Menu

Cervical Spine MCQs

Practice Set 2 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 21

Topic: Cervical Spine

In a patient with long-standing rheumatoid arthritis, which of the following radiographic measurements is the most reliable predictor of impending or irreversible neurologic deficit due to atlantoaxial subluxation?

. Anterior atlantodental interval (ADI) > 3 mm
. Anterior atlantodental interval (ADI) > 9 mm
. Posterior atlantodental interval (PADI) < 14 mm
. Subaxial subluxation of 2 mm
. Cranial settling with the odontoid 2 mm above Chamberlain's line

Correct Answer & Explanation

. Anterior atlantodental interval (ADI) > 3 mm

Explanation

The Posterior atlantodental interval (PADI), also known as the space available for the cord (SAC), is the most critical prognostic indicator. A PADI less than 14 mm is associated with a high risk of permanent neurologic deficit.

Question 22

Topic: Cervical Spine

During an anterior cervical discectomy and fusion (ACDF) at the C6-C7 level, a right-sided surgical approach is chosen. Which of the following structures is at a higher risk of injury compared to a left-sided approach?

. Thoracic duct
. Recurrent laryngeal nerve
. Sympathetic chain
. Superior laryngeal nerve
. Vertebral artery

Correct Answer & Explanation

. Thoracic duct

Explanation

The right recurrent laryngeal nerve is at higher risk during right-sided lower cervical approaches because it leaves the vagus nerve more proximally and courses at a more oblique, unprotected angle compared to the left nerve.

Question 23

Topic: Cervical Spine

To mitigate the incidence of postoperative dysphagia following a multi-level Anterior Cervical Discectomy and Fusion (ACDF), which intraoperative maneuver is most supported by evidence?

. Deflating and re-inflating the endotracheal tube cuff after deep retractor placement
. Utilizing the highest profile anterior cervical plate available
. Maintaining the cervical spine in maximum hyperextension
. Routinely placing retractor blades deep into the longus colli muscle bellies
. Avoiding the use of any local anesthetics near the esophagus

Correct Answer & Explanation

. Deflating and re-inflating the endotracheal tube cuff after deep retractor placement

Explanation

Deflating and subsequently re-inflating the endotracheal tube cuff after retractor placement reduces the compressive pressure against the pharyngeal wall and recurrent laryngeal nerve, significantly lowering the risk of postoperative dysphagia.

Question 24

Topic: Cervical Spine

An 82-year-old male with severe congestive heart failure and COPD sustains a Type II odontoid fracture after a low-energy fall. He is neurologically intact. Which of the following is the most appropriate management for this patient?

. Halo vest immobilization
. Rigid cervical collar immobilization
. Anterior odontoid screw fixation
. Posterior C1-C2 transarticular screws
. Occipitocervical fusion

Correct Answer & Explanation

. Rigid cervical collar immobilization

Explanation

In elderly patients with severe comorbidities, rigid cervical collar immobilization is heavily favored. Surgical intervention and halo vest placement both carry unacceptably high morbidity and mortality rates in frail, elderly populations.

Question 25

Topic: Cervical Spine

A patient sustains an axial load injury resulting in a burst fracture of the C1 ring (Jefferson fracture). Which of the following radiographic measurements on an open-mouth odontoid view suggests rupture of the transverse atlantal ligament?

. Combined lateral mass displacement > 6.9 mm
. Atlantodental interval (ADI) > 3 mm
. Basion-dental interval > 12 mm
. Prevertebral soft tissue > 7 mm at C2
. Space available for the cord (SAC) < 13 mm

Correct Answer & Explanation

. Combined lateral mass displacement > 6.9 mm

Explanation

According to the Rule of Spence, if the sum of the overhang of the C1 lateral masses on C2 is greater than 6.9 mm on an open-mouth view, the transverse ligament is likely ruptured.

Question 26

Topic: Cervical Spine

An 84-year-old female sustains a Type II odontoid fracture with 2 mm of posterior displacement following a ground-level fall. She has no neurological deficits. Which of the following is the most appropriate management?

. Halo vest immobilization for 12 weeks
. Rigid cervical collar for 6-12 weeks
. Anterior odontoid screw fixation
. Posterior C1-C2 transarticular screw fusion
. Non-rigid soft cervical collar for comfort

Correct Answer & Explanation

. Rigid cervical collar for 6-12 weeks

Explanation

In elderly patients with Type II odontoid fractures, rigid cervical collar immobilization is the treatment of choice. Operative intervention and halo vests carry unacceptably high morbidity and mortality rates in this age group.

Question 27

Topic: Cervical Spine

When evaluating a Jefferson burst fracture of the C1 atlas, which finding on the open-mouth odontoid radiograph best indicates rupture of the transverse atlantal ligament (TAL)?

