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1. General Principles & Basic Science MCQs

Practice Set 18 of 789

This practice set contains high-yield board review questions covering key concepts in 1. General Principles & Basic Science. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 341

Topic: Infection, Pharmacology & VTE

A patient with pyogenic vertebral osteomyelitis presents with progressive bilateral lower extremity weakness and bowel incontinence. What is the most appropriate next step in management?

. Increase the dose of IV antibiotics
. Start high-dose IV corticosteroids
. Emergent surgical decompression and stabilization
. CT-guided biopsy of the epidural space
. Bracing with a thoracolumbosacral orthosis

Correct Answer & Explanation

. Emergent surgical decompression and stabilization

Explanation

Progressive neurological deficit in the setting of spinal infection is an absolute indication for emergent surgical decompression and stabilization.

Question 342

Topic: Infection, Pharmacology & VTE

When comparing tuberculous spondylitis (Pott's disease) to pyogenic vertebral osteomyelitis on MRI, which of the following features is most characteristic of tuberculosis?

. Early and severe intervertebral disc destruction
. Absence of a paraspinal soft tissue mass
. Relative preservation of the intervertebral disc until late in the disease
. Preferential involvement of the posterior elements only
. Sclerotic changes visible within 48 hours of infection

Correct Answer & Explanation

. Relative preservation of the intervertebral disc until late in the disease

Explanation

Unlike pyogenic infections which produce proteolytic enzymes destroying the disc early, TB lacks these enzymes. This leads to relative preservation of the disc space and larger paraspinal abscesses in TB.

Question 343

Topic: Infection, Pharmacology & VTE

Review the clinical image. A 55-year-old diabetic male presents with insidious onset back pain and night sweats. MRI reveals endplate destruction and disc space enhancement.

Which laboratory marker is most useful for monitoring the resolution of this condition during antibiotic treatment?

. White blood cell count (WBC)
. Erythrocyte sedimentation rate (ESR)
. C-reactive protein (CRP)
. Procalcitonin
. Alkaline phosphatase

Correct Answer & Explanation

. C-reactive protein (CRP)

Explanation

CRP normalizes much faster than ESR following successful treatment of vertebral osteomyelitis, making it the preferred and most sensitive marker for monitoring treatment response.

Question 344

Topic: Infection, Pharmacology & VTE

What is the recommended duration of intravenous (or highly bioavailable oral) antibiotic therapy for uncomplicated pyogenic vertebral osteomyelitis?

. 1 to 2 weeks
. 3 to 4 weeks
. 6 to 8 weeks
. 12 to 16 weeks
. 6 months

Correct Answer & Explanation

. 6 to 8 weeks

Explanation

Uncomplicated pyogenic vertebral osteomyelitis is typically treated with 6 weeks of targeted antimicrobial therapy. Shorter courses are associated with higher recurrence rates.

Question 345

Topic: Infection, Pharmacology & VTE

A 70-year-old man on chronic hemodialysis presents with severe back pain. MRI shows discitis at L3-L4. Blood cultures grow methicillin-resistant Staphylococcus aureus (MRSA). He is treated with IV vancomycin. What is the most important factor in determining the appropriate dosing of his antibiotic therapy?

. The patient's erythrocyte sedimentation rate
. Trough serum vancomycin levels
. The size of the epidural phlegmon on MRI
. Peak serum vancomycin levels
. The severity of his back pain

Correct Answer & Explanation

. Trough serum vancomycin levels

Explanation

Vancomycin efficacy and toxicity correlate closely with trough levels. In a hemodialysis patient, meticulous monitoring of trough levels is crucial to ensure therapeutic dosing and avoid toxicity.

Question 346

Topic: Infection, Pharmacology & VTE

Which of the following patient populations is most at risk for developing fungal vertebral osteomyelitis, particularly with Aspergillus species?

. Healthy pediatric patients
. Patients with isolated trauma
. Severely immunocompromised patients (e.g., prolonged neutropenia)
. Pregnant females in their third trimester
. Patients with a history of recurrent urinary tract infections

Correct Answer & Explanation

. Severely immunocompromised patients (e.g., prolonged neutropenia)

Explanation

Fungal vertebral osteomyelitis, particularly from Aspergillus, is rare and typically seen in severely immunocompromised hosts, such as those with prolonged neutropenia or solid organ transplants.

