furthermore, the variant of a nonrecurrent inferior laryngeal nerve branching directly off the vagus nerve at the level of the midcervical spine is much more common on the right than the left. Despite this reasoning, there has been no clinical evidence to suggest that laterality of approach for anterior cervical surgery makes any difference in the incidence of vocal cord paralysis. Furthermore, two recent studies have shown that the incidence of RLN injury and vocal cord paralysis is equal with either side of approach.**
**REFERENCES: Beutler WJ, Sweeney CA, Connolly PJ: Recurrent laryngeal nerve injury with anterior cervical spine surgery risk with laterality of surgical approach. Spine 2001;26:1337-1342.**
**Kilburg C, Sullivan HG, Mathiason MA: Effect of approach side during anterior cervical discectomy and fusion on the incidence of recurrent laryngeal nerve injury. J Neurosurg Spine 2006;4:273-277.**
**81****. A 23-year-old man is involved in a motor vehicle accident. An AP radiograph is shown in Figure 29a, and axial and sagittal CT scans are shown in Figures 29b and 29c. Neurologic examination shows 1/5 strength of his quadriceps and iliopsoas on the right, with 1/5 quadriceps function on the left. Definitive treatment of his injury should
consist of
1- anterior corpectomy with interbody strut.
2- posterior fusion with instrumentation and posterolateral decompression.
3- closed reduction and a thoracolumbosacral orthosis (TLSO).
4- anterior reduction and instrumentation.
5- supine bed rest for 6 weeks, followed by immobilization in a TLSO.
PREFERRED RESPONSE: 2**
**DISCUSSION: The imaging studies show a fracture-dislocation. Surgical treatment of this injury consists of a decompression reduction, stabilization, and fusion. A posterolateral decompression can also be performed as necessary. An isolated anterior procedure in this type of injury is contraindicated. The anterior longitudinal ligament is most likely intact; therefore, an anterior procedure further destabilizes the spine. Reduction by an anterior approach would also be difficult. Nonsurgical management of the neurologic injury in this patient is not indicated.**
**REFERENCES: Theiss SM: Thoracolumbar and lumbar spine trauma, in Stannard JP, Schmidt AH, Kregor PJ (eds): Surgical Treatment of Orthopaedic Trauma. New York, NY, Thieme, 2007, pp 179-207.**
**Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.**
**82****. Surgical treatment for symptomatic disk herniations is associated with which of the following?
1- Substantial rate of nerve root injury
2- Early relief of pain sustained out to 2 years
3- Recurrent herniation rate of 35%
4- Outcomes that are substantially worse than nonsurgical management
5- 10% rate of infectious diskitis
PREFERRED RESPONSE: 2**
**DISCUSSION: The recently published SPORT trial verifies that surgical treatment of symptomatic disk herniations is associated with early and sustained pain relief. The trial also verifies that nonsurgical management is associated with improved symptoms as well. Nerve root injury, recurrent herniation, and diskitis are known complications of surgery, but all are less common than described above.**
**REFERENCE: Weinstein JN, Lurie JD, Tosteson TD, et al: Surgical vs nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006;296:2451-2459.**
**83****. A 25-year-old man is unresponsive at the scene of a high-speed motor vehicle accident and remains obtunded. Initial evaluation in the emergency department reveals a left-sided femoral shaft fracture and a right-sided humeral shaft fracture. The cervical spine remains immobilized in a semi-rigid cervical collar, and the initial AP and lateral radiographs obtained in the emergency department are unremarkable. What is the most appropriate management at this time?
