summary Cervical Myelopathy is a common form of neurologic impairment caused by compression of the cervical spinal cord most commonly due to degenerative cervical spondylosis. The condition most commonly presents in older patients with symmetric numbness and tingling in the extremities, hand clumsiness, and gait imbalance. Treatment is usually surgical decompression and stabilization as the condition is associated with step-wise progression. Etiology Pathophysiology etiology degenerative cervical spondylosis (CSM) most common cause of cervical myelopathy compression usually caused by: osteophytes discosteophyte complex degenerative spondylolisthesis hypertrophy of ligamentum flavum congenital stenosis symptoms usually begin when congenital narrowing combined with spondylotic degenerative changes in older patients OPLL tumor epidural abscess trauma cervical kyphosis neurologic injury mechanism of injury direct cord compression ischemic injury secondary to compression of anterior spinal artery Associated conditions lumbar spinal stenosis tandem stenosis occurs in lumbar and cervical spine in ~20% of patients Classification of Myelopathy Nurick Classification based on gait and ambulatory function Nurick Classification Grade 0 Root symptoms only or normal Grade 1 Signs of cord compression; normal gait Grade 2 Gait difficulties but fully employed Grade 3 Gait difficulties prevent employment, walks unassisted Grade 4 Unable to walk without assistance Grade 5 Wheelchair or bedbound Ranawat Classification Ranawat Classification Class I Pain, no neurologic deficit Class II Subjective weakness, hyperreflexia, dysesthesias Class IIIA Objective weakness, long tract signs, ambulatory Class IIIB Objective weakness, long tract signs, non-ambulatory Japanese Orthopaedic Association Classification A point scoring system (17 total) based on function in the following categories upper extremity motor function lower extremity motor function sensory functionbladder function Usually a significant improvement at 1-year postop, even in cases of severe myelopathy Presentation of Myelopathy Symptoms neck pain and stiffness axial neck pain (often absent) occipital headache common extremity paresthesias diffuse, bilateral, nondermatomal numbness and tingling weakness and clumsiness bilateral weakness and decreased manual dexterity (dropping object, difficulty manipulating fine objects) gait instability patient feels "unstable" on feet weakness walking up and down stairs gait changes are most important clinical predictor urinary retention rare and only appear late in disease progression not very useful in diagnosis due to high prevalence of urinary conditions in this patient population Physical exam motor weakness usually difficult to detect on physical exam lower extremity weakness is a more concerning finding finger escape sign when patient holds fingers extended and adducted, the small finger spontaneously abducts due to weakness of intrinsic muscle grip and release test normally a patient can make a fist and release 20 times in 10 seconds. myelopathic patients may struggle to do this sensory proprioception dysfunction due to dorsal column involvement occurs in advanced disease associated with a poor prognosis decreased pain sensation pinprick testing should be done to look for global decrease in sensation or dermatomal changes due to involvement of lateral spinothalamic tract vibratory changes are usually only found in severe case of long-standing myelopathy upper motor neuron signs (spasticity) hyperreflexia may be absent when there is concomitant peripheral nerve disease (cervical or lumbar nerve root compression, spinal stenosis, diabetes) inverted radial reflex tapping distal brachioradialis tendon produces ipsilateral finger flexion Hoffmann's sign snapping patients distal phalanx of middle finger leads to spontaneous flexion of other fingers most common physical exam finding sustained clonus > three beats defined as sustained clonus sustained clonus has poor sensitivity (~13%) but high specificity (~100%) for cervical myelopathy Babinski test considered positive with extension of great toe gait and balance toe-to-heel walk patient has difficulty performing Romberg test patient stands with arms held forward and eyes closed loss of balance consistent with posterior column dysfunction provocative tests Lhermitte Sign test is positive when extreme cervical flexion leads to electric shock-like sensations that radiate down the spine and into the extremities Evaluation Radiographs recommended views cervical AP, lateral, oblique, flexion, and extension views general findings degenerative changes of uncovertebral and facet joints osteophyte formation disc space narrowing decreased sagittal diameter cord compression occurs with canal diameter is < 13mm lateral radiograph important to look for diameter of spinal canal a Pavlov ratio of less than 0.8 suggest a congenitally narrow spinal canal predisposing to stenosis and cord compression sagittal alignment C2 to C7 alignment determined by tangential lines on the posterior