With regards to the compression ration above - the defition states that it is the smallest/largest "CORD" diameter but the illustration is of the spinal canal. What is the appropriate measurement diameters of CORD or SPINAL CANAL?
A 45-year old male is involved in a motor vehicle accident and presents to the emergency room with complaints of neck pain. Physical exam shows he is an ASIA E. An open-mouth cervical radiograph is shown in Figure A. A sagittal CT scan is shown in Figure B. A CT axial angiogram is shown in Figure C. Which of the following treatment options is contraindicated in this patient.
Anterior screw osteosynthesis with single cannulated screw
Anterior screw osteosynthesis with two cannulated screws
C1-C2 transarticular screws
Posterior C1-C2 wiring with autograft
ASIA E is defined as patients who had previous SCI and has regained full neurologic function. Is this applicable here?
In pediatric discitis, which of the following is the most accurate description of the radiographic findings.
The earliest radiographic finding is loss of normal lumbar lordosis, followed by disc space narrowing and endplate erosion.
The earliest radiographic finding is disc space narrowing, followed by endplate erosion and loss or normal lumbar lordosis.
The earliest radiographic finding is endplate erosion, followed by disc space narrowing and loss or normal lumbar lordosis.
The earliest radiographic finding is scalloping of the inferior endplate, followed by disc space narrowing and endplate erosion.
The earliest radiographic finding is vertebra magna, followed by disc space narrowing and endplate erosion.
Illustration C says 5 years after presentation
Straight leg raise test
Physical examination maneuver to identify L5-S1 radiculopathy.
Adult Isthmic Spondylolisthesis
symptoms of neurogenic claudication rare because these slips rarely progress beyond Grade II. I think this statement is incorrect. they can be any grade secondly since the neural arch is broken hence forward slippage does not narrow the canal. The Above grade II statement though is true for degenerative slips.
J Am Acad Orthop Surg. 2011 Dec;19(12):722-7.
Infantile Idiopathic Scoliosis
Dr. Riaz,I do not have the textbook you mention, so I can not take a look to see what their recommendations are. However, the resources I am familiar with would indeed recommend some form of active treatment for Infantile Idiopathic Scoliosis (IIS) if it is progressive beyond 30 or 35°. That active treatment is not necessarily surgery though. For children under the age of 3 (and thus with IIS rather than Juvenile IS) those curves would likely benefit from serial casting as described by Mehta. Surgery for fusion or growing rod constructs would still wait until curves were larger, around 50°.Here are two articles with good reviews of IIS and Early Onset Scoliosis:"Growth friendly" spine surgery: management options for the young child with scoliosis.Gomez JA, Lee JK, Kim PD, Roye DP, Vitale MGJ Am Acad Orthop Surg. 2011 Dec. pii: 19/12/722. 19. (12). :722-7PMID: 22134204 (Link to Abstract)Early onset idiopathic scoliosis.Gillingham BL, Fan RA, Akbarnia BAJ Am Acad Orthop Surg. 2006 Feb. pii: 14/2/101. 14. (2). :101-12PMID: 16467185 (Link to Abstract)
Spinal Cord Injury
Orthopaedic Principles-SICOT Meeting organised by Dr Hitesh Gopalan
great and simple
The Degree of Cobb Angle for Surgery is 35 degrees to my knowledge ref Pediatrics Orthopaedics: Core Knowledge by John Dormans
An awake and cooperative patient presents to the emergency room with the injury seen in the CT scan in Figure A. Prior to the CT scan he had an ASIA Impairment Scale of E. Upon returning from the CT scanner he has an ASIA Impairment Scale of D. What is the most appropriate first step in management?
Immediate closed reduction with cervical traction
Immediate anterior open reduction and surgical fixation
Spinal dose steroids
Cervical immobilization, observation, and serial neurologic exams
Appreciate expert input from Drs. Moore and Vaccaro. Still confused about the reasoning behind our algorithm and timing of MRI for testing purposes. If we have neuro decline during a closed reduction attempt, we stop to get an MRI. If the pt is progressing in neuro decline initially, or has a "significant acute neurologic deficit" prior to reduction, the nature of the injury (i.e. instability, disc herniation, etc.) is/would cause progressive decline regardless of our intervention (which is why we are intervening). Doesn't performing a reduction without imaging have a significant chance to worsen the condition? Dr. Vaccaro's cited reference suggests we are inherently making the injury worse by an increased incidence in disc herniation during reduction. Therefore, would it not be more prudent to assess the nature of the injury prior to any intervention (e.g. closed reduction, open reduction, open fusion/instrumentation) instead of waiting until we try and possibly abort closed reduction by making it worse? If we have to abort closed reduction due to worse exam (unsuccessful attempt), couldn't we have predicted that with an MRI in combination with a significant acute deficit or progressing neuro decline? Is there any data on the association of significant acute neuro deficits and/or progression of deficit and the inability to perform closed reduction, and/or the converse? We can spend the time to wait for an MRI after we abort a closed reduction attempt and before heading to the OR for open reduction, but why not before? From the Dr. Vaccaro cited reference - For testing purposes, is there a guideline or cited literature that orthopaedic surgeons read and neurosurgeons do not read to explain why our algorithm is correct? Also, Dr. Vaccaro's comments imply there is considerable technical skill required to perform the closed reduction and that the inexperienced should obtain an MRI prior to an attempt at reduction. Does this mean that the reduction maneuver is modified depending on the classification of the injury (e.g. presence of disc herniation), or that an inexperienced person should only perform the maneuver if there is no associated soft-tissue injury (e.g. cause/worsen a disc herniation)?
