Menu

Cervical Spine MCQs

Practice Set 10 of 24

This practice set contains high-yield board review questions covering key concepts in Cervical Spine. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 181

Topic: Cervical Spine

A 75-year-old male presents with neck pain following a ground-level fall. CT imaging reveals a Type II odontoid fracture according to the Anderson and D'Alonzo classification. Which of the following anatomical factors is the primary reason for the high rate of nonunion associated with this specific fracture pattern?

. Disruption of the apical ligament
. The presence of a vascular watershed area at the base of the dens
. Interposition of the transverse ligament in the fracture site
. Distraction forces from the alar ligaments
. Excessive motion at the atlanto-occipital joint

Correct Answer & Explanation

. The presence of a vascular watershed area at the base of the dens

Explanation

Type II odontoid fractures occur at the base of the dens. This region represents a vascular watershed area. The blood supply to the odontoid comes primarily from the anterior and posterior ascending arteries (branches of the vertebral arteries), which course cephalad. A fracture at the base disrupts this precarious blood supply, leading to a high rate of nonunion, particularly in the elderly population.

Question 182

Topic: Cervical Spine

Which of the following factors is the strongest independent predictor of non-union in the conservative management of a Type II odontoid fracture?

. Age less than 40 years
. Anterior displacement of 3 mm
. Posterior displacement of 2 mm
. Fracture gap greater than 1 mm
. Fracture displacement greater than 5 mm

Correct Answer & Explanation

. Fracture displacement greater than 5 mm

Explanation

Risk factors for non-union in Type II odontoid fractures include initial displacement > 5 mm, posterior displacement, age > 50 years, and a fracture gap > 1 mm. A displacement greater than 5 mm is one of the strongest independent predictors of failure with conservative care, often prompting early surgical intervention.

Question 183

Topic: Cervical Spine

An 82-year-old male sustains a Type II odontoid fracture with 4 mm of posterior displacement following a low-energy fall. He has no neurologic deficits but has severe neck pain. What is the most appropriate management?

. Rigid cervical collar for 12 weeks
. Halo vest immobilization
. Anterior odontoid screw fixation
. Posterior C1-C2 instrumented fusion
. Occipitocervical fusion

Correct Answer & Explanation

. Posterior C1-C2 instrumented fusion

Explanation

Type II odontoid fractures in the elderly (>70 years) have an unacceptably high nonunion rate with conservative management and poor tolerance/high mortality associated with halo vests. Anterior screw fixation has lower success rates due to osteopenia. Posterior C1-C2 fusion provides the highest union rates and best functional outcomes for displaced Type II fractures in this demographic.

Question 184

Topic: Cervical Spine

A 45-year-old man falls from a height and sustains a Type II odontoid fracture. Displacement is 6 mm posteriorly. Which of the following conditions is an absolute contraindication to anterior odontoid screw fixation?

. Age less than 50 years
. Anterior displacement of 4 mm
. Rupture of the transverse atlantal ligament
. Concomitant C1 anterior arch fracture
. Delay in surgery of 3 days

Correct Answer & Explanation

. Rupture of the transverse atlantal ligament

Explanation

Anterior odontoid screw fixation relies entirely on an intact transverse atlantal ligament (TAL) to maintain C1-C2 stability postoperatively. If the TAL is ruptured (evidenced by MRI or C1 lateral mass displacement >6.9 mm), anterior screw fixation is contraindicated, and posterior C1-C2 fusion is required.

Question 185

Topic: Cervical Spine

An 82-year-old woman with severe osteoporosis falls and sustains a Type II odontoid fracture. She is neurologically intact. Which of the following treatment modalities is associated with the highest rate of morbidity and mortality in this specific patient population, and is therefore generally contraindicated?

. Rigid cervical collar immobilization
. Soft cervical collar immobilization
. Anterior odontoid screw fixation
. Posterior C1-C2 arthrodesis
. Halo vest immobilization

Correct Answer & Explanation

. Halo vest immobilization

Explanation

In the elderly population (typically >65 or >80 years of age), halo vest immobilization for cervical spine fractures is associated with a significantly increased risk of major complications, including aspiration pneumonia, cardiac arrest, respiratory failure, and death. Mortality rates in the elderly treated with a halo vest have been reported as high as 40%. Therefore, halo vest immobilization is generally contraindicated in this age group.