edge of the C2 and C7 body on lateral radiographs in neutral position local kyphosis angle the angle between the lines drawn at the posterior margin of most cranial and caudal vertebral bodies forming the maximum local kyphosis oblique radiograph important to look for foraminal stenosis which often caused by uncovertebral joint arthrosis flexion and extension views important to look for angular or translational instability look for compensatory subluxation above or below the spondylotic/stiff segment sensitivity/specificity changes often do not correlate with symptoms 70% of patients by 70 yrs of age will have degenerative changes seen on plain xrays MRI indications MRI is study of choice to evaluate degree of spinal cord and nerve root compression findings effacement of CSF indicates functional stenosis spinal cord signal changes seen as bright signal on T2 images (myelomalacia) signal changes on T1-weighted images correlate with a poorer prognosis following surgical decompression compression ratio of < 0.4 carries poor prognosis CR = smallest AP diameter of cord / largest transverse diameter of cord sensitivity/specificity has high rate of false positive (28% greater than 40 will have findings of HNP or foraminal stenosis) CT without contrast can provide complementary information with an MRI, and is more useful to evaluate OPLL and osteophytes CT myelography more invasive than an MRI but gives excellent information regarding degrees of spinal cord compression useful in patients that cannot have an MRI (pacemaker), or have artifact (local hardware) contrast given via C1-C2 puncture and allowed to diffuse caudally, or given via a lumbar puncture and allowed to diffuse proximally by putting patient in trendelenburg position. Nerve conduction studies high false negative rate may be useful to distinguish peripheral from central process (ALS) Differential Normal aging mild symptoms of myelopathy often confused with a "normal aging" process Stroke Movement disorders Vitamin B12 deficiency Amyotrophic lateral sclerosis (ALS) Multiple sclerosis Treatment Nonoperative observation, NSAIDs, therapy, and lifestyle modifications indications mild disease with no functional impairment function is a more important determinant for surgery than physical exam finding patients who are poor candidates for surgery modalities medications (NSAIDS, gabapentin) immobilization (hard collar in slight flexion) physical therapy for neck strengthening, balance, and gait training traction and chiropractic modalities are not likely to benefit and do have some risks be sure to watch patients carefully for progression outcomes improved nonoperative outcomes associated with patients with larger transverse area of the spinal cord (>70mm2) some studies have shown improvement with immobilization in patients with very mild symptoms Operative surgical decompression, restoration of lordosis, stabilization indications significant functional impairment AND 1-2 level disease lordotic, neutral or kyphotic alignment techniques appropriate procedure depends on cervical alignment number of stenotic levels location of compression medical conditions (e.g., goiter) treatment procedures include (see below) anterior cervical diskectomy/corpectomy and fusion posterior laminectomy and fusion posterior laminoplasty combined anterior and posterior procedure cervical disk arthroplasty outcomes prospective studies show improvement in overall pain, function, and neurologic symptoms with operative treatment early recognition and treatment prior to spinal cord damage is critical for good clinical outcomes goals prevention of continued neurologic decline Techniques Goals optimal surgical treatment depends on the individual. Things to consider include number of stenotic levels sagittal alignment of the spine degree of existing motion and desire to maintain medical comorbidities (eg, dysphasia) simplified treatment algorithm Anterior Decompression and Fusion (ACDF) alone indications mainstay of treatment in most patients with single or two-level disease fixed cervical kyphosis of > 10 degrees anterior procedure can correct kyphosis compression arising from 2 or fewer disc segments pathology is anterior (OPLL, soft discs, disc osteophyte complexes) approach uses Smith-Robinson anterior approach decompression corpectomy and strut graft may be required for multilevel spondylosis two level corpectomies tend to be biomechanically vulnerable (preferable to combine single level corpectomy with adjacent level diskectomy) 7% to 20% rates of graft dislodgement with cervical corpectomy with associated severe complications, including death, reported. fixation anterior plating functions to increase fusion rates and preserve position of interbody cage or strut graft pros & cons advantages compared to posterior approach lower infection rate less blood loss less postoperative pain disadvantages avoid in patients with poor swallowing function Anterior corpectomy and fusion (ACF) indications extensive retrovertebral disease cervical kyphosis preventing from adequate