Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5211_Библиотеки_им_академика_М_И_Перельмана
.pdf
Prasad Karpe
A. Anterior spinothalamic
B. Corticospinal tract
C. Fasciculus cuneatus
D. Fasciculus gracilis
E. Lateral spinothalamic
43. A 30-year-old man presents with history of back
pain. Imaging reveals a tumour lesion in the
posterior spinal elements of T10.
Which of thefollowing is the least likely diagnosis?
A. Aneurysmal bone cyst
B. Chordoma
C. Osteoblastoma
D. Osteochondroma
E. Osteoid osteoma
44. The most common mode of spread of infection
to the spinal column is which of the following?
A. Along cerebrospinal pathways
B. Arterial
C. Batson plexus
D. Direct
E. Lymphatic
45. A 14-year-old girl is having posterior correction
for scoliosis. Halfway through the procedure
after screws are inserted and correction is done,
there is loss of MEP (Motor Evoked potential) in
both lower extremities with retained SSEP
(Somatosensory evoked potential).
The next step in the management of this
patients is
A. Check leads for loose connection
B. Inform the entire team about loss of signals
C. Intraoperative imaging of the implants, pref-
erable O arm
D. Raise BP and oxygenation
E. Undo the correction
46. A patient with degenerative listhesis at L4–L5 is
likely to have which of the following presentations?
A. Loss of sensation along the lateral border of
the foot
B. Weakness of ankle dorsiflexion
C. Weakness of ankle plantar flexion
D. Weakness of great toe extension
E. Weakness of hip flexion
47. Which of the following is a classical finding in
lumbar canal stenosis?
A. Pain on walking uphill.
B. Pain on spinal extension
C. Positive straight leg raise
D. Weak pedal pulsation
E. Weakness in great toe extension
48. A 42-year-old woman has come to the ED at
20.00h with a 3-week history of back pain and a
2-day onset of bilateral radiculopathy. She denies
any bowel or bladder disturbances. She has bilateral SLR of 30° and no neurological deficit
on examination. MRI images are depicted in
Figure 12.4. Pain is under control after receiving
morphine.
Figure 12.4 (a) Sagittal T2 and (b) axial T2 at level of interest MRI scan spine
264
Spine II Structured SBA
Which of the following is the next best management option?
A. Admit, neurological observations, consider
surgery following day within 24 hours of MRI
B. Bilateral nerve root injection
C. Discharge if pain under control
D. Emergency surgery
E. Epidural injection
49. A 50-year-old man presents with generalised
back pain and gait disturbances. He is a type 2
diabetic on insulin. On examination he has brisk
reflexes in the lower limbs but normal reflex es in
the upper limbs. He also has right ptosis, miosis
and enophthalmos.
Which of the following pathologies can explain
the patient’s findings?
A. Cervical spondylotic myelopathy C4/5
B. Lumbar canal stenosis
C. Lumbar disc prolapse
D. Peripheral neuropathy
E. Thoracic disc disease T1–T2
50. Which of the following is the predominant
blood supply of the spinal cord?
A. Anterior spinal artery
B. Artery of Adamkiewicz
C. Intercostal arteries
D. Posterior spinal artery
E. Segmental arteries
51. Which of the following is arranged in correct
order when approaching the spinal cord from
superficial to deep?
A. Dura mater–subarachnoid space–arachnoid
membrane–pia mater–epidural space
B. Epidural space–pia mater–dura mater–
subarachnoid space–arachnoid membrane
C. Epidural space–dura mater–arachnoid
membrane–subarachnoid space–pia mater
D. Epidural space–dura mater–subarachnoid
space–arachnoid membrane–pia mater
E. Epidural space–dura meter–pia meter–
subarachnoid space–arachnoid membrane
52. Which of the following can be an indication for
cervical disc replacement?
A. Cervical spondylotic myelopathy
B. Infection
C. Instability
D. Osteoporosis
E. Significant facet arthritis
53. A 60-year-old fit and healthy man presents with
a history of gait disturbances and neck pain. MRI
sagittal T2 is as depicted in Figure 12.5.
Figure 12.5 MRI
sagittal T2 view
The next best management of this patient is
which of the following?
