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Cervical Spine MCQs

Practice Set 8 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 141

Topic: Cervical Spine

A 6-year-old child with Down syndrome is evaluated for neck pain. Radiographs show an anterior atlantodental interval (ADI) of 6 mm. What is the most reliable radiographic predictor for the development of neurologic deficit in this patient?

. Anterior atlantodental interval (ADI) > 10 mm
. Space Available for the Cord (SAC) < 14 mm
. Power's ratio > 1
. Wackenheim's line intersecting the dens
. Basion-dental interval > 12 mm

Correct Answer & Explanation

. Space Available for the Cord (SAC) < 14 mm

Explanation

The Space Available for the Cord (SAC), also known as the posterior atlantodental interval (PADI), is the most reliable predictor of neurologic injury. A SAC of less than 14 mm is highly correlated with the development of myelopathic symptoms in atlantoaxial instability.

Question 142

Topic: Cervical Spine

A 55-year-old woman with a 20-year history of severe rheumatoid arthritis complains of neck pain, occipital headache, and subjective bilateral hand clumsiness. Which of the following radiographic measurements is most indicative of basilar invagination (cranial settling) in this patient?

. Anterior atlantodental interval (ADI) > 3.5 mm
. Posterior atlantodental interval (PADI) < 14 mm
. Ranawat value < 13 mm
. Basion-dental interval (BDI) > 12 mm
. Powers ratio > 1

Correct Answer & Explanation

. Ranawat value < 13 mm

Explanation

A Ranawat value (the perpendicular distance from the center of the C2 pedicles to the transverse axis of C1) of less than 13 mm indicates basilar invagination, also known as cranial settling. ADI and PADI are used to assess atlantoaxial instability, not basilar invagination.

Question 143

Topic: Cervical Spine

An 84-year-old female presents with a Type II odontoid fracture with 3 mm of posterior displacement following a low-energy ground-level fall. She is neurologically intact. Which of the following management strategies is generally contraindicated in this specific demographic due to high associated morbidity and mortality?

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

Correct Answer & Explanation

. Rigid cervical collar immobilization

Explanation

Halo vest immobilization in the elderly (over 80 years old) is associated with an unacceptably high risk of severe complications, including pneumonia, cardiac arrest, and death. Management typically involves either a rigid cervical collar or posterior surgical fusion if operative intervention is indicated.

Question 144

Topic: Cervical Spine

A 45-year-old female presents with persistent, severe axial neck pain one year after an anterior cervical discectomy and fusion (ACDF) at C5-C7. Flexion-extension radiographs and a thin-cut CT scan demonstrate a clear pseudarthrosis at the C6-C7 level with loosening of the anterior hardware. She is neurologically intact. What is the most reliable surgical option to achieve solid fusion in this patient?

. Revision anterior discectomy and placement of a larger cage
. Removal of anterior hardware and placement of a standalone PEEK cage
. Posterior cervical instrumented fusion at C6-C7
. Anterior cervical corpectomy of C6
. Placement of a cervical artificial disc at C6-C7

Correct Answer & Explanation

. Posterior cervical instrumented fusion at C6-C7

Explanation

For a symptomatic pseudarthrosis following an initial anterior cervical fusion, a posterior cervical instrumented fusion offers the highest union rate (near 100%) and is considered the rescue procedure of choice, avoiding the scarred anterior approach.

Question 145

Topic: Cervical Spine

A 78-year-old male sustains a Type II odontoid fracture after a ground-level fall. The fracture is displaced posteriorly by 4 mm. He is neurologically intact, but his medical history is significant for severe COPD and osteoporosis. Which of the following is the most appropriate initial management?

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

Correct Answer & Explanation

. Hard cervical collar immobilization

Explanation

In elderly patients with a Type II odontoid fracture, halo vest immobilization is poorly tolerated and associated with high morbidity and mortality (especially with pulmonary issues like COPD). Anterior odontoid screw fixation has high failure rates in osteoporotic bone. A rigid cervical collar is the preferred initial treatment for many elderly patients, prioritizing life and minimizing morbidity, even if it progresses to an asymptomatic fibrous nonunion.

Question 146

Topic: Cervical Spine

A 25-year-old male sustains a C1 burst (Jefferson) fracture after an axial loading injury. An AP open-mouth odontoid radiograph demonstrates lateral mass displacement. The transverse alar ligament is considered ruptured if the combined lateral mass overhang exceeds what specific measurement?

. 2.5 mm
. 4.1 mm
. 6.9 mm
. 9.5 mm
. 11.0 mm

Correct Answer & Explanation

. 6.9 mm

Explanation

The Rule of Spence dictates that a combined lateral mass displacement of C1 on C2 greater than 6.9 mm on an AP open-mouth radiograph implies rupture of the transverse ligament. This indicates an unstable C1 ring injury requiring rigid immobilization or surgical stabilization.

