29. Matching. Match the head position with the location of the aneurysm.

G7 p.159:70mm

Head position:

angled 30 degrees, angled 45 degrees, angled 60 degrees

Location of aneurysm:

a. ICA P-comm

b. carotid terminus

c. middle cerebral artery

d. basilar bifurcation

e. A-comm

30. Name the artery(ies) that cross the sylvian fissure.

none cross

G7 p.161:92mm

31. True or False. A temporal craniotomy can allow access to the following structures.

G7 p.162:120mm

a. foramen ovale

true

b. Meckel cave

true

c. labyrinthine and upper tympanic portion of the facial nerve

true

32. A temporal lobectomy

G7 p.163:115mm

a. can safely resect_____cm in the dominant hemisphere

4 to 5 (before injury to Wernicke area)

b. and_____cm in the nondominant hemisphere.

6 to 7 (before injury to optic radiations)

33. Complete the following regarding the superior sagittal sinus (SSS):

G7 p.163:170mm

a. The risk in sacrifice of the SSS is_____ _____.

venous infarction

b. True or False. It almost always occurs with sacrifice of

     i. the posterior third

true

     ii. the middle third

true

     iii. the anterior third

false

34. The Dolenc approach is

G6 p.609:95mm

a. designed to remove the_____ _____ _____

anterior clinoid extradurally

b. and provide access to the_____ _____ _____

proximal carotid artery

35. Indications for decompressive craniectomy are

G7 p.165:55mm

a.

     i. m_____m_____cerebral artery occlusion

malignant middle

     ii. Primarily for the n_____- d_____ hemisphere

non-dominant

b. p_____ i _____hypertension

persistent intracranial

c. True or False. It is necessary to open the dura.

true

G7 p.165:110mm

d. Skull reimplantation can be considered after_____to_____weeks

6to12

G7 p.165:140mm

e.

G7 p.165:147mm

     i. A _____opening is best

large

     ii. Approximately_____ by_____cm or larger

12 by 12

36. Study Chart.

G7 p. 168:110mm

a. t_____

transcortical

b. t_____

transcallosal

     i. a_____

anterior

     ii. p_____

posterior

c. s_____

subfrontal

     i. s_____

subchiasmatic

     ii. o_____

opticocarotid

     iii. l_____ t_____

lamina terminalis

     iv. t_____

transsphenoidal

d. t_____

transsphenoidal

e. s_____

subtemporal

f. s_____

stereotactic

37. What is the risk of postoperative seizures after a transcortical approach to the anterior third ventricle (e.g., for a colloid cyst)?

5%

G7 p.168:125mm

38. What are the principles of tumor removal

G7 p.168:170mm

a. Veins must be preserved at all_____.

costs

b. First remove the tumor from within the _____

capsule

G7 p.168:180mm

c. If adhesions seem unyielding the most likely cause is i_____ i_____ evacuation.

incomplete intracapsular

G7 p.169:15mm

39. Complete the following:

G7 p. 170:180mm

a. True or False. A disconnection syndrome (split-brain syndrome) is common with

     i. posterior callosotomy through splenium

true (where more visual information crosses)

     ii. anterior callosotomy

false

     iii. callosotomy < 2.5 cm in length from a point 1 to 2 cm behind the tip of the genu.

false

b. Which of the above approaches avoids the disconnection syndrome best?

callosotomy < 2.5 cm in length from a point 1 to 2 cm behind the tip of the genu

40. Describe the transcallosal approach to the third ventricle.

G7 p.169:170mm

a. The superior sagittal sinus (SSS) is often to the _____ of the sagittal suture.

right

b. The cranial opening should be

G7 p.170:40mm

     i. anterior to the coronal suture

two third

     ii. and _____ behind it.

one third

c. The two cingulate gyri may be adherent in the midline and can be mistaken for c_____ c_____.

corpus callosum

G7 p.170:130mm

d.

     i. The corpus callosum has a distinct _____ color.

white

     ii. It is located beneath the paired _____ arteries.

pericallosal

e. The opening is usually made between the p_____ p_____ arteries.

paired pericallosal

G7 p.170:155mm

f. The trajectory of dissection is from the

     i. c _____ s_____

coronal suture

     ii. the e_____ a_____ m_____.

external auditory meatus

     iii. The f_____ of M _____ lies along this line.

foramen of Monro

g.