A. Acupuncture
B. Cervical epidural
C. Facet joint injections
D. Physiotherapy and analgesia
E. Surgery
54. A teenage girl with thoracic scoliosis of Cobb
angle 50° is seen in the clinic. Beaded on history,
examination and investigations, it is suggestive
of adolescent idiopathic scoliosis. Family would
like to know the long-term sequelae of untreated
AIS.
Which of the following is a known outcome of
the natural history of AIS?
A. Absence of backpain
B. Increased lumbar lordosis
C. Psychological concerns
D. Static curve progression
E. Unchanged sagittal alignment
55. Which of the following is not a known compli-
cation of halo application?
A. Abducens nerve palsy
265
Prasad Karpe
B. C5 nerve palsy
C. Loosening
D. Nerve palsy
E. Supratrochlear nerve palsy
56. A 55-year-old man needs revision anterior cer-
vical spine surgery at C4–C5 for adjacent level
nerve root compression. He previously had
fusion at C5–C6 eight years ago. He has no neck
pain but complains mainly of arm pain. X-rays
show good fusion at C5– C6 and MRI confirms a
soft disc at right C4–C5.
Which of the following does he need prior to
the procedure?
A. CT scan cervical spine
B. Gadolinium MRI cervical spine
C. Laryngoscopy
D. Nerve conduction studies
E. Open mouth cervical spine views
57. A 60-year-old rheumatoid patient needs elective
hand surgery under general anaesthesia. She also
complains of chronic neck pain.
Which of the following is the next important
step in the preoperative check-up?
A. AP cervical spine X-ray
B. ESR levels
C. Flexion extension cervical spine X-rays
D. Open mouth view cervical spine
E. Stopping methotrexate
58. An 8-year-old boy presents with short neck, low
hairline and reduced neck range of motion.
Which of the following statements is true about
this condition?
A. It is not associated with Sprengel shoulder
B. It is less prone for degenerative changes in
the cervical spine
C. Long fusions of the cervical spine can allow
participation in contact sports
D. Multiple systemic anomalies are common
E. It occurs due to failure of normal segmenta-
tion in the first 6 months of life
59. A 68-year-old man presents with neurogenic claudication and low back pain. Examination reveals
normal pedal pulses and normal functioning.
MRI reveals an L4–L5 degenerative listhesis and
severe stenosis with tropism of the facets. He is
now receiving pain management and had tried 4
months of conservative treatment. His past medical includes well-controlled hypertension.
What is the next best step to be offered in
management of this patient?
A. Acupuncture
B. Isolated laminectomy
C. Laminectomy with instrumented fusion
D. Laminectomy with non-instrumented fusion
E. Lumbar epidural injection
60. Which of the following regarding spinal
metastases is correct?
A. Most spinal metastases occur in posterior
elements.
B. Spinal cord compression is a component of
SINS (Spinal Instability Neoplasticism Score)
C. Thoracic spine is the most common site
followed by lumbar and cervical
D. Thyroid is the most common primary
followed by prostate.
E. Vertebroplasty can be done even in presence
of a posterior spinal wall defect.
266
SPINE II STRUCTURED SBA ANSWERS
1. Answer E. Triple immobilisation of the cervical
spine with rigid collar
Patients with ankylosing spondylitis have a
kyphotic ankylosed spine. They are prone to
having cervical spine fractures due to underlying
osteoporosis and large lever arms. Inadvertent
rigid collar can force the flexed cervical spine
into extension, leading to neurological deterioration and even mortality.
Pre-injury deformity should be ascertained,
especially in a conscious patient. Patients should
be immobilised in the same position as their preinjury deformity status.
Clarke A, James S, Ahuja S. Ankylosing
spondylitis: inadvertent application of a rigid
collar after cervical fracture, leading to neurological complications and death. Acta Orthop
Belg. 2010;76:413–415.
2. Answer C. It is the angle formed between a line
drawn from the centre of the S1 end plate to the
centre of the femoral head and a second line
drawn perpendicular to the S1 end plate, intersecting it at the centre
Pelvic incidence is the angle formed between a
line drawn from the centre of the S1 end plate to
the centre of the femoral head and a second line
drawn perpendicular to the S1 end plate, intersecting it at the centre
Pelvic incidence never changes with pelvic
morphology as with other pelvic parameters.
