SPINE MCQs

1. SPINE MCQs Friday 25th January Mr P Landham

2. 1 A 52-year-old woman underwent a C5/6 ACDF for cervical radiculopathy through a left-sided approach two years ago. Radiographs are shown in Figure A. She has had an altered voice since this operation. Recently, the patient has developed myelopathic symptoms including gait instability and dexterity problems with her hands. An MRI shows a fusion at C5/6, and an adjacent-level midline disc herniation at C4/5 with cord compression and myelomalacia. Laryngoscopy of the vocal cords demonstrates abnormal function of the vocal cords on the left hand side. Which of the following is the most appropriate treatment for this patient?  • Physical therapy and NSAIDS • High dose methylprednisone • C5/6 hardware removal and C4/5 ACDF using a left sided anterior approach • C5/6 hardware removal and C4/5 ACDF using a right sided anterior approach • C5 to C7 posterior laminectomy and fusion

3. 3. C5/6 hardware removal and C4/5 ACDF using a left sided anterior approach Cervical Myelopathy - due to an anterior midline disc herniation at the adjacent C4/5 level. In addition, she has voice changes and abnormal vocal cord function likely due to an injury to the left recurrent laryngeal nerve (RLN) during her prior left sided approach. The most appropriate treatment at this time is hardware removal at C5/6 (she is fused) and anterior cervical discectomy and fusion at C4/5 utilizing a left sided approach through her old incision. One should avoid using a right-sided approach, as a right recurrent larygngeal nerve (RLN) injury would cause denervation of both vocal cords leading to breathing difficulties and aphonia. Netterville et al showed that multiple branches of the vagus nerve are are risk during surgery. They also concluded that right-sided approaches carry a greater risk to the recurrent laryngeal nerve as its course is more variable. Incorrect Answers: Answer 1 & 2: Because the patient is myelopathic, physical therapy and high dose steroid are not appropriate. Answer 4: See description above. Answer 5: The patient has anterior compression from a midline disc herniation, and therefore a posterior decompression would not adequately address her focal anterior compression.

4. 2 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?  • MRI • Immediate closed reduction with cervical traction • Immediate anterior open reduction and surgical fixation • Spinal dose steroids • Cervical immobilization, observation, and serial neurologic exams

6. 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?  • MRI • Immediate closed reduction with cervical traction • Immediate anterior open reduction and surgical fixation • Spinal dose steroids • Cervical immobilization, observation, and serial neurologic exams

7. 2. Immediate closed reduction with cervical traction The patient presents with a deteriorating neurologic exam in the presence of a bilateral C5-6 facet dislocation. Because the patient is alert, cooperative, and sober, the next step in management is closed reduction with cranial traction while the patient is awake. An ASIA Impairment Scale of E is a normal exam. An ASIA Impairment Scale of D shows preserved motor function below the neurological level, but with more than half of key muscles below the neurological level showing weakness but with a muscle grade greater than 3. Therefore his exam is worsening. You know it is a bilateral facet dislocation as there is 50% subluxation of the vertebral bodies. Because the patient is alert, cooperative, and sober, the next step in management is closed reduction with cranial traction while the patient is awake. Because of his rapid decline in neurologic function you would not want to delay reduction by obtaining an MRI. All facet dislocations need to be stabilized surgically following reduction. Following closed reduction an MRI should be obtained to look for a cervical disc herniation, as the presence of one will determine the approach for stabilization. The cited reference by Star et al is a case series (LOE4) of 53 patients who underwent closed reduction. They found that contrary to prior beliefs, adding weights of > 50 lbs and up to 100 lbs was safe and effective. In their series, 39 patients required greater than 50 lbs to obtain reductions and there was no associated complications with this additional weight. Vaccaro et al performed prereduction and postreduction magnetic resonance imaging in eleven consecutive patients with cervical spine dislocations. They found the process of closed traction reduction appears to increase the incidence of intervertebral disc herniations. The relation of these findings, however, to the neurologic safety of awake closed traction reduction remain unclear. Illustration A shows a simple algorithm to determine the ASIA Impairment Score (AIS).