decompression posteriorly technique anterior fixation alone amenable in up to 2-level corpectomy use of static anterior cervical plate with struct graft combined anterior and posterior fixation indicated in 3-level corpectomy and above use of anterior strut graft and plating combined with posterior lateral mass screw construct anterior fixation alone in 3-level and aboveresults in a high (>70%) catastrophic failure rate Laminectomy with posterior fusion indications multilevel compression with kyphosis of < 10 degrees > 13 degrees of fixed kyphosis is a contraindication for a posterior procedure in flexible kyphotic spine, posterior decompression and fusion may be indicated if kyphotic deformity can be corrected prior to instrumentation contraindications fixed kyphosis of > 10 degrees is a contraindication to posterior decompression will not adequately decompress spinal cord as it is "bowstringing" anterior pros & cons fusion may improve neck pain associated with degenerative facets not effective in patients with > 10 degrees fixed kyphosis Laminoplasty indications gaining in popularity useful when maintaining motion is desired avoids complications of fusion so may be indicated in patients at high risk of pseudoarthrosis congenital cervical stenosis contraindications cervical kyphosis > 13 degrees is a contraindication to posterior decompression will not adequately decompress spinal cord as it is "bowstringing" anterior severe axial neck pain is a relative contraindication and these patients should be fused technique volume of canal is expanded by hinged-door laminoplasty followed by fusion usually performed from C3 to C7 open door technique hinge created unilateral at junction of lateral mass and lamina and opening on opposite side opening held open by bone, suture anchors, or special plates French door technique hinge created bilaterally and opening created midline pros & cons advantages allows for decompression of multilevel stenotic myelopathy without compromising stability and motion (avoids postlaminectomy kyphosis) lower complication rate than multilevel anterior decompression especially in patients with OPLL a motion-preserving technique pseudoarthrosis not a concern in patients with poor healing potential (diabetes, chronic steroid users) can be combined with a subsequent anterior procedure combined laminoplasty with fusion has theoretical benefit of decreased muscular atrophy and preserved muscle attachments disadvantages higher average blood loss than anterior procedures postoperative neck pain still associated with loss of motion outcomes equivalent to multilevel anterior decompression and fusion Combined anterior and posterior surgery indications multilevel stenosis in the rigid kyphotic spine multi-level anterior cervical corpectomies postlaminectomy kyphosis Occipitocervical fusion indications periodontoid pannus posterior-only occipitocervical fusion is safe and effective in promoting pannus resolution transoral approaches are associated with increased morbidity, especially when surgical time exceeds 4 hours Laminectomy alone indications rarely indicated due to risk of post-laminectomy kyphosis pros & cons progressive kyphosis 11 to 47% incidence if laminectomy performed alone without fusion Complications Surgical Infection higher rate of surgical infection with posterior approach than anterior approach Pseudoarthrosis incidence 12% for single level fusions, 30% for multilevel fusions treatment treat with either posterior wiring or plating or repeat anterior decompression and plating if patient has symptoms of radiculopathy Postoperative C5 palsy incidence reported to occur in ~ 4.6% of patients after surgery for cervical compression myelopathy higher incidence reported in males no significant differences between patients undergoing anterior decompression and fusion and posterior laminoplasty higher rates reported following posterior laminectomy and fusion occurs immediately postop to weeks following surgery mechanism mechanism is controversial in laminectomy patients, it is thought to be caused by tethering of nerve root with dorsal migration of spinal cord following removal of posterior elements some studies suggest that prophylactic bilateral keyhole foraminotomies at the C4/5 level may help reduce the incidence of this complication prognosis patients with postoperative C5 palsy generally have a good prognosis for functional recovery, but recovery takes time prolonged recovery associated with: multilevel paresis motor grade ≤2 sensory involvement with intractable pain Recurrent laryngeal nerve injury approach in the past it has been postulated that the RLN is more vulnerable to injury on the right due to a more aberrant pathway recent studies have shown there is not an increased injury rate with a right sided approach prolonged retractor placement at the tracheoesophageal junction places RLN at risk for injury treatment if you have a postoperative RLN palsy, watch over time if not improved over 6 weeks, then ENT consult to scope patient and inject teflon if you are performing