Pelvic incidence is pelvic tilt plus sacral slope.
Higher pelvic incidence necessitates more lumbar
lordosis to maintain sagittal balance, and there is a
direct correlation between pelvic incidence and
the Meyerding grade of spondylolisthesis.
Hanson DS, Bridwell KH, Rhee JM, Lenke
LG. Correlation of pelvic incidence with low-and
high-grade isthmic spondylolisthesis. Spine
2002;27:2026–2029.
3. Answer D. Rib prominence on forward bending
Atypical curve pattern like left-sided curve, short
angular curve, apical kyphosis and excessive
kyphosis are some indications for MRI. Other
indications for MRI are any syndromic features
(neurofibromatosis – axillary freckling), neurological signs or symptoms.
Spine II Structured SBA
Isolated rib prominence is present in AIS,
and on its own is not an indication for MRI scan.
4. Answer A. Fine cuts of CT and MRI scan help
best in determining treatment plan
This is a double question. Understanding the
diagnosis in the stem is the first step. The age,
pain and scoliosis point to osteoid osteoma or
osteoblastoma. However, osteoblastomas do not
behave differently at night and respond poorly to
NSAIDs. So, this boy most likely has scoliosis
secondary to osteoid osteoma, which is less than
1.5cm, on the apex of concave side of scoliosis
and, unlike osteoblastoma, rarely has any neurological deficit.
Fine cuts of the CT will not only show the
sclerosis with surrounding radiolucent nidus,
along with MRI they also help to see the proximity to neural structures. Any lesion less than
2mm from a neural structure should not be
treated with radiofrequency to avoid risk of
neural injury. NSAIDs/observation and not
radiofrequency is the initial treatment for osteoid
osteoma with a very minimal curve.
5. Answer B. Damage to feeding vessel from the
left side between T8 and L1
Based on the fin dings of normal proprioception,
this patient has anterior cord syndrome. Patients
with spinal shock will have no proprioception.
Central cord patients will have more weakness in
the upper limbs. As proprioception is normal,
posterior cord syndrome is ruled out. Damage
to the artery of Adamkiewicz is a known complication of aortic repairs. This can lead to vascular
insult of the spinal cord.
6. Answer D. MRI of cervical and thoracic spine
Although this patienthas lumbar canal stenosis that
may need surgery, he also has symptoms and signs
of cervical myelopathy with upper motor neuron
signs. Tandem stenosis has been reported to have
overall incidence of 7.6% in one series (Hsieh et al.
1998). Cervical surgery is then recommended first
if there are upper motor neuron signs or predominantly signs in upper extremities.
Hsieh CH, Huang TJ, Hsu RW. Tandem
spinal stenosis: clinical diagnosis and surgical
treatment. Changgeng Yi Xue Za Zhi
1998;21:429–435.
267
Prasad Karpe
7. Answer D. The superficial fascia, pretracheal
fascia and prevertebral fascia are encountered
from superficial to deep
Damage to the sympathetic and not the parasympathetic chain can occur with dissections to the
longus colli, leading to Horner’s syndrome. The
sympathetic chain runs over the longus colli
muscle, and hence the retractors need to be placed
cautiously beneath the elevatedlongus collimuscle.
Hyoid bone roughly lines up with C3 and
not C5.
The location of the mandible and not maxilla
decides the ease of access to the C2/3 disc.
The plane is between the carotid sheath laterally and the trachea with oesophagus medially
(internal jugular lies in carotid sheath).
8. Answer A. Chemical destruction of the nerve
endings due to chemical composition of the
cement has been proposed
As per NICE guidance, percutaneous vertebroplasty and percutaneous balloon kyphoplasty
without stenting, are recommended as options
for treating osteoporotic vertebral compression
fractures only in people who have severe ongoing
pain after a recent, unhealed vertebral fracture
despite optimal pain management and in whom
the pain has been confirmed to be at the level of
the fracture by physical examination and imaging.