9. 3 A 16-year-old male is involved in a diving accident six months ago that leads to a spinal cord injury. On physical exam he has 5 out of 5 deltoid and biceps strength. He has good brachioradialis muscle tone and 5 out of 5 bilateral wrist extension. He has 0 out of 5 wrist flexion and triceps strength. He has no anal sphincter tone, absent perianal sensation, absent lower extremity sensation, and an intact bulbocavernosus reflex. He has no motor tone in his lower extremities. How would you define this patients neurologic deficit.  • Complete C5 spinal cord injury (ASIA E) • Incomplete C5 spinal cord injury (ASIA A) • Complete C7 spinal cord injury (ASIA A) • Incomplete C7 spinal cord injury (ASIA B) • Complete C6 spinal cord injury (ASIA A)

10. 5. Complete C6 spinal cord injury (ASIA A)  There are three general steps to define a spinal cord injury using the ASIA classification system. Step 1: Identify the neurologic level, which is described as the lowest segment where motor and sensory function is normal on both sides. Because this patient has normal function at C6 (brachioradialis and wrist extension), and no function at C7 (triceps and wrist flexion), his last normal functional level is C6. Therefore his neurologic level is C6. Step 2: Determine if injury is complete or incomplete. Complete injuries are defined as no voluntary anal contraction (sacral sparing) AND 0/5 distal motor AND 0/2 distal sensory scores (no perianal sensation) AND intact bulbocavernosus reflex (patient not in spinal shock). Therefore, this patient has a complete injury. Step 3: Assign ASIA impairment score. Because this patient has a complete injury, his ASIA impairment score is ASIA A. 

11. 4  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. • Worse outcome in return to work status with equivalence in pain and physical function 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.

12. 4. Improved outcome in pain and physical function at 4 years. Recent evidence now supports that patients who undergo surgery for lumbar disc herniation have improved outcomes in bodily pain and physical function at 4 years. Weinstein et al showed in the as-treated analysis that patients treated surgically for intervertebral disc herniation showed significantly greater improvement in pain, function, satisfaction, and self-rated progress over 4 years compared to patients treated non-operatively. They found at four years there was no significant difference in work status between the surgical and nonsurgical group. (SPORT Trial)Incorrect Answers: Answer 1,2 &3: Surgical patients have improved outcomes in pain, physical function, at 4 years. Answer 5: There is no difference in work status at 4 years.

13. 5 An 18-year-old male is evaluated for a suspected spinal cord injury. His neurological exam shows diminished sensation below the T7 level. His bulbocavernosus reflex is intact. Which physical finding of motor function, below the affected neurological level, would classify this injury as an ASIA B according to the American Spinal Injury Association impairment scale? • More than half of the major muscles demonstrate palpable or visible muscle contraction • At least half of key muscles have a muscle grade of 5. • More than half of key muscles have a muscle grade less than 3. • At least half of key muscles have a muscle grade of 3 or more. • No motor function preserved below affected neurological level

14. 5. No motor function preserved below affected neurological level

16. 6 A 78-year-old female slips and falls in the bathroom. In the emergency room she is found to have a laceration on her forehead. On physical exam she has new onset Grade 3 weakness in her upper extremities, more pronounced in her hands, making it difficult for her to hold objects. In her lower extremities she has Grade 4 weakness, but is able to walk with assistance. She has new onset urinary dysfunction. A radiograph and MRI are shown in Figure A and B respectively. History reveals that prior to the fall she was living independently, was able to go on daily walks, and had normal function of her hands. Which of the following most accurately describes her prognosis with nonoperative treatment.  • The patient will continue to deteriorate in a step-wise manner. • The patient will most likely regain full function in her hands. • More likely than not she will regain her ability to ambulate independently. • There is a less than a 10% chance the patient will regain her bowel and bladder function. • The patient will continue to deteriorate in a rapid and progressive manner.