. Total combined lateral overhang of the C1 lateral masses on C2 > 6.9 mm
. Fracture visible through the anterior arch only
. Asymmetry of the atlantodental interval
. Overhang of the lateral masses > 2.0 mm
. Retropharyngeal swelling > 10 mm

Correct Answer & Explanation

. Total combined lateral overhang of the C1 lateral masses on C2 > 6.9 mm

Explanation

According to Spence's rule, a combined lateral mass overhang of C1 on C2 greater than 6.9 mm on an open-mouth odontoid view implies incompetence or rupture of the transverse atlantal ligament, indicating high instability.

Question 28

Topic: Cervical Spine

Which of the following factors is most strongly associated with an increased risk of non-union in a Type II odontoid fracture treated with non-operative management?

. Age less than 30 years
. Displacement greater than 5 mm
. Mechanism of injury being a low-energy fall
. Posterior displacement of 2 mm
. Concomitant fractures of the C1 anterior arch

Correct Answer & Explanation

. Displacement greater than 5 mm

Explanation

Initial fracture displacement greater than 5 mm is a major risk factor for non-union in Type II odontoid fractures. Other significant risk factors include patient age greater than 50 years and posterior displacement.

Question 29

Topic: Cervical Spine

The Rule of Spence is utilized to evaluate the integrity of the transverse ligament in C1 ring (Jefferson) fractures. A ruptured transverse ligament is indicated if the combined lateral mass overhang on an open-mouth odontoid radiograph exceeds:

. 3.5 mm
. 5.0 mm
. 6.9 mm
. 8.5 mm
. 10.0 mm

Correct Answer & Explanation

. 6.9 mm

Explanation

According to the Rule of Spence, a combined overhang of the lateral masses of C1 on C2 of more than 6.9 mm indicates a rupture of the transverse alar ligament, signifying instability.

Question 30

Topic: Cervical Spine

A patient presents with a traumatic cervical spine injury.

A Type II odontoid fracture is identified. Which of the following factors contributes most significantly to the high nonunion rate of this specific fracture type?

. Excessive motion at the atlanto-occipital joint
. Interruption of the watershed blood supply at the base of the dens
. Interposition of the transverse ligament
. Associated alar ligament rupture
. Poor bone density in the C2 vertebral body

Correct Answer & Explanation

. Interruption of the watershed blood supply at the base of the dens

Explanation

Type II odontoid fractures occur at the base of the dens, which is a vascular watershed area. The limited blood supply to this region is the primary reason for the high nonunion rate associated with these fractures.

Question 31

Topic: Cervical Spine

A cervical radiograph of a trauma patient demonstrates anterior translation of C5 over C6 by approximately 25% of the vertebral body width.

What is the most likely diagnosis?

. Unilateral facet dislocation
. Bilateral facet dislocation
. Clay Shoveler's fracture
. Jefferson fracture
. Hangman's fracture

Correct Answer & Explanation

. Unilateral facet dislocation

Explanation

A unilateral facet dislocation typically results in anterior translation of the involved vertebral body by approximately 25% (up to 50%) of its anteroposterior width. Bilateral facet dislocations usually demonstrate 50% or greater translation.

Question 32

Topic: Cervical Spine

A 35-year-old sustains a Type II odontoid fracture with a reverse obliquity fracture line (sloping from anterior-inferior to posterior-superior). Which fixation method is contraindicated?

. Anterior odontoid screw fixation
. Posterior C1-C2 transarticular screws
. Posterior C1-C2 Harms technique
. Halo vest immobilization

Correct Answer & Explanation

. Anterior odontoid screw fixation

Explanation

Anterior odontoid screw fixation is contraindicated in reverse obliquity Type II fractures because the lag screw trajectory will cause the fracture to shear and displace rather than compress.

Question 33

Topic: Cervical Spine

A 40-year-old man sustains an axial load injury to his head resulting in a Jefferson fracture. Open-mouth odontoid radiographs reveal lateral displacement of the lateral masses of C1 relative to C2. According to the Rule of Spence, what total combined overhang of the lateral masses strongly suggests incompetence of the transverse atlantal ligament?

. > 3 mm
. > 5 mm
. > 6.9 mm
. > 9 mm

Correct Answer & Explanation

. > 3 mm

Explanation

The Rule of Spence dictates that a combined overhang of the C1 lateral masses on C2 of greater than 6.9 mm on an open-mouth radiograph indicates a rupture of the transverse atlantal ligament, rendering the injury highly unstable.

Question 34

Topic: Cervical Spine

A 70-year-old patient falls and sustains a fracture through the base of the odontoid process. Why does this specific fracture type have a high rate of nonunion?

