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Cervical Spine MCQs

Practice Set 20 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 381

Topic: Cervical Spine
What is the most appropriate initial management for a stable type I odontoid fracture?
. Emergent surgical fixation.
. Halo vest immobilization.
. Soft cervical collar for 6 weeks.
. Traction.
. Atlantoaxial fusion.

Correct Answer & Explanation

. Soft cervical collar for 6 weeks.

Explanation

A Type I odontoid fracture is an oblique fracture of the odontoid tip, which is typically stable. It usually heals well with non-operative management, often with a rigid cervical collar (like a Miami J or Philadelphia collar) for 6-12 weeks. Halo vest immobilization or surgical fixation are generally reserved for more unstable Type II or Type III odontoid fractures. Traction is not indicated, and atlantoaxial fusion is a definitive surgical treatment for instability, not initial management for a stable Type I.

Question 382

Topic: Cervical Spine

In a patient with a stable C2 odontoid type II fracture, which of the following treatment options is generally preferred in a younger, active patient?

. Halo vest immobilization
. Transarticular screw fixation (C1-C2)
. Anterior odontoid screw fixation
. Posterior C1-C2 fusion
. Soft cervical collar

Correct Answer & Explanation

. Anterior odontoid screw fixation

Explanation

For a stable C2 odontoid type II fracture, anterior odontoid screw fixation is often preferred in a younger, active patient. It allows for direct fixation of the fracture, preserves C1-C2 rotation, and avoids the need for prolonged external immobilization (halo vest), which can be uncomfortable and associated with complications. Halo vest immobilization has a higher nonunion rate and often prolonged discomfort. Transarticular screw fixation or posterior C1-C2 fusion are options, but they sacrifice C1-C2 rotation, which anterior odontoid screw fixation preserves. A soft cervical collar is inadequate for an odontoid fracture.

Question 383

Topic: Cervical Spine

During an anterior cervical discectomy and fusion (ACDF), aggressive lateral dissection past the uncinate process risks catastrophic injury to the vertebral artery. At which cervical level does the vertebral artery typically enter the transverse foramen?

. C7
. C6
. C5
. C4
. C3

Correct Answer & Explanation

. C7

Explanation

The vertebral artery arises from the first part of the subclavian artery and typically enters the transverse foramen of the cervical spine at the C6 level, bypassing the C7 transverse foramen.

Question 384

Topic: Cervical Spine

A 22-year-old baseball pitcher undergoes an ulnar collateral ligament (UCL) reconstruction. The anterior bundle of the UCL is the primary restraint to valgus stress. Which specific band of the anterior bundle provides the primary restraint during early flexion (0 to 60 degrees)?

. Anterior band
. Posterior band
. Transverse ligament
. Oblique band
. Proximal band

Correct Answer & Explanation

. Anterior band

Explanation

The anterior bundle of the UCL is composed of anterior and posterior bands. The anterior band is the primary restraint to valgus stress in early flexion (up to 60 degrees), while the posterior band provides stability in deeper flexion.

Question 385

Topic: Cervical Spine

A 24-year-old male is involved in a high-speed rollover collision. CT of the cervical spine reveals a Type II odontoid fracture with a reverse obliquity fracture line (sloping from anterior-inferior to posterior-superior). Which of the following surgical interventions is considered the MOST appropriate for this fracture pattern?

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

Correct Answer & Explanation

. Anterior odontoid screw fixation

Explanation

A reverse obliquity Type II odontoid fracture (fracture line angling from anteroinferior to posterosuperior) is a strict contraindication for anterior odontoid screw fixation. Attempting to place an anterior screw in this pattern will cause the fracture to shear and displace anteriorly rather than compress. The preferred surgical management for a young patient with this unstable fracture pattern is a posterior C1-C2 instrumented fusion.

Question 386

Topic: Cervical Spine

An 82-year-old male sustains a Type II odontoid fracture with 2 mm of posterior displacement after a ground-level fall. He is neurologically intact. Which of the following treatments is associated with the highest survival rate for this specific patient demographic?

