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Neurosurgery Rounds > 6. Spine > Flashcards

6. Spine Flashcards

1
Q

of spinal nerves?

A

8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal

Total 31

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2
Q

% people with low back pain sometime in life

A

80%

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3
Q

Definition of acute low back pain

A

<6w

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4
Q

Nonsurgical tx for spinal stenosis

A
  1. NSAIDS
  2. Analgesics (acetaminophen)
  3. Steroid injections (inflammation)
  4. Anesthetic nerve blocks
  5. Restricted activity
  6. PT
  7. Back brace
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5
Q

Radiculopathy

A

Irritation of LMN from mechanical/chemical insult to nerve root at single spinal level.
Burning pain/numbness with weakness/loss of reflex in corresponding nerve distribution

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6
Q

Polyradiculopathy

A

> 1 nerve root compression

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7
Q

Lasegue sign

A

Straight leg raise test (for disc herniation)

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8
Q

If cervical disk herniation at C4-C5, which nerve root will be affected?

A

C5

lower nerve root

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9
Q

Spurling test

A

Increased pain along nerve distribution from cervical extension with axial compression/rotation of head (decrease size of neural foramen)

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10
Q

Cervical myelopathy

A

LMN symptoms in upper extremity (loss of manual dexterity/muscular atrophy), from chronic pressure on cervical spinal cord from degenerative process.
+ neck pain, stiffness, clonus, hoffman/babinski signs

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11
Q

Red flags in spinal eval

A

Fever, pain in recumbent position, weight loss, B&B dysfunction, trauma, hx cancer, saddle anesthesia, failure to respond to tx

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12
Q

Schober test

A

Measures movement of lumbar spine

10cm proximal and 5cm distal to line between posterior superior iliac spine in midline - at least >5cm in extension

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13
Q

Malnourished patient with symmetric paresthesias in feet/hand and poor proprioception

A

B12

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14
Q

Knee reflex

A

L4

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15
Q

Achilles reflex

A

S1

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16
Q

Lateral recess stenosis, SLR negative or positive?

A

Negative

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17
Q

GBS and SLR?

A

SLR often positive in GBS

back pain, radiculopathic symptoms + SLR, and hx of viral event

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18
Q

Patrick test for lower extremities (FABER test for flexion, abduction, and external rotation)

A

Arthritis of hip
1. figure 4 of hip
2. pressure on tested knee
look for pain (anterior hip capsule)

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19
Q

SLR nerve root

A

L5 and S1

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20
Q

Types of nerves in dorsal ramus of nerve root

A

Dorsal portion of trunk carrying visceral motor, somatic motor and sensory to/from skin and back muscles

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21
Q

Types of nerves in ventral ramus of nerve root

A

Visceral motor, somatic motor and sensory to/from ventrolateral body surface, body wall and limbs

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22
Q

Lateral recess stenosis and herniated lumbar disk pain with sitting

A

LRS: relieved by sitting
HLD: exacerbated by sitting

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23
Q

Why C5 radiculopathy can follow anterior/posterior decompression even after no obvious complication

A

C5 radiculopathy (deltoid weakness) from traction of nerve root from posterior migration of cord (shortest length from foramen to muscle ending)

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24
Q

Paget disease: urinary metabolite

A

hydroxyproline

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25
Q

Spinal tract for lower limb subconscious proprioception

A

Spinocerebellar

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26
Q

Intercristal line on AP and lateral x-ray

A

Confirms location of L5 and L4-L5 disk

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27
Q

L’Hermitte phenomenon

A

Electric sensation running down back

MS, cervical myelopathy, subacute combined degeneration

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28
Q

Compressive lesion of craniocervical border - nystagmus?

A

Downbeat

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29
Q

Cape-like sensory deficit

A

Central cord lesion damaging second seonsory neuron crossing to join lateral spinothalamic tract

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30
Q

How can C5-C6 disk cause C7 symptoms

A

Prefixed brachial plexus - normal levels of innervation abberrant by 1 level

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31
Q

Mechanical vs ankylosing spondylitis back pain

A

Relieved by rest vs morning/noctural pain

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32
Q

Why are disk herniations usually posterolateral?