revision anterior cervical surgery, and there is an any suspicion of a RLN from the first operation, obtain ENT consult to establish prior injury if patient has prior RLN nerve injury, perform revision surgery on the same as the prior injury/approach to prevent a bilateral RLN injury Hardware failure and migration 7-20% with two level anterior corpectomies two-level corpectomies should be stabilized from behind Postlaminectomy kyphosis treat with anterior/posterior procedure Postoperative axial neck pain Vertebral artery injury Esophageal Injury Dysphagia & alteration in speech Multiple studies have demonstrated the application of local steroid in retropharyngeal space prior to wound closure decreases rate of dysphagia Epidural hematoma rare complication 1:1000 incidence associated with post-operative motor weakness and parasthesias emergent MRI and hematoma evacuation early evacuation results in better neurologic recovery MRI appearance of hematoma depends on age hyperacute (<24 hours): hyperintense T2, hypointense T1 Prognosis Natural history tends to be slowly progressive and rarely improves with nonoperative modalities progression characterized by steplike deterioration with periods of stable symptoms Prognostic variable early recognition and treatment prior to spinal cord damage is critical for good clinical outcomes
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Posterior Cervical Laminectomy and Fusion Derek W. Moore Spine - Cervical Myelopathy Technique Guide CPT Codes: 62005, Elevation of depressed skull fracture; compound or comminuted, extradural 23615, Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed; 23616 Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed; with proximal humeral prosthetic replacement Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Anterior Cervical Diskectomy and Fusion with Plate and Peak Cage (ACDF) Andrew Hsu Spine - Cervical Radiculopathy
QUESTIONS 1 of 64 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ18SP.54) A 68-year-old male undergoes the procedure depicted in Figures A and B. Post-operatively, you notice that the patient has fairly significant hoarseness. With respect to the most likely injured structure, which of the following is correct? QID: 211696 FIGURES: A B Type & Select Correct Answer 1 Rate of injury is greater on right-sided versus left-sided approaches 17% (159/922) 2 The left side courses around the Subclavian artery 10% (90/922) 3 Immediate re-exploration is required 1% (5/922) 4 Rate of injury is greater with revision surgery 70% (647/922) 5 It originates from cervical branches C1-C3 2% (16/922) L 4 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ18SP.57) A 63-year-old male undergoes a C4-C7 posterior fusion and laminectomy secondary to significant spinal cord stenosis. Pre-operative examination reveals neck pain, spasticity signs, and finger clumsiness. Post-operative day one, he complains of significant weakness with raising his left arm overhead and on further examination, you notice a clear sensation deficit over the lateral shoulder. What is the most commonly affected structure? QID: 211729 Type & Select Correct Answer 1 C4 nerve root 3% (61/1857) 2 Suprascapular nerve 1% (20/1857) 3 Axillary nerve 9% (163/1857) 4 C6 nerve root 2% (36/1857) 5 C5 nerve root 84% (1569/1857) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ18SP.65) A 76-year-old female with severe cervical myelopathy presents with the radiographs depicted in Figure A. She undergoes the procedure depicted in Figure B. On the morning of the first postoperative day, she develops significant dysphagia. Which of the following techniques has been shown in the literature to decrease the symptoms of dysphagia and could have been utilized in this patient? QID: 211817 FIGURES: A B Type & Select Correct Answer 1 Application of topical tranexamic acid (TXA) anterior to ACDF construct 9% (168/1918) 2 Application of local corticosteroid anterior to ACDF construct 43% (829/1918) 3 Utilization of a posterior-only construct 21% (404/1918) 4 Preoperative utilization of intravenous TXA 15% (291/1918) 5 Utilization of a longitudinal incision during the anterior approach 11% (205/1918) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ18.236) A 62-year-old patient presents with gait instability, hand clumsiness, and urinary incontinence that have progressively worsened over the past 2 years. Figures A and B are the sagittal and axial T2 MRI weighted images. The patient opts to undergo surgical treatment. Which of the following is paired with the best treatment and the most correct statement regarding cervical myelopathy? QID: 213132 FIGURES: A B Type & Select Correct Answer 1 Cervical laminectomy C3-7 which is likely to result in complete motor recovery 2% (35/2013) 2 C5 and C6 corpectomy and ACDF C4-7 with good recovery prognosis expected from the presence of myelomalacia 6% (130/2013) 3 Posterior decompression and fusion C4-7 with the goal of surgery being to prevent further neurologic deterioration 72% (1453/2013) 4 Anterior cervical discectomy and