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Cervical Spine MCQs

Practice Set 6 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 101

Topic: Cervical Spine

An 82-year-old male presents with a Type II odontoid fracture after a ground-level fall. He has multiple medical comorbidities, including severe COPD and heart failure. What is the most appropriate management, considering the highest risk of morbidity and mortality?

. Application of a halo vest immobilizer
. Rigid cervical collar for 6-12 weeks
. Anterior odontoid screw fixation
. Posterior C1-C2 transarticular screw fixation
. Posterior C1-C2 wiring and bone grafting

Correct Answer & Explanation

. Rigid cervical collar for 6-12 weeks

Explanation

In elderly patients with Type II odontoid fractures, halo vest immobilization is associated with high morbidity and mortality (up to 40% complication rate). Nonoperative management with a rigid cervical collar is generally preferred for stable patterns in frail elderly patients, accepting a higher nonunion rate for survival.

Question 102

Topic: Cervical Spine

An 82-year-old male sustains a Type II odontoid fracture after a ground-level fall. He is neurologically intact. Given his age and injury type, which of the following is the most appropriate management with the lowest morbidity?

. Halo vest immobilization for 12 weeks
. Rigid cervical collar immobilization for 6-12 weeks
. Anterior odontoid screw fixation
. Posterior C1-C2 fusion
. Transoral odontoidectomy

Correct Answer & Explanation

. Rigid cervical collar immobilization for 6-12 weeks

Explanation

In elderly patients with Type II odontoid fractures, rigid cervical collar immobilization is often preferred due to the high morbidity and mortality associated with halo vests and surgical intervention. Although nonunion rates are high with a collar, a stable fibrous nonunion is typically well-tolerated in this population.

Question 103

Topic: Cervical Spine

A 45-year-old male is involved in a rollover motor vehicle accident and sustains a burst fracture of the C1 ring (Jefferson fracture). Which radiographic finding best indicates a rupture of the transverse ligament and need for surgical stabilization?

. Combined lateral mass overhang of 3 mm on open-mouth odontoid view
. Combined lateral mass overhang greater than 6.9 mm on open-mouth odontoid view
. Predental space of 2 mm on lateral flexion-extension views
. Prevertebral soft tissue swelling of 5 mm at C2
. Avulsion of the anterior arch of C1

Correct Answer & Explanation

. Combined lateral mass overhang greater than 6.9 mm on open-mouth odontoid view

Explanation

According to Spence's rule, a combined lateral mass overhang of the C1 masses on C2 greater than 6.9 mm on an open-mouth odontoid radiograph indicates a competent transverse ligament rupture. MRI is often used today for confirmation, but 6.9 mm remains the classic threshold for instability.

Question 104

Topic: Cervical Spine

A 45-year-old male sustains a burst fracture of the C1 ring (Jefferson fracture) after diving into shallow water. Open mouth odontoid radiographs demonstrate bilateral lateral mass overhang. According to the Rule of Spence, what is the critical threshold of combined lateral mass overhang that strongly suggests a transverse ligament rupture?

. 3.5 mm
. 4.5 mm
. 5.9 mm
. 6.9 mm
. 8.5 mm

Correct Answer & Explanation

. 6.9 mm

Explanation

The Rule of Spence states that a combined C1 lateral mass overhang on C2 of 6.9 mm or greater on an open-mouth odontoid radiograph indicates a rupture of the transverse ligament. This renders the C1-C2 articulation highly unstable, often requiring halo immobilization or surgical fusion.

Question 105

Topic: Cervical Spine

In an adult trauma patient, an atlantodens interval (ADI) greater than 3 mm on lateral cervical spine radiographs most specifically indicates incompetence of which stabilizing structure?

. Alar ligament
. Apical ligament
. Transverse ligament
. Posterior longitudinal ligament
. Ligamentum flavum

Correct Answer & Explanation

. Transverse ligament

Explanation

The transverse ligament is the primary static stabilizer of the atlantoaxial joint. An ADI > 3 mm in an adult suggests transverse ligament rupture, while an ADI > 5 mm implies additional injury to the alar and apical ligaments.

