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A 36-year-old presents to the emergency department with upper back and neck pain after being rear-ended by another vehicle. The patient’s past medical history is significant for ankylosing spondylitis, for which he takes etanercept. On physical exam, he has tenderness to the cervical spine posteriorly, walks with a normal gait and is neurovascularly intact to the bilateral upper and lower extremities. AP and lateral radiographs of the cervical and thoracic spines show squaring of the vertebral bodies but are otherwise unremarkable. What is the best next step?
Flexion extension radiographs of the cervical spine
CT cervical, thoracic and lumbar spines
Soft cervical collar
Outpatient follow up with repeat radiographs in 7-10 days
NSAIDs and physical therapy evaluation
Select Answer to see Preferred Response
A 65 year-old man known to have ankylosing spondylitis slipped on ice and sustained a fall from standing height. Upon arrival to the hospital, the patient complains of neck pain. On physical examination, no neurological deficits are identified. Several hours later the patient develops progressive lower extremity weakness. Figure A is an MRI of the patient’s cervical spine. Management of this patient’s condition should consist of the following:
Immobilization with hard-collar and observation
Dexamethasone followed by repeat MRI
Anterior instrumented fusion
Posterior decompression and instrumented fusion
A 39-year-old male falls off his bicycle and complains of neck pain and tingling in his fingers. Trauma series radiographs are seen in Figures A and B. Which of the following is likely to be true?
Examination would likely reveal a short neck, low posterior hairline and limited neck motion.
Serum human leukocyte antigen B27 is likely to be positive.
He is likely to be of Japanese descent.
The disease is defined by flowing ossification of the anterior longitudinal ligament at 4 consecutive levels.
Rheumatoid factor is likely to be positive.
A 48-year-old man is brought in by emergency services after falling down a flight of stairs. He complains of weakness in both hands. Examination reveals weak grip bilaterally. Injury CT scans are shown in Figure A. What is the most appropriate treatment option?
Hard cervical orthosis
Immobilization in cervico-thoraco-lumbo-sacral orthosis
Anterior decompression and fusion of C4-C7
Posterior decompression and fusion of C5-C6
Posterior decompression and fusion of C3-T2
A 73-year-old male presents to the emergency department after a fall from a ladder complaining of severe acute on chronic neck pain. Physical exam shows he has diffuse tenderness in the posterior cervical spine, normal strength in all motor groups, and 2+ bilateral patellar reflexes. A clinical photograph of him prior to the fall is shown in Figure A. The patient had bilateral hip replacements 2 years ago in the same hospital and his preoperative radiographs are shown in Figure B. He has a long history of chronic low back pain, and radiographs of the lumbar spine from 1 year ago are shown in Figure C. What is the most likely diagnosis, and what should be the next step in management?
Ankylosing spondylitis, immobilize in hard collar in existing kyphotic position, admit for addition imaging and observation
Ankylosing spondylitis, immobilize in hard collar in existing kyphotic position, discharge with followup with surgeon within 5 days
Ankylosing spondylitis, immobilize in hard collar in neutral kyphosis, discharge with followup with surgeon within 5 days
DISH, immobilize in hard collar in existing kyphotic position, admit for addition imaging and observation
DISH, immobilize in hard collar in neutral kyphosis, discharge with followup with surgeon within 5 days
A 55-year-old otherwise healthy man presents to the emergency department with severe back pain after fall down two stairs outside his home. Genetic testing has shown he is positive for HLA-B27. He has no numbness or tingling, full sensation and motor function, and intact bladder/bowel function. His injury is shown in Figures A and B. What is the best course of management?
Bedrest for 3 days then gradual mobilization with thoracolumbrosacral orthosis (TLSO)
Immediate mobilization with TLSO
TLSO placement, standing upright xrays, then mobilization based on alignment on xrays
Posterior fusion with short segment pedicle screw fixation
Posterior fusion with long segment pedicle screw fixation
Which of the following is the greatest risk factor for a paradoxical embolus from a venous air embolus (VAE) when performing complex cervical spine deformity operations in the beach-chair position?
Nitrous oxide anesthesia
Persistent foramen ovale (PFO)
All of the following are characteristics of juvenile ankylosing spondylitis EXCEPT?
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
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
A 61-year-old man with ankylosing spondylitis falls and hits his forehead while getting out of the shower. On arrival to the emergency room he complained of neck pain, but his neurologic exam is normal. A CT scan shows a nondisplaced extension-type fracture of the lower cervical spine and no evidence of epidural hematoma. He is treated with a cervical orthosis and admitted for pain management. Seven hours later he reports increasing paresthesias in his upper and lower extremities. Examination now shows weakness in his upper and lower extremities, including 3+/5 ankle dorsal and ankle plantar flexion. An MRI scan is performed emergently and is shown in Figure A . What is the most appropriate next step in management.
Methylprednisolone at 30 mg/kg over 1st hour followed by 5.4 mg/kg/hr drip for 23 hours
Repeat MRI in twelve hours with serial neurologic exam
Anterior cervical fusion
Posterior cervical laminectomy
Posterior cervical laminectomy and fusion with instrumentation
A 32-year-old man presents with low back and hip pain that has been gradually worsening over the past year. He reports the symptoms are worse in the morning. Radiographs are shown in Figure A. Laboratory studies show a positive HLA-B27. What additional finding will help confirm the diagnosis?
Positive Rheumatoid Factor
Elevated urine phosphoethanolamine
A 69-year-old man falls on the ice. On arrival to the emergency room he is found to have a 2 cm laceration on the back of his head. He complains of neck pain, but is oriented to place and time and his neurologic exam is normal. Cervical and lumbar radiographs are shown in Figures A-C. What is the next most appropriate step in treatment?
Obtain flexion-extension radiographs
Obtain a CT scan of the lumbar spine
Obtain a CT scan of the cervical spine
Obtain a technetium bone scan
Treat with soft collar and discharge patient to home
A 45-year-old man with ankylosing spondylitis presents with fixed sagittal imbalance and difficulty with horizontal gaze. His kyphotic deformity is localized to the thoracolumbar spine. Which of the following procedures allows the most correction in the sagittal plane at a single level without having to resect the intevertebral disc?
Pedicle subtraction osteotomy (PSO)
Vertebral column resection (VCR)
Single-level opening wedge osteotomy
Multi-level opening wedge osteotomies