18. 6 A 78-year-old female slips and falls in the bathroom. In the emergency room she is found to have a laceration on her forehead. On physical exam she has new onset Grade 3 weakness in her upper extremities, more pronounced in her hands, making it difficult for her to hold objects. In her lower extremities she has Grade 4 weakness, but is able to walk with assistance. She has new onset urinary dysfunction. A radiograph and MRI are shown in Figure A and B respectively. History reveals that prior to the fall she was living independently, was able to go on daily walks, and had normal function of her hands. Which of the following most accurately describes her prognosis with nonoperative treatment.  • The patient will continue to deteriorate in a step-wise manner. • The patient will most likely regain full function in her hands. • More likely than not she will regain her ability to ambulate independently. • There is a less than a 10% chance the patient will regain her bowel and bladder function. • The patient will continue to deteriorate in a rapid and progressive manner.

19. 3. More likely than not she will regain her ability to ambulate independently. Central Cord Syndrome - patients with central cord syndrome usually regain bowel and bladder function and their ability to ambulate. Return of upper extremity function is less reliable, and patients are often left with deficits in their upper extremity, worse distally, characterized by "clumsy" hands. Harrop et al. describe "classic" central cord syndrome in the elderly, which presents after a hyperextension mechanism and cord compression as the result of a stenotic spondylotic cervical canal where no fracture is evident. They report that the majority of patients have some degree of recovery with nonoperative treatment. They recommend surgical decompression only when there is persistent cord compression or spinal instability. Incorrect Answers: Answer 1: "Step-wise" deterioration is consistent with chronic cervical myelopathy, and not central cord syndrome. Answer 2: Patient with central cord syndrome typically do not gain normal function of their hands, and are left with "clumsy" hands.Answer 4: Patient with central cord syndrome usually regain bowel and bladder function. Answer 5: Rapid progression of neurologic deficits is typical for acute and progressive spinal cord compression, as seen with an epidural abscess or tumor.

20. 7 All of the following are attributed to the loss of supraspinal control of the sympathetic nervous system that commonly occurs in patients with spinal cord lesions at T-6 or higher EXCEPT  • Supine hypotension • Orthostatic hypotension • Spasticity • Autonomic dysreflexia • Cardiac arrhythmias

21. 3. Spasticity Spasticity is unrelated to the sympathetic system and usually occurs after the acute phase of spinal cord injury (SCI), when spinal shock has resolved. Furlan et al states that sympathetic decentralization leads to altered regulation of the autonomic function, despite the presence of intact parasympathetic (vagal) afferent and efferent pathways in patients with SCI. Hypotension (supine and orthostatic), cardiac arrythmias, and autonomic dysreflexia are all the result of loss of supraspinal control of the sympathetic nervous system. Autonomic dysreflexia is defined as “an increase in systolic blood pressure of at least 20% associated with a change in heart rate and accompanied by at least one of the following signs (sweating, piloerection, facial flushing), or symptoms (headache, blurred vision, stuffy nose)” due to a stimulus such as overdistended bladder or bowel impaction. Guidelines for treatment of autonomic dysreflexia include 1) patient immediately placed in a sitting position if the person is supine. 2) clothing or constrictive devices need to be loosened 3) troubleshoot etiologies for bladder distention or bowel impaction 4) a SBP >150 mmHg may need to be treated with nifedipine or nitrates 5) close monitoring of symptoms, blood pressure, and heart rate for at least 2 hours.

22. 8 A 49-year-old male fell from a height of 10 feet while cleaning his roof. He sustained the isolated injury shown in Figures A and B. Upon transfer from the outside hospital 10 hours later, he has 0/5 motor strength in bilateral lower extremities, no sensation distal to umbilicus, and an intact bulbocavernosous reflex. He has no perianal sensation or rectal tone. He received no medical management at the outside hospital. Which of the following is the most appropriate use of methylprednisolone in this patient.? • Initiate high-dose methylprednisolone with a loading dose of 30mg/kg and a drip of 5.4 mg/kg/hr • Initiate high-dose methylprednisolone, without a loading dose, at 5.4 mg/kg/hr • Initiate high-dose methyprednisolone if his neurologic status does not improve over the next 14 hours • Administer a one-time dose of methylprednisolone at a dose of 30 mg/kg • Do not initiate treatment with methylprednisolone