G7 p.170:173mm

     i. It is helpful to fenestrate the s _____ P_____

septum pellicidum

     ii. to prevent it from b_____ into the ventricle

bulging

     iii. especially in a case of c_____ c_____.

colloid cyst

41. How can you tell which ventricle you are in?

G7 p.171:38mm

a. The foramen of Monro is located m_____

medially

b. If the choroid plexus goes to the left to enter the foramen of Monro you are in the _____ ventricle.

right

c. If you see no choroid plexus and no veins you may be in a c_____ s_____ p _____

cavum septum pellucidum

G7 p.171:80mm

d. The safe way to enlarge the foramen of Monro is posteriorly between the _____ _____ and the _____.

choroid plexus; fornix

G7 p.171:115mm

42. Complete the following about approaches to the third ventricle:

G7 p.172:145mm

a. The interhemispheric approach runs risk of injury to _____ _____ _____

bilateral cingulate gyrus

b. which may produce _____ _____.

transient mutism

c. The anterior transcallosal approach runs risk of injury to _____ _____

bilateral fornices

d. which may produce problem with s_____-t_____ m_____ and n_____ l_____.

short-term memory and new learning

G7 p.172:135mm

e. The transcortical approach is

G7 p.172:98mm

     i. made through the_____ _____ gyrus.

middle frontal

     ii. This is about the same spot used for e_____v_____d_____.

external ventricular drain

     iii. called_____point.

Kocher

43. Localizing levels in spine surgery. Most patients have _____ presacral vertebra.

24

G7 p.173:175mm

44. The aortic bifurcation is at the mid-body of _____.

L3

G7 p.175:90mm

45. Complete the following regarding transoral approach to anterior craniocervical junction:

G7 p.176:125mm

a. What percent of patients need posterior fusion after a transoral odontoidectomy?

75%

b. The patient must be able to open the mouth at least mm.

25

G7 p.177:115mm

c.

G7 p.177:140mm

     i. The tubercle of the_____

atlas

     ii. can be palpated through the posterior _____

pharynx

     iii. in order to locate the _____.

midline

d. If C1 sparing is not done the central _____ cm of the _____ is removed.

3; atlas

G7 p.177:168mm

e. i. There is about to _____ mm working distance

20 to 25

G7 p.177:175mm

     ii. between the _____ _____ _____ where

two vertebral arteries

     iii. they enter the f_____ t_____ at the inferior aspect of

foramen transversarium

     iv. the lateral masses of _____

C2

46. Complete the following regarding anterior access:

G7 p.178:110mm

a. To T3 use a s_____ s_____ approach.

sternal splitting

b. At T10 the attachment of the increases the difficulty of this approach.

diaphragm

G7 p.179:45mm

c. The location of the bifurcation of the vena cava is from just above to just below the _____ disc.

L4-L5

G7 p.179:90mm

47. What are the disadvantages of occipitocervical fusion?

G7 p.179:140mm

a. r _____range of motion

reduces (movement at the occipitocervical junction)

b. _____ is higher than_____

nonunion rate; C1-C2 fusion

48. True or False. The following is an indication for occipitocervical fusion:

G7 p.179:150mm

a. congenital absence of C1 arch

true

b. upward migration of the odontoid into the foramen magnum

true

c. congenital anomalies of occipitocervical joints

true

d. type II odontoid fracture

false

49. Complete the following regarding occipitocervical fusion:

G7 p.179:145mm

a. Patient will lose about _____% of neck flexion.

30%

b.

G7 p.180:80mm

     i. Keel plate must be placed at the

thickest

     ii. Region of the_____ occipital bone.

midline

     iii. It is advisable to _____ it pre-operatively.

measure

50. True or False. After occipito-cervical fusion we use a halo for

G7 p.181:64mm

a. severe fractures

true

b. elderly patients

true

c. unreliable patients

true

d. smokers

true

e. 8 to 12 weeks

true

51. True or False. The C1-C2 complex is responsible for the following percentage of axial rotation:

G7 p.181:89mm

a. 10%

false

b. 15%

false

c. 25%

false

d. 50%

true

e. 75%

false

52. Complete the following regarding anterior odontoid screw fixation:

G7 p.181:89mm

a. C1-C2 complex is responsible for _____ % of head rotation.

50%

b. Stability depends on the integrity of the

G7 p.181:101mm

     i. o_____ p_____and the

odontoid process

     ii. a_____ t_____ligament

atlantoaxial transverse

c. Indicated in patients who have a type _____ odontoid fracture and an intact _____ligament

II, transverse

G7 p.181:130mm

d. Contraindicated if there is a fracture

G7 p.181:140mm

     i. of the _____ _____

vertebral body

     ii. and if the fracture is less than _____ months old

6

G7 p.181:162mm

e.