1- Lateral radiographs with passive flexion/extension views
2- Helical CT scan of the cervical-thoracic region
3- Careful manual palpation of the cervical spine for subtle defects or step-offs
4- MRI of the cervical spine
5- Continued use of the cervical collar until the patient becomes responsive for examination
PREFERRED RESPONSE: 2**
**DISCUSSION: Clearance of the cervical spine can be difficult in the obtunded or unresponsive patient. Various trauma series have been reported to detect up to 95% of cervical fractures but only when ideal imaging views have been obtained, which is not often possible in the unresponsive or uncooperative patient. Passively performed cervical flexion-extension under live fluoroscopy has been suggested but is not without inherent risk in the potentially unstable cervical spine. CT of the cervical spine has gained acceptance for the evaluation of these patients given the excellent evaluation of the osseous anatomy and for the common availability in most emergency departments. Sanchez and associates, using a protocol to evaluate for cervical spine injuries after blunt trauma, were able to detect 99% of cervical fractures with 100% specificity.**
**REFERENCES: Chiu WC, Haan JM, Cushing BM, et al: Ligamentous injuries of the cervical spine in unreliable blunt trauma patients: Incidence, evaluation, and outcome. J Trauma 2001;50:457-463.**
**Sanchez B, Waxman K, Jones T, et al: Cervical spine clearance in blunt trauma: Evaluation of a computed tomography-based protocol. J Trauma 2005;59:179-183.**
**Nunez D Jr: Value of complete cervical helical computed tomographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries:
A prospective study. J Trauma 2000;48:988-989.**
**84****. A 55-year-old woman undergoes an anterior cervical diskectomy and fusion at C5-C6 through a left-sided approach. One year later, she requires an anterior cervical diskectomy and fusion on another level. Which of the following is considered a contraindication to performing a right-sided approach for the revision procedure?
1- Revision surgery caudad to C6
2- Persistent left cervical radiculopathy
3- History of a left-sided Horner’s syndrome
4- Transient dysphagia following the initial anterior cervical procedure
5- Nonfunctional left vocal cord
PREFERRED RESPONSE: 5**
**DISCUSSION: When attempting a revision anterior cervical approach from the side opposite the original approach, it is important to evaluate the function of the vocal cords. If this evaluation reveals dysfunction of the vocal cord on the side of the original approach, then an approach on the contralateral side should not be attempted. Injury to the stellate ganglion, which causes a Horner’s syndrome, should not preclude an approach on the contralateral side. While the side of the symptomatology can influence the surgeon’s choice as to the side of an anterior approach, it does not preclude a certain approach. When approaching the lower cervical spine from the right side, the recurrent laryngeal nerve can cross the surgical field and should be preserved. Excessive intraoperative pressure on the esophagus can increase the incidence of dysphagia, but its incidence is no different with either approach.**
**REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 387-394.**
**Edwards CC II, Riew KD, Anderson PA, et al: Cervical myelopathy: Current diagnostic and treatment strategies. Spine J 2003;3:68-81.**
**85****. A 56-year-old woman sustained the fracture shown in Figures 30a and 30b in a motor vehicle accident. What mechanism is most likely responsible for the injury?
1- Flexion distraction
2- Vertical shear
3- Extension distraction
4- Flexion compression
5- Axial load
PREFERRED RESPONSE: 5**
**DISCUSSION: The CT scans show a burst fracture that results from an axial load injury. The radiographic hallmark of a burst fracture is compression of the posterior cortex of the vertebral body with retropulsion of bone into the spinal canal. AP radiographs often show widening of the interpedicular distance with a fracture of the lamina.**
**REFERENCES: Theiss SM: Thoracolumbar and lumbar spine trauma, in Stannard JP, Schmidt AH, Kregor PJ (eds): Surgical Treatment of Orthopaedic Trauma. New York, NY, Thieme, 2007, pp 179-207.**
**Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.**
**86****. In providing culturally competent care to a Muslim woman with a cervical spine injury, which of the following most accurately describes the steps a male orthopaedist should take to respect her religious beliefs during his examination?
1- No one should be in the exam room except the patient and the physician.
2- Another woman should be in the exam room and only the affected body part should be exposed.
3- A chaperone of either gender should be in the exam room and no skin should be exposed.
4- No particular steps need to be taken in this case.
5- The patient’s closest male relative should be in the exam room but a standard hospital gown may be used.
