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Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC.
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?
Rate of injury is greater on right-sided versus left-sided approaches
The left side courses around the Subclavian artery
Immediate re-exploration is required
Rate of injury is greater with revision surgery
It originates from cervical branches C1-C3
Select Answer to see Preferred Response
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?
C4 nerve root
C6 nerve root
C5 nerve root
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?
Application of topical tranexamic acid (TXA) anterior to ACDF construct
Application of local corticosteroid anterior to ACDF construct
Utilization of a posterior-only construct
Preoperative utilization of intravenous TXA
Utilization of a longitudinal incision during the anterior approach
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?
Cervical laminectomy C3-7 which is likely to result in complete motor recovery
C5 and C6 corpectomy and ACDF C4-7 with good recovery prognosis expected from the presence of myelomalacia
Posterior decompression and fusion C4-7 with the goal of surgery being to prevent further neurologic deterioration
Anterior cervical discectomy and fusion (ACDF) C5-7 which is associated with lower rates of C5 palsy compared to posterior decompression
Laminoplasty which ideally addresses a kyphotic spine with focal disease
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?
C4; deltoid weakness
C4; biceps weakness
C5; biceps weakness
C5; triceps weakness
C6; triceps weakness
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?
All of the following are characteristics of myelopathy hand EXCEPT:
Intrinsic plus posturing
Involuntary flexion of the thumb and/or index finger when the examiner flicks the fingernail of the middle finger down
Small finger escape
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?
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:
Higher risk of infection
Lower risk of C5 radiculopathy
Higher over-all complication rate
Lower average blood loss
Increased rate of numbness to the long finger and wrist flexion weakness
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?
MRI of the lumbar spine
C4 corpectomy and instrumented fusion
C4 and C5 corpectomy and anterior instrumented fusion
Posterior cervical decompression and fusion
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.
MRI of her lumbar spine
Six weeks of physical therapy and anti-inflammatory medication
Determine the patients ankle brachial index
Cervical Spine MRI
Lumbar Epidural Injection
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?
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.
Lumbar epidural injection
Physical therapy with core strengthening and anti-inflammatory medications as needed
Lumbar decompression and fusion
MRI of the cervical and thoracic spine
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?
Physical therapy and close observation
Physical therapy, an epidural steroid injection and evaluation after the injection
C5/6 and C6/7 Anterior Cervical Discectomy and Fusion
C5, C6 and C7 posterior laminectomy
Posterior C6 and C7 foraminotomies
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?
Electric shock-like sensations that radiate down the spine and into the extremities
Involuntary contraction of the thumb IP joint
Spontaneously abduction of the 5th digit
Spontaneously extension of the great toe
Unilateral arm pain and paresthesias in a dermatomal distribution
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?
Reassurance and period of observation
Night splinting in cock-up wrist splints
Carpal tunnel corticosteroid injection
Electromyographic studies of the upper extremities
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.
Lumbar decompression with arthrodesis
A trial of physical therapy and NSAIDS
Lumbar epidural steroid injections
CT myelogram of cervical spine
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?
NSAIDS, physical therapy, and clinical observation
C3 to C6 cervical laminectomy
C3 to C6 laminoplasty using an open-door technique
C3 to C6 decompressive laminectomy with instrumented fusion
Multilevel anterior cervical decompression with strut grafting and anterior plate fixation, followed by posterior decompression and fusion
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?
C4-7 anterior decompression with instrumented fusion
C4-7 posterior decompression with instrumented fusion
C4-7 posterior decompression without fusion
C5/6 anterior discectomy and fusion
Which of the following variables has the strongest association with poor clinical outcomes in patients who undergo expansive laminoplasty for cervical spondylotic myelopathy?
Duration of symptoms
Local kyphosis angle > 13 degrees
MRI finding of CSF effacement
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?
All of the following clinical signs are characteristic of an upper motor neuron disorder EXCEPT
Exaggerated deep tendon reflexes
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?
Anterior decompression and fusion
Laminectomy and fusion
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
Change in voice and difficulty swallowing
Deviation of the tongue
Ptosis, miosis, anhydrosis
In patients with symptoms of cervical myelopathy, what variable is associated with improved outcomes with nonoperative management?
Increased Central Motor Conduction Time (CMCT)
Transverse area of the spinal cord >70mm2
Isolated low intramedullary signal on T1WI
A midsagittal diameter of the spinal canal of <13mm
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?
Lumbar decompression only
Lumbar decompression and instrumented fusion
MRI of the cervical spine
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?
C4 to C7 cervical laminectomy
C4 to C7 cervical laminectomy with fusion
C4 to C7 laminoplasty with plate fixation
Multilevel anterior cervical decompression with fusion and stabilization
Immobilization in a halo orthosis for 6 weeks followed by gradual ROM exercises
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?
Motor-dominant radiculopathy with weakness of the deltoid
Sensory-dominant radiculopathy with pain in the lateral shoulder
Motor-dominant radiculopathy with weakness of the wrist extensors
Sensory-dominant radiculopathy with pain in the lateral forearm
Motor-dominant radiculopathy with weakness of the triceps
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?
Physical therapy and anti-inflammatory medication
Anterior cervical diskectomy and fusion
Posterior cervical laminotomy-foraminotomy
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?
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?
Stable over time.
Improvement following a course of high-dose IV spinal steroids.
Improvement following a period of rest, physical therapy, and oral medication.
Slow progression in a pattern of stepwise deterioration following periods of stable symptoms.
Rapid and serious deterioration requiring urgent surgical treatment.