24. 8 A 49-year-old male fell from a height of 10 feet while cleaning his roof. He sustained the isolated injury shown in Figures A and B. Upon transfer from the outside hospital 10 hours later, he has 0/5 motor strength in bilateral lower extremities, no sensation distal to umbilicus, and an intact bulbocavernosous reflex. He has no perianal sensation or rectal tone. He received no medical management at the outside hospital. Which of the following is the most appropriate use of methylprednisolone in this patient.? • Initiate high-dose methylprednisolone with a loading dose of 30mg/kg and a drip of 5.4 mg/kg/hr • Initiate high-dose methylprednisolone, without a loading dose, at 5.4 mg/kg/hr • Initiate high-dose methyprednisolone if his neurologic status does not improve over the next 14 hours • Administer a one-time dose of methylprednisolone at a dose of 30 mg/kg • Do not initiate treatment with methylprednisolone

25. 5. Do not initiate treatment with methylprednisolone • Data does not support the administration of high-dose methylprednisolone if the injury occurs greater than 8 hours before presentation.  • ?? Steroids not indicated at all

26. 9 Following an acute spinal cord injury a patient presents with systemic hypotension and relative bradycardia. His bulbocavernosus reflex is present. This is characteristic of what type of response in acute spinal cord injuries?  • Neurogenic shock • Cardiac shock • Septic shock • Spinal shock • Hypovolemic shock

27. 1. Neurogenic Shock Neurogenic Shock is characterized by hypotension & relative bradycardia in a patient with an acute spinal cord injury. It is potentially fatal. Treatment includes Swan-Ganz monitoring for careful fluid management and pressors to treat hypotension. Spinal shock is defined as temporary loss of spinal cord function and reflex activity below the level of a spinal cord injury. It is characterized by bradycardia & hypotension (due to loss of sympathetic tone) and an absent bulbocavernosus reflex. The concept of spinal shock is important because one cannot evaluate the neurologic deficit until spinal shock phase has resolved. The end of spinal shock is indicated by return of the bulbocavernous reflex. 

28. 10 Cervical facet dislocations are characteristically caused by which of the following mechanisms of injury?  • Flexion-compression • Flexion-distraction • Vertical compression • Extension-compression • Extension-distraction

29. 2. Flexion Distraction Allen and Ferguson classification of cervical spine injuries • flexion-compression • vertical-compression • flexion-distraction • extension-compression • extension-distraction • lateral flexion. In a facet dislocation the posterior structures (interspinous ligament, facet capsule, ligamentum flavum, posterior annulus) are likely disrupted, whereas the anterior structures (anterior longitudinal ligament) are usually preserved.

30. 11 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

32. 11 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

33. 3. Obtain a CT scan of cervical spine Ankylosing Spondylitis - due to the stiffness of the spine, there is an increased risk for cervical fractures. A cervical fracture in a patient with ankylosing spondylitis is often very difficult to see on plain radiographs. In addition, there is a high mortality rate secondary to epidural hemorrhage. Therefore, in a patient with AS and a high suspicion for a neck injury, plain radiographs should be supplemented with additional imaging studies to look for acute fracture and epidural hemorrhage.

34. 12 A 71-year-old female who has no significant medical comorbidities presents to the emergency department after sustaining a compression fracture of L2. The patient has moderate back pain but is neurologically intact. Radiographs of the entire spine reveal a L2 compression fracture with 30% loss of vertebral body height loss and 15 degrees of local kyphosis. What would be the appropriate management for this patient? • Bedrest for ten days • Oral pain medications, thoracolumbosacral orthosis, and progressive increase in activity level • Posterior percutaneous pedicular fixation from L1 to L5 • Posterolateral fusion from L2 to L4 with instrumentation • Anterior column reconstruction with strut grafting and plate fixation

35. 2. Oral pain medications, thoracolumbosacral orthosis, and progressive increase in activity level Initial treatment of osteoporotic compression fractures without neurologic compromise consists of pain control, progressive increase in activity levels, and a TLSO, or thoracolumbosacral orthosis.  Compression fractures are common in the elderly with osteoporosis as a result of low energy trauma. Most of these can be managed without surgery in a brace and oral pain medication. Initial management consists of pain control and a gradual return to activity. If pain continues after 6 weeks of non-operative therapy, kyphoplasty or vertebroplasty are available options. If a neurologic deficit is present, management would include surgical decompression and stabilization.