Question 186

Topic: Cervical Spine

A 65-year-old female with a 20-year history of rheumatoid arthritis presents with progressive hand clumsiness. Flexion-extension cervical radiographs show an anterior atlantodens interval (ADI) of 11 mm. What is the most reliable radiographic predictor of impending neurologic deficit in this patient?

. Anterior atlantodens interval (ADI) > 10 mm
. Posterior atlantodens interval (PADI) < 14 mm
. Cervical lordosis angle < 10 degrees
. Presence of subaxial subluxation
. Basilar invagination > 5 mm

Correct Answer & Explanation

. Posterior atlantodens interval (PADI) < 14 mm

Explanation

In rheumatoid arthritis, the posterior atlantodens interval (PADI), also known as the space available for the cord (SAC), is the most reliable predictor of neurologic deficit. A PADI of less than 14 mm is associated with a high risk of neurologic compromise.

Question 187

Topic: Cervical Spine

A 30-year-old male dives into a shallow pool and sustains a C1 Jefferson fracture. Open-mouth odontoid radiographs reveal lateral displacement of the lateral masses. According to the Rule of Spence, rupture of the transverse ligament is highly suspected if the combined lateral mass overhang exceeds:

. 3.1 mm
. 5.1 mm
. 6.9 mm
. 8.1 mm
. 10.0 mm

Correct Answer & Explanation

. 6.9 mm

Explanation

The Rule of Spence dictates that a combined lateral mass overhang of C1 on C2 greater than 6.9 mm on an open-mouth AP radiograph suggests a ruptured transverse ligament. MRI is typically used in modern practice to confirm this ligamentous disruption.

Question 188

Topic: Cervical Spine

A 78-year-old man falls and sustains a Type II odontoid fracture with 1 mm of displacement. He has a history of severe chronic obstructive pulmonary disease (COPD) and heart failure. He is neurologically intact. What is the most appropriate initial management?

. Halo vest immobilization
. Rigid cervical collar
. Anterior odontoid screw fixation
. Posterior C1-C2 fusion
. Cervical traction

Correct Answer & Explanation

. Rigid cervical collar

Explanation

Elderly patients with Type II odontoid fractures have significantly higher mortality rates with halo vest immobilization. Given this patient's severe medical comorbidities and minimal fracture displacement, a rigid cervical collar is the safest and most appropriate initial management.

Question 189

Topic: Cervical Spine

In evaluating an atlas (C1) ring fracture, lateral mass displacement on the open-mouth odontoid radiograph indicates a tear of the transverse atlantal ligament if the combined displacement exceeds what value?

. 3 mm
. 5 mm
. 7 mm
. 9 mm
. 11 mm

Correct Answer & Explanation

. 7 mm

Explanation

The Rule of Spence states that a combined lateral mass displacement of C1 on C2 greater than 6.9 mm (typically rounded to 7 mm) on an AP open-mouth radiograph indicates a rupture of the transverse atlantal ligament. This implies transverse instability requiring more rigid fixation or prolonged halo immobilization.

Question 190

Topic: Cervical Spine

Which of the following factors is most predictive of nonunion following nonoperative management (halo immobilization) of a Type II odontoid fracture?

. Age less than 40 years
. Anterior displacement of 3 mm
. Posterior displacement of 2 mm
. Initial displacement greater than 5 mm
. Concomitant fracture of the C1 posterior arch

Correct Answer & Explanation

. Initial displacement greater than 5 mm

Explanation

High risk of nonunion in Type II odontoid fractures managed conservatively is associated with initial displacement greater than 5 mm, age > 50 years, and posterior displacement. These factors often necessitate surgical stabilization, such as an anterior odontoid screw or posterior C1-C2 fusion.

Question 191

Topic: Cervical Spine

An 82-year-old male sustains a Type II odontoid fracture after a ground-level fall. He has multiple medical comorbidities. Which of the following management strategies carries the lowest treatment-related morbidity while still providing acceptable clinical outcomes, despite having the highest rate of nonunion?