fusion (ACDF) C5-7 which is associated with lower rates of C5 palsy compared to posterior decompression 18% (368/2013) 5 Laminoplasty which ideally addresses a kyphotic spine with focal disease 0% (10/2013) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (SBQ18SP.7) A 56-year-old man undergoes the procedure depicted in Figure A for severe cervical myelopathy. Postoperatively, he develops 3 out of 5 weakness in one motor group in his right upper extremity. Which of the following is the nerve root and functional deficit that most likely describes this new deficit? QID: 211179 FIGURES: A Type & Select Correct Answer 1 C4; deltoid weakness 5% (111/2326) 2 C4; biceps weakness 1% (20/2326) 3 C5; biceps weakness 86% (2009/2326) 4 C5; triceps weakness 2% (36/2326) 5 C6; triceps weakness 5% (127/2326) N/A Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (SBQ18SP.2) A 72-year-old patient with progressive myelopathy undergoes a cervical laminoplasty alone. Given this scenario with all other patients factors being the same, which of the following preoperative images would suggest the best indication for this procedure? QID: 211124 FIGURES: A B C D E Type & Select Correct Answer 1 A 46% (1138/2467) 2 B 13% (326/2467) 3 C 32% (798/2467) 4 D 3% (75/2467) 5 E 4% (105/2467) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ18SP.67) All of the following are characteristics of myelopathy hand EXCEPT: QID: 211839 Type & Select Correct Answer 1 Dysdiadochokinesia 22% (483/2148) 2 Intrinsic plus posturing 51% (1103/2148) 3 Involuntary flexion of the thumb and/or index finger when the examiner flicks the fingernail of the middle finger down 3% (68/2148) 4 Small finger escape 8% (168/2148) 5 Webspace atrophy 15% (316/2148) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ16.19) A 64-year-old male presents for evaluation of slowly progressive neck pain, loss of manual dexterity, and gait disturbance. Assuming the patient's alignment is unchanged on flexion/extension radiographs, which of the following images suggests a contraindication for an isolated posterior surgical approach? QID: 8781 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 11% (262/2444) 2 Figure B 10% (254/2444) 3 Figure C 73% (1786/2444) 4 Figure D 2% (57/2444) 5 Figure E 2% (59/2444) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ14.199) A 68-year-old male presents with gait instability, clumsiness of the hands, and the MRI images shown in Figure A. You decide to proceed with surgical decompression. When planning your surgical treatment, it is important to note that compared to a posterior approach, the anterior procedure has: QID: 5609 FIGURES: A Type & Select Correct Answer 1 Higher risk of infection 2% (80/4145) 2 Lower risk of C5 radiculopathy 17% (707/4145) 3 Higher over-all complication rate 16% (667/4145) 4 Lower average blood loss 62% (2562/4145) 5 Increased rate of numbness to the long finger and wrist flexion weakness 3% (106/4145) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.181.1) An 80-year-old man complains of axial neck pain and worsening upper extremity weakness after striking his forehead during a fall. For the last 2 years, he has been using a walker because of frequent falls and no longer wears dress shirts because of difficulty with buttons. Examination reveals a positive finger-escape sign, and he is unable to make a fist and release 10 times in 10 seconds. Distal lower extremity muscle groups are stronger than proximal muscle groups. There is no instability on flexion-extension radiographs. An MRI image is shown in Figure A. Which of the following is the most appropriate treatment of the options listed? QID: 216655 FIGURES: A Type & Select Correct Answer 1 Gait training 2% (14/839) 2 MRI of the lumbar spine 9% (72/839) 3 C4 corpectomy and instrumented fusion 2% (20/839) 4 C4 and C5 corpectomy and anterior instrumented fusion 11% (94/839) 5 Posterior cervical decompression and fusion 76% (634/839) L 5 Question Complexity Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ13.124) A 65 year-old female presents to your clinic with a chief complaint of difficulty walking. She states that she has had low back pain and balance difficulties for the last 2 years, but over the last few months new bilateral posterior thigh and buttock pain has prevented her from walking more than 100 feet. She states the only place she can walk comfortably is in the grocery store.On physical exam she is unable to preform a tandem gait, and she has 5/5 strength with hip flexion, knee flexion/extension, ankle dorsiflexion/plantar flexion and great toe extension. Her sensation is intact in L2-S2, and she has equal and symmetric 3+ achilles and patellar reflexes. She has 8 beats of clonus, and a down-going Babinski reflex bilaterally. Radiographs of her lumbar spine are seen in figures A and B. What is the next step. QID: 4759 FIGURES: A B Type & Select Correct Answer 1 MRI of her lumbar spine 24% (1030/4348) 2 Six weeks of physical therapy and anti-inflammatory medication 5% (227/4348) 3 Determine the patients ankle brachial