Question 106

Topic: Cervical Spine

A 35-year-old male sustains a transverse Type II odontoid fracture with 15% anterior displacement following a diving accident. He is neurologically intact. Which of the following treatments provides the highest rate of fusion while preserving maximal C1-C2 rotatory motion?

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

Correct Answer & Explanation

. Anterior odontoid screw fixation

Explanation

Anterior odontoid screw fixation is ideal for young patients with a transverse Type II fracture pattern as it provides direct osteosynthesis while preserving the normal C1-C2 rotation lost in posterior fusion techniques.

Question 107

Topic: Cervical Spine

A 65-year-old female with a long history of rheumatoid arthritis presents with progressive hand clumsiness and hyperreflexia. Radiographs reveal atlantoaxial instability. Which of the following radiographic measurements is the most reliable predictor of neurologic recovery following cervical fusion?

. Anterior atlantodental interval (ADI) of 5 mm
. Posterior atlantodental interval (PADI) of less than 14 mm
. Powers ratio greater than 1
. Basion-dental interval greater than 12 mm
. Cervical lordosis angle of 10 degrees

Correct Answer & Explanation

. Posterior atlantodental interval (PADI) of less than 14 mm

Explanation

The posterior atlantodental interval (PADI) directly measures the space available for the spinal cord. A PADI of less than 14 mm is a critical threshold and the most reliable predictor of potential neurologic recovery in rheumatoid atlantoaxial subluxation.

Question 108

Topic: Cervical Spine

A 60-year-old male presents with bilateral hand clumsiness, frequent dropping of objects, and a broad-based, unsteady gait. Physical exam reveals a positive Hoffman's sign bilaterally and hyperreflexia in the lower extremities. MRI reveals continuous ossification of the posterior longitudinal ligament (OPLL) from C3 to C6, causing severe ventral cord compression. The cervical spine maintains normal lordosis. What is the most appropriate surgical approach?

. Anterior cervical discectomy and fusion (ACDF) from C3 to C6
. Posterior cervical laminectomy and fusion from C3 to C6
. Anterior cervical corpectomy and fusion at C4 and C5
. Cervical disc arthroplasty at C4-C5 and C5-C6
. Posterior cervical foraminotomy

Correct Answer & Explanation

. Posterior cervical laminectomy and fusion from C3 to C6

Explanation

Posterior laminectomy and fusion is the preferred approach for multi-level OPLL (>3 levels) in a lordotic spine. Anterior approaches for extensive OPLL carry a high risk of dural tears, construct failure, and pseudoarthrosis.

Question 109

Topic: Cervical Spine
A 35-year-old female presents after a high-speed motor vehicle collision. Lateral cervical spine radiographs demonstrate approximately 25% anterior subluxation of the C4 vertebral body over C5. Which of the following injuries is most consistent with this radiographic finding?
. Bilateral facet dislocation
. Unilateral facet dislocation
. Hangman's fracture
. Clay Shoveler's fracture
. Odontoid Type III fracture

Correct Answer & Explanation

. Unilateral facet dislocation

Explanation

Unilateral facet dislocations typically present with 25% anterior subluxation of the vertebral body on lateral plain films. Bilateral facet dislocations usually demonstrate 50% or greater anterior subluxation.