G7 p.183:80mm

     i. The immediate postop strength is only _____%.

50%

     ii. Therefore a brace is recommended for weeks.

6

     iii. If the patient has osteoporosis use a _____.

halo

53. Complete the following regarding anterior odontoid screw fixation:

G7 p.181:101mm

a. The most important structure holding the odontoid in position against the anterior arch of C1 is the_____ ligament.

transverse

b. aka the _____ligament.

atlantoaxial

c. It is the horizontal limb of the_____ ligament.

cruciate

54. True or False. The following condition is an indication for anterior odontoid screw fixation:

G7 p.181:130mm

a. pathologic odontoid fracture

false

b. type III odontoid fracture where the fracture line is in the caudal portion of body of C2

false

c. type I odontoid fracture that is reducible

false

d. type II irreducible odontoid fracture

false

e. type II reducible odontoid fracture

true

f. age of fracture is less than 6 months

true

55. What are indications for odontoid screw?

G7 p.181:131mm

a. Fracture must be_____

reducible

b. Type_____ fracture

II

c. Which ligament must be intact?

transverse

56. True or False. The following are contraindications for anterior odontoid screw fixation:

G7 p.181:140mm

a. disruption of atlantal transverse ligament

true

b. disruption of apical ligament

false

c. fracture of C2 vertebral body

true

d. reducible odontoid type II fracture

false

57. Indications for odontoid screw fixation include

G7 p.181:160mm

a. type of fracture:_____

II odontoid

b. age of fracture: less than_____ _____ old

6 months

c. ligament: t_____ l_____ i_____

transverse ligament intact

d. judged by:

     i. _____ and

MRI

     ii. _____ of _____

rule of Spence

e.

     i. The immediate postop strength is only _____%

50%

G7 p.183:80mm

     ii. Therefore a brace is recommended for _____ weeks

6

     iii. If the patient has osteoporosis, use a halo _____

58. Provide fusion rates with age of fracture.

G7 p.181:162mm

a. Fusion rates in fractures more than 18 months old: _____%

25%

b. Fusion rates in fractures less than 6 months old: _____%

90%

59. Characterize atlantoaxial fusion (C1-C2 arthrodesis).

G7 p.183:125mm

a. The patient will lose about _____%of head rotation

50%

b. Transarticular screws

G7 p.184:150mm

     i. Danger is to the v_____ a_____

vertebral artery

     ii. Provides i_____ s_____

immediate stabilization

     iii. Requires preop _____ to study vertebral arteries

CT

G7 p.184:175mm

60. True or False. The following is an indication for atlantoaxial fusion:

G7 p.183:140mm

a. type I odontoid fracture

false

b. disruption of alar ligament of dens

false

c. disruption of apical ligament of dens

false

d. vertebrobasilar insufficiency with head turning

true (Disruption of alar or apical ligament of dens does not render the spine unstable as long as the transverse ligament is intact.)

61. Characterize bow hunter’s sign.

G7 p.183:82mm

a. What is bow hunter’s sign?

vertebrobasilar insufficiency with head turning

b. What is the treatment for bow hunter’s sign?

atlantoaxial fusion (C1-C2 arthrodesis)

62. Characterize a C1-C2 fusion.

G7 p.183:125mm

a. What mobility is lost?

Also

     i. head rotation _____%

50%

G6p.623:170mm

     ii. lateral mobility_____ %

35%

b. Which technique produces less loss of mobility?

     i. Brooks

All are the same in regard to loss of mobility.

     ii. Gallie

All are the same in regard to loss of mobility.

     iii. Sonntag

All are the same in regard to loss of mobility.

63. Describe the fusion technique and differentiate.

G7 p.184:75mm Also

a. Brooks fusion

G6p.624:120mm

     i. sublaminar to_____

C1 and C2 sublaminar wiring

     ii. with _____ grafts

two-wedge bone

b. Gallie fusion

     i. sublaminar to_____

C1 only

     ii. with _____ graft

“H” graft wired into place to C1 only

c. Sonntag fusion

     i. sublaminar to

C1 only

     ii. with _____ graft

bicortical graft wedged between C1 and C2

64. Characterize C1-C2 transarticular facet screw

G7 p.184:175mm

a. Special preop test needed is a thin cut CT scan from the

     i. _____ _____

occipital condyles

     ii. through to C_____

C3

     iii. to look for the location of the _____ _____.

vertebral arteries

b. A fusion rate of up to _____% has been reported.

