Soal Acak Orthobullets 2019

Soal Acak Orthobullets
Pediatric
1
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
FIGURES: A B C
1C4-7 anterior decompression with instrumented fusion

2C4-7 posterior decompression with instrumented fusion
3C4-7 posterior decompression without fusion
4C5/6 anterior discectomy and fusion
5Physical therapy
2
A 38-year-old man reports a 2-week history of acute lower back pain
with radiation into the left lower extremity. There is no history of
trauma and no systemic signs are noted. Examination reveals a positive
straight leg test at 35 degrees on the left side and a contralateral
straight leg raise on the right side. Motor testing demonstrates mild
weakness of the gluteus medius and weakness of the extensor hallucis
longus of 3+/5. Sensory examination demonstrates decreased
sensation along the lateral aspect of the calf and top of the foot. Knee
and ankle reflexes are intact and symmetrical. Radiographs
demonstrate no obvious abnormality. MRI scans show a posterolateral
disk hernation. The diagnosis at this time is consistent with a herniated
nucleus pulposus at
1. L1-2.
2. L2-3.
3. L3-4.
4. L4-5.
5. L5-S1.
3
4
• SUBMIT RESPONSE 2
• The clinical presentation is consistent with neurofibromatosis with associated anterolateral tibial
bowing. Neurofibromatosis is the most common cause of anterolateral tibial bowing and
congenital pseudoarthrosis of the tibia, two conditions which represent a continuum of the same
disease process. Because there is no fracture or pseudoarthrosis the treatment in this case is
bracing in a total contact orthosis, otherwise known as a clamshell orthosis. If the patient had a
fracture or a pseudoarthrosis, then you would treat him with surgery. The reference by Crawford
et al is a review article that describes the incidence and treatment of orthopaedic conditions seen
with neurofibromatosis. In their database of 588 patients they found the incidence of spinal
deformity in children with NF-1 to be 21%; pectus deformity, 4.3%; limb-length inequality, 7.1%;
congenital tibial dysplasia, 5%; hemihypertrophy, 1.4%; and plexiform neurofibromas, 25%. The
cited reference by Feldman et al is a more recent review article that also discusses the
orthopaedic manifestations of neurofibromatosis. There are various tibial bowing conditions
found in children and one should be familiar with the differential diagnosis and associated
conditions. Bowing of the tibia that is present at birth typically occurs either anteriorly (in
association with fibular hemimelia), anterolaterally (in association with congenital
pseudoarthrosis), or posteromedially (in association with calcaneovalgus foot deformity).
5
• The most effective way to measure a limb-length discrepancy in a
patient with a knee flexion contracture is a lateral CT scanogram. All
the other methods listed provide inaccurate results with a knee
flexion contracture because the measurements are made in the
coronal plane.
6
A 34-year-old male sustains the closed finger injury shown in Figure A one week
ago. He undergoes closed reduction and pinning shown in Figure B to correct
alignment. Which of the following is responsible for the apex palmar fracture
deformity noted on the preoperative radiographs?
B
A
1 Indirect pull of the central slip on the distal fragment and the interossei insertions at the base
of the proximal phalanx
2 Intrinsic muscle fibrosis and intrinsic minus contracture
3 PIP joint volar plate attenuation and extensor tendon disruption
4 Rupture of the central slip with attenuation of the triangular ligament and palmar migration of
the lateral bands
5 Flexor tendon disruption with associated overpull of the extensor mechanism
7
A 58-year-old man presents with right middle finger swelling. Radiographs and an MRI of his hand
are shown in Figure A and B. Tissue biopsy and staging investigations are performed. The tumor is
then resected en bloc with the middle metacarpal, which is amputated 1.5cm from the
carpometacarpal joint. The attached deep transverse intermetacarpal ligaments are sacrificed. To
prevent scissoring of the remaining digits and small objects falling through the gap between index
and ring fingers, which of the following procedures should be performed?
A B
1 iliac crest bone grafting

2 ring metacarpal transposition
3 second toe transfer
4 index metacarpal transposition
5 suture of deep transverse intermetacarpal ligaments
8
A 24-year-old racquetball player presents after accidentally striking his racket against the wall
during a match two months ago. He is tender to palpation over the hypothenar mass, and his pain is
aggrevated by grasping. A radiograph and CT scan of his wrist are shown in Figures A and B. Which
of the following treatment methods has been definitively shown in the literature to have a favorable
outcome, and a high chance to return to pre-injury activities in patients with this injury?
A BB
1 Activity restriction and continued monitoring

2 Open reduction and internal fixation
3 Casting for 6 weeks, followed by physical therapy
4 Corticosteroid injection and immediate return to play
5 Surgical excision
9
• Group B Streptococcus is the most common causative organism of neonatal septic
arthritis. It should be noted in the subgroup of neonates who acquire nosocomial septic
arthritis, Staph Aureus is more common than Group B Strep. These infections often arise
from invasive procedures such as central lines and indwelling catheters. Children in the
first 2 years of life have the highest frequency of septic arthritis. In children 3 months of
age to 2 years, H. Influenzae was traditionally the most common organism, but its
prevalence has fallen significantly since the introduction of H. Flu vaccinations. In
children over 2 years of age, Staph Aureus is the most common causative organism.
In an Instructional Course Lecture, McCarthy et al summarize the pathogenesis,
evaluation, treatment, and prognosis of musculoskeletal infections in children. They
emphasize long-term follow up as a musculoskeletal infection in a growing child may
have further impact as the child ages.
Dan et al reviews a case series of pediatric septic hips to correlate the most common
bacterial isolates in young infants.
10
• The question stem is describing a patient with osteogenesis imperfecta Type IV,
which is caused by a qualitative defect in the synthesis of Type I collagen.
Inherited or spontaneous genetic mutations of genes COL1A1 and COL1A2 are
known to be the basic anomaly that alters the collagen synthesis and structure.
The quantitative disorders of type I collagen are associated with milder forms of
OI (Type I), whereas the qualitative disorders are associated with more severe
phenotypes (Types II, III and IV). Moderate clinical severity with white sclera and
dentinogenesis imperfecta, shown in Figure A, are classically associated with Type
IV OI. Figure B demonstrated lower extremity bowing and malunion,
characteristic of OI.
In their review article, Baitner et al describe the major osteochondrodysplasias,
define their causes and clinical manifestations, and discuss the underlying
molecular defects as well as the anatomical aspects of these disorders.
11
• Based on the clinical findings and figures shown, the patient has developed a septic
arthritis of the left hip. As the patient has 3 out of the 4 Kocher criteria, he has a 93%
chance of having a septic hip. The next best step in management would be to take the
patient to the operating room for an emergent irrigation and debridement of the
affected hip.
Septic arthritis in the pediatric population often occurs in the first few years of life, with
50% of cases occurring in those less than 2 years of age. Patients may present with a
toxic appearance. The likelihood of a patient having a septic hip can be ascertained with
use of the Kocher criteria (WBC > 12, ESR > 40, T > 38.5 and an inability to bear weight on
the affected hip). Patients meeting all four criteria have a 99% chance of having a septic
hip, whereas those meeting just one of the criteria have a 3% chance of having a septic
hip. Rapid breakdown of the hyaline articular cartilage occurs via enzymes (matrix
metalloproteinases & hyaluronidase) produced by the bacteria. This may be mitigated
with an emergent surgical irrigation and debridement.
12
• The clinical presentation and image are consistent with a calcaneonavicular tarsal
coalition. For symptomatic patients, a trial of nonoperative treatment is the first
line of treatment. A firm orthosis to decrease inversion and eversion stress can be
utilized or a short leg casting may be tried.
Tarsal coalition is the most common cause of peroneal spastic flatfoot (pes
planus). It is a disorder of mesenchymal segmentation leading to fusion of tarsal
bones and rigid flatfoot. Calcaneonavicular coalitions are the most common form,
and usually present in children 10-12 yrs of age.
Vincent reviewed tarsal coalitions and painful flatfeet in adolescent children,
determining an overall prevalence of 1%. He found calcaneonavicular coalitions
to be the most common, followed by a middle facet talocalcaneal coalition. He
advocated initial immobilization, followed by surgical treatment in recalcitrant
cases.
13
• This patient most likely has a septic hip based on clinical, radiographic, and
laboratory data. Traumatic effusions have less than 5,000 leukocytes, toxic
synovitis (5,000-15,000 leuckocytes with <25% PMNs), rheumatic fever
(10,000-15,000 leukocytes with 50% PMNs), and JRA (15,000-80,000
leukocytes with 75% PMNs). Synovial fluid analysis for septic arthritis
includes >50,000 leukocytes and >75% PMNs. The review article by Sucato
et al notes that JRA can be present similarly to a septic joint with a hip
effusion with high leukocyte count and >75% PMN's. However, they
mention that JRA patients often have gradual onset of symptoms, less pain,
usually continue weightbearing activities, and lack constitutional
symptoms. Illustration A compares the sonographic findings in a normal hip
compared to a hip with an effusion.
14
• Based on the arithmetic method for prediction of limb length discrepancy, the patient in
question has about 2 years of growth remaining, and it can be calculated that his left
tibia will be short by about 15 mm at maturity (6mm/yr for proximal tibia x 2 yrs +
existing 3mm). Typically, LLD at maturity of <2cm is treated nonoperatively with
observation and shoe lift if needed.
Treatment is dictated by the length discrepancy at maturity (not at the original
presentation): <2cm is treated nonoperatively, 2-5cm is treated with epiphysiodesis or
ostectomy, and greater than 5-6cm is treated with limb lengthening, and possible
contralateral epiphysiodesis.
Stanitski discusses the presentation, prediction of discrepancy, and treatment of leg
length discrepancy in children in her review article. The arithmetic method for prediction
of limb length discrepancy (LLD) is described as being based on four assumptions about
growth: (1) boys stop growing at age 16; (2) girls stop growing at age 14; (3) the distal
femoral physis grows 10 mm yearly; and (4) the proximal tibia grows 6 mm yearly.
15
• This child is presenting with radiographic and clinical findings consistent
with the sequelae of untreated septic hip arthritis. Specifically, the child is
limping and there is complete destruction of the femoral head/neck in the
pelvic radiograph. Furthermore, the radiograph is not consistent with any
of the remaining choices.
Dobbs et al. review a case series of 5 patients with previous untreated
septic arthritis, treated with proximal femoral osteotomy. The authors
found all 5 patients had stable, painless, and functional hips.
Vitale and Skaggs review the diagnosis, treatment, and outcome of young
patients (6 months to 4 years) with developmental dysplasia of the hip.
16
• Histologic studies have shown that increased bone turnover is the
rule in OI. Pamidronate (and all bisphosphonates) reduce osteoclast-
mediated bone resorption. Osteoblastic new bone formation on the
periosteal surface of long bones is minimally impaired. With inhibition
of osteoclastic bone resorption on the endosteal surface, the cortex
of the bone can begin to thicken as it does with normal growth in
individuals unaffected by OI. Mineralization and collagen matrix
organization are not directly affected by pamidronate
17
• The child has a near complete central physeal arrest of the distal
femur and worsening limb-length discrepancy will develop. She is
growing at the average rate for the population. The distal femoral
physis grows at a rate of roughly 9 mm per year. Girls finish their
growth at approximately age 14 years. Thus, at maturity the left leg
will be 6.4 cm longer than the right. An angular deformity has not
developed at this point and her arrest is central; therefore, angular
deformity is unlikely to develop in any plane.
18
• The radiographs in Figure A show radial bowing. Image B shows a Lisch nodules.
These findings are consistent with neurofibromatosis. Neurofibromatosis is an
autosomal dominant condition that has multiple cutaneous and musculoskeletal
manifestations including café au lait spots, neurofibromas on the skin, Lisch
nodules in the eye, scoliosis, and long bone bowing & pseudoarthrosis. It is
caused by a mutation in NF1 gene that codes for neurofibromin protein. The
reference by Bell et al is a case series of 6 patients with congenital
pseudoarthrosis of the forearm. They found promising results utilizing a free
vascularized fibular transfer, and present it as an alternative to existing treatment
options. The reference by Feldman et al reviews the different orthopaedic
manifestations of neurofibromatosis type I. They emphasize a multidisciplinary
treatment approach as NF-1 affects multiple organ systems. Anterolateral tibial
bowing is a common presenting condition, and is more common than forearm
bowing.
19
• The clinical presentation is consistent for symptoms of myelopathy in a patient with Osteogenesis
imperfecta (OI). Basilar invagination is the most likely cause.
Osteogenesis imperfecta (OI) is a genetic disease resulting from mutations in type I collagen
genes causing bone fragility and deformities (including wormian bone appearance). Patients with
osteogenesis imperfecta are known to develop basilar invagination, defined as a protrusion of the
odontoid process into the foramen magnum. Basilar invagination is commonly seen with Klippel-
Feil syndrome, occipitocervical synostosis, achondroplasia, osteogenesis imperfecta, Morquio
syndrome, and spondyloepiphyseal dysplasia.
Kovero et al evaluated skull base anatomy in 54 patient with OI (type I, III, and IV) and 108
controls. They found 22.2% of the OI group had basilar invagination while none of the controls
did. Screening radiographs are recommended in this group along with MRI in those whose films
suggest the possibility of basilar invagination. Surgical decompression and fusion is recommended
in those with neurologic symptoms. In patients with severe OI, an open door maxillotomy may be
required (Le Fort I osteotomy of the maxilla combined with a midline split of the soft palate and
maxilla).
20
• The clinical scenario is consistent with a pediatric septic hip. The AP
pelvis in figure A shows soft-tissue swelling with mild subluxation of
the right hip due to a septic effusion, and the ultrasound in figure B
also shows a hip effusion. The hip aspiration is consistent with an
infectious process. An aspirate with WBC >50,000 is highly suggestive
of a septic hip. Jackson et al reviewed pediatric septic arthritis and
describe four poor prognostic signs: age <6 months, joint effusion
with underlying osteomyelitis, hip involvement, and delay in
treatment >4 days. In a review of pediatric septic hips, Sucato et al
state that hip aspiration is the most sensitive test and that I&D is
required to prevent late sequlae.
21
• A CT scanogram, shown in Illustration A has the advantage of being able to calculate accurate
length measurement in the presence of joint contractures, and typically utilizes a single
anteroposterior scout film upon which digital length measurements can be made. In the presence
of severe flexion contractures, lateral scout films can be added to improve measurement
accuracy. A teloradiograph is single exposure of both legs on a long film, and has the advantage of
being able to accurately assess angular deformity. An example is shown in Illustration B. However,
it is less accurate in measuring limb-length discrepency due to variations in magnification caused
by parallax of the x-ray beam. The orthoradiograph (Illustration C) and scanogram (Illustration D)
avoid the magnification factor by taking three separate exposures, (hip, knee, and ankle) so that
the central x-ray beam passes through the joints, giving true readings from the scale. The
advantage of a scanogram is that it is obtained on smaller cassettes, and there is less error if the
patient moves.
Moseley, in the ICL, discusses radiologic assessment of limb length discrepency and provides step-
by-step instructions on three methods used for assessment of past growth and prediction of
future growth.
22
• Children with severe forms of osteogenesis imperfecta and progressive scoliosis
should be treated with posterior spinal fusion with instrumentation when the
curve exceeds 35 degrees.
Spinal deformity is common in children with osteogenesis imperfecta, particularly
in severe forms. Curves develop early and generally progress. Bracing is not
indicated due to the complications associated with the brace on the soft bones of
the rib cage. In the patient with severe disease with thin bones and numerous
fractures, posterior correction and fusion is indicated, and should be done early
when the curve is greater than 35 degrees. In the patient with mild disease and
thick bones surgery is indicated when the curve is greater than 45 degrees.
Burnei et al review the diagnosis and treatment of OI. They report that medical
treatment with bisphosphonates, even in patients younger than age 2 years, have
become widely accepted in the symptomatic treatment of OI. They report
alendronate has a proven beneficial effect, demonstrating a decrease in fracture
frequency and improvement of vertebral bone density and quality of life.
23
(SAE09TR.74) A 40-year-old man sustains a fracture-dislocation of C4-5.