Question 110

Topic: Cervical Spine

An 80-year-old man with a history of chronic obstructive pulmonary disease (COPD) and dementia is involved in a fall from standing height, striking his forehead. He is seen in the emergency department with predominantly mechanical neck pain but no obvious neurologic deficits. Radiographs reveal a nondisplaced type II odontoid fracture. What is the most appropriate treatment? Review Topic

. Immobilization in a 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
. Halo skeletal fixation

Correct Answer & Explanation

. Immobilization in a rigid cervical orthosis for 6 to 8 weeks

Explanation

The treatment options for a type II odontoid fracture include halo immobilization, odontoid screw fixation, and posterior atlantoaxial arthrodesis. However, surgical care at this time without attempting nonsurgical management is not warranted; therefore, the most appropriate management at this time is immobilization in a rigid cervical orthosis for 6 to 8 weeks. Halo vest fixation can lead to high healing rates but is generally contraindicated in elderly patients, especially one with COPD and dementia. Posterior surgical fusion techniques provide high fusion rates, but do so at the expense of loss of cervical rotation and surgical complications. Resection of a nondisplaced odontoid fracture without cord compression via a transoral approach is not necessary.

Question 111

Topic: Cervical Spine
Figure 25 shows the CT scan of an adult patient who has neck pain following a motor vehicle accident. What is the most likely diagnosis?
. Jefferson’s fracture
. C1-C2 rotational instability
. Transverse ligament rupture
. Normal finding
. Basilar invagination

Correct Answer & Explanation

. Transverse ligament rupture

Explanation

DISCUSSION: If the atlanto-dens interval is greater than 3 mm in an adult, a transverse ligament rupture usually is suspected. The atlanto-dens interval can be seen with CT or in lateral radiographs of the upper cervical spine. Transverse ligament rupture can occur as an isolated entity or in association with an odontoid or a Jefferson’s fracture. Patients with this type of injury usually require fusion. REFERENCES: Dickman CA, Greene KA, Sonntag VK: Injuries involving the transverse atlantal ligament: Classification and treatment guidelines based upon experience with 39 injuries. Neurosurgery 1996;38:44-50. Clark CR: The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 362-363.

Question 112

Topic: Cervical Spine

What is the structure indicated by the letter “A” in Figure A? Review Topic

. Annular ligament
. Lateral ulnar collateral ligament
. Accessory collateral ligament
. Radial collateral ligament
. Transverse ligament

Correct Answer & Explanation

. Annular ligament

Explanation

The ligaments shown are the components of the lateral collateral ligament complex, and the structure indicated by the letter “A” is the radial collateral ligament. The lateral ulnar collateral ligament is the structure indicated by the letter “C” and the annular ligament is indicated by the letter “B.” The transverse ligament is a component of the medial collateral ligament complex.

Question 113

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

. Continued immobilization in a semi-rigid cervical orthosis for 6 to 8 weeks

Explanation

DISCUSSION: 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 1 fractures typically can be treated nonsurgically with 6 to 8 weeks of immobilization with a semi-rigid cervical orthosis.  Nondisplaced, deep type III fractures generally are treated with skeletal halo fixation.  Deep, displaced, and angled type III fractures can be treated with closed reduction and skeletal halo fixation.  Shallow type III fractures are sometimes amenable to anterior odontoid screw fixation.  Type II fractures can be managed nonsurgically or surgically.  Treatment options include halo immobilization, internal fixation (odontoid screw fixation), and posterior atlantoaxial arthrodesis.  Management with the halo vest usually is considered if the initial dens displacement is less than 6 mm, the reduction is performed within 1 week of the injury and is able to be maintained, and the patient is younger than age 60 years.  Halo vest immobilization can lead to a healing rate of more than 90%.  Posterior surgical fusion techniques provide high fusion success rates but do so at the expense of cervical rotation.  Up to 50% of rotation is lost with these techniques.  Anterior odontoid single screw fixation is often tolerated better than skeletal halo fixation and also is noted to preserve the normal rotation at C1/C2.  Studies have shown less of a malunion and nonunion rate in the treatment of type II odontoid fractures with anterior odontoid screw fixation.  Osteoporosis, short neck and barrel-chested anatomy, and fractures that are more than 4 weeks old preclude anterior odontoid fixation.REFERENCES: Shilpakar S, McLaughlin MR, Haid RW Jr, et al: Management of acute odontoid fractures: Operative techniques and complication avoidance.  Neurosurg Focus 2000;8:e3.Subach BR, Morone MA, Haid RW Jr, et al: Management of acute odontoid fractures with single-screw anterior fixation.  Neurosurgery 1999;45:812-819.Fountas KN, Kapsalaki EZ, Karampelas I, et al: Results of long-term follow-up in patients undergoing anterior screw fixation for type II and rostral type III odontoid fractures.  Spine 2005;30:661-669.

