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Cervical Spine MCQs

Practice Set 4 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 61

Topic: Cervical Spine

A 40-year-old man dives into a shallow pool and sustains a C1 burst fracture. An open-mouth odontoid radiograph demonstrates a combined lateral mass overhang of 8 mm. What does this measurement critically indicate?

. Intact transverse ligament
. Rupture of the transverse ligament
. Rupture of the alar ligament
. Rupture of the apical ligament
. Intact tectorial membrane

Correct Answer & Explanation

. Rupture of the transverse ligament

Explanation

In a Jefferson fracture (C1 burst), the Rule of Spence dictates that a combined lateral mass overhang on C2 of 7 mm or more on an open-mouth view implies rupture of the transverse atlantal ligament. This indicates a highly unstable injury requiring rigid immobilization or surgical fusion.

Question 62

Topic: Cervical Spine

Which of the following is the most statistically significant risk factor for non-union in a Type II odontoid fracture treated with non-operative halo immobilization?

. Age less than 40 years
. Anterior displacement > 2 mm
. Posterior displacement > 5 mm
. Initial displacement > 5 mm
. Fracture gap < 1 mm

Correct Answer & Explanation

. Initial displacement > 5 mm

Explanation

High risk factors for non-union in Type II odontoid fractures include age greater than 50 years, initial displacement greater than 5 mm, posterior displacement, and a fracture gap greater than 1 mm.

Question 63

Topic: Cervical Spine

An 82-year-old male sustains a Type II odontoid fracture with 3 mm of posterior displacement. He has significant medical comorbidities. What is the most appropriate initial management?

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

Correct Answer & Explanation

. Rigid cervical collar

Explanation

In elderly patients with significant comorbidities, a rigid cervical collar is often preferred for Type II odontoid fractures. This is due to the high morbidity and mortality associated with halo vests and surgical intervention in this specific population.

Question 64

Topic: Cervical Spine

A 34-year-old manual laborer complains of lower neck pain after forcefully shoveling heavy snow. Radiographs reveal an isolated oblique fracture through the spinous process of C7. What is the most appropriate management?

. Anterior cervical discectomy and fusion
. Rigid cervical collar for 6 weeks
. Symptomatic treatment with NSAIDs and early mobilization
. Halo vest immobilization
. Posterior cervical fusion

Correct Answer & Explanation

. Symptomatic treatment with NSAIDs and early mobilization

Explanation

A Clay Shoveler's fracture is a stable avulsion fracture of a lower cervical or upper thoracic spinous process. Treatment is conservative, focusing on symptomatic relief, analgesics, and early mobilization.

Question 65

Topic: Cervical Spine

A patient sustains a Levine-Edwards Type IIA Hangman's fracture, which is characterized by severe angulation and minimal translation. What is the most appropriate initial management?

. Hard cervical collar for 6 weeks
. Halo vest immobilization applied in extension
. Halo vest immobilization applied in compression
. Anterior cervical discectomy and fusion
. Posterior C1-C2 transarticular screw fixation

Correct Answer & Explanation

. Halo vest immobilization applied in compression

Explanation

A Type IIA Hangman's fracture involves severe angulation with distraction, typically due to a flexion-distraction injury. Traction is contraindicated as it exacerbates the deformity; therefore, it is managed with a halo vest applied in slight compression.

Question 66

Topic: Cervical Spine

An open-mouth odontoid radiograph of a patient with a suspected Jefferson fracture shows lateral displacement of the C1 lateral masses relative to C2. According to the Rule of Spence, what total combined overhang indicates a likely rupture of the transverse ligament?

. Greater than 3 mm
. Greater than 5 mm
. Greater than 6.9 mm
. Greater than 9 mm
. Greater than 11 mm

Correct Answer & Explanation

. Greater than 6.9 mm

Explanation

The Rule of Spence dictates that a combined overhang of the C1 lateral masses on C2 of 6.9 mm or greater on an AP open-mouth radiograph indicates a highly probable transverse ligament rupture. This renders the C1 ring highly unstable, often necessitating surgical stabilization.

Question 67

Topic: Cervical Spine

A 5-year-old child falls from a swing. Cervical radiographs reveal 3 mm of anterior displacement of C2 on C3. The Swischuk line passes 1 mm anterior to the anterior cortex of the posterior arch of C3. What is the most likely diagnosis?

. Type II odontoid fracture
. Normal physiologic pseudosubluxation
. Hangman fracture
. C2-C3 bilateral facet dislocation
. Ruptured transverse ligament

Correct Answer & Explanation

. Normal physiologic pseudosubluxation

Explanation

Pseudosubluxation of C2 on C3 is a normal physiologic variant in young children due to horizontal facets and ligamentous laxity. A Swischuk line passing within 1.5 mm of the posterior arch of C3 confirms the alignment is physiologic rather than a true fracture or dislocation.