A

Posterior longitudinal ligament in the center prevents herniating posteriorly directly

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33
Q

What makes up the annulus fibrosis?

A

Fibrocartilage

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34
Q

Most common extraarticular manifestation of ankylosing spondylitis

A

Acute anterior uveitis

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35
Q

Types of spondylolisthesis?

A

Spondylolisthesis: forward displacement of vertebra

Congenital, ischemic, degenerative, traumatic, pathologic, iatrogenic/post-surgical

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36
Q

What spondylolisthesis is thought to result from stress fracture of pars interarticularis?

A

isthmic spondylolisthesis

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37
Q

Main causes of thoracic myelopathy from degenerative dx

A

Herniated disks, ossification of posterior longitudinal ligament/flavum, posterior bone spurs

38
Q

What MSK conditions can mimic lumbar spine problems?

A

Hip osteoarthritis - check hip internal rotation
Vascular insufficiency/claudication (peripheral vasc. exam)
Piriformis syndrome/inflammatory sacroillitis (mimic S1) with buttock pains/radicular pain in S1

39
Q

How long must elective surgery wait for patient taking clopidogrel?

A

7-10 days

40
Q

Lab test to test coagulation for patient on clopidogrel

A

Bleeding time (PT/PTT/INR may be normal)

41
Q

Cervical level of inferior edge of mandible

A

C2

42
Q

Cervical level of hyoid bone

A

C3

43
Q

Cervical level of thyroid cartilage

A

C4-5

44
Q

Cervical level of cricoid ring

A

C6

45
Q

Largest/strongest cervical vertebra

A

C2

46
Q

Which vertebra has no body

A

C1

47
Q

Cervicothoracic inflection point (point where cervical lordosis becomes thoracic kyphosis)

A

T3

48
Q

Best way to verify T7 when patient is prone

A

line between scapula tip to another

49
Q

Normal ROM of cervical spine

A

Flexion 45
Extension 55
Lateral 40
Rotation 70

50
Q

Sensory/motor distribution and reflex of C5

A

S: lateral arm
M: deltoid
R: none

51
Q

Sensory/motor distribution and reflex of C6

A

S: lateral forearm
M: wrist extension, biceps
R: brachioradialis

52
Q

Sensory/motor distribution and reflex of C7

A

S: middle finger
M: tricep, wrist flex, finger extension
R: triceps

53
Q

Sensory/motor distribution and reflex of C8

A

S: small finger
M: finger flexion
R: none

54
Q

Sensory/motor distribution and reflex of T1

A

S: medial arm
M: interossei
R: none

55
Q

Which nerves arise from lateral cord?

A

lateral pectoral nerve (pectoralis major)

musculocutaneous (biceps)

56
Q

Which nerves arise from posterior cord?

A

Upper subscapular nerve (C7/8) to subscapularis
Lower subscapular nerve (C5/6) to teres major
Thoracodorsal nerve (C6-8) to lat dorsi
Axillary nerve (deltoid)
Radial nerve (Tricheps, brachioradiali, finger/wrist extensors)

57
Q

Motor/sensory distribution of L1

A

Sensation of anterior thigh

Innervation of psoas muscle

58
Q

Motor/sensory distribution of L2

A

Sensation of anterior thigh/groin

Innervation of quadriceps

59
Q

Motor/sensory distribution of L3

A

Sensation of anterior/lateral thigh

Innervation of quadriceps muscle

60
Q

Motor/sensory distribution of L4

A

Sensation of medial leg/foot

Innervation of tib ant

61
Q

Motor/sensory distribution of L5

A

Sensation of lateral leg/dorsal foot

Innervation of ex hal long

62
Q

Motor/sensory distribution of S1

A

Sensation of lateral and plantar foot

Innervation of gastroc and peronealis

63
Q

Dissection of psoas muscle should take into account which nerve on anterior surface of the muscle?

A

Genitofemoral

64
Q

Where/how does disk herniation cause radiculopathy?