Chemical destruction, physical destruction and
mechanical stabilisation are all proposed mechanisms by which vertebroplasty reduces pain.
It works by mechanical stabilisation of the
fractured bone.
It works by thermal destruction of the nerve
endings due to the high temperature reached by
the polymerisation of the injected cement.
It is indicated in patients with ongoing pain
after recent unhealed fracture; pain is confirmed
at the level of fracture by examination and MRI
showing high signal on T2.
It has fewer advantages as compared with
kyphoplasty. Kyphoplasty has the added advantage of correcting kyphosis and providing pain
relief for a longer duration.
9. Answer C. Most common organism is
Staphylococcus aureus Loss of lordosis may be
the earliest and only X-ray finding for discitis in
children. This is followed by disc space
narrowing and end plate erosion (10–21 days).
The haematogenous route is the most common
pathway of spread to spine.
MRI imaging is the investigation of choice.
Vertebral end plates get affected first.
Unlike adults, in children the disc is vascular,
with the blood vessels extending from the cartilaginous end plate to the nucleus pulposus. So, primary infection of the disc occurs first in children
followed by spread of infection to vertebral body.
In adults, however, the end plates get infected first,
followed by spread to adjacent disc space.
10. Answer D. Posterior elements are most com-
monly affected
Posterior elements are most commonly affected
in spinal metastases. Vertebral end plates are
most commonly affected in spinal infection in
adults. In malignancy, disc space is always preserved. Vertebral body collapse does occur due to
bone destruction that can lead to canal compromise and neurological deficit.
In degenerative spine, end plates are preserved and there is minimal or no enhancement
with gadolinium. Gadolinium enhances infections and malignancy.
11. Answer D. S1/S2
Ankle reflex is a deep tendon reflex that checks if
S1 and S2 nerve roots are intact.
The major S2 myotomes are the hamstrings
and calf muscles. The S2 dermatome consists of a
strip of skin along the back of thigh and calf. S1
dermatome is the lateral aspect of the foot and it
supplies gluteal, hamstring, calf and a few
muscles in the foot.
12. Answer E. Skeletally immature patients
Immature patients are ideal candidates for a
brace, as the brace can prevent deformity progression. A brace serves no purpose when the
growth is complete. Thoracic lordosis is a contraindication, as it can lead to potential cardiopulmonary restriction.
Curves greater than 40° usually need surgery.
13. Answer C. Upper cervical trauma is more
common in children younger than 8 years of age
268
Spine II Structured SBA
In children older than 8 years, the subaxial region
is the most common site of cervical trauma.
The spinal column in children is more elastic
than the spinal cord. Hence, SCIWORA (spinal
cord injuries without radiographic abnormalities) can be seen in children.
MRI scan is the investigation to diagnose
injury to the cord and ligament injuries.
As children have a large cranium in relation
to the thorax, immobilisation on a standard
spinal board will place the cervical spine in
flexion. Use of a paediatric spinal board with a
recess for the occiput or double mattress below
the thorax is recommended in paediatric cervical
spine injuries.
Pseudosubluxation, that is, normal anterior
translation, can occur between C2/3 and less
commonly between C3/4.
14. Answer A. Correction happens at the level of
the vertebral body and not the disc
Smith-Petersen osteotomy, pedicle subtraction
osteotomy and vertebral column resection can
correct sagittal plane deformities.
SPO can correct mild to moderate deformities and it opens up the anterior column, closes
the middle column somewhat and closes the
posterior column. Correction happens at the disc
level.
PSO corrects severe sagittal imbalance. It
hinges on the anterior column and closes the
middle and posterior column. Correction
happens at the vertebral level. VCR provides
more correction than PSO.
Correction is usually performed at L12 levels,
as the lever at this level allows more correction of
the deformity than the thoracic level. The spinal
cord ends at this level, minimising the risk of
cord damage. The greater disc height and mobility at the lumbar level than the thoracic leve l
allow more correction if performing an SPO, as
the correction happens at the disc level.
PSO is a technically demanding procedure
and is associated with high number of complications (up to 61% in one series).
Hyun SJ, Rhim SC. Clinical outcomes and
complications after pedicle subtraction osteotomy for fixed sagittal imbalance patients: a
long-term follow-up data. J Korean Neurosurg
Soc. 2010; 47:95.