99%

65. With postoperative immobilization:

G6 p.625:25mm

a. The use of what apparatus is considered optimal immobilization of the cervical spine?

halo brace

b. It reduces cervical motion by_____ %.

95%

c. It is mandatory for use in

     i. r_____ _____

rheumatoid arthritis

     ii. o_____

osteopenia

d. The next best apparatus is the_____- _____ -_____ _____ _____.

sternal-occipital-mandibular immobilizer (SOMI) brace

e. Use this apparatus for_____weeks.

12to16

f. Follow with a_____ for_____ weeks.

hard collar for 4 to 6

g. Use _____-_____ _____ to determine if this treatment was satisfactory.

flexion-extension films

66. Give the frequency of osseous fusions for the listed techniques.

G6 p.625:60mm

a. Brooks _____%

70 to 85%

b. Gallie _____%

70 to 85%

c. Sonntag_____ %

97%

67. True or False. The following is associated with nonunion in atlantoaxial fusion:

G6 p.625:80mm

a. rheumatoid arthritis

true

b. cigarette smoking

true

c. osteoporosis

true

d. nonsteroidal antiinflammatory drugs (NSAIDs)

true

68. What are modifying correctible risk factors for a C1-C2 arthrodesis?

G6p.625:100mm

a. c_____ s_____

cigarette smoking

b. m _____-o_____

malnutrition-osteoporosis

c. N_____

stopping suppressive drugs (NSAID) 1 week before and 2 weeks after surgery

d. s_____

steroids

e. i_____

immunosuppressives

f. a _____b_____

use autologous bone

69. Complete the following:

G6p.625:105mm

a. How does smoking produce nonunion of fusions?

interferes with vascularization of healing bone grafts

b. What is the responsible chemical?

nicotine

c. Will it help if patients stop smoking by using nicotine patches?

no

70. Complete the following concerning an anterior odontoid screw:

G7 p.183:85mm

a. After placement what postop treatment is recommended?

immobilization in cervical brace

b. How long?

6 weeks

c. If patient has osteoporosis, use_____

halo

71. Complete the following concerning a C1-C2 transarticular facet screw:

G7 p.184:140mm

a. Indication—used in conjunction with _____ _____

Sonntag fusion

b. Benefit

     i. provides immediate_____

stabilization

     ii. avoids postoperative_____

external orthosis

     iii. A major risk of the procedure is _____ _____ _____.

vertebral artery injury

72. Characterize atlantoaxial-axial fusion (C1-C2arthrodesis).

G7 p.183:125mm

a. The patient will lose about _____% of head rotation.

50%

b. Transarticular screws

G7 p.184:150mm

     i. Danger is to the v_____ a_____

vertebral artery

     ii. Provides i_____ s_____

immediate stabilization

     iii. Requires preop _____ to study vertebral arteries

CT

G7 p.184:175mm

73. Complete the following regarding surgical fusion of lumbar and lumbosacral spine:

G7 p.191:103mm

a. True or False. A lumbar fusion that includes L1

     i. Should not be terminated at L1

true

     ii. Should not be terminated at T12

true

b. Pedicle screws

G7 p.191:145mm

     i. Should be _____ to _____ % of pedicle

70 to 80%

     ii. Should be greater than mm in the adult

5.5

     iii. The length should be _____ to _____ % of the vertebral body

70 to 80%

     iv. typically_____ to _____mm long

40 to 50

c. Medial angles for lumbar pedicle screws

G7 p.192:15mm

     i. L1 level—medial angle should be _____ degrees

5

     ii. L2 level—medial angle should be _____degrees

10

     iii. L3 level—medial angle should be _____degrees

15

     iv. L4 level—medial angle should be _____degrees

20

     v. L5 level—medial angle should be _____degrees

25

     vi. S1 level—medial angle should be _____degrees

25

     vii. S2 level—medial angle should be _____degrees

45

d. On AP view if screw tip

     i. Crosses the midline there is a _____ breech

medial

     ii. Does not pass medial to the medial edge of the pedicle there is likely a _____ breech

lateral

e. Posterior lumbar interbody fusion (Plif and Tlif)