. Halo vest immobilization
. Rigid cervical collar
. C1-C2 posterior fusion
. Anterior odontoid screw fixation
. Minerva cast

Correct Answer & Explanation

. Rigid cervical collar

Explanation

A rigid cervical collar is the preferred initial treatment for many elderly patients with Type II odontoid fractures who are poor surgical candidates. While it has a high nonunion rate, fibrous nonunions are generally well-tolerated, and it avoids the high morbidity and mortality associated with halo vest immobilization in the elderly.

Question 192

Topic: Cervical Spine

A 78-year-old man presents with severe neck pain after a low-energy fall. Radiographs and CT scan reveal a Type II odontoid fracture with 6 mm of posterior displacement and comminution at the fracture base. He is neurologically intact. His medical history includes hypertension and mild osteopenia. What is the most appropriate management for this patient?

. Rigid cervical collar for 12 weeks
. Halo vest immobilization for 12 weeks
. Anterior odontoid screw fixation
. Posterior C1-C2 instrumented fusion
. Occipitocervical fusion

Correct Answer & Explanation

. Posterior C1-C2 instrumented fusion

Explanation

Posterior C1-C2 instrumented fusion is the most reliable treatment for elderly patients with displaced Type II odontoid fractures. Nonoperative management (halo or collar) has an unacceptably high nonunion rate and morbidity in this age group, while anterior screw fixation is contraindicated given his osteopenia and fracture comminution.

Question 193

Topic: Cervical Spine

A 24-year-old man is brought to the emergency department after a shallow water diving accident. He is awake, alert, and cooperative, with no other traumatic injuries. Examination reveals full strength and sensation in all extremities. Radiographs and CT scan show a C5-C6 bilateral facet dislocation with 50% translation. What is the most appropriate immediate management?

. Immediate MRI of the cervical spine
. Application of a hard cervical collar and delayed posterior fusion
. Awake closed reduction via cranial traction
. Emergent anterior cervical discectomy and fusion (ACDF)
. Emergent posterior cervical laminectomy and fusion

Correct Answer & Explanation

. Awake closed reduction via cranial traction

Explanation

In an awake, alert, and cooperative patient with a cervical facet dislocation, rapid closed reduction using cranial traction is safe and indicated before obtaining an MRI. If the patient has an altered mental status or fails closed reduction, an MRI should be obtained prior to surgical intervention to evaluate for an extruded disc.

Question 194

Topic: Cervical Spine

A 25-year-old man is brought to the ED after a motor vehicle collision. He is awake, alert, and cooperative. Examination reveals intact motor and sensory function in all extremities. Cervical spine imaging demonstrates a right-sided unilateral C5-C6 facet dislocation. What is the recommended initial management?

. Immediate anterior cervical discectomy and fusion (ACDF)
. Urgent MRI prior to any attempted reduction
. Awake closed reduction using cranial traction
. Posterior cervical fusion
. Application of a halo vest and discharge

Correct Answer & Explanation

. Awake closed reduction using cranial traction

Explanation

In an awake, cooperative, and neurologically intact patient with a cervical facet dislocation, urgent awake closed reduction via cranial traction is recommended. MRI is generally reserved for patients who fail closed reduction, have an altered mental status, or develop neurologic deficits during traction.

Question 195

Topic: Cervical Spine
A previously healthy 35-year-old man was involved in a rollover motor vehicle accident 2 days ago. He was placed in a semi-rigid cervical orthosis. He now reports mostly axial neck pain with attempted range of motion. Examination reveals the mechanical neck pain but no obvious neurologic deficits. AP, flexion, and extension radiographs are shown in Figures 10a through 10c, and sagittal and coronal CT scans are shown in Figures 10d and 10e. What is the most appropriate management at this time?
. Continued immobilization in a semi-rigid cervical orthosis for 6 to 8 weeks
. Posterior occipital-cervical fusion with iliac crest bone graft
. Open reduction and internal fixation of the odontoid process with an anterior odontoid screw
. Resection of the odontoid process through a transoral approach
. Reduction with Gardner-Wells tong traction and 6 weeks of skeletal traction

Correct Answer & Explanation

. Open reduction and internal fixation of the odontoid process with an anterior odontoid screw

Explanation

Odontoid fractures can be classified based on the anatomic position of the fracture within the dens itself. Type I is an oblique fracture through the upper part of the odontoid process. Type II is a fracture that occurs at the base of the odontoid as it attaches to the body of C2; type III occurs when the fracture line extends through the body of the axis. Type I fractures typically can be treated nonsurgically with 6 to 8 weeks of immobilization with a semi-rigid cervical orthosis.