15. Answer E. Sacroiliac joint involvement is often
asymmetric
Sacroiliac joint is symmetric in AS.
If there is asymmetric involvement, consider
other diagnoses such as psoriatic arthritis or
infections. A normal SIJ precludes an imaging
diagnosis of AS.
16. Answer C. Combined physical and psycho-
logical programmes
Though this question is vague with not much on
history and examination, it is based on the recommendations for chronic back pain as per
NICE.
Caudal epidural is indicated only for sciatica.
Opioids, belts/corsets or acupuncture are not
recommended for management of chronic back
pain.
https://pathways.nice.org.uk/pathways/lowback-pain-and-sciatica/managing-low-backpain-and-sciatica.
17. Answer D. The inferior limit of the spinal cord
in adults is L1 or L2
The preganglionic cell bodies of the sympathetic
nervous system are located in the intermediolateral nuclei of the thoracolumbar (T1–L2) portion
of the spinal cord.
The postganglionic cell bodies of the sympathetic nervous system are found in either the
prevertebral ganglia or the paravertebral ganglia.
The preganglionic parasympathetic preganglionic cell bodies lie in sacral segments S2, S3, S4,
while the postganglionic are located in the terminal ganglia near the organ innervated or the
wall of the organ.
The spinal nerves exit the cervical spine above
their corresponding vertebral body level. For
example, the C5 nerve root exits above C4
through the C4–5 neural foramen. C8 exits in
between C7 and T1 since there is no C8 vertebral
body level. So, C8 exits inferior to pedicle of C7.
This orientation is reversed in the thoracic
and lumbar spine. In the thoracic and lumbar
spine, spinal nerve roots exit below their corresponding vertebral body level. For example, the
L5 nerve root exits below L5 through the L5/S1
foramen. The inferior limit of the dural sac is S2,
not L2. That is the reason lumbar puncture is
usually done at the L3/L4 level.
269
Prasad Karpe
18. Answer D. MRI scan
This patient has bilateral facet subluxation. For
any patient with mental changes, an MRI scan of
the neck is the first step to look for disc herniation that can compress the spinal cord. Closed
reduction can further compress the cord, which
will be difficult to monitor in patients with
mental changes. Closed reduction can be performed only in patients who are awake, followed
by MRI and open reduction.
Cervical orthosis is indicated in patients with
facet fractures with no subluxation.
Posterior cervical fusion is indicated in patients
in the absence of significant disc herniation.
Anterior fusion can be performed after
obtaining MRI to look at disc, cord and ligament
status.
19. Answer C. Orthostatic hypertension
Up to 11% of patients with spinal cord injuries
suffer from major depressive episodes associated
with suicidal ideation.
Autonomic dysreflexia is a life-thre atening
condition that can cause death. The most
common causes of autonomic dysreflexia are
bladder and bowel distension. It can present with
raised BP, bradycardia, pounding headache,
flushing, sweating or blotching above the level
of the injury and pale, cold goose bumps below
the level of the injury.
Urosepsis is a common cause of death. Strict
asepsis is to be maintained while inserting catheter, and bladder should not be allowed to
become overly distended.
As patients have reduced mobility, DVT and
PE are dreaded complications.
Orthostatic hypotension, not hypertension,
results due to lack of sympathetic tone.
Bombardier CH, Richards JS, Krause JS,
Tulsky D, Tate DG. Symptoms of major depres-
sion in people with spinal cord injury: implications for screening. Arch Phys Med Rehabil.
2004;85:1749–1756.
20. Answer B. Pelvic incidence
Pelvic incidence correlates with the severity of
the disease and does not change with posture.
The rest of all parameters given change with
posture. Pelvic incidence is the sum of pel vic tilt
and sacral slope.
21. Answer D. There is ossification of ligaments
and entheses in DISH while erosive enthesopathy in AS
DISH, also known as Forestier disease, is defined
by presence of non-marginal syndesmophytes at
three successive levels (involving 4 contiguous
vertebrae).
In AS discs are ossified while DISH the discs
are normal.