PREFERRED RESPONSE: 2**
**DISCUSSION: In examining a traditional Muslim woman, a male physician should have another woman present, and the patient’s husband, if possible. Only the affected limb or area needing examination should be exposed.**
**REFERENCE: Jimenez R, Lewis VO (eds): Culturally Competent Care Guidebook. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007.**
**87****. Figure 31 shows the radiograph of a 64-year-old woman who is seen in the emergency department following a motor vehicle accident. She has no voluntary motor function in her distal upper extremities or lower extremities. She does not have a bulbocavernosus reflex. She has a blood pressure of 80/50 mm Hg with a pulse of 50/min. Her hypotension does not improve with initial fluid resuscitation. Further treatment of her hypotension should consist of
1- continued rapid fluid infusion.
2- administration of broad-spectrum antibiotics.
3- administration of 30/mg/kg methylprednisolone over 1 hour.
4- administration of pressors.
5- cardioversion and implantation of a pacemaker.
PREFERRED RESPONSE: 4**
**DISCUSSION: The hallmark of neurogenic shock is hypotension without tachycardia. It is associated most commonly with high cervical spinal cord injuries and results from loss of function of the sympathetic nervous system. Because the peripheral vasculature is dilated due to loss of its sympathetic tone, continued rapid administration of fluid corrects the hypotension and can quickly lead to fluid overload and congestive heart failure. Therefore, neurogenic shock is best treated by the use of pressors. Cardioversion or administration of antibiotics or systemic steroids is not appropriate treatment for this patient’s hypotension.**
**REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 179-187.**
**Nockels RP: Nonoperative management of acute spinal cord injury. Spine 2001;26:S31-S37.**
**88****. What is the typical axial plane transverse angulation of the thoracic pedicles?**
**1- 5 degrees medial at T** 1**and T** 2**; 10 degrees from T3 to T10**
**2- 5 degrees lateral at T** 1**; neutral at T** 2**; 5 degrees medial from T3 to T12
3- 10 degrees medial from T1 to T10; 15 degrees medial at T11 and T12
4- 10 degrees medial from T** 1**to T12**
**5- 25 degrees medial at T** 1**; 15 degrees at T** 2**; and 10 degrees medial from T3 to T10**
**PREFERRED RESPONSE: 5**
**DISCUSSION: Thoracic pedicles typically are angled 25 degrees medially at T** 1**so the
starting point is more lateral. T**2**angles about 15 degrees, and then the pedicles average about
5 to 7 degrees down to T10. At T11 and 12, the angulation is minimal.**
**REFERENCES: Weinstein L: Pediatric Spine Principles and Practice. New York, NY, Raven Press, 1994, pp 1659-1681.**
**Lenke LG, Orchowski J: Segmental posterior spinal instrumentation: Thoracic spine to sacrum, in Frymoyer JW, Wiesel SW (eds): The Adult and Pediatric Spine, ed 3. Philadelphia, PA, Lippincott Williams and Wilkins, 2004, pp 537-552.**
**89****. What muscle is most often encountered during surgical approaches to C5-6?
1- Omohyoid
2- Cricohyoid
3- Splenius capitus
4- Thyrohyoid
5- Posterior digastric
PREFERRED RESPONSE: 1**
**DISCUSSION: The omohyoid muscle crosses the surgical field from inferior lateral to anterior superior traveling from the scapula to the hyoid bone and may need to be transected. The posterior digastric crosses the field as well but higher near C3-4. The other muscles run longitudinally.**
**REFERENCES: Chang U, Lee MC, Kim DH: Anterior approach to the midcervical spine, in Kim DH, Henn JS, Vaccaro AR, et al (eds): Surgical Anatomy and Techniques to the Spine. Philadelphia, PA, Saunders Elsevier, 2006, pp 45-56.**
**Netter GH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy Corporation, 1989.**
**90****. Which of the following lumbar disk components has the highest tensile modulus to resist torsional, axial, and tensile loads?