Question 147

Topic: Cervical Spine

A 60-year-old Asian male presents with progressive hand clumsiness and gait imbalance. CT of the cervical spine demonstrates continuous ossification of the posterior longitudinal ligament (OPLL) from C3 to C6 with a canal occupying ratio of 65%. The cervical spine is neutrally aligned. Which of the following is the most appropriate surgical approach with the lowest risk of direct dural injury?

. Anterior cervical corpectomy and fusion C3-C6
. Anterior cervical discectomy and fusion C3-C6
. Posterior cervical laminectomy and fusion C3-C6
. Cervical disc arthroplasty C3-C6
. Stand-alone anterior cervical laminectomy

Correct Answer & Explanation

. Posterior cervical laminectomy and fusion C3-C6

Explanation

In patients with severe OPLL (occupying ratio >50-60%) and neutral or lordotic alignment, a posterior approach (laminectomy and fusion or laminoplasty) is generally preferred over an anterior approach. Anterior resection of continuous OPLL carries a very high risk of dural tear and cerebrospinal fluid leak because the ossified mass is often densely adherent to or incorporated into the dura.

Question 148

Topic: Cervical Spine

An 80-year-old man falls from a standing height and sustains an Anderson and D'Alonzo Type II odontoid fracture with 3 mm of posterior displacement. He is neurologically intact. DEXA scan reveals severe osteoporosis (T-score -3.1). He is a community ambulator and has no other major medical comorbidities. What is the most appropriate definitive management?

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

Correct Answer & Explanation

. Posterior C1-C2 instrumental fusion

Explanation

In an elderly patient with a Type II odontoid fracture, conservative management (halo or collar) is associated with unacceptably high rates of nonunion, morbidity, and mortality (especially halo vests, which are poorly tolerated in the elderly). Anterior odontoid screw fixation is contraindicated in the setting of severe osteoporosis due to poor screw purchase, and is less successful with posterior displacement. Posterior C1-C2 instrumental fusion provides rigid fixation with high fusion rates and is the gold standard for definitive surgical management in this population.

Question 149

Topic: Cervical Spine

A 78-year-old male sustains a Type II odontoid fracture after a low-energy fall. Which of the following factors is most strongly associated with a high risk of non-union if treated conservatively with a halo vest?

. Age less than 50 years
. Initial fracture displacement > 5 mm
. Posterior displacement of the dens
. Concomitant C1 arch fracture
. Presence of a neurologically intact examination

Correct Answer & Explanation

. Initial fracture displacement > 5 mm

Explanation

Risk factors for non-union of Type II odontoid fractures treated non-operatively include initial displacement > 5 mm, age > 65 years, angulation > 10 degrees, and delayed treatment. Posterior displacement versus anterior displacement is debated, but displacement > 5mm and advanced age are well-established primary risk factors for failure of conservative management.

Question 150

Topic: Cervical Spine

A 60-year-old man presents with progressive clumsiness in his hands and a wide-based gait. Imaging reveals multi-level ossification of the posterior longitudinal ligament (OPLL) from C3 to C6. The K-line on the sagittal T1 MRI is negative. What is the most appropriate surgical management?

. C3-C6 posterior laminoplasty
. C3-C6 posterior laminectomy without fusion
. Anterior cervical corpectomy and fusion
. Posterior cervical laminectomy and instrumented fusion
. C1-C2 transarticular screw fixation

Correct Answer & Explanation

. Anterior cervical corpectomy and fusion

Explanation

A negative K-line indicates that the anterior compressive lesion (OPLL) is so large that the spinal cord will not shift posteriorly enough to be adequately decompressed by a posterior approach alone. Therefore, an anterior decompression and fusion (or combined approach) is required.

Question 151

Topic: Cervical Spine

A 72-year-old man sustains a Type II odontoid fracture after a ground-level fall. The fracture is displaced 6 mm posteriorly. What is the most significant risk factor for non-union if this fracture is treated non-operatively with a rigid cervical collar?

. Posterior direction of displacement
. Patient age greater than 65 years
. Mechanism of injury
. Associated mandible fracture
. Patient gender

Correct Answer & Explanation

. Patient age greater than 65 years

Explanation

In Type II odontoid fractures, age greater than 65 years is one of the most significant risk factors for non-union, with non-union rates exceeding 50% in this demographic when treated non-operatively. Displacement greater than 5 mm is also a major risk factor.

Question 152

Topic: Cervical Spine

The distal tibiofibular syndesmosis is stabilized by several key ligamentous structures. During biomechanical testing, which specific ligament provides the greatest proportion of resistance (approximately 42%) against lateral displacement of the fibula (diastasis)?

. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Interosseous membrane
. Interosseous ligament
. Inferior transverse ligament

Correct Answer & Explanation

. Posterior inferior tibiofibular ligament (PITFL)

Explanation

While the Anterior Inferior Tibiofibular Ligament (AITFL) is the most commonly injured ligament in syndesmotic sprains, biomechanical studies demonstrate that the Posterior Inferior Tibiofibular Ligament (PITFL) provides the greatest structural resistance to diastasis (lateral displacement), contributing approximately 42% of the overall syndesmotic strength. The AITFL contributes roughly 35%, and the interosseous ligament contributes about 22%.