Question 347

Topic: 1. General Principles & Basic Science

The natural history of an asymptomatic thoracic disk herniation is:

. Rapid progression to a symptomatic thoracic disk herniation
. A slow progression to a symptomatic thoracic disk herniation
. To remain asymptomatic
. To completely resorb and remain asymptomatic
. To completely resorb and progress to a degenerative disk

Correct Answer & Explanation

. To remain asymptomatic

Explanation

The natural history of an asymptomatic thoracic disk herniation is to remain asymptomatic and exhibit little change in size. In a series of 48 asymptomatic thoracic disk herniations, Wood found that all disks remained asymptomatic at follow-up with little fluctuation in size of the disk.

Question 348

Topic: 1. General Principles & Basic Science

A 48-year-old man presents with acute onset of unilateral, anterior band-like chest pain after lifting heavy machinery at work. The history and physical examination and the magnetic resonance image confirm a T9-T10 thoracic disk herniation. The best initial treatment for this patient is:

. Bed rest and traction for 6 weeks
. C ostotransversectomy to remove the T9-T10 disk herniation
. Activity modification and physical therapy
. Transthoracic decompression of the disk
. Laminectomy and decompression of the disk

Correct Answer & Explanation

. Activity modification and physical therapy

Explanation

Brown et al retrospectively reviewed the natural history of symptomatic thoracic disk herniations and found 77% of patients did well with nonsurgical management. The patients returned to their previous level of activity following activity modification and physical therapy.

Question 349

Topic: 1. General Principles & Basic Science

The most common site of a thoracic disk herniation requiring surgery is from levels:

. T1-T4
. T4-T7
. T8-T11
. T11-T12
. T12-L1

Correct Answer & Explanation

. T8-T11

Explanation

T8-T11 is the most common site of disk herniation that requires surgery. A review of 71 patients with 82 thoracic disk herniations undergoing surgery found that 66% of disks were between T8-T11. The most common disk level was T9-T10, which represented 26% of the herniations.C orrect Answer: T8- T11

Question 350

Topic: 1. General Principles & Basic Science

The most common location for a thoracic disk herniation is:

. C entral
. Lateral
. C entrolateral
. Medial
. Mediolateral

Correct Answer & Explanation

. C entrolateral

Explanation

The most common locations for a thoracic disk herniation are centrolateral (94%) and lateral (6%). Disks classified as centrolateral have the bulk of the disk herniation medial to the lateral margin of the thecal sac.

Question 351

Topic: 1. General Principles & Basic Science

A 38-year-old construction worker falls from a scaffolding and sustains a pure flexion-compression injury to T12. In this type of injury, which portion of the vertebral body fails first:

. End plate
. Subcortical cancellous bone
. Posterior elements
. Middle column
. Lamina

Correct Answer & Explanation

. End plate

Explanation

Failure occurs first at the end plate. The intact intervertebral disk has limited compressibility. Therefore, when the compressive forces exceed the disk compressibility, the load is transmitted to the contiguous bone. The end plate will rupture first followed by the subcortical cancellous vertebral bone.

Question 352

Topic: Infection, Pharmacology & VTE

Which of the following describes the magnetic resonance image (MRI) appearance of vertebral osteomyelitis:

. Increased signal onT1 images, decreased on T2 images
. Decreased signal onT1 images, decreased on T2 images
. Decreased signal onT1 images, increased on T2 images
. Increased signal onT1 images, increased on T2 images
. MRI is usually unable to detect vertebral osteomyelitis

Correct Answer & Explanation

. Decreased signal onT1 images, increased on T2 images

Explanation

Magnetic resonance image (MRI) carries a 95% accuracy rate. Infected disk and vertebral bone appear on MRI with decreased signal onT1 images and increased signal on T2 images. Gadoliniun enhancement is useful in differentiating spinal infection or abscess from epidural scar in the postoperative setting.

Question 353

Topic: Infection, Pharmacology & VTE

Antibiotic treatment for spinal tuberculosis includes all of the following except:

. Isoniazid
. Ethambutol
. Pyrazinamide
. Rifampin
. C efotaxime

Correct Answer & Explanation

. C efotaxime

Explanation

A four-drug regimen against spinal tuberculosis is recommended because of the high prevalence of organism resistance. Cefotaxime is a cephalosporin not active against mycobacterial infection.

Question 354

Topic: Infection, Pharmacology & VTE

Which of the following antibiotics would not be useful in staphylococcal vertebral osteomyelitis:

. C efuroxime
. Nafcillin
. C efazolin
. C iprofloxicin
. Tobramycin

Correct Answer & Explanation

. Tobramycin

Explanation

Aminoglycosides, such as tobramycin, are active against gram-negative organisms. First- and second-generation cephalosporins are alternatives to semisynthetic penicillins that may be useful if the organism is not resistant. Ciprofloxicin has also been considered a possible alternative to penicillins against gram-positive vertebral osteomyelitis.