Question 68

Topic: Cervical Spine
A 7-year-old boy is intubated after being involved in a motor vehicle accident. His lateral cervical film (Slide 1) reveals a:
. Normal study
. Jefferson fracture
. Hangman's fracture
. Occiput-C2 subluxation
. Subaxial subluxation

Correct Answer & Explanation

. Occiput-C2 subluxation

Explanation

Extensive prevertebral soft tissue swelling is present. This patient received an injury that disrupted the ligaments of the atlantooccipital and atlantoaxial joint. Additionally, he has a congenital synchondrosis of the C1 ring. The dens-basion distance (dens to the anterior rim of the foramen magnum) is 13 mm; the normal distance is less than 10 mm to 12 mm. The patient is pentaplegic. Three-dimensional computed tomography scans (Slide 2, Slide 3) are presented.

Question 69

Topic: Cervical Spine

A 6-year-old child is involved in a motor vehicle accident. What injury is demonstrated by the computed tomography (C T) (Slide

. Jefferson fracture
. Transverse ligament injury
. Odontoid fracture
. Hangmans fracture
. Pseudosubluxation

Correct Answer & Explanation

. Transverse ligament injury

Explanation

This patient has an avulsion injury of the transverse ligament of the atlas. The bony avulsion is visible from its attachment to the left lateral mass and allows the atlas to move forward in relation to the axis. Hematoma and occiptocervical flexion is visible on the MRI. If it were anodontoid injury, the odontoid would still have a normal relationship to the ring of C 1 on the C T. Treatment involves reduction and fusion of C 1-C 2.

Question 70

Topic: Cervical Spine

A 6-year-old child presents with severe disproportionate short-trunk dwarfism, corneal clouding, and normal intelligence. Radiographs show universal platyspondyly and hypoplasia of the odontoid. The patient is deficient in which of the following enzymes?

. Alpha-L-iduronidase
. Iduronate sulfatase
. Galactosamine-6-sulfatase
. Glucocerebrosidase
. Sphingomyelinase

Correct Answer & Explanation

. Galactosamine-6-sulfatase

Explanation

Morquio syndrome (MPS IV) is characterized by normal intelligence, severe skeletal dysplasia, and odontoid hypoplasia predisposing to atlantoaxial instability. It is caused by a deficiency in the enzyme galactosamine-6-sulfatase.

Question 71

Topic: Cervical Spine

A 15-month-old toddler, who is neurologically intact, presents with a fracture (pic). Which of the following is the recommended treatment:

. Posterior C1-C 2 fusion
. Posterior occiput-C2 fusion
. Open reduction and screw fixation
. C 2 corpectomy and C1-C3 fusion anteriorly
. Reduction and halo vest immobilization

Correct Answer & Explanation

. Reduction and halo vest immobilization

Explanation

This odontoid physeal fracture should be treated by postural reduction and external immobilization. The reduction maneuver is posterior translation with slight axial traction, which may be accomplished by a halter or a halo vest. Immobilization must include a device such as a Minerva cast or a halo vest that can control the head well.C orrect Answer: Reduction and halo vest immobilization

Question 72

Topic: Cervical Spine

Which of the following measurements is considered normal for the atlanto-dens interval (ADI) on a lateral cervical radiograph in a 6-year-old child?

. Up to 3 mm
. Up to 5 mm
. Up to 7 mm
. Up to 9 mm
. Up to 11 mm

Correct Answer & Explanation

. Up to 5 mm

Explanation

In children, an ADI of up to 4-5 mm is considered normal due to increased ligamentous laxity. In adults, the normal upper limit is 3 mm.

Question 73

Topic: Cervical Spine

A 6-year-old boy presents with torticollis following a mild upper respiratory infection. He holds his head tilted to the right and rotated to the left. Radiographs reveal an atlantoaxial rotatory subluxation. According to the Fielding and Hawkins classification, a Type 1 injury is characterized by:

. Rotatory fixation with anterior displacement of the atlas 3-5 mm
. Rotatory fixation without anterior displacement of the atlas
. Rotatory fixation with anterior displacement of the atlas >5 mm
. Rotatory fixation with posterior displacement of the atlas
. Complete disruption of the transverse ligament

Correct Answer & Explanation

. Rotatory fixation without anterior displacement of the atlas

Explanation

Fielding and Hawkins Type 1 is rotatory fixation with no anterior displacement (pivot on the odontoid), representing the most common type. The transverse ligament remains intact.