Question 114

Topic: Cervical Spine
Stability at the atlanto-occipital joint is provided mainly by:
. Inherent stability secondary to the shape of the bones.
. The apical ligament and the anterior atlanto-occipital ligament.
. The transverse ligament.
. The tectorial membrane and the alar ligaments.
. The accessory ligaments.

Correct Answer & Explanation

. The tectorial membrane and the alar ligaments.

Explanation

DISCUSSION: The atlanto-occipital joint is inherently unstable and would easily dislocate without the supporting ligaments. The apical ligament attaches to the basion and tip of the dens but does not provide adequate stability to the joint. Werne demonstrated that dividing the tectorial membrane and the alar ligaments resulted in gross joint instability. The anterior longitudinal ligament turns into the anterior atlanto-occipital membrane. This is called a membrane rather than a ligament because it is not strong enough to support these two structures.

Question 115

Topic: Cervical Spine

A 51-year-old woman with no preoperative neurologic deficit is undergoing elective anterior cervical diskectomy and fusion (ACDF) with plating and fusion for a C5-6 disk herniation with right-sided neck pain. Thirty minutes into the surgery the neurophysiologic monitoring shows a rapid drop and then loss of amplitude in the right cortical somatosensory-evoked potential waveform. All other waveforms remained normal and unchanged, including right-sided cervical (subcortical) and peripheral (Erb’s point), and those from the left-sided upper extremity and both lower extremities. What is the most likely cause of the change? Review Topic

. Electrode placement
. Stimulation failure
. Anesthetic effect
. Cord ischemia from retraction
. Cerebral ischemia from retraction

Correct Answer & Explanation

. Electrode placement

Explanation

The change noted is focal and confined to the cortex, sparing the opposite side, both lower extremities, and the subcortical waveforms, making all the choices unlikely with the exception of carotid compression with focal cortical ischemia. This may be associated with poor collateral flow from the opposite hemisphere due to an incomplete circle of Willis.

Question 116

Topic: Cervical Spine
A 29-year-old man reports a 2-week history of severe neck pain after being struck sharply on the back of the head and neck while moving a refrigerator down a flight of stairs. Initial evaluation in the emergency department revealed no obvious fracture and he was discharged in a soft collar. Neurologic examination is within normal limits, and radiographs taken in the office are shown in Figures 21a through 21c. Subsequent MRI scans show intra-substance rupture of the transverse atlantal ligament. What is the most appropriate treatment option at this time?
. Discontinue use of the soft collar and encourage range of motion
. Semi-rigid collar immobilization for 6 to 8 weeks
. Surgical stabilization
. Halo skeletal fixation
. Outpatient physical therapy with isometric neck exercises

Correct Answer & Explanation

. Surgical stabilization

Explanation

DISCUSSION: Dickman and associates classified injuries of the transverse atlantal ligament into two categories. Type I injuries are disruptions through the substance of the ligament itself. Type II injuries render the transverse ligament physiologically incompetent through fractures and avulsions involving the tubercle of insertion of the transverse ligament on the C1 lateral mass. Type I injuries are incapable of healing without supplemental internal fixation. Type II injuries can be treated with a rigid cervical orthosis with a success rate of 74%. Surgery may be required for type II injuries that fail to heal with 3 to 4 months of nonsurgical management.

Question 117

Topic: Cervical Spine

During an ulnar collateral ligament (UCL) reconstruction using the docking technique, the sublime tubercle is utilized for the ulnar tunnel. The sublime tubercle serves as the anatomic insertion for which bundle of the UCL?