Question 355

Topic: Surgical Anatomy & Approaches

A 55-year-old male presents with progressive spastic paraparesis and hyperreflexia. Magnetic resonance imaging demonstrates a large, calcified, central thoracic disk herniation at T8-T9 causing severe cord compression. Which of the following surgical approaches is contraindicated?

. Costotransversectomy
. Transthoracic anterior decompression
. Lateral extracavitary approach
. Standard posterior laminectomy
. Transpedicular decompression

Correct Answer & Explanation

. Standard posterior laminectomy

Explanation

A standard posterior laminectomy is strictly contraindicated for central, calcified thoracic disk herniations. Removing posterior elements allows the spinal cord to bowstring posteriorly over the anterior mass, creating an unacceptably high risk of catastrophic iatrogenic spinal cord injury.

Question 356

Topic: Physiology & Rehabilitation

A patient presents with a right-sided paracentral T7-T8 disk herniation leading to Brown-Sequard syndrome. Which of the following neurological findings is expected below the level of the lesion?

. Right-sided loss of pain and temperature; left-sided motor loss
. Right-sided motor loss; left-sided loss of pain and temperature
. Bilateral motor loss; right-sided preservation of proprioception
. Right-sided flaccid paralysis; bilateral loss of pain and temperature
. Left-sided motor loss; right-sided loss of proprioception

Correct Answer & Explanation

. Right-sided motor loss; left-sided loss of pain and temperature

Explanation

Brown-Sequard syndrome (hemicord syndrome) results in ipsilateral loss of motor function (corticospinal tract) and proprioception/vibration (dorsal columns). It also causes contralateral loss of pain and temperature sensation (spinothalamic tract).

Question 357

Topic: Infection, Pharmacology & VTE

A 55-year-old male with a history of intravenous drug use presents with severe midthoracic back pain. Gadolinium-enhanced MRI demonstrates epidural enhancement and high T2 signal within the T6-T7 disc space and adjacent endplates. What is the most common organism responsible for this condition?

. Pseudomonas aeruginosa
. Escherichia coli
. Staphylococcus aureus
. Enterococcus faecalis
. Klebsiella pneumoniae

Correct Answer & Explanation

. Staphylococcus aureus

Explanation

Staphylococcus aureus remains the most common causative organism of pyogenic spinal infections (discitis/osteomyelitis) across all patient groups, including intravenous drug users. Pseudomonas is a notable risk in the IVDU population, but S. aureus is still more frequent.

Question 358

Topic: 1. General Principles & Basic Science

Which of the following is considered the most common initial presenting symptom in a patient with a symptomatic thoracic disk herniation?

. Axial thoracic back pain
. Lower extremity spasticity
. Bowel or bladder incontinence
. Gait ataxia
. Unilateral lower extremity radicular pain

Correct Answer & Explanation

. Axial thoracic back pain

Explanation

The vast majority of symptomatic thoracic disk herniations initially present with localized axial back pain. Radicular pain wrapping around the chest wall or myelopathic lower extremity symptoms typically develop later as the herniation enlarges.

Question 359

Topic: Physiology & Rehabilitation

A patient with a right-sided paracentral disc herniation at T7-T8 develops a Brown-Sequard syndrome. What pattern of neurological deficit is expected on physical examination?

. Bilateral loss of proprioception and vibratory sensation
. Right-sided loss of pain and temperature, left-sided motor weakness
. Right-sided motor weakness, left-sided loss of pain and temperature
. Symmetrical flaccid paraplegia
. Bilateral absent patellar reflexes with normal sensory exam

Correct Answer & Explanation

. Right-sided motor weakness, left-sided loss of pain and temperature

Explanation

Brown-Sequard syndrome involves hemicord compression. It presents with ipsilateral loss of motor function and proprioception (right side), and contralateral loss of pain and temperature sensation (left side) due to the crossover of the spinothalamic tracts.

Question 360

Topic: 1. General Principles & Basic Science

During an anterior transthoracic resection of a heavily calcified T8-T9 disc, an intraoperative dural tear occurs resulting in a cerebrospinal fluid (CSF) leak. What is the most appropriate intraoperative management?

. Placement of a chest tube on high suction to drain the CSF
. Primary direct suture repair with or without a fascial or muscle patch
. Placement of an epidural blood patch
. Immediate conversion to a posterior laminectomy
. Ligation of the affected thoracic nerve root

Correct Answer & Explanation

. Primary direct suture repair with or without a fascial or muscle patch

Explanation

Anterior dural tears during thoracic disc surgery should be primarily repaired if possible, often augmented with a fascial or muscle patch and fibrin glue. Placing a chest tube on high suction is contraindicated as it can exacerbate the fistula and cause intracranial hypotension.

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