1- Nucleus pulposus
2- Cartilaginous end plate
3- Anterior longitudinal ligament
4- Annulus fibrosis
5- Cellular matrix
PREFERRED RESPONSE: 4**
**DISCUSSION: The annulus fibrosis has a multilayer lamellar architecture mode of type I collagen fibers. Each successive layer is oriented at 30 degrees to the horizontal in the opposite direction, leading to a “criss-cross” type pattern. This composition allows the annulus, which has the highest tensile modulus, to resist torsional, axial, and tensile loads.**
**REFERENCE: Rhee JM, Schaufele M, Abdu WA: Radiculopathy and the herniated lumbar disc: Controversies regarding pathophysiology and management. J Bone Joint Surg Am 2006;88:2070-2080.**
**91****. When comparing the overall outcomes of surgical versus nonsurgical treatment of stable thoracolumbar burst fractures in patients without neurologic injury, 5 years following injury, the principle differences lie in
1- fracture kyphosis.
2- reduction of retropulsed bone.
3- pain reduction.
4- incidence of complications.
5- return to work.
PREFERRED RESPONSE: 4**
**DISCUSSION: When patients are compared at 5 years follow-up, there are no statistically significant differences between the two groups with respect to kyphosis, the degree of retropulsed bone resorption, pain and function levels, or the ability to return to work. Nonsurgical management of stable neurologically intact burst fractures has a very low incidence of complications.**
**REFERENCES: Wood K, Butterman G, Mehbod A, et al: Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: A prospective, randomized study. J Bone Joint Surg Am 2003;85:773-781.**
**Shen WJ, Liu TJ, Shen YS: Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures without neurologic deficit. Spine 2001;26:1038-1045.**
**92****. 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?
1- Continued nonsurgical management to include long-acting narcotic analgesics
2- Referral for vertebral axial decompression
3- Referral to interventional pain management for a spinal cord stimulator
4- Intradiskal electrothermal therapy (IDET) at L5-S1
5- Lumbar spinal fusion at L5-S1
PREFERRED RESPONSE: 5**
**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.**
**93****. Figure 33 shows the MRI scan of a 55-year-old woman who has had a 6-week history of back and leg pain. Which of the following clinical scenarios is most consistent with the MRI scan findings at L4-L5?
1- L4 nerve root radiculopathy
2- L5 nerve root radiculopathy
3- Associated bowel and bladder dysfunction
4- Symptoms associated with arachnoiditis
5- Wide-based gait, left-sided Hoffman’s sign
PREFERRED RESPONSE: 1**
**DISCUSSION: The MRI scan reveals a L4-L5 foraminal disk herniation originating from the L4-5 disk space that has migrated up into the foramen, compressing the left L4 nerve root. There is normal distribution of the roots in the cerebrospinal fluid, excluding arachnoiditis as a diagnosis, and disk herniation in this location would not result in cauda equina syndrome or myelopathy.**
**REFERENCE: McCullouch JA, Transfeldt EE: Macnab’s Backache, ed 3. Philadelphia, PA, Williams and Wilkins, 1997, pp 569-608.**
**94****. Intradiskal electrothermal therapy (IDET) uses an intradiskal catheter to deliver controlled thermal energy to the inner periphery of the annulus fibrosis of a chronically painful intervertebral disk. Lumbar diskography is used diagnostically to identify the presumed pain generator to be targeted with IDET. Based on the medical literature, what can be said about the current status of IDET?
1- IDET has been proven to seal annular tears in the annulus fibrosis.
2- IDET restores segmental stability by shrinking collagen fibrils in the disk.
3- IDET has demonstrated no significant benefit over placebo in controlled trials.
4- IDET is an unsafe procedure with significant risk of permanent complications.
5- IDET has demonstrated poor clinical results in all reported series to date.
PREFERRED RESPONSE: 3**
**DISCUSSION: Intradiskal electrothermal therapy (IDET) initial clinical results were reported in 2000. The early case series were quite encouraging with reported therapeutic success rates of 60% to 80%. Early enthusiasm was high as IDET provided a nonsurgical treatment option for an otherwise complex and difficult clinical entity, chronic diskogenic low back pain. The actual mechanism of action was not well understood, and while the theoretic explanation made good sense, it did not hold up under laboratory testing. Soon clinical results from the field did not meet the high expectations set by the developers of the technique. Since those early case studies, a few level I evidence studies have been conducted, one by Freeman and associates and one by Pauza and associates. These randomized, placebo-controlled trials demonstrated no significant benefit of IDET over the placebo.**
**REFERENCES: Freeman BJ, Fraser RD, Cain CM, et al: A randomized, double-blind, controlled trial: Intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. Spine 2005;30:2369-2377.**
**Pauza KJ, Howell S, Dreyfuss P, et al: A randomized, placebo-controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain. Spine J 2004;4:27-35.**
**Wetzel FT, McNally TA: Treatment of chronic discogenic low back pain with intradiskal electrothermal therapy. J Am Acad Orthop Surg 2003;11:6-11.**
**95****. A 56-year-old mechanic has had pain in the hypothenar region of his dominant right hand for the past 6 months. He reports weakness in his grip and pain is worse with activity. Which of the following examination findings is most suggestive of a cervical etiology?