Examination reveals no motor or sensory function below the C5 level. All
extremities are areflexic. The bulbocavernosus reflex is absent. The prognosis
for this patient’s neurologic recovery can be best determined by
QID: 6962
1myelography with CT.
2spinal cord-evoked potentials.
3repeat physical examinations.
4MRI.
5electromyography and nerve conduction velocity studies.
• The patient has spinal shock. Steroid administration and MRI are
appropriate therapeutic and diagnostic procedures. Myelography
with CT is of little value unless there is an unusual skeletal variant.
Spinal cord-evoked potentials have no value. The best method to
determine the patient’s neurologic recovery is repeated physical
examinations over the first 48 to 72 hours.
24
45-year-old manual laborer presents to the office with acute onset
back pain that radiates to his right leg after carrying a heavy object.
He also has mild non-progressive weakness with ankle dorsiflexion
on that side. A representative MRI cut is shown in Figure A. What
should be his initial treatment?
QID: 154
FIGURES: A
1Microdiskectomy
2Posterior spinal fusion with instrumentation
3Decompression only
4Strict bedrest
5Anti-inflammatory medication
and physical therapy
• Lumbar disc herniation is the most common cause of radicular pain in the adult working
population. 95% of these herniations involve L4/5, L5/S1 lumbar disc spaces. Patients
typically present with low back pain and sharp stabbing leg pain with sensory symptoms
in a specific dermatomal distribution. Persistent intractable pain following non-surgical
treatment during a minimum 6 week period is the most frequent indication for surgery.
The Weber article was a RCT over 10 yrs of 126 pt with sciatica due to herniated lumbar
discs. The results of surgical treatment were significantly better than the results in the
conservatively treated group after one year of observation, however this difference
became much less pronounced after nine more years.
Saal et al retrospectively reviewed 11 patients treated nonoperatively with lumbar disc
extrusions through CT/MRI to evaluate disc morphology initially and at follow up (mean
25 mos). Only 1 patient had progression of stenosis, and all patients had disc dessication
at the level of disc herniation with contiguous levels being normally hydrated. All patients
had a decrease in neural impingement.
25
(SAE09SN.19) A 68-year-old woman undergoes a complicated four-level anterior
cervical diskectomy and fusion at C3-7 with iliac crest bone graft and
instrumentation for multilevel cervical stenosis. Surgical time was approximately 6
hours and estimated blood loss was 800 mL. Neuromonitoring was stable
throughout the procedure. The patient’s history is significant for smoking. The most
immediate appropriate postoperative management for this patient should include
1 normal postoperative orders with frequent neurologic evaluations for the first 24
hours.
2 administration of IV steroids and placement of a soft cervical collar for 24 hours.
3 placement of both deep and superficial surgical drains prior to wound closure.
4 administration of IV mannitol and placement of a soft collar.
5 maintaining intubation for up to 24 to 48 hours.
• Airway complications after anterior cervical surgery can be a
catastrophic event necessitating emergent intubation for airway
protection. Multilevel surgeries requiring long intubation and
prolonged soft-tissue retraction as well as preexisting comorbidities
may predispose a patient to postoperative airway complications. Sagi
and associates reported that surgical times greater than 5 hours,
blood loss greater than 300 mL, and multilevel surgery at or above
C3-4 are risk factors for airway complications. In surgical procedures
with the aforementioned factors, serious consideration should be
given to elective intubation for 1 to 3 days to avoid urgent
reintubation.
A 69-year-old man presents with several months of worsening balance, gait,
and problems with manual dexterity. Physical exam shows bilateral Hoffman
signs and hyperreflexia of his patellar reflexes. His radiograph and MRI are
shown in figures A and B, respectively. He undergoes the procedure shown in
figure C. Which of the following statements is true regarding this
procedure? Review Topic
QID: 3769
FIGURES: A B C
1It leads to less blood loss than anterior cervical discectomy and fusion
(ACDF)
2It is contraindicated in patients with > 10 degrees of cervical lordosis
3It preserves more range of motion than laminectomy and fusion
4It has a lower rate of post operative C5 palsy than laminectomy and fusion
5It has a higher risk of adjacent segment degeneration than laminectomy and
fusion
• The patient is presenting with symptoms and imaging findings consistent with cervical spondylotic myelopathy (CSM) and
undergoes a cervical laminoplasty. Cervical laminoplasty is useful because it helps preserve cervical range of motion.
Patients with myelopathy may present with any combination of fine motor loss, gait disturbance, pain, and bowel/bladder
symptoms. While patients can have a myriad of physical exam findings, a positive Hoffmann's sign is seen in about 80% of
patients and is more common with more severe myelopathy. Treatment consisted of anterior and/or posterior surgery,
traditionally in the form of fusion. Cervical laminoplasty is a newer, motion-sparing technique for decompression that avoids
the complications of fusion. While laminoplasty helps preserve more motion that fusion, studies show there can still be some
loss of mobility.
Blizzard et al. retrospectively studied patients with CSM who underwent laminoplasty and laminectomy and fusion. While
both groups lost range of motion, the laminoplasty group lost less than the LF group. Most clinical outcomes were similar in
the two groups.
Sung et al. studied 16 asymptomatic patients with positive Hoffmann's sign and found a high incidence of cervical spondylosis
and cord compression on imaging studies. However, this work-up did not change management or clinical course and so they
do not recommend routine imaging for a positive reflex.
Yoon et al. conducted a systematic review looking at laminoplasty versus laminectomy and fusion (LF) for CSM. They found no
difference in outcomes for these two procedures, but conclusions were limited due to the few number of studies.
Figure is A is a standing lateral cervical spine radiograph showing multi-level spondylosis. Figure B is an accompanying MRI
with significant canal stenosis from C3-C6 secondary to disc-osteophyte complexes. Figure C is a postoperative radiograph of
the same patient after cervical laminoplasty.
Incorrect Answers:
Answer 2: ACDF has less blood loss than laminoplasty
Answer 3: Laminoplasty is best used in patients with neutral or lordotic cervical alignment. It is contraindicated in patients
with > 10 degrees of rigid cervical kyphosis.
Answer 4: Laminoplasty is a non-fusion technique and, therefore, there is no risk of pseudarthrosis between vertebral levels;
there is, however, a very small risk of pseudarthrosis at the hinge site of the laminoplasty.
Answer 5: Increased risk of adjacent segment degeneration is typically seen with fusion techniques. The natural history of
degenerative spinal disorders may lead to adjacent segment degeneration after non-fusion techniques, but the risk is
increased when a fusion is done.
26
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?
1Posterior foraminotomy
2Anterior decompression and fusion
3Laminectomy alone
4Laminectomy and fusion
5Hinge-door laminoplasty
• The patient in this scenario is suffering from cervical spondylotic myelopathy, as
they are experiencing decreased manual dexterity and likely an ataxic shuffling gait.
MRI shows a narrowed canal with significant spinal cord compression and
myelomalacia (spinal cord signal on T2 images). In addition, as seen in the second
image, the patient has greater than 10 degrees of kyphosis.
Geck et al review the surgical treatment options for myelopathy. Myelopathy with
motor/gait impairment is a surgical indication. The question they are testing is
whether to do an anterior or posterior decompression. Kyphosis of > 10 degrees is a
contraindication to posterior decompression, making the correct choice to be
answer 2, anterior decompression and fusion. Per the cited article, the indications
for an ACDF include cervical myelopathy from soft disc herniation or from
spondylitic degeneration that is limited to the disc level (for one to two level
spondylosis without retrovertebral disease). If there is compression behind the
body from migrated disc fragments or from ossification of the PLL (retrovertebral
disease), then another operation should be performed; usually an anterior
corpectomy and strut grafting will enable better decompression and is ideal for
patients with kyphosis or neck pain. Laminectomy historically has poor results from
late deformity and late neurologic deterioration. Laminoplasty was developed to
address cervical stenosis of THREE or more segments, and compares favorably with
anterior corpectomy and fusion for neurologic recovery. Laminoplasty does have a
lower complication rate than corpectomy and strut grafting, but has a higher
incidence of postop axial symptoms.
27
• Scoliotic deformities in patients with NF1 are often dysplastic with
short, angular curves. Posterior arthrodesis is made more difficult by
the presence of kyphosis and of weak posterior elements caused by
dural ectasia. Combined anterior and posterior spinal arthrodesis is
generally preferred for progressive dysplastic curves to maximize
deformity correction and to decrease the risk of pseudarthrosis.
Anterior fusion may also prevent crankshaft phenomenon in young
children. Brace treatment is not effective for large, rigid, or dysplastic
curves.
28
• The history and imaging are consistent with a symptomatic calcaneonavicular coalition.
The short duration of pain with no known history of prior symptoms warrant a trial of
non-operative treatment with immobilization.
Symptomatic hindfoot coalition is a relatively rare condition, occurring in approximately
1% of the population. The two most common locations are the talocalcaneal (middle
facet) and calcaneonavicular joints. Diagnosis should be suspected in the pre-teen or
teenage patient with insidious or sudden onset of pain in the midfoot to hindfoot, and/or
a frequent history of ankle sprains.
Vincent reviews the management of tarsal coalitions and the painful flatfoot. The
authors notes that the initial management of symptomatic coalitions should consist of a
trial of immobilization with transition to an orthosis.
Mosca in a more recent review also notes that surgery should be reserved for those who
have failed a prolonged initial nonoperative course of treatment.
29
A 36-year-old male involved in a high speed motor vehicle accident is found on
exam to have Grade 2 of 5 motor strength in 80% of his key muscle groups in his
lower extremity. His perianal sensation and rectal tone are intact. A
bulbocavernosus reflex is present. His sensation is decreased from a point at the
intersection of the mid-clavicular line and the 4th intercostal space at the level of
the nipples distally. Based on the American Spinal Injury Association (ASIA)
classification system, what ASIA grade is he?
QID: 4544
1ASIA A
2ASIA B
3ASIA C
4ASIA D
5ASIA E
• This patient is presenting with an ASIA C high thoracic level injury.
The ASIA classification is used to determine severity of injury. ASIA A is a complete spinal cord
injury. ASIA B is characterized by preserved sensory function but no motor function below the
neurological level. ASIA C is characterized by preserved motor function below the neurological
level, but more than half of key muscles below the neurological level have a muscle grade less
than 3. ASIA D is characterized by preserved motor function below the neurological level, and
at least half of key muscles below the neurological level have a muscle grade of 3 or more.
ASIA E is a normal exam.
Waters et al. followed 148 patients prospectively and demonstrated that no individual
presenting with a complete neurologic level of injury above T9 ever regained any lower
extremity motor function. Patients with a complete neurologic level below T9 had some return
of function. One fifth of patients with complete injuries below T12 were eventually able to
ambulate using conventional orthoses and crutches.
Harrop et al. reviewed 150 patients treated over a 10 year period with a spinal cord injury
between T4 and S5. Patients were stratified based on level of injury, initial American Spinal
Injury Association (ASIA), age, race, and etiology. A total of 92.9% of lumbar (conus) patients
neurologically improved one ASIA level or more compared with only 22.4% of thoracic or
thoracolumbar spinal cord-injured patients.
Illustration A is the ASIA worksheet that helps to classify a spinal cord injury. Illustration B
shows the ASIA classification in chart format.
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
30 No 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.?
QID: 3648
FIGURES: A B
1Initiate high-dose methylprednisolone with a loading dose of 30mg/kg and a drip of
5.4 mg/kg/hr
2Initiate high-dose methylprednisolone, without a loading dose, at 5.4 mg/kg/hr
3Do not initiate treatment with methylprednisolone
4Initiate high-dose methyprednisolone if his neurologic status does not improve over
the next 14 hours
5Administer a one-time dose of methylprednisolone at a dose of 30 mg/kg
• The clinical presentation describes a lower thoracic spine burst fracture with a complete neurological spinal cord injury. Since the
patient's injury occurred ten hours prior to presentation, the original studies did not support initiation of high-dose methylprednisolone.
In fact, more recent studies than the ones they quoted when this question first appeared in 2011 have suggested that steroids are no
longer indicated for spinal cord injury regardless of timing.
High-dose corticosteroid administration following spinal cord injury was thought to work by stabilizing neuronal membranes and reducing
