w Adult Spine 201
Self-Assessment Examination 201
2015
AAOS
Yowr Sorefor Lifelong Orthopaedic learig
,1 - Figures 1 and 2 are CT scans obtained from a 68-year-old man who has had progressive neck pain and stiffness,
worsening gait imbalance, upper extremity weakness, early muscle fatigue, difficulty with fine motor control, and
difficulty with activities of daily living over the past few years. On physical examination, he has a wide based stiff legged
gait, generalized upper extremity weakness, dense sensory loss in the upper and lower extremities, and markedly brisk
reflexes. What is the most appropriate treatment for this patient?
Figure 1 Figure 2
A. Observation
B. Cervical epidural injections
C. Multilevel anterior cervical decompression and fusion
D. Posterior cervical laminoplasties from C3-6
Correct answer: D
This patient has progressive myelopathy secondary to ossification of the posterior longitudinal ligament. Diagnostic
imaging reveals multilevel cervical cord compression from C4-6. The patient has maintained reasonable cervical lordosis.
A posterior procedure such as multilevel laminoplasty decompresses the spine, is motion preserving, and has a low
complication rate. Observation and cervical epidural injections are not viable options in patients with progressive
myelopathy. Anterior cervical decompression, including corpectomy, is an option; however, anterior procedures have an
increased risk of complications such as dural tear or cerebrospinal fluid leak. The axial CT image shows a "double layer"
sign, which is consistent with dural ossification and increases the risk of dural injury with anterior decompression.
2 - When compared with posterior decompression and fusion, the addition of an interbody fusion for the treatment of
degenerative spondylolisthesis and stenosis has been shown to
A. result in increased patient functional outcome scores.
B. reduce the incidence of symptomatic pseudarthrosis.
, C. increase the length of hospital stay.
D. increase hospital costs.
Correct answer: D
The use of an interbody graft has been shown to increase hospital costs. Gottschalk and associates found no
change in Oswestry Disability Index (ODI) or 36-Item Short-Form Health Survey (SF-36) scores when
comparing patients fused using either posterior fusion or transforaminal interbody fusion. They also found no
change in fusion rates at 3 years after surgery. Carreon and associates showed some that using a posterior place
interbody transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF) did result
in improved ODI and SF-6D scores but did not result in any change in EuroQol five dimensions questionnaire
(EQ-5D) scores. Using the EQ-5D data, they estimated that the use of an interbody graft becomes cost
prohibitive if the charges exceed $1,570 above the cost of a posterior fusion. The use of an interbody cage has
not been shown to increase hospital stay.
3 - Figures 1 and 2 are MRI images obtained from a 22-year-old man who fell from a 2-story building. On examination, he
has diminished rectal tone and urinary retention. If surgical stabilization is elected, what is the most biomechanically
stable option?
Figure 1 Figure 2
A. Sacral plating
B. Iliosacral screws
C. Iliosacral screws and lumbopelvic fixation
D. External fixation
, Correct answer: C
The patient has a U-shaped sacral fracture or spondylopelvic dissociation. Treatment options for these fractures range
from percutaneous placement of iliosacral screws to lumbopelvic fixation (lumbar pedicle screws and iliac screws).
Lumbopelvic fixation can be supplemented by iliosacral screws, which has been termed triangular osteosynthesis.
Biomechanical studies have shown that iliosacral screws with lumbopelvic fixation—or triangular osteosynthesis—is the
most stable construct when compared with iliosacral screws alone. The advantage of lumbopelvic fixation is that
concurrent sacral laminectomy can be performed, which is recommend in this patient because of his neurologic
symptoms. External fixation or sacral plating play minimal roles in U-shaped sacral fractures.
4 - Clinical Situation
Figure 1 shows a CT from the cervical spine of an 85-year-old woman who fell from a standing height 1 week
earlier. She is independent and ambulatory and resides in an assisted living facility. She reports persistent neck
pain but denies arm pain or weakness. She is neurologically intact.