1- Relief of symptoms with shoulder abduction (placing hand over the head)
2- Hypothenar atrophy
3- Reproduction of pain with hyperflexion and contralateral rotation of the head
4- Positive Tinel’s sign at the levator scapulae
5- Subluxable ulnar nerve at the cubital tunnel
PREFERRED RESPONSE: 1**
**DISCUSSION: Hypothenar atrophy is a nonspecific sign that can be seen in ulnar neuropathy, C8 radiculopathy, or even cervical myelopathy; however, the atrophy usually is not unilateral and includes other muscle groups. The Spurling test is an excellent method of eliciting cervical radicular pain but involves hyperextension and ipsilateral rotation of the cervical spine, resulting in nerve root compression by reducing the cross-sectional area of the ipsilateral neuroforamen. Tinel’s sign at the levator scapulae, if present, is indicative of an upper cervical (C3 or C4) radiculopathy. A subluxable ulnar nerve at the cubital tunnel, while often asymptomatic, points toward cubital tunnel syndrome as an etiology for this patient’s pain. The shoulder abduction relief (SAR) sign (relief of upper extremity pain with shoulder abduction) is virtually pathognomic of cervical radiculopathy because this maneuver results in relaxation of a compressed and/or inflamed cervical nerve root. The SAR sign is the converse analog of the straight leg raising sign in the lumbar examination for lumbar radiculopathy, as it relieves tension in the nerve root, thereby relieving symptoms.**
**REFERENCES: Ducker TB, Zeidman SM: Neurologic and functional evaluation, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 143-161.**
**An HS: Clinical presentation of discogenic neck pain, radiculopathy, and myelopathy, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 755-764.**
**Hoppenfeld S: Physical examination of the cervical spine and temporomandibular joint, in Physical Examination of the Spine and Extremities. New York, NY, Appleton-Century-Crofts, 1976, pp 105-132.**
**96****. A 35-year-old woman reports an 8-week history of neck pain radiating to her right upper extremity. She denies any history of trauma or provocative event. Examination reveals decreased pinprick sensation in her right middle finger, otherwise sensation is intact bilaterally. Finger flexors and interossei demonstrate 5/5 motor strength bilaterally. Finger extensors are 4/5 on the right and 5/5 on the left. The triceps reflex is 1+ on the right and 2+ on the left. The most likely diagnosis is a herniated nucleus pulposus at what level?**
1- C3-4
2- C4-5
3- C5-6
4- C6-7
**5- C7-T** 1
**PREFERRED RESPONSE: 4**
**DISCUSSION: The patient’s neurologic examination is consistent with a C7 radiculopathy on the right side. In a patient with this symptom complex in the absence of trauma, a cervical disk herniation is the most common etiology for a C7 radiculopathy. There are eight cervical nerve roots and the C7 nerve exits at the C6-7 disk space and is most frequently impinged by a disk herniation at this level.**
**REFERENCES: Houten JK, Errico TJ: Cervical spondylotic myelopathy and radiculopathy: Natural history and clinical presentation, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005, pp 985-990.**
**Hoppenfeld S: Orthopaedic Neurology: A Diagnostic Guide to Neurologic Levels. Philadelphia, PA, JB Lippincott, 1977, pp 7-43.**
**97****. What is the most common nonanesthetic-related reversible cause of changes in intraoperative neurophysiologic monitoring data?