inflammation. While there is much controversy regarding this topic, recommendations from the most recent Cochrane review when this
question was asked was to give a 30mg/kg bolus followed by a 5.4 mg/kg drip if the injury occurred less than 8 hours prior to
presentation. If the injury was sustained less than 3 hours prior to presentation, the methylprednisolone drip was to continue for 23
hours. If the injury occurred from 3-8 hours prior to presentation, the steroid drip was to be continued for 48 hours. Contraindications to
steroid therapy include injuries that occur greater than 8 hours prior to presentation, pregnancy, gunshot wounds, patients under the age
of 13, and brachial plexus injuries.
Ito et al. performed a prospective study in which they gave high-dose methylprednisolone (30 mg/kg bolus, then 5.4 mg/kg/hr for 23
hours) to all patients with a cervical spinal cord injury that occurred less than 8 hours prior to presentation. They compared this to a
similar group that did not receive methylprednisolone. All patients underwent decompression and stabilization as soon as possible after
the injury. They found an increased risk of pneumonia in the group treated with steroids, highlighting the potential side-effects of such
therapy.
Kwon et al. provide a review on subaxial cervical spine trauma. They discuss the importance of making the correct diagnosis upon initial
presentation and discuss that the treatment algorithm should take into account stability, neurologic status, and patient-related factors
such as DISH. They comment that corticosteroids should be considered.
Bracken provides the most recent Cochrane review on the use of steroids in acute spinal cord injury. Methylprednisolone sodium
succinate was shown to improve neurologic outcome up to one year post-injury if administered within eight hours of injury and in a dose
regimen of: bolus 30mg/kg over 15 minutes, with maintenance infusion of 5.4 mg/kg per hour infused for 23 hours. One trial showed a
benefit to extending the duration of treatment to 48 hours if starting between 3 and 8 hours after injury.
Figures A and B are the sagittal and axial CT cuts that show a T9 burst fracture with rotational malalignment and moderate
anterolisthesis.
Incorrect Answers:
Answers 1,2,4,5: Data does not support the administration of high-dose methylprednisolone if the injury occurs greater than 8 hours
before presentation.
31
A 42-year-old woman has a 3-week history of acute lower back pain with radiation into the
left lower extremity. There is no history of trauma and no systemic symptoms are noted.
Examination reveals a positive straight leg test at 25 degrees on the left side. Motor testing
reveals mild weakness of the gluteus maximus and weakness of the gastrocnemius at 3/5.
Sensory examination reveals decreased sensation along the lateral aspect of the foot. Knee
reflex is intact; however, the ankle reflex is absent. MRI scans show a posterolateral disk
herniation. The diagnosis at this time is consistent with a herniated nucleus pulposus at
what level?
1L1-2
2L2-3
3L3-4
4L4-5
5L5-S1
• The patient's history and examination findings are
consistent with a lumbar disk herniation at the L5-S1
level. Weakness of the gastrocnemius and gluteus
maximus are consistent with an S1 lumbar
radiculopathy. Nerve root tension signs are also
consistent with a disk herniation at L5-S1, which
typically affects the traversing S1 nerve root.
32
A 22-year-old man has an acute spinal cord injury after a diving accident.
Preliminary radiographs reveal bilateral jumped facets at C6-7. Neurologic
examination shows an incomplete spinal cord injury consistent with an ASIA B
impairment grade. The patient is otherwise hemodynamically stable with no other
injuries. Attempts at closed high weight reduction with tong traction have so far
been unsuccessful. What is the most appropriate management at this
time? Review Topic
QID: 7995
1Continue a high weight closed reduction of the fracture-dislocation
2Urgent surgical intervention for reduction and decompression
3High-dose steroids for 48 hours before surgical stabilization
4Halo fixation
5Closed reduction under general anesthesia
• Although there are no current standards for the
timing of surgical intervention for acute spinal cord
injuries there is increasing data, including animal
studies, suggesting that early decompression and
stabilization of an acute spinal cord injury can be
beneficial. Continuing attempts at closed reduction is
not advised given the failure of attempted high
weight reduction. In light of the neurologic deficit,
waiting 48 hours with or without steroid treatment is
not recommended. Likewise, halo fixation without
reduction of the dislocation should not be considered
for definitive treatment. Closed reductions should not
be performed under general anesthesia.
33
Figures 23a and 23b show the MRI scans of a 50-year-old woman who has
increasing gait disturbance. She reports three falls in the past week. Examination
reveals hyperreflexia, motor weakness in the biceps and triceps, and a positive
Hoffman’s sign. What is the most appropriate treatment plan? Review Topic
QID: 6845
FIGURES: A B
1Observation
2Physical therapy
3Epidural steroid injections
4Cervical laminectomy
5Anterior cervical diskectomy and fusion
• The patient has obvious signs of progressive
myelopathy. Based on her significant physical
examination findings, nonsurgical management will
not significantly impact her outcome. Cervical
decompression alone is contraindicated in patients
with cervical kyphosis such as seen here. Anterior
cervical fusion is the best option.
34
(SAE12SN.14) What clinical scenario is most consistent
with the MR image of the L4-L5 disk level shown in
Figure 14? QID: 7927
FIGURES: A
1Left L4 nerve root radiculopathy
2Right L5 nerve root radiculopathy
3Bowel and bladder dysfunction
4Arachnoiditis
5Symptomatic pseudomeningocele
• The MRI scan reveals a foraminal disk herniation
originating from the L4-L5 disk space that has
migrated into the foramen compressing the left L4
nerve root. There is no evidence of compression of
the right L5 nerve root. Bowel and bladder
dysfunction are not associated with L4-mediated
nerve function. There is no evidence of arachnoiditis
or pseudomeningocele.
35
A 38-year-old male presents with a three month history of low back pain and right leg pain that has
failed to improve with nonoperative modalities including selective nerve root corticosteroid
injections. Leg pain and paresthesias are localized to his buttock, lateral and posterior calf, and the
dorsal aspect of his foot. On strength testing, he is graded a 4/5 for plantar-flexion and 4+/5 to ankle
dorsiflexion. On flexion and extension radiographs there is no evidence of spondylolisthesis. Sagittal
and axial T2-weighted MRI images are shown in Figure A and B. Which of the following treatment
modalities will allow the greatest improvement of physical functioning? Review Topic
QID: 4590
FIGURES: A B
1Observation alone
2Physical therapy
3Medical management with GABA analogs
4Discectomy
5Disectomy and instrumented fusion
• The clinical presentation is consistent for a lumbar disc herniation with symptoms of a combined L5
and S1 radiculopathy that has failed to improve with extensive nonoperative treatment. At this time
a discectomy would lead to the greatest improvement in physical functioning.
Anderson et al. reviewed the adequacy of randomized controlled studies completed over 25 years
(1983-2007) that attempted to compare discectomy with non-surgical treatment. Given the high
crossover rates and heterogeneity of outcome measures, the authors are unable to make conclusions
as to the benefit of one treatment modality over another.
Weinstein et al. reviewed greater than 1000 patients who had imaging confirmed lumbar disc
herniations; treatment modalities were non operative or operative (discectomy). Significant
improved in physical function, bodily pain and disability scales were seen at even 4 years
postoperatively.
Figures A and B show the axial and sagittal sequences of a T2-weighted MRI of the lower lumbar
spine. A large L5/S1 para-central disc herniation is seen that has migrated cephalad. Therefore, it is
irritating both the exiting L5 nerve root and descending S1 nerve root.
Incorrect answers
Answers 1, 2, 3: Many (> 90%) disc herniations have a self-limited natural history; the symptoms may
be alleviated by bedrest and activites as tolerated, administration of anti-inflammatories or GABA
analogs and completion of physical therapy. For symptoms that persist greater than 6 weeks and are
disabling, surgery is indicated. Recent data from the SPORT trial suggests that functional outcomes
may be improved by completion of discectomy.
Answers 5: Completion of a discectomy and instrumented fusion is not indicated in this patient.
Without evidence of degenerative changes in the lumbar spine or evidence of spondylolisthesis, a
posterior spinal instrumented fusion is not warranted.
36
• This patient has clinical signs of infection with symptoms localized to the pelvis.
The differential diagnosis of an infectious presentation with NWB in a child
should include: discitis, sacroilitis, transient synovitis, septic hip, osteomyelitis,
and Iliopsoas abscess. Further imaging is required to confirm the diagnosis. The
radiographs are not consistent with a slipped capital femoral epiphysis.
An appropriate workup has been completed for septic arthritis, which is a surgical
emergency and prompts drainage and debridement of the hip joint. The Kocher
criteria for septic arthritis include fever>38.5 degrees centigrade, inability to bear
weight, ESR>40 mm/h, and WBC count>12,000/ul. In this case, 2/4 of the criteria
are positive (inability to bear weight & ESR>40mm/h), which indicates
approximately a 40% likelihood of septic arthritis. Synovial fluid analysis is used to
either confirm or reject the hypothesis of suspected septic arthritis; an aspiration
of < 50,000 leukocytes per mL virtually rules out sepsis of the joint.
37
A 33-year-old woman reports pain down her right leg and
numbness across the dorsum of her right foot which started 3
months ago during a bowel movement. Prior to this she had had 1
month of low back pain. She had a lumbar microdiscectomy at L4/5
3 years ago which was successful. On physical exam she has
weakness to ankle dorsiflexion and great toe extension on the right.
Her new radiograph and MRI images are shown in Figure A and B
respectively. After a failure of nonoperative treatment, which of the
following is the most appropriate surgical treatment?
QID: 3488
FIGURES: A B
1L4/5 microdiskectomy through midline approach
2L4/5 microdiskectomy with far lateral Wiltse approach
3L4/5 Decompression, TLIF, and instrumented fusion
4L4/5 Decompression, PLIF, and instrumented fusion
5L4/5 Anterior Lumbar Interbody Fusion
• The clinical presentation is consistent with a recurrent lumbar
disc herniation. If conservative measures fail, the most
appropriate treatment is revision microdiskectomy.
Papadopoulos et al. looked at a total of 27 patients who had
undergone revision discectomies for recurrent lumbar disc
herniation. They found revision discectomy is as successful as
primary discectomy for patient satisfaction and function.
Suk et al. studied conventional discectomy for treatment of
recurrent lumbar disc herniation and found results to be
comparable to discectomy for a primary herniation.
Incorrect Answers:
Answer 2: A L4/5 microdiskectomy with far lateral Wiltse
approach is indicated in a far lateral or foraminal disc
herniation. An example of a far lateral disc herniation is shown
in Illustration A.
Answer 3,4,5: A fusion would not be indicated at this time, as
there is no sign of instability or spondylolisthesis.
38
A 23-year-old man falls down a flight of stairs while intoxicated and is brought to
the emergency room the following morning. On physical exam he has no motor
function in his upper and lower extremities. Sensory exam shows diminished but
present sensation in the perianal area and in the lower extremities. Reflex exam
shows his bulbocavernosus reflex is intact. The inital CT and MRI are seen in Figures
A and B. According to the American Spinal Injury Association (ASIA), how would this
injury be classified? QID: 3432
FIGURES: A B
1ASIA A
2ASIA B
3ASIA C
4ASIA D
5ASIA E
• This patient has some sensory function but no motor function below the injury
level. His bulbocavernosus reflex is intact so we know he is no longer in spinal
shock. Therefore, he would be classified as an ASIA B.
The imaging studies show a type II odontoid fracture, a congenital fusion at C2/3
and C4/5, and a large soft disc herniation at C3/4 with spinal cord compression and
myelomalacia.
The ASIA system describes the exam below the level of the injury.
ASIA A: Complete. No motor or sensory
ASIA B: Incomplete. No motor function but some remaining sensory
ASIA C: Incomplete. 50% or more of muscles below injury are less than Grade 3.
ASIA D: Incomplete. 50% or more of muscles below injury are equal to or greater
than Grade 3.
ASIA E: Normal
Furlan et al reviewed the ASIA classification in the assessment of motor and sensory
function in patents with spinal cord injury (SCI). Although many studies suggest
convergent and divergent construct validity, they determined that the ASIA
classification is an adequate instrument to evaluate patients with SCI.
Illustration A outlines the ASIA classification. The complete ASIA assessment chart is
in Illustration B.
39 A 36-year-old man presents to the clinic with left-sided back and leg
pain that involves the lateral calf that began after a lifting incident 2
weeks ago. The pain is severe in nature, and is making it difficult to
sleep and work. Physical exam shows he is unable to walk on his
heels on the left. A para-sagittal T1 MRI on the left is shown in
Figures A. A T2 axial MRI at the L4/5 disc level is shown in Figure B.
For treatment, over the past 2 weeks, he has attempted physical
therapy, NSAIDs, and gabapentin, none of which lead to significant
improvement in his symptoms. What is the most appropriate next
best step in management?
QID: 3755 FIGURES: A B
1L5-S1 left-sided translaminar epidural steroid injection