Question 196

Topic: Cervical Spine

An 82-year-old man with a history of falls presents with neck pain. CT of the cervical spine reveals a Type II odontoid fracture with 2 mm of posterior displacement. He is neurologically intact. What is the most appropriate management?

. Halo vest immobilization
. Rigid cervical collar
. Anterior odontoid screw fixation
. Posterior C1-C2 fusion
. Observation without orthosis

Correct Answer & Explanation

. Rigid cervical collar

Explanation

In elderly patients with Type II odontoid fractures and minimal displacement (< 5 mm), a rigid cervical collar is the preferred treatment. Surgery has higher perioperative risks, and halo vests carry high morbidity and mortality in the elderly.

Question 197

Topic: Cervical Spine

A 30-year-old man sustains a C1 burst fracture. An open-mouth odontoid radiograph demonstrates that the lateral masses of C1 overhang the lateral masses of C2 by a combined total of 8 mm. What does this finding most likely indicate?

. An intact transverse ligament
. A ruptured transverse ligament
. A ruptured alar ligament
. A ruptured apical ligament
. Atlanto-occipital dissociation

Correct Answer & Explanation

. A ruptured transverse ligament

Explanation

According to the Rule of Spence, a combined lateral mass overhang of 6.9 mm or greater (often cited as 7 mm on standard X-rays due to magnification) indicates incompetence or rupture of the transverse ligament.

Question 198

Topic: Cervical Spine

A 75-year-old woman falls from a standing height and sustains a Type II odontoid fracture with 3 mm of posterior displacement. She is neurologically intact. Given her age, which of the following treatment options is associated with the highest risk of mortality and severe morbidity?

. Rigid cervical collar
. Halo vest immobilization
. Anterior odontoid screw fixation
. Posterior C1-C2 instrumentation and fusion
. Minerva cast

Correct Answer & Explanation

. Halo vest immobilization

Explanation

In elderly patients (especially those >65 years), halo vest immobilization for odontoid fractures is poorly tolerated and associated with high rates of severe complications, including pneumonia, respiratory failure, and increased mortality.

Question 199

Topic: Cervical Spine

During an anterior cervical discectomy and fusion (ACDF) at C6-C7 using a right-sided approach, the patient subsequently develops postoperative hoarseness. Which anatomical characteristic of the recurrent laryngeal nerve (RLN) makes it more susceptible to injury on the right side compared to the left?

. The right RLN passes anterior to the carotid sheath
. The right RLN courses inferior to the right subclavian artery and ascends obliquely
. The right RLN loops under the aortic arch
. The right RLN runs consistently within the tracheoesophageal groove
. The right RLN innervates the cricothyroid muscle directly

Correct Answer & Explanation

. The right RLN courses inferior to the right subclavian artery and ascends obliquely

Explanation

The right recurrent laryngeal nerve loops under the right subclavian artery and ascends obliquely into the neck, making its course variable and more susceptible to injury during a right-sided approach. The left RLN loops under the aortic arch and runs safely in the tracheoesophageal groove.

Question 200

Topic: Cervical Spine

An 82-year-old man presents with neck pain after a ground-level fall. CT scan reveals a displaced Type II odontoid fracture. He is neurologically intact. Given his age, what is the most appropriate management to minimize mortality and morbidity?

. Halo vest immobilization for 12 weeks
. Hard cervical collar for 6 weeks
. Anterior odontoid screw fixation
. Posterior C1-C2 instrumented fusion
. Occipitocervical fusion

Correct Answer & Explanation

. Posterior C1-C2 instrumented fusion

Explanation

Type II odontoid fractures in the elderly have a high rate of nonunion, and halo vest immobilization is associated with high mortality. Posterior C1-C2 instrumented fusion provides definitive stabilization with better outcomes.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page