. Anterior bundle
. Posterior bundle
. Transverse ligament
. Oblique bundle
. Superior bundle

Correct Answer & Explanation

. Anterior bundle

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow. It originates on the anterior inferior surface of the medial epicondyle and inserts distally on the sublime tubercle of the ulna.

Question 118

Topic: Cervical Spine
A 36-year-old woman has neck pain in the upper cervical region and occipital discomfort after being involved in a motor vehicle accident. Examination reveals no forehead or scalp lacerations. The neurologic examination is normal. A CT scan shows no evidence of bony injury. Figures 39a and 39b show a lateral radiograph and an MRI scan. Management should consist of:
. a hard cervical collar for 6 weeks.
. skeletal traction for 6 weeks, followed by halo vest immobilization for 6 weeks.
. halo vest immobilization for 3 months.
. posterior cervical C1-2 wiring with arthrodesis.
. anterior C2-3 diskectomy, fusion, and plating.

Correct Answer & Explanation

. posterior cervical C1-2 wiring with arthrodesis.

Explanation

Discussion: The lateral radiograph shows 8 mm of atlantoaxial translation. In the absence of a bony injury, this represents rupture of the transverse atlantal ligament. These injuries require arthrodesis because nonsurgical measures will not provide stability.

Question 119

Topic: Cervical Spine

What is the standard interval for placement of an anterolateral portal in ankle arthroscopy?

. Peroneus brevis to peroneus longus
. Peroneus tertius to extensor hallucis longus
. Peroneus tertius to superficial peroneal nerve
. Extensor hallucis longus to deep peroneal nerve
. Extensor hallucis longus to extensor digitorum longus

Correct Answer & Explanation

. Peroneus brevis to peroneus longus

Explanation

As with arthroscopy of the knee, the anterolateral (AL) portal is the primary diagnostic portal used for initial placement of the arthroscope. The AL portal is made 5 mm below the joint line just lateral to the extensor tendons. The lateral cutaneous branch of the superficial peroneal nerve lies near this portal region. From this approach, one can visualize the anteromedial (AM), anterocentral (AC), and most of the AL areas of the tibiotalar joint. With the addition of laterally based external distraction instrumentation, the surgeon can usually advance the arthroscope posterocentrally and posterolaterally to visualize most of the articulation and the structures in the central and posterior compartments: the intraarticular aspects and synovium of the distal tibiofibular syndesmosis, the posterior tibiofibular ligament, the transverse ligament, and the synovial plicae that overlie the transverse ligament.

Question 120

Topic: Cervical Spine
The space available for the cord is an important determinant in neurologic recovery. Recent analysis suggests that the most reliable radiographic predictor for neurologic recovery after surgery in patients with rheumatoid arthritis and paralysis is a preoperative
. anterior atlanto-odontoid interval of less than 9 mm.
. anterior atlanto-odontoid interval of greater than 9 mm.
. posterior atlanto-odontoid interval of greater than 10 mm.
. posterior atlanto-odontoid interval of greater than 12 mm.
. posterior atlanto-odontoid interval of greater than 14 mm.

Correct Answer & Explanation

. posterior atlanto-odontoid interval of greater than 10 mm.

Explanation

DISCUSSION: Boden and associates’ recent article presents significant evidence that patients with rheumatoid arthritis, neurologic deterioration, and C1-2 instability are more likely to improve after surgery if the posterior atlanto-odontoid interval is greater than 10 mm preoperatively. The accepted safe range for the posterior atlanto-odontoid interval is 14 mm. This measurement is believed to better represent the space available for the cord than the anterior atlanto-odontoid interval. REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 273-279. Boden SD, Dodge LD, Bohlman HH, Rechtine GR: Rheumatoid arthritis of the cervical spine: A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am 1993;75:1282-1297. Wattenmaker I, Concepcion M, Hibberd P, Lipson S: Upper airway obstruction and perioperative management of the airway in patients managed with posterior operations on the cervical spine for rheumatoid arthritis. J Bone Joint Surg Am 1994;76:360-365.

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