2Left L5 transforaminal selective nerve root corticosteroid injection
3Left L4 transforaminal selective nerve root corticosteroid injection
4Hemilaminotomy and discectomy
5Pedicle to pedicle laminectomy with interbody fusion
• The patient is presenting with an acute (two weeks) L4/5 paracentral lumbar disc herniation that has failed first-line conservative measures with
activity modification, therapy, and oral medications. The most appropriate next step in treatment is a selective nerve root corticosteroid injection
of the L5 nerve root. Surgical management should only be considered when nonoperative treatment has failed for 6 weeks or more.
Lumbar disc herniation occurs at the L4-L5 and L5-S1 segments in 95% of cases. Approximately 90% of cases can be treated nonoperatively. In the
absence of cauda equina syndrome, first-line treatment is with activity modification, oral medications (NSAIDS, medrol dose pack, GABA inhibitors),
and physical therapy. Selective nerve root corticosteroid injection is second-line treatment and can be helpful in up to 50% of patients. Failure of
nonoperative measures including steroid injection for 6 weeks is an indication for surgical intervention in the form of hemilaminotomy and
discectomy.
Radcliff et al. looked at the impact of epidural steroid injections in patients with Lumbar Disc Herniations in the SPORT study. They found while
epidural steroid injections did not make a difference on long term outcomes, patients who had the epidural steroid injection where more likely to
change from their randomized assigned surgical treatment group to the nonoperative treatment group (41% versus 12% in the No-ESI, p < 0.001).
Young et al. reviewed the utilization of lumbar epidural steroid injections (ESI) for low back and leg pain. The authors concluded that lumbar ESIs
are a reasonable nonsurgical option to provide temporary symptomatic relief. Fluoroscopic guidance facilitates accurate placement of the injection
into the epidural space, while not using it may lead to higher percentage of technical failures. Lastly, the transforaminal approach is more selective
than the interlaminar approach and can provide diagnostic information as well as symptom relief.
Rhee et al.reviewed the pathophysiology and management of lumbar disc herniations. They suggest that surgical management should be
independent of size of the disc herniation and rather based on symptoms and lack of response to nonoperative care.
Atlas et al. undertook a prospective cohort study to evaluate outcome of lumbar disc herniations at 10 years. They found more complete relief of
leg pain in the surgical group but return to work and disability outcomes were similar. The surgical and nonoperative groups had similar
(re)operation rates at 10 years, at around 25%.
Figure A and B are T1 MRI sagittal and T2 MRI axial images, respectively, showing a left-sided paracentral disc herniation at the L4-L5 level leading
to compression of the descending L5 nerve root. Illustration A shows the axial image with the affected L5 nerve root highlighted.
Incorrect Answers:
Answer 1: The patient has a L5 radiculopathy from herniation at the L4-L5 level. A translaminar injection at one level below is the not the most
appropriate target for injection.
Answer 3: The patient has a L5 radiculopathy due to a paracentral disc herniation at L4-L5. A disc herniation in this location does not affect the L4
nerve root, and therefore would not be an appropriate target for a selective nerve root injection.
Answer 4: Hemilaminotomy and discectomy is not indicated until the patient has failed at least 6 weeks of nonoperative measures. This patient has
only had symptoms for two weeks.
Answer 5: Laminectomy and fusion is not indicated in this patient.
40
Figure 16 shows the CT scan of a 44-year-old woman who sustained a
direct blow to the head after falling while snowboarding. She is unable
to move her upper or lower extremities and has diffuse numbness.
Examination reveals normal strength in the deltoid muscles bilaterally
but 0/5 strength in the remaining upper or lower extremity muscle
groups. She is absent light touch, pinprick, and proprioceptive function
in her upper and lower extremities. She has decreased rectal tone and
intact perirectal sensation with an intact bulbocavernosus reflex. The
patient's spinal cord injury is best classified as QID: 7604
FIGURES: A
1complete, ASIA A.
2complete, ASIA B.
3incomplete, ASIA B.
4incomplete, ASIA C.
5incomplete, ASIA D.
• The patient has sustained a C5 tear-drop fracture with
spinal cord injury. Examination demonstrated sacral
sparing with perirectal sensation; therefore, this is an
incomplete injury. Given her absent motor function,
she would be classified as an ASIA (American Spinal
Injury Association) B. ASIA A represents a complete
spinal cord injury with no motor or sensory sparing
below the level of injury. ASIA B is an incomplete
spinal cord injury with sacral sparing (preservation of
sacral sensation). ASIA C and ASIA D injuries reveal
some motor function in the lower extremities. ASIA C
injuries result in grade 3/5 or less strength, while ASIA
D injuries show greater than 3/5 strength.
41
A patient who underwent an L5-S1 hemilaminotomy
and partial diskectomy for radiculopathy 3 weeks ago
now reports increasing leg and back pain with radicular
signs. An axial T2-weighted MRI scan is shown in Figure
97a, an axial T1-weighted MRI scan is shown in Figure
97b, and a contrast enhanced T1-weighted MRI scan is
shown in Figure 97c. What is the most appropriate
management for the patient's symptoms? QID: 8010
FIGURES: A B C
1Irrigation and debridement of deep wound infection
2CT-guided needle biopsy and IV antibiotics
3Revision laminotomy and diskectomy
4L4-L5 anterior debridement and fusion
5Open repair of the L4-L5 pseudomeningocele
• The MRI scans show a recurrent disk herniation.
There is no increase fluid signal or enhancement to
suggest infection or any other pathologic process.
There is no infection; therefore, IV antibiotics and
debridement are not indicated. Similarly, a
pseudomeningocele is not present. In addition, with
progressive weakness, physical therapy is not
appropriate. A revision diskectomy is useful for
recurrent radiculopathy.
42 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. FIGURES: A B C
1Lumbar decompression
2Lumbar decompression with arthrodesis
3A trial of physical therapy and NSAIDS
4Lumbar epidural steroid injections
5CT myelogram of cervical spine
• The clinical presentation and imaging studies are consistent with concurrent symptoms of myelopathy and neurogenic
claudication in a patient with lumbar degenerative spondylolisthesis. An CT myelogram of the cervical spine would be the
most appropriate next step in management as the patient is unable to obtain an MRI due to the pacemaker.
Symptomatic tandem stenosis can present with a confusing scenario of both neurogenic claudication and myelopathy. The
prevalence has been estimated to be from 5% to 25%. Depending on the severity of symptoms, the cervical myelopathy
usually takes treatment precedence.
Lee et al. performed a cadaveric study looking at the incidence of tandem stenosis. They found a prevalence of tandem
stenosis from 0.9% to 5.4% in the sample population. The association of cervical and lumbar stenosis was found to be
statistically significant, and stenosis in one part of the spine positively predicts for stenosis in the other area of the spine
15.3% to 32.4% of the time.
Eskander et al. looked at the ideal treatment algorithm (staged or simultaneous) in patients with symptomatic tandem
stenosis in the lumbar and cervical spine. They report treatment outcomes are similar regardless of the surgical choice, but
that complications are significantly increased by increasing patient age, blood loss, and operative time. Therefore, the decision
to approach the lumbar and cervical spine simultaneously or staged depends on the characteristic of the patient and
whichever approach the surgeon feels will minimize blood loss and operative time.
Rhee et al. looked at the sensitivity and specificity of different physical exam findings for cervical myelopathy. They found
sustained clonus was poorly sensitive (13%) but highly specific (100%) for cervical myelopathy.
Figure A, B, and C show a lumbar myelogram in AP, flexion, and extension respectively. There is a degenerative
spondylolisthesis with associated spinal stenosis. Figure V is a video showing sustained clonus with forced ankle dorsiflexion. 3
beats of clonus or less is considered normal. Illustration A is a table from the Rhee study which shows the sensitivity and
specificity of different physical exam findings for cervical myelopathy.
Incorrect Answers:
Answer 1: The patient has degenerative spondylolisthesis, and therefore even after the cervical spine is evaluated, a
laminectomy alone would not be indicated.
Answer 2,3 and 4: All of these are appropriate treatment options for the degenerative spondylolisthesis in this patient.
However the question asks for the next step in management, would should be focused evaluating the cervical spine.
43
An 82-year-old man is seen in consultation after being admitted for a fall from ground
level. There was no loss of consciousness and the patient recalls striking his head and
sustaining a hyperextension-type injury to the cervical spine. Examination reveals an 8-cm
head laceration with only mild axial neck tenderness. He has generalized weakness
throughout the upper extremities and maintained motor function of the lower extremities.
There are no obvious sensory deficits, and the bulbocavernous reflex and deep tendon
reflexes are maintained. What is the most appropriate diagnosis at this time?
QID: 6837
1Anterior cord syndrome
2Central cord syndrome
3Posterior cord syndrome
4Brown-Séquard syndrome
5Spinal shock
• Incomplete cord syndromes have variable neurologic findings with
partial loss of sensory and/or motor function below the level of
injury. Incomplete cord syndromes include the anterior cord
syndrome, the Brown-Séquard syndrome, central cord syndrome,
and posterior cord syndrome. Central cord syndrome is characterized
with greater motor weakness in the upper extremities than in the
lower extremities. The pattern of motor weakness shows greater
distal involvement in the affected extremity than proximal muscle
weakness. Anterior cord syndrome involves a variable loss of motor
function and pain and/or temperature sensation, with preservation
of proprioception. The Brown-Séquard syndrome involves a
relatively greater ipsilateral loss of proprioception and motor
function, with contralateral loss of pain and temperature sensation.
Posterior cord syndrome is a rare injury and is characterized by
preservation of motor function, sense of pain, and light touch, with
loss of proprioception and temperature sensation below the level of
the lesion. Spinal shock is the period of time, usually 24 hours, after
a spinal injury that is characterized by absent reflexes, flaccidity, and
loss of sensation below the level of the injury.
44
A patient who underwent a L4-L5 hemilaminotomy and partial diskectomy for
radiculopathy 8 weeks ago now reports increasing low back pain without neurologic
symptoms. A sagittal T2-weighted MRI scan is shown in Figure 13a, and a contrast
enhanced T1-weighted MRI scan is shown in Figure 13b. What is the most appropriate
management for the patient’s symptoms?
QID: 6823
FIGURES: A B
1Physical therapy
2CT-guided needle biopsy and IV antibiotics
3Revision laminotomy and diskectomy
4L4-L5 anterior debridement and fusion
5Open repair of the L4-L5 pseudomeningocele
• The MRI scans show Modic changes in the L4-L5
vertebral bodies due to spondylosis. There is no
increased fluid signal or enhancement in the L4-L5
disk to suggest infection or any other pathologic
process. Therefore, the patient’s pain should be
treated with a course of physical therapy and
rehabilitation. There is no infection; therefore, IV
antibiotics and debridement are not indicated.
Similarly, a pseudomeningocele is not present. A
revision diskectomy is useful for recurrent
radiculopathy but would not be helpful for
degenerative low back pain.
45
A 65-year-old woman presents with neck pain for 18
months. She has taken NSAIDs and undergone physical
therapy without improvement. Over the past 6 months,
she has also noticed progressive hand clumsiness and
difficulty with gait. Sagittal and axial MRI images are
shown in figures A and B, respectively. What is the most
appropriate next step in management? QID: 5437
FIGURES: A B
1Physical therapy with emphasis on neck muscle
strengthening and posture improvement
2Epidural steroid injection
3Anterior cervical discectomy and fusion
4Laminectomy alone
5Multi-level laminectomy and fusion
• This patient presents with clinical and radiographic evidence of cervical myelopathy with progression of gait
imbalance and hand clumsiness. The most appropriate management is anterior cervical discectomy and fusion
(ACDF).
Cervical myelopathy is typically caused compression on the spinal cord and classically present with neck pain,
parasthesias, clumsiness, gait imbalance, and/or urinary retention. Nonoperative management is reserved for
patients without functional impairment. ACDF is the treatment of choice for focal compression from anterior disc-
ostephyte changes. Posterior decompression is indicated in patients with multi-level disease. It is important to note
in patients with significant kyphosis, the kyphosis must be reversed in order for decompression alone to be
effective.
Hsu reviewed posterior decompression techniques in the cervical spine. They state that the choice of anterior versus
posterior approach is determined based on sagittal spine alignment, extent and location of pathological
involvement, and patient preference. They recommend laminectomy and fusion for cervical stenosis and kyphosis
<10 degrees. The use of BMP-2 as an adjunct in the cervical spine is not recommended by the author.
Emery reviewed cervical spondylotic myelopathy and recommend nonoperative treatment in patients with minimal
symptoms without pathologic reflexes or gait imbalances. They suggest that the preferred posterior techniques are
now laminectomy and fusion or laminoplasty.
Figure A and B are sagittal and axial T2 MRI sequences showing a degenerative disc osteophyte complex at C5-C6
with resultant canal stenosis and cord compression. Illustration A is a lateral C spine radiograph in a patient who is
status post ACDF at C5-C6.
Incorrect Answers:
Answers 1 and 2: The patient has neurological impairment in the form on gait imbalance and clumsiness.
Nonoperative treatment is not recommended.
Answer 4: Laminectomy alone is not recommended for decompression. There is a risk of post-operative kyphosis.
Answer 5: Laminectomy and fusion is recommended in multi-level disease with kyphosis less than 10 degrees.
46
A 36-year-old male presents with acute onset of right buttock and leg
pain following lifting a heavy object. On physical exam he has weakness
to knee extension, numbness over the medial malleolus, and a
decreased patellar reflex. Which of the following would most likely
explain this clinical presentation
1. Lumbar arachnoiditis
2. L4/L5 paracentral disc herniation
3. L3/L4 far lateral (foraminal) disc herniation
4. L4/L5 far lateral (foraminal) disc herniation
5. L5/S1 far lateral (foraminal) disc herniation
• The clinical presentation is consistent with a L4 radiculopathy. A L4/L5 far lateral
(foraminal) disc herniation would compress the exiting root (L4) and cause these
symptoms.
The location of a prolapsed lumbar disc determines its symptoms. Central disc
herniations may give rise to back pain or cauda equina syndrome. Paracentral disc
herniations (90-95% of cases) affect the traversing nerve root. Far lateral disc
herniations (5-10%) affect the exiting nerve root.
Gregory et al. summarize physical signs in lumbar disc herniation. They state that the
straight-leg-raise is the most sensitive (73-98% sensitive) test and the crossed straight-
leg-raise is the most specific (88-98% specific) test for lumbar disc herniation. Other
specific tests include weak ankle dorsiflexion (89% specific), absent ankle reflex (89%
specific), and calf wasting (94% specific, but a late finding).
Illustration A shows how a paracentral L4/L5 disc herniation affects the traversing L5
root, but a far lateral L4/L5 disc herniation affects the L4 root. Illustration B shows the
dermatomal distribution of pain with root involvement from L3 to S1.
Incorrect Answers:
Answer 1: Lumbar arachnoiditis will not give rise to radiculopathy. This patient did not
have invasive spinal procedures that would put him at risk of this condition. Symptoms
of arachnoiditis include chronic pain, numbness and tingling of the extremities,
abnormal bowel, bladder and sexual function.
Answer 2: L4/L5 paracentral disc herniation would affect the traversing root (L5) and
give rise to L5 radiculopathy.
Answer 3: L3/L4 far lateral (foraminal) disc herniation would affect the exiting root (L3)
and give rise to L3 radiculopathy.
Answer 5: L5/S1 far lateral (foraminal) disc herniation would affect the exiting root (L5)
and give rise to L5 radiculopathy.
47
A 56-year-old right hand dominant male presents to your office complaining of right thumb
pain worsened with pincer grip and using his mobile phone. He is a writer, and is having
difficulty holding his pen. Radiographs from this visit are shown in Figure A. Compared with
trapeziectomy alone, which of the following treatment options is likely to result in superior
pain relief and improvement of key-pinch strength?
1 Trapeziometacarpal corticosteroid injection followed by aggressive occupational therapy