The facet joints are normal in DISH while
fused in AS
Unilateral/Bilateral sacroiliac joints are
involved in AS while normal SI joints in DISH.
There is ossification of ligaments and
entheses in AS while erosive enthesopathy in
DISH.
Marginal syndesmophytes in AS and flowing
periosteal reaction/non-marginal in DISH.
Besides, in DISH these no osteopenia but
normal or increased bone density. In AS due to
inflammatory process and disuse, there is osteopenia/osteoporosis.
22. Answer D. It tends to exhibit longer curves as
compared with idiopathic scoliosis
Neuromuscular scoliosis presents earlier than
most cases of idiopathic scoliosis. Since it presents early, it tends to progress rapidly. It rarely
responds well to orthotic treatment, and surgery
is frequently needed, depending on fitness for
surgical intervention.
The curves tend to be longer, involving more
vertebrae, and long segment fusion is usually
needed.
23. Answer C. Long segment fusion
95% of patients with Duchenne muscular dystrophy develop scoliosis. A s these curves progress rapidly with further reduction in
pulmonary function, surgical stabilisation is
recommended once curves reach 20°. Long
segment fusion is the treatment of choice from
T2 to iliac fixation, especially with pelvic
obliquity.
Combined fusion is indicated in severe
deformities and skeletally immature patients
to prevent crankshaft phenomenon usually
in idiopathic scoliosis. Combined fusion is
high-risk surgery in Duchenne muscular
dystrophy.
270
Spine II Structured SBA
24. Answer A. CT evidence of canal compromise
with no neurology
With patients with burst fractures and intact
neurology, the fact the patient remains neurologically intact means that degree of canal compromise is sufficient not to damage the cord.
Shen WJ, Shen YS. Nonsurgical treatment of
three-column thoracolumbar junction burst fractures without neurologic deficit. Spine
1999;24:412–415.
25. Answer D. Little or no comminution
All other factors result in a poor outcome
following conservative treatment. Also, consideration of surgery is done if there is sternal fracture
(regarded as the 4th column for thoracic spine),
T1–T10 fractures, high ISS or injury severity
score and multiple rib fracture such as flail chest
that could lead to a delay in the patient sitting up.
The above factors are for A0, A1, A2, A3, A4
and B2 fractures.
A0, B1, B3 and C fractures are treated with
surgical intervention.
26. Answer A. Canal compromise on axial CT scan
TLICS has the following criteria
Injury morphology
Compression (1 point).
Burst (+1 point).
Rotation/translation (+3 point).
Distraction (+4 point).
Neurological status
Intact (+0 point).
Nerve root (+2 point).
Incomplete spinal cord or conus medullaris
injury (+3 point).
Complete spinal cord or conus medullaris
injury (+2 point).
Cauda equina syndrome (+3 point).
Posterior ligamentous complex integrity
Intact (+0 point) – no interspinous ligament
widening seen with flexion views. MRI shows
no oedema in interspinous ligament region.
Suspected/indeterminate (+2 point) – MRI
shows some signal in region of interspinous
ligaments
Disrupted (+3 point) – widening of
interspinous distance seen.
A score less than 4 is usually indicative of nonsurgical management, while a score above 4 is indicative of surgical management. A score of 4 suggests either surgical or non-surgical management.
MRI signal change in the region of interspinous ligaments or widening of interspinous distance is indicative of disruption of the posterior
ligamentous injury. Canal compromise bears no
relevance in TLICS classification.
27. Answer E. Progressive kyphosis is a known
complication in unrecognised injuries
Chance fractures involve all three columns of the
spine with the axis of rotation anterior to the
vertebral body. Chance fractures could be purely
bony or ligamentous. Bony Chance fractures are
rare. Injury pattern need not always be through
disc; the fracture can run through the bone.
There is a high incidence of intra-abdominal
injuries, especially the bowel.
Although most injuries need surgical stabilisation and decompression, bony Chance with no
neurology can be treated with TLSO brace in
extension.
Unrecognised injury to the PLL leads to progressive kyphosis and pain.