Fractures in this region of C2 have a high risk of
Figure 1
A. spinal cord injury.
B. union.
C. nonunion.
D. stroke.
Self-Assessment Examination 201
2015
AAOS
Yowr Sorefor Lifelong Orthopaedic learig
,1 - Figures 1 and 2 are CT scans obtained from a 68-year-old man who has had progressive neck pain and stiffness,
worsening gait imbalance, upper extremity weakness, early muscle fatigue, difficulty with fine motor control, and
difficulty with activities of daily living over the past few years. On physical examination, he has a wide based stiff legged
gait, generalized upper extremity weakness, dense sensory loss in the upper and lower extremities, and markedly brisk
reflexes. What is the most appropriate treatment for this patient?
Figure 1 Figure 2
A. Observation
B. Cervical epidural injections
C. Multilevel anterior cervical decompression and fusion
D. Posterior cervical laminoplasties from C3-6
Correct answer: D
This patient has progressive myelopathy secondary to ossification of the posterior longitudinal ligament. Diagnostic
imaging reveals multilevel cervical cord compression from C4-6. The patient has maintained reasonable cervical lordosis.
A posterior procedure such as multilevel laminoplasty decompresses the spine, is motion preserving, and has a low
complication rate. Observation and cervical epidural injections are not viable options in patients with progressive
myelopathy. Anterior cervical decompression, including corpectomy, is an option; however, anterior procedures have an
increased risk of complications such as dural tear or cerebrospinal fluid leak. The axial CT image shows a "double layer"
sign, which is consistent with dural ossification and increases the risk of dural injury with anterior decompression.
2 - When compared with posterior decompression and fusion, the addition of an interbody fusion for the treatment of
degenerative spondylolisthesis and stenosis has been shown to
A. result in increased patient functional outcome scores.
B. reduce the incidence of symptomatic pseudarthrosis.
, C. increase the length of hospital stay.
D. increase hospital costs.
Correct answer: D
The use of an interbody graft has been shown to increase hospital costs. Gottschalk and associates found no
change in Oswestry Disability Index (ODI) or 36-Item Short-Form Health Survey (SF-36) scores when
comparing patients fused using either posterior fusion or transforaminal interbody fusion. They also found no
change in fusion rates at 3 years after surgery. Carreon and associates showed some that using a posterior place
interbody transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF) did result
in improved ODI and SF-6D scores but did not result in any change in EuroQol five dimensions questionnaire
(EQ-5D) scores. Using the EQ-5D data, they estimated that the use of an interbody graft becomes cost
prohibitive if the charges exceed $1,570 above the cost of a posterior fusion. The use of an interbody cage has
not been shown to increase hospital stay.
3 - Figures 1 and 2 are MRI images obtained from a 22-year-old man who fell from a 2-story building. On examination, he
has diminished rectal tone and urinary retention. If surgical stabilization is elected, what is the most biomechanically
stable option?
Figure 1 Figure 2
A. Sacral plating
B. Iliosacral screws
C. Iliosacral screws and lumbopelvic fixation
D. External fixation
, Correct answer: C
The patient has a U-shaped sacral fracture or spondylopelvic dissociation. Treatment options for these fractures range
from percutaneous placement of iliosacral screws to lumbopelvic fixation (lumbar pedicle screws and iliac screws).
Lumbopelvic fixation can be supplemented by iliosacral screws, which has been termed triangular osteosynthesis.
Biomechanical studies have shown that iliosacral screws with lumbopelvic fixation—or triangular osteosynthesis—is the
most stable construct when compared with iliosacral screws alone. The advantage of lumbopelvic fixation is that
concurrent sacral laminectomy can be performed, which is recommend in this patient because of his neurologic
symptoms. External fixation or sacral plating play minimal roles in U-shaped sacral fractures.
4 - Clinical Situation
Figure 1 shows a CT from the cervical spine of an 85-year-old woman who fell from a standing height 1 week
earlier. She is independent and ambulatory and resides in an assisted living facility. She reports persistent neck
pain but denies arm pain or weakness. She is neurologically intact.
Fractures in this region of C2 have a high risk of
Figure 1
A. spinal cord injury.
B. union.
C. nonunion.
D. stroke.