2 Trapeziectomy with interpositional palmaris longus arthroplasty
3 Trapeziectomy, interpositional arthroplasty, and palmar oblique ligament reconstruction using flexor carpi
radialis autograft
4Partial trapeziectomy with capsular interpositional arthroplasty
5None of the above
48
A 54-year-old woman who has a history of undergoing left trapezium
excision with ligament reconstruction and tendon interposition using the
entire flexor carpi radialis performed by another surgeon, now reports left
basilar thumb pain. Examination reveals pain and subluxation of the
carpometacarpal joint with axial loading. The metacarpophalangeal joint
hyperextends to 60 degrees, but radiographs show intact joint space. What is
the best option to improve function?
1 Bracing with a hand-based thumb spica splint

2 Pinning of the carpometacarpal joint
3 Pinning of the carpometacarpal and metacarpophalangeal joints
4 Carpometacarpal revision stabilization
5 Carpometacarpal revision stabilization and metacarpophalangeal joint fusion
49
A 44-year-old man presents with ulnar-sided right wrist pain and mild
constant tingling in the fourth and fifth digits after injuring his wrist
while playing golf. Although pain and function have improved with
conservative treatment 6 months following the injury, he still reports
difficulty with his golf game. Which of the following should initially be
obtained in this patient to aide in the diagnosis?
1 Bone scan of the wrist and hand