G7 p.193:15mm

     i. Not appropriate if _____height is preserved

disc

     ii. Usually supplemented with_____ _____

pedicle screws

f. Anterior lumbar interbody fusion

G7 p.195:18mm

     i. has a risk of_____ _____

retrograde ejaculation

     ii. of from _____ to _____%

2 to 45%

74. True or False or Unreliable. In assessing lumbar fusion the following tests can suggest success:

G7 p.198:40mm

a. static x-rays

false

b. flexion—extension views

true

c. technetium 99 bone scan

false

d. good clinical outcome

unreliable

e. CT scan

true

75. Components necessary for bone graft fusion are

G7 p.198:100mm

Hint: IGC

a. Osteoinduction is _____ of mesenchymal cells.

recruitment

b. Osteogenesis is the process of forming _____ _____.

new bone

c. Osteoconduction structure adds _____ _____ and acts as a _____.

new vessels, scaffold

Hint:

Induces mesenchymal cells to

transform

Generates bone cells

Constructs bone scaffold

76. Allograft provides only osteo- _____.

conduction

G7 p.199:92mm

77. DBM

G7 p.199:92mm

a. aka as d_____ bone m_____

demineralized; matrix

b. has _____ and _____ properties

inductive and conductive

78. BMP

G7 p.199:145mm

a. aka bone m_____ p_____

morphogenic protein

b. has _____ properties

inductive

c. may cause e_____ b_____

ectopic bone

d. approved by FDA only for_____

Alif

G7 p.199:163mm

79. Complete the following regarding graft procurement:

G7 p.200:73mm

a. Anterior iliac bone graft

     i. Obtain _____to _____cm

3to4

     ii. _____to the anterior superior iliac crest

lateral

     iii. To avoid the l_____ f_____ c_____ nerve

lateral femoral cutaneous

     iv. Also need to avoid injury to the i_____ and i_____

ilioinguinal and iliohypogastric

b. Posterior iliac crest bone graft

G7 p.200:103mm

     i. Obtain from the_____

medial

     ii. _____to _____cm of the iliac crest

6 to 8

     iii. To avoid the s_____ c_____ nerves

superior cluneal

     iv. If injured, they cause b_____ n_____ or p_____ n_____

buttock numbness or painful neuromas

c. The “dimple of Venus” lies directly

G7 p.200:133mm

     i. above the s_____ joint.

sacro iliac

     ii. Incise a little _____to it.

lateral

     iii. Avoid mistaking the s_____

sacrum

     iv. and the i_____ s_____

iliac spine

80. Complete the following regarding lumbar punctures:

G7 p.201:175mm

a. For lumbar puncture (LP) the platelet count should be higher than_____.

50,000/mm³

b. In SAH, LP might increase the_____ pressure and precipitate aneurismal rupture.

transmural

G7 p.202:15mm

c. An LP in patients with spinal block may produce deterioration in as many as _____%.

14%

G7 p.202:25mm

81. The spinal cord ends at the given location for what percentage of adults?

G7 p.202:45mm

a. between T12 and L1

30%

b. between L1 and L2 middle thirds

51 to 68%

c. between L2 and L3

10%

d. between T12 and L2

94%

82. The intercristal line

G7 p.202:60mm

a. connects the superior border of the_____ _____

iliac crests

b. occurs in most adults between the spinous processes of _____ and _____

L4 and L5

83. Complete the following statements:

G7 p.202:95mm

a. When an LP is performed, we must always advance the needle with _____ _____ in place.

the stylet

b. Otherwise we may introduce_____ _____,

epidermal cells

c. which could produce an iatrogenic _____ _____.

epidermoid tumor

84. Describe the Queckenstedt test and expected results.

G7 p.202:180mm

a. What do you compress?

the jugular vein

b. One or both?

one then the other, while measuring ICP

c. If no block what will happen with compression?

pressure should rise 10 to 20 cm from baseline

d. If no block what happens upon release of compression

return to the original level within 10 seconds

e. If there is a block what will happen?

no rise in pressure from baseline

85. Complete the following about lumbar punctures:

G7 p.203:85mm

a. Incidence of severe postpuncture headache is _____%.

0.1 to 0.5%

b. Severe means_____.

lasting longer than 7 days

86. Complete the following about lumbar punctures:

G7 p.203:155mm

a. Can a sixth nerve (abducens nerve) palsy occur after lumbar puncture?

yes

b. If so when?

after 5 to 14 days

c. If it occurs when does it resolve?

4 to 6 weeks

87. True or False. Regarding fundus exam for papilledema:

G7 p.204:25mm

a. It is a reliable test to assure safety of LP.

false

b. It is an unreliable test.

true