index 3% (128/4348) 4 Cervical Spine MRI 67% (2909/4348) 5 Lumbar Epidural Injection 0% (10/4348) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ12SP.7) Cervical decompression and fusion through a posterior approach alone would be most appropriate in a patient with progressive neurologic deficits and the MRI images shown in which of the following figures? QID: 3705 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 6% (138/2388) 2 Figure B 13% (313/2388) 3 Figure C 10% (249/2388) 4 Figure D 64% (1523/2388) 5 Figure E 6% (133/2388) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ12SP.1) A 65-year-old female with a history of breast cancer presents with bilateral buttock and leg pain that is worse with walking and improves with sitting. In addition, she reports that she feels unsteady on her feet and requires holding the railing when going up and down stairs. On physical exam she is unable to complete a tandem gait and has hip flexion weakness, ankle dorsiflexion weakness, and ankle plantar flexion weakness. Her reflex exam shows 3+ bilateral patellar reflexes. Radiographs and an MRI are shown in Figure A and B. What is the next most appropriate step in management. QID: 3699 FIGURES: A B Type & Select Correct Answer 1 Lumbar epidural injection 1% (51/4814) 2 Physical therapy with core strengthening and anti-inflammatory medications as needed 3% (161/4814) 3 Lumbar decompression 3% (123/4814) 4 Lumbar decompression and fusion 21% (1009/4814) 5 MRI of the cervical and thoracic spine 71% (3432/4814) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ12SP.16) A 50-year-old female presents with 3 years of increasing clumsiness in her hands that has progressed to the point that it is now difficult to open jars and use her keys. On physical exam she is unable to perform a tandem gait, has positive Hoffman’s signs bilaterally, and has 3+ patellar reflexes. She has 5/5 strength in all her major muscle groups. Figure A is her mid sagittal MRI. Figure B, C and D are axial images at C4/5, C5/6 and C6/7 respectively. What is the most appropriate treatment? QID: 3714 FIGURES: A B C D Type & Select Correct Answer 1 Physical therapy and close observation 2% (85/5619) 2 Physical therapy, an epidural steroid injection and evaluation after the injection 2% (129/5619) 3 C5/6 and C6/7 Anterior Cervical Discectomy and Fusion 90% (5075/5619) 4 C5, C6 and C7 posterior laminectomy 4% (251/5619) 5 Posterior C6 and C7 foraminotomies 1% (36/5619) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (SBQ12SP.5) A 70-year-old presents with gait instability and difficulty buttoning his shirts which has been progressively worsening over the last several months. His physical exam is notable for exaggerated patellar reflexes and sustained clonus. The provocative maneuver shown in Figure V would most likely produce which of the following symptoms or physical exam finding? QID: 3703 FIGURES: V Type & Select Correct Answer 1 Electric shock-like sensations that radiate down the spine and into the extremities 91% (4944/5447) 2 Involuntary contraction of the thumb IP joint 2% (104/5447) 3 Spontaneously abduction of the 5th digit 2% (89/5447) 4 Spontaneously extension of the great toe 1% (59/5447) 5 Unilateral arm pain and paresthesias in a dermatomal distribution 4% (207/5447) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ12.247) A 51-year-old presents for evaluation of clumsiness of her hands. She complaints of difficulty with buttoning her shirt. On physical exam she is unable to preform a tandem gait. The strength in her upper extremities proximally is graded a 4/5, but she has significant bilateral intrinsic hand weakness and a positive Hoffmann's sign. When told to hold her fingers in an extended and adducted position, her ring and small fingers flex and abduct within 20 seconds. What is the most appropriate next step in management? QID: 4607 Type & Select Correct Answer 1 Reassurance and period of observation 0% (16/3287) 2 Night splinting in cock-up wrist splints 0% (16/3287) 3 Carpal tunnel corticosteroid injection 0% (15/3287) 4 Electromyographic studies of the upper extremities 2% (75/3287) 5 Cervical Spine MRI 96% (3148/3287) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ12.174) A 47-year old female with Type-2 diabetes and a pacemaker presents with bilateral buttock and leg pain that is worse with prolonged walking and improves with sitting. Her lower extremity symptoms are severe enough that she reports she feels "unstable" on her feet. Physical exam shows 5/5 strength in all muscles groups in the lower extremity. Figure V shows a result of forced ankle dorsiflexion on physical exam. A lumbar myelogram is performed and shown in Figure A, B, and C. What is the most appropriate next step in treatment. QID: 4534 FIGURES: V A B C Type & Select Correct Answer 1 Lumbar decompression 5% (221/4139) 2 Lumbar decompression with arthrodesis 29% (1202/4139) 3 A trial of physical therapy and NSAIDS 9% (369/4139) 4 Lumbar epidural steroid injections 2% (80/4139) 5 CT myelogram of cervical spine 