2 EMG study of the affected extremity
3 Carpal tunnel view radiograph
4 CT scan of the distal forearm and wrist
5 Contrast enhanced magnetic resonance angiogram
50
A 45-year-old patient undergoes multiple debridements for necrotizing fasciitis of the forearm,
leaving the defect shown in Figure A. The surgeon plans free fasciocutaneous flap transfer using an
antegrade flap based on septocutaneous perforators running in the intermuscular septum, as seen
in the cadaveric dissection in Figure B. At 4 months, the donor site incision has the appearance
shown in Figure C. Which vessel do these perforators originate from?
c
A B
1 Brachial artery
2 Posterior radial collateral artery
3 Recurrent interosseous artery
4 Posterior ulnar recurrent artery
5 Middle collateral artery
51
A 60-year-old man has chronic pain at the base of this thumb and weakness
on attempted thumb pinch. A radiograph is shown in Figure A. Which
injection would likely reduce his pain and increase his function?
1 Saline
2 Steroid
3 Hylan
4 All of the above are equally effective
5 All of the above are detrimental
52Figure 38 shows the radiograph of a 41-year-old man who reports ulnar
palmar pain, decreased sensibility and tingling in the ring and little fingers,
and a grating sensation in the ulnar fingers with motion. He reports that he
sustained a fall on an outstretched hand 6 months ago. What is the most
appropriate treatment option?
1 Ulnar gutter cast

2 Short arm cast
3 Carpal tunnel release
4 Decompression of Guyon's canal
5 Excision of a fractured hook of hamate
53
A 68-year-old female office assistant reports left thumb pain that has progressively worsened over
the past 2 years. She is left hand dominant and reports difficulty with opening jars and holding a
coffee cup. On examination of the left hand she has a positive thumb carpometacarpal grind test
and has a fixed deformity at the thumb metacarpalphalangeal joint. Figure A demonstrates the left
hand grasping an object and Figure B shows a radiograph of the left thumb. What is the most
appropriate next step in treatment?
A
B
1 Carpometacarpal joint fusion and metacarpophalangeal joint volar capsulodesis

