Spine

Questions

1. The Thoracolumbar Injury Classification and Severity (TLICS) Score includes all of the following except:

   1. Fracture mechanism

   2. Neurological involvement

   3. ASIA grading

   4. Posterior ligamentous complex integrity

   5. Fracture morphology
       

2. According to the TLICS Score, a definitive indication for surgery would be:

   1. Score 0-1

   2. Score 2-3

   3. Score 3-4

   4. Score 4-5

   5. Score 5-6
       

3. Which of the following spinal cord injuries carries the best prognosis?  

   1. Central cord syndrome

   2. Anterior cord syndrome

   3. Complete spinal cord injury

   4. Brown Sequard syndrome

   5. Single root lesions
       

4. Which of the following spinal cord injuries carries the worst prognosis?

   1. Central cord syndrome

   2. Anterior cord syndrome

   3. Complete spinal cord injury

   4. Brown Sequard syndrome

   5. Single root lesions
       

5. Which of the following spinal cord injuries is the most common and is often seen in patients with pre-existing cervical spondylosis?

   1. Central cord syndrome

   2. Anterior cord syndrome

   3. Complete spinal cord injury

   4. Brown Sequard syndrome

   5. Single root lesions
       

6. According to the Frankel classification, Grade D correlates with:

   1. Normal function (grade 5/5)

   2. Sensory function only below injury level

   3. Complete paralysis

   4. Incomplete motor function (grade 1-2/5) below injury level

   5. Fair to good motor function (grade 3-4/5) below injury level
       

7. Degenerative spondylolisthesis is more common in all of the following cases except:

   1. African Americans

   2. Diabetics

   3. > 40 years

   4. L5/S1 level

   5. Females
       

8. The lateral spinothalamic tract include nerve fibers transmitting:

   1. Light touch to the ipsilateral side of the body

   2. Pain and temperature to the contralateral side of the body

   3. Light touch to the contralateral side of the body

   4. Pain and temperature to the ipsilateral side of the body

   5. Position and fine touch to the ipsilateral side of the body
       

9. According to Anderson and D’Alonzo classification of odontoid peg fractures, which of the following types carry the highest risk of nonunion?

   1. Type I

   2. Type II

   3. Type III

   4. Type IV

   5. Type V
       

10. During the anterior approach to the cervical spine, all of the following structures are normally encountered except:

    1. Carotid sheath

    2. Superior and inferior thyroid arteries

    3. Sternocleidomastoid and strap muscles

    4. Vertebral artery

    5. Pretracheal and prevertebral fascia

Answers

1. c
   Discussion: ASIA grading system is used to define and describe the extent and severity of spinal cord injury and help determine future rehabilitation and recovery needs. It is based on motor and sensory testing and is ideally completed within 72 hours after the initial injury.
   Reference: Vaccaro AR, Lehman RA Jr, Hurlbert RJ, et al. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine. 2005 Oct 15; 30(20): 2325-33

2. e
   Discussion: Score 0-3 nonoperative treatment. Score 4 either nonoperative or operative treatment, according to qualifiers such as comorbid medical conditions or other injuries. Score > 4 operative treatment
   Reference: Vaccaro AR, Lehman RA Jr, Hurlbert RJ, et al. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine. 2005 Oct 15; 30(20): 2325-33

3. d
   Discussion: Brown Sequard syndrome damages half of the cord, causing ipsilateral motor loss, position/propioception loss and contralateral pain, and temperature loss (usually two levels below the insult). This injury, usually the result of penetrating trauma carries the best prognosis.
   Reference: Review of Orthopaedics, Miller

4. b
   Discussion: Anterior cord syndrome is the second most common injury, in which the damage is primarily in the anterior two-thirds of the cord, sparing the posterior columns (propioception and vibration sensation). These patients demonstrate greater motor loss in the legs than in the arms. CT scan may demonstrate bony fragments compressing the anterior cord. The anterior cord syndrome carries the worse prognosis.
   Reference: Review of Orthopaedics, Miller

5. a
   Discussion: Central cord syndrome is the most common and is often seen in patients with pre-existing cervical spondylosis who sustain a hyperextension injury. The cord is anteriorly compressed by Osteophytes and posteriorly by the infolded ligamentum flavum. The cord is injured in the central gray matter, which results in proportionately greater loss of motor function to the upper extremities than to the lower extremities, with variable sensory sparing. 
   Reference: Review of Orthopaedics, Miller

6. e
   Discussion: Frankel classification is useful when considering functional recovery from spinal cord injury and includes the following grades:
      A: Complete paralysis
      B: Sensory function only below injury level
      C: Incomplete motor function (grade 1-2/5) below injury level
      D: Fair to good motor function (grade 3-4/5) below injury level
      E: Normal function (grade 5/5)
   ​Reference: Review of Orthopaedics, Miller

7. d
   Discussion: It is most common with L4/5 level
   Reference: Review of Orthopaedics, Miller

8. b
   Discussion:
      Anterior corticospinal tract → contralateral skilled movement
      Lateral corticospinal tract → ipsilateral skilled movement
      Anterior spinothalamic tract → contralateral light touch
      Lateral spinothalamic tract → contralateral pain and temperature
      Fasciculus gracilis → ipsilateral position/fine touch  
   Reference: Campbell’s Operative Orthopaedics

9. b
   Discussion: Type I fractures are uncommon, and even if nonunion occurs after inadequate immobilization, no instability results. Type II are the most common, and Anderson and D’Alonzo reported 36% nonunion rate for displaced and non-displaced type II fractures. Type III fractures have a large cancellous base and heal without surgery in 90% of cases. There is no type IV or V in Anderson and D’Alonzo classification.
   Reference: Campbell’s Operative Orthopaedics

10. d
    Discussion: The vertebral artery which lies in the costotransverse foramen on the lateral portion of the transverse processes should not be visible during the approach unless the plane of operation strays well away from the midline.
    Reference: Hoppenfeld Surgical Exposures in Orthopaedics