1- Pedicle screw misplacement
2- Patient positioning
3- Spinal cord ischemia
4- Retractor placement
5- Hypotension
PREFERRED RESPONSE: 2**
**DISCUSSION: Patient positioning that results in local nerve compression, plexus traction, or improper neck alignment is the most common nonanesthetic-related cause of changes in intraoperative neurophysiologic monitoring data during spinal surgery.**
**REFERENCES: Jones SC, Fernau R, Woeltjen BL: Use of somatosensory evoked potentials to detect peripheral ischemia and potential injury resulting from positioning of the surgical patient: Case reports and discussion. Spine J 2004;4:360-362.**
**Schwartz DM, Sestokas AK, Hilibrand AS, et al: Neurophysiological identification of position-induced neurologic injury during anterior cervical spine surgery. J Clin Monit Comput 2006;20:437-444.**
**98****. During a left-sided transforaminal lumbar interbody fusion at the L4-5 level, the surgeon notes a significant amount of bleeding that cannot be controlled while using a pituitary rongeur. What anatomic structure has been injured?
1- Aorta
2- Common iliac artery
3- Common iliac vein
4- External iliac artery
5- External iliac vein
PREFERRED RESPONSE: 2**
**DISCUSSION: The surgeon perforated the anterior longitudinal ligament and injured the common iliac artery. Bingol and associates described injuries to the vascular structures during lumbar disk surgery. The common iliac artery was most commonly affected and constituted 76.9% of injuries.**
**REFERENCE: Bingol H, Cingoz F, Yilmaz AT, et al: Vascular complications related to lumbar disc surgery: J Neurosurg 2004;100:249-253.**
**99****. Six weeks after onset, what is the most clearly accepted indication for surgical management for lumbar disk herniation?
1- Stable sensory loss
2- Stable motor weakness
3- Refractory radicular pain
4- Size of the herniation
5- Lost time at work
PREFERRED RESPONSE: 3**
**DISCUSSION: In the absence of a cauda equina syndrome or progressive weakness, the best indication for surgical management is refractory radicular pain. Surgical decision-making should not be based on the size of the herniation. Large extruded herniations tend to resolve more predictably than smaller herniations. Stable motor weakness and numbness resolve similarly in both surgical and nonsurgical management, although surgery hastens the process. When intractable radicular pain is the strict indication for surgery, surgical intervention provides substantial and more rapid pain relief than nonsurgical care.**
**REFERENCES: Rhee JM, Schaufele M, Abdu WA: Radiculopathy and the herniated lumbar disc: Controversies regarding pathophysiology and management. J Bone Joint Surg Am 2006;88:2070-2080.**
**Atlas SJ, Keller RB, Wu YA, et al: Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the Maine lumbar spine study. Spine 2005;30:927-935.**
**100****. A 45-year-old woman has idiopathic scoliosis. Surgery is to include an anterior thoracic release through an open left thoracotomy. The thoracotomy will have what effect on the patient’s pulmonary function postoperatively?
1- Unaffected
2- Transiently reduced postoperatively but ultimately improves to greater than preoperative function
3- Transiently reduced immediately postoperatively but then quickly returns to preoperative levels
4- Improves postoperatively due to correction of the scoliosis and is maintained long term
5- Reduced postoperatively and often remains reduced long term
PREFERRED RESPONSE: 5**
**DISCUSSION: A thoracotomy in an adult with idiopathic scoliosis causes a reduction in pulmonary function that often does not return to preoperative levels. What pulmonary function that does recover, recovers over many months. Long-term improvement in pulmonary function, compared to preoperative function, is rarely seen. This should be considered in planning surgical intervention in adults with scoliosis.**
**REFERENCES: Graham EJ, Lenke LG, Lowe TG, et al: Prospective pulmonary function evaluation following open thoracotomy for anterior spinal fusion in adolescent idiopathic scoliosis. Spine 2000;25:2319-2325.**
**Kishan S, Bastrom T, Betz RR, et al: Thoracoscopic scoliosis surgery affects pulmonary function less than thoracotomy at 2 years postsurgery. Spine 2007;32:453-458.**