2 Carpometacarpal joint resection arthroplasty and metacarpophalangeal joint volar capsulodesis
3 Carpometacarpal joint resection arthroplasty and metacarpophalangeal joint fusion
4 Carpometacarpal joint resection arthroplasty and temporary metacarpophalangeal joint
percutaneous pin fixation
5 Carpometacarpal joint fusion and metacarpophalangeal joint fusion
54
A 24-year-old professional baseball outfielder reports persistent pain in
the hypothenar region when batting for the past year. His CT scan is
shown in Figure A. What is the recommended treatment?
1 pisiform excision
2 hook of hamate excision
3 carpal tunnel release
4 decompression of Guyon's canal
5 open reduction and internal fixation
54
A 47-year-old woman falls and sustains a direct blow to her middle finger.
She notes pain and swelling and is unable to move the proximal
interphalangeal (PIP) or distal interphalangeal (DIP) joints. Radiographs are
shown in Figures 8a through 8c. Proper management should consist of
A B C
1 closed reduction and splinting in metacarpophalangeal (MCP) and PIP joint extension.
2 closed reduction and splinting in MCP joint flexion and PIP joint extension.
3 reduction and percutaneous intramedullary Kirschner wire fixation.
4 reduction and lag screw fixation.
5 buddy taping and early range of motion.
55
What is the name of the pathologic structure, identified by the white arrow
in Figure A, that displaces the digital neurovascular bundle and places it at
risk during during surgical treatment of Dupuytren's disease?
1 Pretendinous cord
2 Pretendinous band
3 Spiral cord
4 Spiral band
5 Natatory cord
56
A 50-year-old woman complains of severe pain and clicking in her right thumb after
opening a jar 1 year ago. She recalls a history of steroid injection for a chronic tenosynovitis
of the flexor pollicis longus tendon. Examination reveals diminished range of thumb
motion. A clinical photograph is shown in Figure A. An MRI scan is shown in Figure B. An
intraoperative photograph is shown in Figure C. What is the diagnosis?
A B C
1 Pulley rupture
2 Radial collateral ligament rupture
3 Flexor pollicis longus musculotendinous avulsion
4 Flexor pollicis longus bony avulsion
5 Gout
57
Figures 65a and 65b show the MRI scans of a 33-
year-old man with severe left leg pain. He has
had symptoms for 3 months with progressive
worsening pain and function. Examination
reveals ankle plantar-flexor weakness and
diminished light touch sensation on the plantar
surface of the foot. What treatment provides the
best outcome? FIGURES: A B
1Transforaminal epidural injection
2Laminotomy and limited diskectomy
3Laminotomy and complete diskectomy
4Laminectomy and complete diskectomy
5Laminotomy, diskectomy, and arthrodesis
• The patient's signs and symptoms are consistent with
lumbar radiculopathy. Surgical treatment for this
condition has been shown to yield significantly improved
outcomes when compared with nonsurgical management.
Surgical management is best performed with a
laminotomy and removal of the sequestered disk
herniation ("limited diskectomy"). A complete (ie,
subtotal) diskectomy may reduce the rate of recurrence
for disk herniation but has been shown to worsen back
pain postoperatively. A laminectomy may be necessary for
larger herniations with severe central stenosis; the patient
does not meet those criteria and, as noted, a total
diskectomy is not indicated. Arthrodesis in the setting of
primary lumbar disk herniation is not indicated and is
considered overly aggressive treatment.
58
A 36-year-old man has a 2-day history of acute lower back pain with severe
radicular symptoms in the left lower extremity. The patient has a positive
straight leg test at 40 degrees on the left side and mild decreased sensation
on the dorsum of the left foot. What is the most appropriate management at
this time? QID: 7937
1Urgent admission to the hospital for surgical intervention

2Immediate MRI of the lumbar spine as an outpatient
3Anti-inflammatory medications and activity modification
4Caudal epidural steroid injection
5Electromyography
• In the absence of any severe progressive neurologic
deficits or other red flags, the most appropriate
management for an acute lumbar disk herniation is
nonsurgical care. Conservative treatments such as
limited bed rest, anti-inflammatory medications, and
judicious use of pain medications are appropriate in
this clinical situation. Up to 90% of patients will
experience a resolution of symptoms without the
need for surgical intervention within a 3-month
window. In the acute setting, with no neurologic
deficits, immediate MRI of the lumbar spine is neither
beneficial nor warranted. Likewise, without signs of
an acute deficit, emergent surgical intervention and
caudal epidural steroid injections are not needed.
59
A 32-year-old woman jammed her ring finger. Figures 77a and 77b
show radiographs of the finger after a closed reduction. Which of the
following interventions, if done correctly, is likely to result in the best
possible final clinical outcome?
A B
1 Early removal of a splint and application of continuous passive motion

2 Application of dynamic extension bracing after the first week
3 Maintaining reduction of the middle phalanx on the condyles of the proximal phalanx with dynamic
external fixation
4 Open reduction and anatomic restoration of the middle phalanx articular surface
5 Surgical advancement of the volar plate into the middle phalanx base
60 ]A 50-year-old man presents with basal thumb pain and weakness. He is
found to have Stage IV osteoarthritis (OA) of the carpometacarpal joint
(CMC) of the thumb. He undergoes Weilby suspension arthroplasty using the
flexor carpi radialis tendon (FCR). He returns 1 year later with recurrent pain.
Radiographs are shown in Figure A. What is the next best step?
1 Trapeziometacarpal arthrodesis
2 Weilby suspension arthroplasty with extensor carpi radialis longus (ECRL) tendon
3 Ligamentous reconstruction tendon interposition (LRTI) with FCR tendon
4 Prosthetic arthroplasty
5 LRTI with ECRL tendon
61
A 62-year-old woman has long-standing left thumb pain and weakness when grasping objects.
Examination reveals a positive grind test and dynamic thumb metacarpophalangeal hyperextension.
Prolonged bracing, anti-inflammatories and oral analgesics has failed to relieve her symptoms.
Clinical and radiographic images are seen in Figures A and B. What would be the best treatment
option to relieve this patients pain and improve function?
A B
1 Extension osteotomy of the first metacarpal

2 Carpometacarpal joint resection arthroplasty
3 Carpometacarpal joint resection arthroplasty and metacarpophalangeal joint arthrodesis
4 Carpometacarpal joint arthrodesis and metacarpophalangeal joint arthrodesis
5 Carpometacarpal joint arthroscopy and debridement +/- ligament reconstruction
62
A 55-year-old female patient presents with pain along the thumb ray and increasing deformity of
her right hand. Key pinch causes her pain. The appearance of her hand is seen in Figure A. Range of
motion of her thumb is seen in Figure B. What is the most likely cause of her deformity?
B
A
1 Type II hypoplastic thumb

2 Median nerve neuropathy
3 Lupus thumb deformity
4 Extensor tendon rupture
5 Osteoarthritis of the trapeziometacarpal joint
63
A 38-year-old man who works as an auto mechanic reports right wrist pain and intermittent
paresthesias and numbness into the ulnar two digits of his hand. The pain symptoms begin after a
day of particularly strenuous repetitive use of the right hand. He denies any color changes to the
digits but does report a significant smoking history. Weakness of the interossei muscles are seen on
manual testing. Both radial and ulnar pulses are palpable at the wrist. The patient states that
sensation on the dorsum of his ring and little fingers is normal. Radiographs are shown in Figures
25a through 25c. What is the most likely diagnosis?
A B C
1 Idiopathic compression of the ulnar nerve at Guyon's canal
2 Ulnar hammer syndrome
3 Cubital tunnel syndrome
4 Pseudoaneurysm of the ulnar artery in the hand
5 Nonunion of the hamate
20
A 32-year-old male sustains a type IIIb open proximal third tibia fracture. Four days after
intramedullary nailing of the tibia, the wound is clean and ready for coverage with a medial
gastrocnemius rotational flap. What is the dominant arterial blood supply to this flap?
1 Superior and inferior genicular arteries

2 Anterior tibial artery
3 Posterior tibal artery
4 Sural artery
5 Saphenous artery
21
A 53-year-old white male presents with contractures of his ring finger and lesions over the dorsum of his hand.
On examination of the lesions, they are subcutaneous, solid, and firm lesions measuring about 5 mm in
diameter. They are located over the dorsum of the PIP joints of his ring and long finger. They become more
mobile while the joint is in neutral and less mobile when the joint is in flexion. He also has a 5 degree flexion
contracture his ring finger MCP joint. Examination of his palm reveals a palpable cord over the volar ring finger.
His neurovascular examination is normal. The appearance of the dorsum of his hand is seen in Figure A. What
is the next most appropriate step in treatment?
1 Collagenase injection and resection of dorsal finger lesions

2 Collagenase injection without resection of dorsal finger lesions
3 Observation and follow up
4 Surgical resection/fasciectomy and resection of dorsal finger lesions
5 Surgical resection/fasciectomy without resection of dorsal finger lesions
22
A 50-year-old patient presents with stiffness in her hand. A clinical photo is shown
in Figure A. During surgical exposure, the neurovascular bundle is identified and
dissected. What is the clinically most important pathologic structure to identify and
what is its location relative to the neurovascular bundle in the digit?
1 Spiral cord which is central and superficial to the neurovascular bundle

2 Central cord which is midline and superficial to the neurovascular bundle
3 Retrovascular cord which is central and superficial to the neurovascular bundle
4 Spiral cord which is lateral and deep to the neurovascular bundle
5 Central cord which is lateral and deep to the neurovascular bundle
23
A 7-year-old boy is referred to your office 3 months after jamming his finger while
playing basketball. Examination reveals 40 degrees of active and passive motion at
the proximal interphalangeal (PIP) joint. The PIP joint is stable to radial and ulnar
stressing. Radiographs are shown in Figures 76a and 76b. What is the most
appropriate management?
B
A
1 Observation
2 Corrective osteotomy
3 Ostectomy
4 Hand therapy for aggressive stretching
5 Dynamic splinting
• This question is describing a scenario in which you must rule out a septic hip, and
therefore the most appropriate next step in management is aspiration.
Prematurity and c-section are both risk factors for a septic hip in the new
born.While there is no fever in this case, there is swelling, pain with passive
motion, no active motion secondary to pain, and a radiograph which indicates an
effusion in the hip as seen by lateral displacement of the left proximal femur.
Suspicion for a septic hip should be high, and the next most appropriate step is a
hip aspiration. If no fluid is obtained, arthrography should be performed to
confirm intra-articular position of the needle. The aspirate should be sent for a
stat CBC with diff, culture (aerobic, anaerobic and acid-fast bacilli +/- fungal), and
gram stain. A WBC greater than 50,000/uL or a positive gram stain suggest septic
arthritis and are an indication for surgical incision and drainage and initiation of
IV antibiotics.
24 A 32-year-old man sustains a traumatic amputation of his right thumb
(Figure A). He undergoes the soft-tissue coverage procedure shown in Figure
B. What artery does this flap rely on, and which nerve is at risk during this
procedure?
A B
1 Medial femoral circumflex artery; femoral branches of genitofemoral nerve

2 Medial femoral circumflex artery; lateral femoral cutaneous nerve
3 Superficial circumflex iliac artery; femoral branches of genitofemoral nerve
4 Superficial circumflex iliac artery; lateral femoral cutaneous nerve
5 Superficial circumflex iliac artery; ilioinguinal nerve
23-year-old man is evaluated in the emergency department after a diving
accident. Radiographs reveal bilateral jumped facets at C6-7. Examination
reveals no motor function below the C7 level. There is some maintained
sensation in the lower extremities. What is the patient's current grade on the
ASIA (American Spinal Injury Association) impairment scale?
QID: 7928
1ASIA A
2ASIA B
3ASIA C
4ASIA D
5ASIA E
• The American Spinal Injury Association (ASIA)
provides a standard method of measurement of
spinal cord injury. The ASIA impairment scale is based
on a comprehensive motor and sensory examination.
An ASIA A grade is ascribed to a patient with an injury
with no motor or sensory preservation below the
injury. An ASIA B grade is defined as no motor
preservation below the level of injury but some
sensory preservation below the injury level. An ASIA C
grade is defined as a motor function grade of less
than 3 below the injury level. An ASIA D grade is
defined as a motor function grade of greater than 3
below the injury level. An ASIA E grade is defined as a
normal neurologic examination.
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
FIGURES: A
1Higher risk of infection