28. Answer D. Myasthenia gravis
Myelopathy is any neurological deficit related to
the spinal cord. It is an upper motor neuron type
lesion with brisk reflexes and hypertonia in
muscles. Myelopathy can be surgical, wherein
there is compressive lesion-like cervical disc prolapse or bilateral facet dislocation.
Multiple sclerosis is a demyelinating disorder
that can affect any part of the nervous system
including the spinal cord.
Subacute combined degeneration of the
spinal cord is a result of B
deficiency that
12
affects lateral and posterior columns of the spinal
cord.
Multiple sclerosis and B
deficiency are
12
examples of non-compressive myelopathy or
medical myelopathy.
Myasthenia gravis does not affect the spinal
cord but does affect the neuromuscular junction.
It is an autoimmune disease that results in
producing antibodies that destroy acetylcholine
receptors, thereby preventing nerve impulses
from triggering muscle contraction.
271
Prasad Karpe
29. Answer E. Thoracic spine metastases
The spinal cord ends at L1, and any compression
above this will present with upper motor neuron
findings in the lower limbs. As the upper limb examination is normal, it is unlikely that there is a compressive lesion either in the brain or cervical spine.
Although this patient is likely to have peripheral neuropathy because of his age and diabetes,
this would present as sluggish ifnot absentreflexes.
Hence, the most likely explanation is a lesion
in the thoracic spine. Bear in mind that this
patient will still require a full workup including
whole spine MRI, as he could still have lesions in
the brain or lumbar or cervical spine that are not
yet compressive. Such lesions may change the
management of this patient.
30. Answer D. Thoracolumbar spine
The thoracolumbar spine is a transition between
the fixed thoracic spine and mobile lumbar
spine. This is where the force is concentrated
and is most likely to be injured after trauma.
50% of all thoracic and lumbar fractures occur
between T11 and L2 (thoracolumb ar region).
The thoracic spine is inherently stable due to
the sternum and rib cage that significantly limit
motion. The orientation of the facets in coronal
alignment helps resist flexion and extension
forces. However, if fractures do occur here, there
is a higher likelihood of neurological injury due
to smallest canal-to-cord ratio.
Upper cervical spine injuries constitute a
large proportion of cervical trauma in patients
older than 60 years. Out of these, the C1/2 complex accounts for the majority of these injuries.
However, this incidence is still low compared
with the incidence of thoracolumbar fractures.
31. Answer D. Reversal of spinal shock
The bulbocavernosus reflex is mediated by the
S2–S4 nerves. It consists of contraction of the
bulbocavernosus muscle in response to squeezing the glans penis or clitoris and is mediated
through the pudendal nerve.
It serves to indicate presence or absence of a
spinal shock. Its absence means spinal shock and
return means end of spinal shock.
The bulbocavernosus reflex is also absent in
conus medullaris lesions and lesions of sacral
nerves S2–S4.
Neurogenic shock is loss of sympathetic out-
flow in high thoracic, cervical or brain lesions.
After return of the bulbocavernosus reflex, if
there is some motor or sensory function below
the level of injury, it means incomplete spinal
cord injury. Likewise, no motor or sensory function means a complete spinal cord injury.
32. Answer A. There is a high risk of associated
spinal injury at another level
A Jefferson fracture is a bilateral anterior and
posterior arch fracture. It is caused by axial compression but can also be caused by hyperextension or latera l compression.
Risk of neurological injury is low, as the canal
is wide and there is adequate space for the cord.
However, there can be neurological injury if
there is gross displacement or other associated
fractures.
There is a 50% chance of patients having
other spinal injuries.
Stability of a Jefferson fracture depends on
the integrity of the transverse ligament. If this is
ruptured, then a combined displacement of more
than 7mm is seen on open mouth view and this
injury is unstable. In this case, the injury is
stable, as combined displacement is 5mm. This
can be treated with a hard collar or halo
immobilisation.
The unstable Jefferson fracture needs surgery
in the form of C1/2 fusion or occipitocervical
fusion.
33. Answer E. Caused by hyperextension with sec-
ondary flexion
Hangman’s fracture is traumatic anterior spondylolisthesis of C2 due to bilateral fracture of
pars interarticularis. It is usually associated with
a low incidence of neurological injury due to
space available for cord at that level.