. Disruption of the transverse ligament
. Poor blood supply to the dens watershed area
. Interposition of the alar ligaments
. Inadequate immobilization with a halo vest
. High proportion of cancellous bone at the base

Correct Answer & Explanation

. Poor blood supply to the dens watershed area

Explanation

Type II odontoid fractures occur at the junction of the dens and the body of C2. They have a high nonunion rate due to the tenuous blood supply at this watershed area and the relatively small fracture surface area.

Question 35

Topic: Cervical Spine

A 25-year-old male dove into a shallow pool and sustained a burst fracture of the C1 ring. Which radiographic finding on the open-mouth odontoid view is most critical for determining the integrity of the transverse atlantal ligament?

. Prevertebral soft tissue swelling > 6 mm
. Anterior atlantodental interval (ADI) > 3 mm
. Combined lateral mass displacement > 6.9 mm
. Basion-dens interval > 12 mm
. C2-C3 subluxation > 3 mm

Correct Answer & Explanation

. Combined lateral mass displacement > 6.9 mm

Explanation

In a Jefferson fracture, a combined lateral mass overhang (displacement) of greater than 6.9 mm on the AP open-mouth view strongly suggests a rupture of the transverse atlantal ligament. This indicates significant atlantoaxial instability.

Question 36

Topic: Cervical Spine

A patient undergoes anterior cervical discectomy and fusion at C5-C6. Postoperatively, a new C6 nerve root palsy is noted. Which motor deficit is most likely expected?

. Weakness of shoulder abduction
. Weakness of elbow extension
. Weakness of wrist extension
. Weakness of finger flexion
. Weakness of finger abduction

Correct Answer & Explanation

. Weakness of wrist extension

Explanation

The C6 nerve root innervates the extensor carpi radialis longus and brevis, primarily controlling wrist extension. It also contributes heavily to elbow flexion.

Question 37

Topic: Cervical Spine

A 30-year-old male is involved in a severe motor vehicle crash. Lateral cervical radiograph shows a 50% anterior subluxation of C5 on C6. What is the most likely structural injury?

. Unilateral facet dislocation
. Bilateral facet dislocation
. Clay shoveler's fracture
. Teardrop fracture
. Odontoid fracture

Correct Answer & Explanation

. Unilateral facet dislocation

Explanation

Anterior translation of a cervical vertebral body by 50% or more over the adjacent inferior segment is highly indicative of bilateral facet dislocation. Unilateral facet dislocation typically presents with approximately 25% anterior translation.

Question 38

Topic: Cervical Spine

A 65-year-old woman with severe, long-standing rheumatoid arthritis is scheduled for a total knee arthroplasty. Which preoperative radiographic view of the cervical spine is most critical for the anesthesiologist to review prior to intubation?

. AP lower cervical spine
. Flexion-extension lateral cervical spine
. Oblique cervical spine
. Swimmer's view
. AP open-mouth odontoid view

Correct Answer & Explanation

. AP lower cervical spine

Explanation

Patients with rheumatoid arthritis frequently develop atlantoaxial instability due to pannus destruction of the transverse ligament. Flexion-extension lateral radiographs are critical to evaluate for abnormal atlantodental interval (ADI) prior to intubation.

Question 39

Topic: Cervical Spine

During an anterior cervical discectomy and fusion (ACDF) at C5-C6, the patient develops postoperative hoarseness. Which nerve was most likely injured and where does it reside?

. Superior laryngeal nerve in the tracheoesophageal groove
. Recurrent laryngeal nerve in the tracheoesophageal groove
. Cervical sympathetic trunk over the longus colli
. Hypoglossal nerve above the hyoid bone
. Vagus nerve within the carotid sheath

Correct Answer & Explanation

. Superior laryngeal nerve in the tracheoesophageal groove

Explanation

The recurrent laryngeal nerve courses in the tracheoesophageal groove and is vulnerable during lower cervical anterior exposures. Injury results in unilateral vocal cord paralysis, which presents clinically as hoarseness.

Question 40

Topic: Cervical Spine

During an anterior cervical discectomy and fusion (ACDF) at the C5-C6 level, a right-sided approach is utilized. Postoperatively, the patient complains of persistent hoarseness. Which of the following structures was most likely injured?

. Superior laryngeal nerve
. Recurrent laryngeal nerve
. Hypoglossal nerve
. Glossopharyngeal nerve
. Cervical sympathetic chain

Correct Answer & Explanation

. Recurrent laryngeal nerve

Explanation

The recurrent laryngeal nerve is at risk during anterior cervical approaches. A right-sided approach has historically been associated with a slightly higher risk due to the nerve's more variable and oblique course compared to the left.

Test Yourself

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

On this Page