Question 153

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?

Anatomy Board Review 2005: High-Yield MCQs (Set 2) - Figure 25

. Jefferson's fracture
. C1-C2 rotational instability
. Transverse ligament rupture
. Normal finding
. Basilar invagination

Correct Answer & Explanation

. Transverse ligament rupture

Explanation

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. 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.

Question 154

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?

Spine Surgery 2009 Practice Questions: Set 1 (Solved) - Figure 25

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

Correct Answer & Explanation

. Cerebral ischemia from retraction

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. Drummond JC, Englander RN, Gallo CJ: Cerebral ischemia as an apparent complication of anterior cervical discectomy in a patient with an incomplete circle of Willis. Anesth Analg 2006;102:896-899.

Question 155

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

Spine Surgery Board Review 2000: High-Yield MCQs (Set 2) - Figure 16

. anterior alanto-odontoid interval of less than 9 mm.
. anterior alanto-odontoid interval of greater than 9 mm.
. posterior alanto-odontoid interval of greater than 10 mm.
. posterior alanto-odontoid interval of greater than 12 mm.
. posterior alanto-odontoid interval of greater than 14 mm.

Correct Answer & Explanation

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

Explanation

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 alanto-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 alanto-odontoid interval. 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.

Question 156

Topic: Cervical Spine

A 42-year-old woman reports that she has low back pain and had a transient loss of consciousness after falling off a horse. She denies having neck pain but notes that she was involved in a motor vehicle accident 2 years ago and had neck pain at that time. Examination reveals full range of motion of the neck and no localized tenderness. The neurologic examination is normal. A lateral radiograph of the cervical spine is obtained. Figures 41a and 41b show CT and MRI scans. What is the most likely diagnosis?

. Cervical sprain
. Atlas fracture
. Acute displaced odontoid fracture
. Odontoid nonunion
. Hangman's fracture

Correct Answer & Explanation

. Odontoid nonunion

Explanation

The examination findings do not correlate with an acute injury (full range of cervical motion and the absence of pain). Radiographically, the fracture appears old based on the smooth contour of the fracture fragments and the absence of soft-tissue swelling. Flexion-extension radiographs can be obtained to determine potential instability; if present, stabilization and fusion should be considered. Schatzker J, Rorabeck CH, Waddell JP: Non-union of the odontoid process: An experimental investigation. Clin Orthop 1975;108:127-137.

Question 157

Topic: Cervical Spine

In Figure 49, line AB connects the anterior arch of C1 to the posterior margin of the foramen magnum. Line CD connects the anterior margin of the foramen magnum to the posterior arch of C1. What is the normal ratio of displacement from CD to AB (Power's ratio)?

Anatomy Board Review 2005: High-Yield MCQs (Set 4) - Figure 13

. 0.25
. 0.5
. 1.0
. 1.5
. 2.0

Correct Answer & Explanation

. 1.0

Explanation

The ratio of displacement from CD to AB normally equals 1.0. If the ratio is greater than 1.0, an anterior atlanto-occipital dislocation may exist. Ratios slightly less than 1.0 are normal except in posterior dislocations, fractures of the odontoid process or ring of the atlas, or congenital abnormalities of the foramen magnum. In these conditions, the ratio may approach 0.7. Powers B, Miller MD, Kramer RS, et al: Traumatic anterior atlanto-occipital dislocation. Neurosurgery 1979;4:12-17.

Question 158

Topic: Cervical Spine

Figure 21 shows the tomogram of a 26-year-old woman who sustained an axial load injury to her neck in a fall off a horse. What ligament is injured?

Spine Surgery 2006 Practice Questions: Set 3 (Solved) - Figure 9

. Anterior longitudinal
. Posterior longitudinal
. Alar
. Apical
. Transverse

Correct Answer & Explanation

. Transverse

Explanation

Levine and Edwards, in their description of the classic C1 burst (Jefferson) fracture, noted that spread of the lateral masses of more than 7 mm is indicative of a transverse ligament rupture. Long-term C1-C2 instability, however, has not been described with this fracture pattern. Although long-term traction followed by halo vest immobilization has been described as the best technique for achieving an ideal result, treatment of this injury remains somewhat controversial. Levine AM, Edwards CC: Fractures of the atlas. J Bone Joint Surg Am 1991;73:680-691.

Question 159

Topic: Cervical Spine

What is the structure indicated by the letter "A" in Figure 21?

Anatomy Board Review 2008: High-Yield MCQs (Set 2) - Figure 13

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

Correct Answer & Explanation

. Radial collateral 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. Morrey BF: Anatomy of the elbow joint, in Morrey BF (ed): The Elbow and Its Disorders. Philadelphia, PA, WB Saunders, 1993, p 30.

Question 160

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

. Semi-rigid collar immobilization for 6 to 8 weeks

Explanation

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 injures that fail to heal with 3 to 4 months of nonsurgical management. Findlay JM: Injuries involving the transverse atlantal ligament: Classification and treatment guidelines based upon experience with 39 injuries. Neurosurgery 1996;39:210.

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