2Lower risk of C5 radiculopathy
3Higher over-all complication rate
4Lower average blood loss
5Increased rate of numbness
to the long finger and wrist flexion weakness
• Surgical decompression of cervical myelopathy via an anterior procedure has lower reported blood loss compared to a
posterior procedure.
Cervical myelopathy has a progressive course and therefore if there is evidence of functional impairment surgical
decompression is indicated. Either an anterior decompression or posterior decompression can be used depending on a
variety of factors including number of levels involved and sagittal alignment of the cervical spine. In general, a posterior
approach is used when three or more levels are involved and the spine is in neutral or lordotic alignment.
Fehlings et al. did a prospective study on the risks of complications associated with surgical treatment of cervical
myelopathy. They found that combined anterior and posterior procedures had a significantly higher rate of complication
than either anterior-only or posterior-only procedures. Posterior procedures had a higher rate of wound infections
compared to anterior. They found no statistical difference in the over-all complication rate, incidence of C5 radiculopathy, or
dysphagia between an anterior-only or posterior-only procedure.
Fehlings et al. did a prospective study on outcomes following surgical treatment of cervical myelopathy. At one year follow-
up they found a significant improvement in mJOA score, Nurick grade, NDI score, and all SF-36v2 dimensions. With the
exception of mJOA scores, these improvements were not statistically related to severity of disease.
Liu et al. performed a meta-analysis of outcomes following surgical decompression of cervical myelopathy. They found
outcomes following anterior procedures were better than those for posterior procedures when there were less than 3
affected levels. With 3 or greater levels, no statistical difference in outcomes could be found between the two approaches.
They note none of their reviewed publications represent high-quality prospective randomized trials.
Figure A is a sagittal MR image of the cervical spine showing multi-level degenerative disease with cord compression
consistent with cervical myelopathy.
Incorrect Answers:
Answer 1: Incidence of wound infection was found to be higher in patients following a posterior procedure.
Answer 2: No statistically significant difference was found in the incidence of C5 radiculopathy between the anterior or
posterior procedures.
Answer 3: No statistically significant difference was found in the over-all complication rate between the anterior or posterior
procedures.
Answer 5: No statistically significant difference was found in the incidence of C5 radiculopathy between the anterior or
posterior procedures.
25
(OBQ13.240) A 30-year-old male sustains a 3.5 cm long thumb pulp injury seen in Figure A.
He undergoes a procedure to restore the soft tissue envelope. Which treatment option is
contraindicated because of increased risk of interphalangeal joint stiffness?
1 Moberg volar advancement flap

2 Foucher first dorsal metacarpal artery flap
3 Littler neurovascular island flap
4 Free great toe pulp transfer
5 Holevich first dorsal metacarpal artery flap
• With femoral lengthening of the limb along its mechanical axis, the goal is overall
mechanical axis preservation and this is not altered. When lengthening the limb along
the anatomical axis of the femur, there is lateral mechanical axis deviation (LAD).
There is a difference of approximately 7° between the mechanical axis of the limb and
the anatomical axis of the femur. Lengthening along the anatomical axis of the femur
leads to lateral MAD. Similarly, shortening along the anatomical axis of the femur leads to
medial MAD.
Kasis et al. described limb shortening of 4cm using external fixator assistance to dial in
compression before fixation with a blade plate. They claimed this allowed correction of
any tendency to medialize the mechanical axis of the limb prior to plate fixation.
Burghardt et al. described femoral lengthening over a telescoping nail and found lateral
shift of the mechanical axis in 26 of 27 limbs, although many were minor and
inconsequential. As a rule of thumb, the mechanical axis will shift about 1 mm laterally
for every 1 cm of lengthening.
A 26-year-old arena football player is seen in the emergency room after
he was injured playing football. On physical exam the patient has 4/5
strength in his deltoid, and 0/5 strength in the remainder of his
extremities. He has no perianal sensation or rectal tone, but his
bulbocavernosus reflex is intact. He has no other injuries except for
those seen in Figures A and B. Which of the following is
true? FIGURES: A B
1The patient has a complete injury, so early decompression (< 24 hours)

will not increase the liklihood of neurologic recovery compared to
delayed treatment
2The patient has an incomplete injury, and he should be taken to the OR
for early decompression (< 24 hours) to improve neurologic recovery
3The patient has a complete injury, but early decompression (< 24
hours) will increase the likelihood of neurologic recovery
4The patient has a complete injury, and early decompression (< 24
hours) will increase risk of mortality within 30 days of the injury
5The patient has a complete injury, and early decompression (< 24
hours) will increase the peri-operative complications
• The patient has a complete spinal cord injury. Early decompression (<24 hours) leads to an increased
likelihood of neurologic recovery.
The patient has a complete spinal cord injury. According to the ASIA classification, a patient with a
complete spinal cord injury has no motor or sensation caudal to the injury level, and does not have
rectal tone or perianal sensation. Additionally, a patient cannot truly be considered complete until
the bulbocavernosus reflex has returned. Prior to return of the bulbocavernosus reflex, the patient is
still in spinal shock, and it cannot be definitively stated if the patient has a complete or an
incomplete injury. While a complete spinal cord injury has a worse prognosis than an incomplete
injury, early decompression (<24 hours) has been shown to increase the likelihood of neurologic
recovery in both complete and incomplete injuries.
Fehlings et al. performed a multicenter prospective cohort study on the timing of intervention for
spinal cord injuries. They found improved neurological outcome for patients with complete or
incomplete spinal cord injuries that were decompressed within 24 hours compared to those that
were decompressed at a later time. Additionally, they found no increased risk of mortality or
complications for patients who underwent early surgical intervention.
Fehlings et al. also surveyed spine surgeons on their treatment of patients with acute spinal cord
injuries, and found that when central cord syndrome was excluded, 80% of spine surgeons
recommended early decompression (< 24 hours).
Figure A demonstrates a sagittal image from the CT scan. The patient has a flexion-distraction injury
with significant canal compromise. Figure B demonstrates a sagittal image from the MRI. Significant
compression of the spinal cord can be seen. Illustration A is an summary chart of the ASIA
impairment scale. Illustrations B and C are the front and back pages of the ASIA examination sheet.
Incorrect Answers:
Answer 1: Early decompression does increase the likelihood of neurologic recovery, even in complete
injuries.
Answer 2: The patient has a complete injury.
Answer 4: Early decompression does not increase the risk of mortality or complications.
Answer 5: Early decompression does not increase the risk of mortality or complications.
• Recurrent ankle sprains may be associated with tarsal coalition between the talus, the
calcaneus, and/or the navicular. Calcaneonavicular coalitions are most common in
children aged 8 to 12 years and talocalcaneal coalitions are most common in the 12 to 15
year age group. 10% to 20% of patients with tarsal coalitions have two coalitions and
50% are bilateral. Tarsal coalitions are often asymptomatic, and can present in late
childhood or adolescence due to stresses transferred from the rigid hindfoot. Patients
with tarsal coalition often exhibit a rigid flatfoot as shown in Figures A and B.
Kumar et al present Level 4 evidence describing the 3 types of fusion (fibrous,
cartilaginous, or osseous) and note that in 18 cases surgical resection of the coalition had
good or excellent results in all but 2 feet.
Churchill et al report in their Level 5 review that plain radiographs, as shown in Figures C
and D, may demonstrate talar beaking or the “anteater nose” sign in the distal calcaneus.
CT scans, as shown in Illustration A and B, can be helpful adjuncts for identification and
delineation, particularly talocalcaneal coalitions.
• The radiograph shows an incompletely ossified calcaneonavicular coalition.
When symptomatic, a trial of cast immobilization is reasonable. If this fails
to provide relief, the preferred treatment is resection of the coalition.
Before attempting surgery, a CT scan should be obtained to rule out
ipsilateral subtalar coalition. Recurrence of the coalition is usually
prevented with interposition of autogenous fat graft or with local
interposition of the extensor digitorum brevis muscle. Approximately 80%
of patients treated in this manner have decreased pain and improved
subtalar motion. When the flatfoot deformity is mild, calcaneal lengthening
or medial translation osteotomy is unnecessary. Primary triple arthrodesis
may be indicated if degenerative changes are present in the subtalar or
midfoot joints. Peroneal lengthening has been described for treatment of
the peroneal spastic flatfoot without demonstrable tarsal coalition.
• Premature consolidation is a complication that is unique to gradual bone
lengthening after corticotomy. Causes include excessive latency period,
inadequate distraction rate, exuberant bone formation, patient compliance
problems, and mechanical failure of the distraction apparatus. The femur
and fibula are most commonly involved. This patient did not have an
incomplete corticotomy, as initial distraction occurred before the
distraction device was noted to seize up. The radiographs show bowing of
the Ilizarov wires and mature regenerate bone, both suggestive of
premature consolidation. No wire breakage or joint subluxation is seen on
the radiographs. Treatment for premature consolidation includes
continuing distraction until the consolidation bridge ruptures, or additional
surgery may include closed rotational osteoclasis or repeat corticotomy.

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1C4-7 anterior decompression with instrumented fusion

1 iliac crest bone grafting

1 Activity restriction and continued monitoring

(SAE09TR.74) A 40-year-old man sustains a fracture-dislocation of C4-5.

1L5-S1 left-sided translaminar epidural steroid injection

1 Trapeziometacarpal corticosteroid injection followed by aggressive occupational therapy

1 Bracing with a hand-based thumb spica splint

1 Bone scan of the wrist and hand

1 Ulnar gutter cast

1 Carpometacarpal joint fusion and metacarpophalangeal joint volar capsulodesis

1Urgent admission to the hospital for surgical intervention

1 Early removal of a splint and application of continuous passive motion

1 Extension osteotomy of the first metacarpal

1 Type II hypoplastic thumb

1 Superior and inferior genicular arteries

1 Collagenase injection and resection of dorsal finger lesions

1 Spiral cord which is central and superficial to the neurovascular bundle

1 Medial femoral circumflex artery; femoral branches of genitofemoral nerve

1Higher risk of infection

1 Moberg volar advancement flap

1The patient has a complete injury, so early decompression (< 24 hours)

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