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

Correct Answer & Explanation

. Halo vest immobilization

Explanation

In elderly patients (typically over 80 years) with Type II odontoid fractures, rigid cervical collar immobilization is favored as it has the lowest morbidity and highest survival rates. Halo vest immobilization in this age group carries a high risk of respiratory complications and mortality.

Question 387

Topic: Cervical Spine

A 25-year-old male presents with a C5-C6 bilateral facet dislocation after a motor vehicle accident. He is awake, alert, cooperative, and has no neurological deficits. What is the most appropriate next step in management?

. Immediate MRI to assess the intervertebral disc status
. Immediate closed reduction with cranial traction under fluoroscopy
. Emergent open posterior reduction and instrumented fusion
. Emergent open anterior reduction and ACDF
. Application of a hard collar and delayed MRI in 24 hours

Correct Answer & Explanation

. Immediate MRI to assess the intervertebral disc status

Explanation

In an awake, alert, and cooperative patient with a cervical facet dislocation, immediate closed reduction with cranial traction is indicated without waiting for an MRI. Pre-reduction MRI is reserved for patients who are obtunded or fail closed reduction.

Question 388

Topic: Cervical Spine

An 82-year-old male falls and sustains a Type II odontoid fracture. Imaging reveals that the dens is displaced 6 mm posteriorly. He is neurologically intact but in significant pain. What is the most appropriate definitive management for this patient?

. Immobilization in a rigid cervical collar for 12 weeks
. Halo vest immobilization
. Anterior odontoid screw fixation
. Posterior C1-C2 instrumented fusion
. Observation and physical therapy

Correct Answer & Explanation

. Immobilization in a rigid cervical collar for 12 weeks

Explanation

In elderly patients (>80 years), non-operative management of Type II odontoid fractures with >5 mm displacement carries a very high nonunion rate and morbidity. Posterior C1-C2 fusion is the treatment of choice, as anterior screw fixation has a high failure rate in osteopenic bone.

Question 389

Topic: Cervical Spine

A surgeon is performing an anterior cervical discectomy and fusion (ACDF) at C5-C6. During lateral decompression of the uncovertebral joint, there is a risk of injuring the vertebral artery. In the standard human anatomy, at which cervical level does the vertebral artery typically enter the transverse foramen?

. C4
. C5
. C6
. C7
. T1

Correct Answer & Explanation

. C4

Explanation

The vertebral artery typically enters the transverse foramen at the C6 vertebral level in over 90% of individuals. It does not pass through the C7 transverse foramen, which usually transmits only the vertebral vein.

Question 390

Topic: Cervical Spine

An 80-year-old woman is involved in a low-speed motor vehicle collision. CT scan reveals a Type II odontoid fracture with 2 mm of posterior displacement. She is neurologically intact. What is the most appropriate treatment?

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

Correct Answer & Explanation

. Halo vest immobilization for 12 weeks

Explanation

In elderly patients (>65 years) with Type II odontoid fractures, morbidity and mortality from rigid halo vest immobilization are significantly high. A hard cervical collar is typically recommended for initial management of minimally displaced fractures in this age group, balancing the high risk of nonunion against the risks of surgery or a halo.

Question 391

Topic: Cervical Spine

A 65-year-old female with long-standing Rheumatoid Arthritis presents with neck pain and occipital headaches. Lateral cervical flexion-extension radiographs show an anterior atlantodental interval (ADI) of 11 mm. What is the most appropriate management?

. Observation and serial radiographs
. Hard cervical collar
. Posterior C1-C2 fusion
. Occipitocervical fusion
. Subaxial cervical decompression

Correct Answer & Explanation

. Observation and serial radiographs

Explanation

In rheumatoid arthritis, anterior atlantoaxial subluxation is an indication for surgery when the ADI is > 9-10 mm. The standard surgical procedure for isolated C1-C2 instability without cranial settling is a posterior C1-C2 fusion.

Question 392

Topic: Cervical Spine

A 25-year-old diver impacts the bottom of a pool, sustaining an axial load injury. An open-mouth odontoid radiograph demonstrates a Jefferson fracture. According to Spence's rule, a combined lateral mass overhang of C1 on C2 greater than what measurement implies incompetence of the transverse alar ligament?