53% (2212/4139) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.251) A 68-year-old female presents with progressive loss of ability to ambulate and dexterity problems with her hands. Six months ago she was able to walk with a cane, but now has difficulty with ambulating with a walker. She also reports difficulty with her hands and needs assistance with eating. Physical exam shows limited neck extension. Radiographs, tomography, and magnetic-resonance-imaging are shown in Figure A, B, and C respectively. What is the most appropriate treatment? QID: 3674 FIGURES: A B C Type & Select Correct Answer 1 NSAIDS, physical therapy, and clinical observation 1% (65/5244) 2 C3 to C6 cervical laminectomy 1% (29/5244) 3 C3 to C6 laminoplasty using an open-door technique 1% (53/5244) 4 C3 to C6 decompressive laminectomy with instrumented fusion 15% (787/5244) 5 Multilevel anterior cervical decompression with strut grafting and anterior plate fixation, followed by posterior decompression and fusion 82% (4289/5244) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ11.209) A 56-year-old woman presents for initial evaluation of her neck pain which has been worsened by activity for the last several years. On exam, she has 5/5 motor strength throughout bilateral upper and lower extremities. She has a normal gait and no difficulties with manual dexterity. Reflex testing shows hyperreflexia in bilateral Achilles tendons. Lateral radiographs are shown in Figure A, and MRI scan is shown in Figures B and C. What is the most appropriate management? QID: 3632 FIGURES: A B C Type & Select Correct Answer 1 C4-7 anterior decompression with instrumented fusion 11% (427/3758) 2 C4-7 posterior decompression with instrumented fusion 7% (278/3758) 3 C4-7 posterior decompression without fusion 2% (58/3758) 4 C5/6 anterior discectomy and fusion 20% (747/3758) 5 Physical therapy 59% (2227/3758) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ10.163) Which of the following variables has the strongest association with poor clinical outcomes in patients who undergo expansive laminoplasty for cervical spondylotic myelopathy? QID: 3256 Type & Select Correct Answer 1 Multi-level stenosis 6% (267/4134) 2 Duration of symptoms 15% (633/4134) 3 Local kyphosis angle > 13 degrees 73% (3025/4134) 4 Osteoporosis 2% (85/4134) 5 MRI finding of CSF effacement 2% (101/4134) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (SBQ09SP.3) Figures A-E show the neutral lateral cervical radiographs and corresponding T2-weighted MRI of 5 patients with symptoms and physical exam findings consistent with cervical myelopathy. In which of these patients would a cervical laminoplasty alone be contraindicated as surgical treatment? QID: 3366 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 2% (46/2725) 2 Figure B 5% (124/2725) 3 Figure C 6% (166/2725) 4 Figure D 84% (2293/2725) 5 Figure E 3% (78/2725) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ09.253) All of the following clinical signs are characteristic of an upper motor neuron disorder EXCEPT QID: 3066 Type & Select Correct Answer 1 Fasciculations 65% (2192/3362) 2 Spasticity 4% (148/3362) 3 Muscle weakness 28% (938/3362) 4 Exaggerated deep tendon reflexes 1% (28/3362) 5 Sustained clonus 1% (45/3362) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.131) A 56-year-old male presents with gait imbalance and decreased manual dexterity. Sagittal T2 MRI images are shown in Figures A and B. What is the most appropriate surgical management? QID: 517 FIGURES: A B Type & Select Correct Answer 1 Posterior foraminotomy 1% (22/3019) 2 Anterior decompression and fusion 80% (2425/3019) 3 Laminectomy alone 2% (70/3019) 4 Laminectomy and fusion 14% (422/3019) 5 Hinge-door laminoplasty 2% (60/3019) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ08.106) Following a C3-C7 laminoplasty in a myelopathic patient with cervical stenosis, the most common neurologic complication would manifest with which of the following new postoperative exam findings QID: 492 Type & Select Correct Answer 1 Change in voice and difficulty swallowing 12% (504/4198) 2 Triceps weakness 5% (192/4198) 3 Deviation of the tongue 2% (84/4198) 4 Ptosis, miosis, anhydrosis 7% (312/4198) 5 Biceps weakness 73% (3085/4198) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ07.189) In patients with symptoms of cervical myelopathy, what variable is associated with improved outcomes with nonoperative management? QID: 850 Type & Select Correct Answer 1 Increased Central Motor Conduction Time (CMCT) 3% (66/2015) 2 Transverse area of the spinal cord >70mm2 62% (1256/2015) 3 Isolated low intramedullary signal on T1WI 5% (95/2015) 4 A midsagittal diameter of the spinal canal of <13mm 4% (74/2015) 5 Younger age 26% (515/2015) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ07.45) A 67-year-old woman presents with low back pain and bilateral buttock and leg pain. She prefers to stoop over the shopping cart whenever shopping. She recently noticed difficulty picking up small objects and buttoning her shirt. Physical exam shows normal strength in