A

Posterolateral disk herniation: compress traversing nerve root
Lateral herniation: compress exiting nerve root
Large central herniation: single/multiple caudal nerve roots (caudal equina)

65
Q

Posterolateral vs lateral L4-L5 disk herniation affects what roots?

A

Posterolateral: L5
Lateral: L4

66
Q

Superficial abdominal reflex

A

Stroking each four quadrants of abdomen - mvm of umbilicus toward stroked segment (nml - UMN reflex)
Asymmetry suggests intraspinal pathology (thoracic MRI)

67
Q

Anatomic landmark to verify location of lumbar pedicle

A

Crest of transverse process

68
Q

Which ligament serves as ventral extent of safe dissection to avoid injury to spinal nerve root during exposure/decortication of transverse process?

A

Intertransverse ligament

69
Q

The first vertebra that can safely accomodate a pedicle screw?

A

C7 (no vertebral artery)

70
Q

Sympathetic plexus lies ventral to what joint?

A

Costovertebral joint

71
Q

Sympathetic outflow arises from what nucleus of the cord and what spinal cord levels?

A

Intermediolateral nucleus of T1-L2

72
Q

Best place near nerve root to expose intervertebral herniated disk

A

Shoulder of nerve root

73
Q

Indications for surgery in lumbar spine?

A

Emergent: cauda equina/progressive motor deficit
Elective: incapacitating leg pain, nerve root tension signs, failure to respond to conservative tx

74
Q

Indications for cervical spine surgery?

A

Significant radicular pain, progressive neurologic deficity, myelopathy or radiculopathy

75
Q

Surgical intervention for spinal infection

A 
Open biopsy (if closed failed)
Drainage of abscess
Decompression of cord/nerve root with neurologic deficit
76
Q

Surgical indication for primary spine tumor

A

Open biopsy
Failure of chemo/radiation
Decompression of cord/root for neurologic deficit

77
Q

Surgical indication for metastatic spine tumor

A

Open biopsy
Failure of chemo/rad
Decompression
Intractable pain despite steroids

78
Q

Indication for adult spine scoliosis

A

Progressive deformity, intractable pain, cardiopulm symptoms

79
Q

Name for dorsal ramus of C1 nerve root

A

Suboccipital nerve

80
Q

Anterior cervical diskectomy

A
  1. Plastysma (first muscle)
  2. Palpate carotid - displace laterally
  3. Identify esophagus - displace medially
  4. Anterior spine
81
Q

Which groove is the recurrent laryngeal nerve located?

A

Tracheoesophageal groove

82
Q

Which side of neck does laryngeal nerve have more variable course?

A

Right side - increased risk of injury

83
Q

Complications from anterior cervical diskectomy/fusion?

A

Postop dysphagia, hematoma, recurrent laryngeal nerve palsy, esophageal perforation, Horner

84
Q

How can patient develop horner syndrome after anterior cervical diskectomy?

A

Disruption of sympathetic plexus - dissection too lateral on longus colli muscle

85
Q

Occipitocervical fusion - where is it safe to drill a hole and place a screw in the occiput?

A

Halfway between foramen magnum/transverse sinus, 3cm off midline

86
Q

Drugs that inhibit bony fusion

A

Steroids, NSAIDS, immunosuppresants, nitocine

87
Q

Somatosensory evoked potential?

A

Direct feedback on integrity of posterior columns by stimulating posterior tibial nerve and recording response of somatosensory cortex (spinal cord function, but not motor)

88
Q

Transcranial motor evoked potential

A

Stimulate scalp over motor cortex - integrity of corticospinal tract

89
Q

Pedicle screw stimulation

A

Integrity of pedicle. Bone is insulator - intact pedicle require threshold of 8 mA to activate nerve

90
Q

Bone morphogenetic protein

A

Bone growth factor to promote bone formation

91
Q

How is far lateral disk herniation identified; most common location?

A

Lateral to line drawn between 2 adjacent pedicles - most common is L4-L5

92
Q

Best place to insert intrathecal baclofen pump

A

T10-T12 - spastic diplegia
C5-T2 - spastic tetraplegia
C1-C4 - generalized secondary dystonia

Neurosurgery Rounds (10 decks)

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