. > 3.0 mm
. > 5.0 mm
. > 6.9 mm
. > 9.0 mm
. > 11.0 mm

Correct Answer & Explanation

. > 3.0 mm

Explanation

Spence's rule states that a combined lateral mass displacement of C1 on C2 greater than 6.9 mm on an open-mouth odontoid view is highly suggestive of a ruptured transverse ligament, rendering the fracture highly unstable.

Question 393

Topic: Cervical Spine

A 30-year-old female sustains a Levine-Edwards Type IIa Hangman's fracture. Radiographs demonstrate an angulated C2 pars fracture with minimal translation. What treatment modality is strictly contraindicated in this specific injury pattern?

. Rigid cervical collar
. Halo vest immobilization in compression
. Axial cervical traction
. C2-C3 anterior cervical discectomy and fusion
. Posterior C1-C3 fusion

Correct Answer & Explanation

. Rigid cervical collar

Explanation

A Type IIa Hangman's fracture is caused by flexion-distraction and features severe angulation with minimal translation. Axial traction is strictly contraindicated as it can cause over-distraction and severe neurologic injury.

Question 394

Topic: Cervical Spine

An 82-year-old male with severe chronic obstructive pulmonary disease and heart failure presents after a mechanical fall from a standing height. He reports significant neck pain. Neurologic examination is unremarkable.

Imaging demonstrates a displaced Type II odontoid fracture. What is the most appropriate management for this patient?

. Halo vest immobilization
. Rigid cervical collar immobilization
. Anterior odontoid screw fixation
. Posterior C1-C2 instrumented fusion
. Cervical traction followed by surgical stabilization

Correct Answer & Explanation

. Halo vest immobilization

Explanation

In elderly patients (typically >80 years old) with significant medical comorbidities, nonoperative management with a rigid cervical collar is the treatment of choice for Type II odontoid fractures. While the rate of nonunion is high, stable fibrous nonunions are generally well-tolerated. Halo vest immobilization is contraindicated in this demographic due to an unacceptably high rate of morbidity and mortality, primarily from respiratory complications. Surgery is high-risk in the setting of severe comorbidities.

Question 395

Topic: Cervical Spine

A 7-year-old boy presents with painful torticollis 10 days after undergoing a routine tonsillectomy. On examination, his head is tilted to the right and his chin is rotated to the left. Neurologic examination is intact. What is the most appropriate initial management?

. C1-C2 posterior instrumented fusion
. Intravenous antibiotics and soft cervical collar
. Closed reduction under anesthesia and halo vest application
. Anterior cervical discectomy and fusion
. Observation only with outpatient follow-up

Correct Answer & Explanation

. C1-C2 posterior instrumented fusion

Explanation

This patient is presenting with Grisel's syndrome, which is a non-traumatic atlantoaxial subluxation most commonly seen in children following an upper respiratory infection or ENT surgery (like tonsillectomy). The pathophysiology involves inflammatory hyperemia spreading to the periodontoid vascular plexus, causing laxity of the transverse ligament. Initial management for early Fielding types (I and II) is medical, consisting of intravenous antibiotics, muscle relaxants, and a soft cervical collar.

Question 396

Topic: Cervical Spine

A 75-year-old male sustains a Type II odontoid fracture after a ground-level fall. Which of the following radiographic factors is MOST strongly associated with non-union if treated non-operatively in a halo vest?

. Initial fracture displacement > 5 mm
. Posterior angulation of 5 degrees
. Comminution of the C1 lateral masses
. Presence of a concomitant C3 compression fracture
. Fracture gap of 0.5 mm

Correct Answer & Explanation

. Initial fracture displacement > 5 mm

Explanation

Type II odontoid fractures occur at the base of the dens. Risk factors for non-union with non-operative management include age > 50 years, initial displacement > 5 mm, angulation > 10 degrees, and a fracture gap > 1 mm. Given the patient's age and displacement, surgical stabilization (e.g., posterior C1-C2 fusion) is often indicated to avoid the high morbidity of halo vests in the elderly and the high rate of non-union.