In patients with lumbar disc herniations resulting in significant unilateral leg pain but no functionally limiting weakness, surgical decompression has what long term effects when compared to nonoperative management?
Worse outcomes in pain, physical function, and return to work status at 4 years.
Equivalent outcome in pain and physical function at 4 years.
Improved outcome in pain and physical function at 4 years.
Improved outcome in return to work status only at 4 years.
Worse outcome in return to work status with equivalence in pain and physical function at 4 years.
"I think this question needs to be updated. JAMA forced Weinstein to publish intent to treat which ended up with meaningless data. Spine allowed publication of as-treated analysis which provides much more meaningful data."This is just wrong on many levels. Huge bias is introduced by repackaging the results on 'as-treated' basis. The 'as-treated' results are in fact meaningless, as they are highly open to bias.
This is dubious. Original Weinstein write up states:"Patients in both the surgery and the nonoperative treatment groups improved substantially over a 2-year period. Because of the large numbers of patients who crossed over in both directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis."The problem with the 4 year analysis is that it IS NOT on an 'intention to treat' basis. Therefore it is highly biased.
Spine (Phila Pa 1976). 2014 Feb 01;39(3):E191-8.
In patients with degenerative spondylolisthesis undergoing posterolateral fusion, use of pedicle screws has been shown to confer which of the following effects?
Have no effect on the rate of pseudoarthosis
Decrease the rate of pseudoarthrosis
Increase the level of postoperative pain at one year
Increase patient satisfaction with the procedure
Decrease the rate of postoperative infection
Should add findings from Kornblum (Spine 2004): Pedicle screws 86% vs 56% fusion rates. Patients with solid fusion (both groups) had better clinical outcomes.
L4/5 Far Lateral Disc Herniation on Left. (C1064)
59 / M - The patient is 59-year-old male that was moving a tree branch when he developed severe pain in his left leg 10 days ago. He localizes the pain to his knee and his medial calf and ankle. He reports his pain was so severe initially he could not get off the ground, and has remained severe enough that he is unable to perform ADL, and is having difficulty sleeping. He was given a steroid taper and narcotics by his PCP, but his symptoms remained severe so an MRI was performed and he was referred to my office. He does report initially he could not "extend his knee", but reports that is improving.
Would you operate on this patient acutely
A ten days history of leg pain, with slight improvement on knee extension following steroids and narcotics use, literature supports conservative management with medication and physiotherapy for at least 3months before opting for surgery unless the patient is deteriorating neurologically.
A 75-year-old man presents to your office complaining of inability to lift his head and look ahead. He states that initially he was unable to turn his head sideways, and that this progressed to his current state. A clinical photo is provided in Fig A. Radiographs of his cervical spine and lumbar spine are provided in Figure B and C. What is the most appropriate management?
Anterior osteotomy, anterior decompression and fusion
Halo traction for 6 weeks only
Posterior fusion in situ
Anterior osteotomy, posterior instrumentation
Posterior extension osteotomy, then posterior fusion and instrumentation
Agree with Dr McCarthy
Spine (Phila Pa 1976). 2009 Sep 15;34(20):2222-32.
J Orthop Sci. 2005 Nov;10(6):671-5.
A patient with ankylosing spondylitis and a hip flexion contracture undergoes uneventful right total hip replacement using a Kocher (posterior) approach. This patient is at increased risk for which of the following complications post-operatively?
Posterior hip dislocation
Anterior hip dislocation
Is it that when you release hip flexion contracture, you allow the pelvis to retrovert (pelvic tilt), so acetabulum goes to a more anteverted position an thus make it more prone to anterior dislocation?Thanks.Dave
A 62-year-old man presents with 6 months of bilateral buttock and leg pain that is worse with prolonged standing and relieved with sitting. He denies symptoms with exercise on a stationary bike. Initial treatment including physical therapy, NSAIDS, and an epidural steroid injection provided only temporary relief of his symptoms, which have returned and are now severe. On physical exam he has normal motor strength in his lower extremities, negative straight-leg raise tests bilaterally, and palpable bilateral dorsalis pedis pulses. Lumbar flexion-extension radiographs show no spondylolisthesis or instability. A sagittal and axial T2 MRI is shown in Figure A and B, respectively. What is the most appropriate next step in management?
A decompressive laminectomy with bilateral medial facetectomies and foraminotomies
A decompressive laminectomy, bilateral medial facetectomies and foraminotomies, and an instrumented fusion
A left sided microdiskectomy
Continues physical therapy
Referral to vascular surgery for evaluation for peripheral vascular disease
Even though there says that XR show no listhesis nor segmental instability, the MRI provided shows anterolisthesis (associated with L4-5 facet joint sinovitis) which could make it difficult to take answer #1 as correct if you don´t obviate those findings.For testing purposes, I think MRI image should be revised.Thanks OB.Regards,Dave