her lower extremities, and 3+ bilateral patellar reflexes. Gait examination shows a broad, unsteady gait. Flexion and extension radiographs of the lumbar spine are shown in Figure A and B. A lumbar MRI is shown in Figure C. What is the most appropriate next step in management? QID: 706 FIGURES: A B C Type & Select Correct Answer 1 Lumbar decompression only 1% (39/3441) 2 Lumbar decompression and instrumented fusion 17% (598/3441) 3 Discogram 0% (2/3441) 4 MRI of the cervical spine 80% (2751/3441) 5 Lumbar epidural injection 1% (34/3441) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ07.180) A 63-year-old female presents with a broad-based shuffling gait, loss of manual dexterity, and exaggerated deep tendon reflexes in the lower extremities. A T2-weighted MRI scan is shown in Figure A. What is the most appropriate treatment? QID: 841 FIGURES: A Type & Select Correct Answer 1 C4 to C7 cervical laminectomy 1% (46/3180) 2 C4 to C7 cervical laminectomy with fusion 22% (709/3180) 3 C4 to C7 laminoplasty with plate fixation 4% (116/3180) 4 Multilevel anterior cervical decompression with fusion and stabilization 72% (2279/3180) 5 Immobilization in a halo orthosis for 6 weeks followed by gradual ROM exercises 0% (7/3180) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ05.92) Postoperative radiculopathy is a known complication of posterior cervical decompression for myelopathy. One potential mechanism of nerve root injury is thought to be tethering of the nerve root with dorsal migration of the spinal cord. What is the most common radicular pattern seen with this condition? QID: 978 Type & Select Correct Answer 1 Motor-dominant radiculopathy with weakness of the deltoid 64% (1724/2700) 2 Sensory-dominant radiculopathy with pain in the lateral shoulder 19% (526/2700) 3 Motor-dominant radiculopathy with weakness of the wrist extensors 7% (195/2700) 4 Sensory-dominant radiculopathy with pain in the lateral forearm 6% (175/2700) 5 Motor-dominant radiculopathy with weakness of the triceps 3% (70/2700) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ04.207) A 45-year-old man presents to your office with difficulty ambulating and buttoning his shirt. It started two years ago but has worsened significantly over the last year. On physical exam he is unable to perform a tandem gait and has a positive Hoffman's sign bilaterally, however he has no clonus and a down-going babinski bilaterally. He has 4/5 strength in his hands, but 5/5 strength in all other muscle groups. Figure A is a sagittal MRI. Figures B and C are an axial MRI cuts through C4/5 and C5/6, respectively. What is the appropriate next step? QID: 1312 FIGURES: A B C Type & Select Correct Answer 1 Observation 1% (19/3061) 2 Epidural injection 1% (22/3061) 3 Physical therapy and anti-inflammatory medication 5% (150/3061) 4 Anterior cervical diskectomy and fusion 83% (2543/3061) 5 Posterior cervical laminotomy-foraminotomy 10% (303/3061) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ04.205) A 35-year-old man complains of clumsiness when buttoning his shirt and frequent episodes of falling when ambulating. Further work-up reveals congenital cervical spinal stenosis with spinal cord compression. Because of his young age, posterior laminoplasty is performed. Which nerve root is most likely to be adversely affected following surgery? QID: 1310 Type & Select Correct Answer 1 C2 3% (75/2941) 2 C3 2% (53/2941) 3 C4 3% (87/2941) 4 C5 83% (2441/2941) 5 C6 9% (274/2941) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ04.61) A 66-year-old male presents with neck pain, difficulty with fine motor activities like buttoning shirts, and mild gait instability. On physical examination he has 5 of 5 motor strength in all muscles groups in his upper and lower extremities, a bilateral Hoffman sign, bilateral 3+ patellar reflexes, 3 beats of clonus on the right, and no clonus on the left. Radiographs show segmental kyphosis of 12 degrees from C4 to C7. MRI shows circumferential compression at C5/6 with complete effacement of CSF and T2 intramedullary signal. What is the most accurate description of how his symptoms will progress over time? QID: 1166 Type & Select Correct Answer 1 Stable over time. 1% (22/3069) 2 Improvement following a course of high-dose IV spinal steroids. 1% (19/3069) 3 Improvement following a period of rest, physical therapy, and oral medication. 1% (41/3069) 4 Slow progression in a pattern of stepwise deterioration following periods of stable symptoms. 88% (2691/3069) 5 Rapid and serious deterioration requiring urgent surgical treatment. 9% (272/3069) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic
All Videos (17) Podcasts (2) Login to View Community Videos Login to View Community Videos 2022 Castellvi Spine Symposium Cervical Myelopathy: Pro - Decompression and Posterior Fusion - William C. Welch, MD Anonymous Person Spine - Cervical Myelopathy 1 week ago 56 views 4.0 (1) 2022 Castellvi Spine Symposium Pro: Cervical Laminoplasty - Marc A. Weinstein, MD Marc Weinstein Spine - Cervical Myelopathy 1 week ago 108 views 4.0