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 apatient ahas aa aU-shaped asacral afracture aor aspondylopelvic adissociation. aTreatment aoptions afor athese
afractures arange afrom apercutaneous aplacement aof ailiosacral ascrews ato alumbopelvic afixation a(lumbar apedicle
ascrews aand ailiac ascrews).
Lumbopelvic afixation acan abe asupplemented aby ailiosacral ascrews, awhich ahas abeen atermed atriangular
aosteosynthesis. aBiomechanical astudies ahave ashown athat ailiosacral ascrews awith alumbopelvic afixation—or
atriangular aosteosynthesis—is athe amost astable aconstruct awhen acompared awith ailiosacral ascrews aalone. aThe
aadvantage aof alumbopelvic afixation ais athat aconcurrent asacral alaminectomy acan abe aperformed, awhich ais
arecommend ain athis apatient abecause aof ahis aneurologic asymptoms. aExternal afixation aor asacral aplating aplay
aminimal aroles ain aU-shaped asacral afractures.
4 - aClinical aSituation
Figure a1 ashows aa aCT afrom athe acervical aspine aof aan a85-year-old awoman awho afell afrom aa astanding
aheight a1 aweek aearlier. aShe ais aindependent aand aambulatory aand aresides ain aan aassisted aliving afacility. aShe
areports apersistent aneck apain abut adenies aarm apain aor aweakness. aShe ais aneurologically aintact.
Fractures ain athis aregion aof aC2 ahave aa ahigh arisk aof
Figure 1
A. spinal acord ainjury.
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 apatient ahas aa aU-shaped asacral afracture aor aspondylopelvic adissociation. aTreatment aoptions afor athese
afractures arange afrom apercutaneous aplacement aof ailiosacral ascrews ato alumbopelvic afixation a(lumbar apedicle
ascrews aand ailiac ascrews).
Lumbopelvic afixation acan abe asupplemented aby ailiosacral ascrews, awhich ahas abeen atermed atriangular
aosteosynthesis. aBiomechanical astudies ahave ashown athat ailiosacral ascrews awith alumbopelvic afixation—or
atriangular aosteosynthesis—is athe amost astable aconstruct awhen acompared awith ailiosacral ascrews aalone. aThe
aadvantage aof alumbopelvic afixation ais athat aconcurrent asacral alaminectomy acan abe aperformed, awhich ais
arecommend ain athis apatient abecause aof ahis aneurologic asymptoms. aExternal afixation aor asacral aplating aplay
aminimal aroles ain aU-shaped asacral afractures.
4 - aClinical aSituation
Figure a1 ashows aa aCT afrom athe acervical aspine aof aan a85-year-old awoman awho afell afrom aa astanding
aheight a1 aweek aearlier. aShe ais aindependent aand aambulatory aand aresides ain aan aassisted aliving afacility. aShe
areports apersistent aneck apain abut adenies aarm apain aor aweakness. aShe ais aneurologically aintact.
Fractures ain athis aregion aof aC2 ahave aa ahigh arisk aof
Figure 1
A. spinal acord ainjury.
B. union.
C. nonunion.
D. stroke.