Question 74

Topic: Cervical Spine
A 14-year-old boy incidentally undergoes cervical spine radiographs which reveal a well-corticated, round ossicle separated from a hypoplastic dens by a wide gap, lying cranial to the superior articular facets of the axis. What is the most likely diagnosis?
. Acute Type II Odontoid fracture
. Os odontoideum
. Acute Type III Odontoid fracture
. Persistent terminal ossicle
. Odontoid aplasia

Correct Answer & Explanation

. Os odontoideum

Explanation

Os odontoideum is characterized by a smooth, well-corticated ossicle separated from the base of the dens. It is distinct from an acute Type II fracture, which typically presents with irregular, non-corticated fracture margins.

Question 75

Topic: Cervical Spine

A 40-year-old laborer complains of lower neck pain after forcefully shoveling dirt. Radiographs reveal an isolated avulsion fracture of the C7 spinous process. What is the recommended treatment?

. Anterior cervical discectomy and fusion (ACDF)
. Halo vest immobilization for 6 weeks
. Posterior cervical wiring
. Symptomatic treatment with analgesia and a soft collar
. Rigid cervical orthosis for 12 weeks

Correct Answer & Explanation

. Symptomatic treatment with analgesia and a soft collar

Explanation

A Clay Shoveler's fracture is a stable avulsion fracture of a lower cervical spinous process. It does not compromise the structural stability of the cervical spine and is treated symptomatically.

Question 76

Topic: Cervical Spine

When interpreting pediatric cervical spine radiographs, it is important to distinguish fractures from normal development. At what age does the basilar synchondrosis (between the odontoid process and the body of C2) typically fuse?

. 1-2 years
. 3-4 years
. 5-7 years
. 9-11 years
. 12-14 years

Correct Answer & Explanation

. 5-7 years

Explanation

The basilar synchondrosis separates the dens from the body of C2 and typically fuses between 5 and 7 years of age. Before it fuses, this normal anatomical feature can easily be mistaken for a Type II odontoid fracture.

Question 77

Topic: Cervical Spine

A 6-year-old girl presents with persistent torticollis for two weeks following severe pharyngitis. Radiographs and CT scan confirm atlantoaxial rotatory subluxation (AARS) without neurologic deficits. What is the most appropriate initial management?

. Immediate posterior C1-C2 fusion
. Halo vest application
. Soft cervical collar and NSAIDs
. Cervical traction followed by bracing
. Anterior cervical discectomy and fusion

Correct Answer & Explanation

. Cervical traction followed by bracing

Explanation

Grisel's syndrome is a non-traumatic atlantoaxial rotatory subluxation associated with head or neck infections. For AARS present for 1-4 weeks, initial management typically involves cervical traction to achieve reduction followed by rigid bracing.

Question 78

Topic: Cervical Spine

Which of the following structures is the primary stabilizer of the atlantoaxial segment against anterior atlantal translation:

. Apical ligament
. Alar ligament
. Anterior atlantodental ligament
. Transverse ligament
. Ligamentum nuchae

Correct Answer & Explanation

. Transverse ligament

Explanation

The transverse ligament is the primary stabilizer of the atlantoaxial segment against anterior atlantal translation. The transverse ligament runs between the lateral masses of C1 and behind the odontoid process. The apical ligament is attached to the tip of the odontoid and the occiput, but not C1. The paired alar ligaments run obliquely and are secondary restraints, as is the anterior atlantodental ligament. The ligamentum nuchae is a strong condensation of fibers extending from the external occipital protuberance to the tips of the spinous processes C2-C 7.

Question 79

Topic: Cervical Spine

The radiographic line delimiting the foramen magnum that is used in determining basilar invagination is the:

. McGregor line
. McRae line
. Chamberlain line
. Ranawat line
. Swischuk line

Correct Answer & Explanation

. McRae line

Explanation

The McRae line is from the anterior to the posterior lip of the foramen magnum. Protrusion of the odontoid above this line indicates basilar invagination. The McGregor and Ranawat lines are also used to evaluate basilar invagination. The Swischuk line is from the posterior cortex of C1 to C3 lamina and is used in evaluating pseudosubluxation.

Question 80

Topic: Cervical Spine

A 6-year-old child presents with severe genu valgum, short stature, and normal intelligence. Radiographs show platyspondyly and odontoid hypoplasia. A deficiency in which of the following enzymes is the most likely cause?

. Galactosamine-6-sulfatase
. Alpha-L-iduronidase
. Iduronate sulfatase
. Arylsulfatase B
. Glucocerebrosidase

Correct Answer & Explanation

. Galactosamine-6-sulfatase

Explanation

Morquio syndrome (MPS IV) presents with normal intelligence, severe skeletal dysplasia, and odontoid hypoplasia. It is caused by a deficiency in galactosamine-6-sulfatase (Type A) or beta-galactosidase (Type B).

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