Question 397

Topic: Cervical Spine

In a patient with cervical Ossification of the Posterior Longitudinal Ligament (OPLL), what does a "negative K-line" on a lateral radiograph imply regarding surgical planning?

. The patient is best treated with posterior laminoplasty alone
. The OPLL mass is non-compressive
. Posterior decompression alone will likely fail to achieve adequate cord drift-back
. The patient has an absolute contraindication to anterior cervical surgery
. The ossification has fused completely to the dura mater

Correct Answer & Explanation

. The patient is best treated with posterior laminoplasty alone

Explanation

The K-line is drawn from the mid-point of the spinal canal at C2 to the mid-point at C7. If the OPLL mass exceeds this line (a negative K-line), the cervical alignment is often kyphotic or the mass is so large that posterior decompression (laminectomy/laminoplasty) will not allow the spinal cord to drift backward sufficiently. These patients typically require an anterior or combined approach for direct decompression.

Question 398

Topic: Cervical Spine
According to the Fielding and Hawkins classification for atlantoaxial rotatory subluxation (AARS) in pediatric patients, what radiographic parameter defines a Type II injury?
. Rotatory fixation with an atlantodens interval (ADI) less than 3 mm
. Rotatory fixation with anterior displacement and an ADI of 3 to 5 mm
. Rotatory fixation with anterior displacement and an ADI greater than 5 mm
. Rotatory fixation combined with posterior displacement of the atlas
. Rotatory fixation with significant vertical translation

Correct Answer & Explanation

. Rotatory fixation with anterior displacement and an ADI of 3 to 5 mm

Explanation

The Fielding and Hawkins classification for AARS is: Type I: Rotatory fixation with no anterior displacement (ADI < 3 mm); transverse ligament intact. Type II: Rotatory fixation with anterior displacement of 3-5 mm; transverse ligament ruptured but alar ligaments intact. Type III: Anterior displacement > 5 mm; rupture of transverse and alar ligaments. Type IV: Posterior displacement of the atlas.

Question 399

Topic: Cervical Spine

Fractures of the odontoid process (dens) are classified into three types by Anderson and D'Alonzo. Type II fractures are notorious for having a high rate of nonunion. What is the primary anatomical reason for this high nonunion rate?

. They occur through the area of highest biomechanical stress at the tip.
. They directly sever the primary blood supply from the vertebral artery.
. The fracture line passes through a watershed vascular zone at the base of the dens.
. There is constant interposition of the transverse ligament in the fracture gap.
. Disruption of the alar ligaments leaves the proximal fragment entirely avascular.

Correct Answer & Explanation

. They occur through the area of highest biomechanical stress at the tip.

Explanation

Type II odontoid fractures occur at the base (junction) of the dens and the body of C2. This region represents a vascular watershed zone between the blood supply provided by the apical arcade (via the alar ligaments) and the vessels supplying the body of C2. This tenuous blood supply, combined with the small surface area and high mobility of the segment, leads to a high rate of nonunion if not adequately immobilized or surgically fixed.

Question 400

Topic: Cervical Spine

A 22-year-old male is evaluated after a diving accident. An open-mouth odontoid radiograph demonstrates a C1 ring fracture (Jefferson fracture). Which of the following radiographic measurements on the open-mouth view strongly suggests an incompetent transverse atlantal ligament (TAL)?

. An atlantodens interval (ADI) > 3 mm
. Combined overhang of the C1 lateral masses on C2 > 6.9 mm
. A basion-dental interval (BDI) > 10 mm
. Prevertebral soft tissue swelling > 7 mm at C2
. C2-C3 angulation > 11 degrees

Correct Answer & Explanation

. An atlantodens interval (ADI) > 3 mm

Explanation

The Rule of Spence states that a combined lateral mass overhang of C1 on C2 of greater than 6.9 mm on an open-mouth radiograph suggests rupture of the transverse atlantal ligament (TAL). A ruptured TAL renders the fracture highly unstable, often necessitating surgical stabilization or a rigid halo, rather than simple collar immobilization.

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