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Images 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
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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
Anterior Cervical Diskectomy and Fusion with Plate and Peak Cage (ACDF)
- Spine
- - Cervical Radiculopathy
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(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
L 2 A
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(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
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
L 4 A
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(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
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
L 2 A
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(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
N/A A
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(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
L 4 A
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(SBQ18SP.67) All of the following are characteristics of myelopathy hand EXCEPT:
QID: 211839
Involuntary flexion of the thumb and/or index finger when the examiner flicks the fingernail of the middle finger down
L 4 A
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(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
L 3 A
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(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
Lower risk of C5 radiculopathy
Higher over-all complication rate
Increased rate of numbness to the long finger and wrist flexion weakness
L 4 B
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(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
Six weeks of physical therapy and anti-inflammatory medication
Determine the patients ankle brachial index
Lumbar Epidural Injection
L 3 B
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(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
L 2 B
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(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
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
L 2 B
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(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
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
L 1 B
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(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
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
L 1 A
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(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
Reassurance and period of observation
Night splinting in cock-up wrist splints
Carpal tunnel corticosteroid injection
Electromyographic studies of the upper extremities
L 1 A
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(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
Lumbar decompression with arthrodesis
A trial of physical therapy and NSAIDS
Lumbar epidural steroid injections
CT myelogram of cervical spine
L 4 B
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(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
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
L 2 B
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(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
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
L 3 C
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(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
Local kyphosis angle > 13 degrees
MRI finding of CSF effacement
L 2 B
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(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
L 1 B
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(OBQ09.253) All of the following clinical signs are characteristic of an upper motor neuron disorder EXCEPT
QID: 3066
Exaggerated deep tendon reflexes
L 3 C
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(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
Anterior decompression and fusion
L 2 C
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(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
Change in voice and difficulty swallowing
Ptosis, miosis, anhydrosis
L 2 A
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(OBQ07.189) In patients with symptoms of cervical myelopathy, what variable is associated with improved outcomes with nonoperative management?
QID: 850
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
L 1 D
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(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
Lumbar decompression only
Lumbar decompression and instrumented fusion
MRI of the cervical spine
Lumbar epidural injection
L 2 B
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(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
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
L 3 C
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(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
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
L 3 A
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(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
Physical therapy and anti-inflammatory medication
Anterior cervical diskectomy and fusion
Posterior cervical laminotomy-foraminotomy
L 1 B
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(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
L 1 A
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(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
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.
L 2 D
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