The mechanism is hyperextension with secondary flexion. Contrary to the name, most
hangman’s fractures are not seen in judicial
hangings where the forces are of the large traction type.
If the displac ement is less than 3mm between
C2 and C3, they are stable. Otherwise, fractures
with more than 3mm of displacement, significant
angulation or with C2/3 facet dislocation need
stabilisation and/or surgical reduction.
272
Spine II Structured SBA
34. Answer E. Stinger
Stinger is a peripheral nerve injury that is associated with pain that follows a dermatomal distribution. Only 5–10% have a neurological deficit
that may last hours to weeks, but most often
pain, and neurological injury resolves spontaneously in 10– 15 minutes.
As this patient has normal ROM of cervical
spine, fracture and disc prolapse are ruled out.
Isolated scapula fracture alone cannot explain
this injury pattern.
Brachial plexus axonotmesis will have long-
lasting weakness and not transient weakness.
35. Answer A. Axial compression of the cervical
spine
Stinger or burner is a peripheral nerve injury that
is associated with unilateral paraesthesia. It may
be accompanied by motor weakness that is usually transient.
Nerve root contusion leading to stinger can
happen with hyperextension, compression and
rotation towards the involved arm.
Direct trauma to the brachial plexus just above
the clavicle or Erb’s point also can lead to stingers.
Erb’s point is a site at the upper trunk of the
brachial plexus located 2–3cm above the clavicle.
Lateral neck flexion with shoulder depression
leads to brachial plexus stretch, leading to stingers.
Axial compression of the cervical spine leads
to upper cervical fractures such as Jefferson fracture or subaxial cervical spine injuries such as
comminuted body or facet fractures.
36. Answer B. Dorsal root ganglion innervates the
annulus fibrosus through the sinuvertebral
nerve
Annulus fibrosus is the outer structure that contains predominantly type I collagen that is
obliquely oriented. The high tensile strength
resists distraction but remains flexible to allow
some motion.
Nucleus pulposus contains a low collagen-toproteoglycan ratio. The proteoglycans interact
with water to resist compression. It contains
predominantly type II collagen.
Nutrition occurs through diffusion via end
plates that are porous and not annulus. In children, it is vital to remember that the disc is
vascular.
Outer layers of annulus are innervated by the
sinuvertebral nerve. The posterior part of the
disc receives direct branches in its posterolateral
aspect from the ramus communicans or the ventral ramus. Branches of the grey ramus communicans also supply the lateral aspect of the disc.
Anterior discal nerves arise solely from the sympathetic plexus surrounding the anterior longitudinal ligament.
Edgar MA. The nerve supply of the lumbar
intervertebral disc. J Bone Joint Surg Br.
2007;89:1135–1139.
37. Answer E. Reduction in nutritional transport
across the end plates
Water content, disc height and proteoglycans
decrease with age. The total amount of collagen
remains the same.
The main nutritional pathway of the disc is
through the adjacent vertebral end plate. This
source of nutrition is at great risk in the ageing
disc, as the permeability of the end plate diminishes with advancing age.
Grob D. The aging spine. Eur Spine J.
2003;12:S84–S85.
38. Answer B. Epidural haematoma at L4 level
Meralgia paresthetica is compression of the lateral femoral cutaneous nerve. This is a purely
sensory nerve consisting of the posterior nerve
roots L2 and L3.
Compression can occur at the level of nerve
roots L2 and L3 (disc prolapse), in the abdominal
cavity (space occupying lesions, traction in a
retroperitoneal approach) or as it exits the pelvis
at the level of ASIS (corsets).
Tight TLSO or faulty prone positioning can
compress the nerve at the ASIS. Traction of the
nerve or haematoma during graft harvest from
the ASIS can also cause symptoms.
Diabetic peripheral neuropathy is a systemic
condition and can affect all nerves, including
LFCN.
Isolated epidural haematoma at L4 cannot
explain symptoms at L2–3 but will lead to signs
and symptoms of nerves at the lower lumbar and
or sacral nerve root levels.
39. Answer E. There is a high risk of non-union if
there is delay in starting treatment
273
Соседние файлы в папке Библиотека им академика М.И. Перельмана