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Cervical Spine MCQs

Practice Set 9 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 161

Topic: Cervical Spine

An 82-year-old frail female with osteopenia sustains a fall and presents with neck pain. CT scan reveals a displaced Type II odontoid fracture.

Conservative management with a hard cervical collar is considered but has a known high nonunion rate. If surgical intervention is elected, what is the preferred technique given her age and bone quality?

. Anterior single odontoid screw fixation
. Anterior dual odontoid screw fixation
. Posterior C1-C2 instrumented fusion
. Occipitocervical fusion
. Halo vest immobilization

Correct Answer & Explanation

. Posterior C1-C2 instrumented fusion

Explanation

Type II odontoid fractures in the elderly (>70-80 years) present a significant challenge. While a rigid collar is often used, nonunion rates are very high. Halo vest immobilization is contraindicated in this demographic due to unacceptably high morbidity and mortality (e.g., respiratory complications, falls). If surgery is indicated, anterior odontoid screw fixation relies on good bone quality (which is lacking in osteopenia) and an intact transverse ligament. Therefore, posterior C1-C2 instrumented fusion (e.g., Harms technique) provides the highest union rates and biomechanical stability for elderly osteopenic patients with displaced Type II fractures.

Question 162

Topic: Cervical Spine

An 82-year-old male sustains a fall from standing and presents with neck pain. Computed tomography reveals a Type II odontoid fracture with 2 mm of posterior displacement.

He is neurologically intact. What is the most appropriate management, considering his age and fracture pattern?

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

Correct Answer & Explanation

. Rigid cervical collar

Explanation

Management of Type II odontoid fractures in the elderly is controversial. However, recent evidence suggests that rigid cervical collar immobilization is the preferred initial treatment for stable or minimally displaced Type II odontoid fractures in patients over 80 years old, as it provides a lower complication rate and lower 1-year mortality compared to surgical intervention or halo vest immobilization. Halo immobilization in the elderly is associated with high morbidity and mortality (up to 40%).

Question 163

Topic: Cervical Spine

During an ulnar collateral ligament (UCL) reconstruction in a professional baseball pitcher, the surgeon aims to reconstruct the primary restraint to valgus stress at the elbow. Which specific band or bundle is the most critical to reconstruct?

. Posterior bundle
. Transverse ligament
. Anterior band of the anterior bundle
. Posterior band of the anterior bundle
. Radial collateral ligament

Correct Answer & Explanation

. Anterior band of the anterior bundle

Explanation

The ulnar collateral ligament (UCL) complex consists of the anterior bundle, posterior bundle, and transverse ligament. The anterior bundle is the primary restraint to valgus stress at the elbow from 30 to 120 degrees of flexion. The anterior bundle is further divided into an anterior band (tight in extension to 60 degrees of flexion) and a posterior band (tight in flexion >60 degrees). The anterior band is the most isometric and critical component reconstructed during surgery.

Question 164

Topic: Cervical Spine

An 82-year-old male with a history of severe osteoporosis presents after a ground-level fall. Imaging reveals a displaced Type II odontoid fracture. He has significant neck pain but is neurologically intact. To optimize union rates and minimize morbidity and mortality, which of the following is the most appropriate surgical management?

. Anterior odontoid screw fixation
. Application of a halo vest
. Cervical collar application and strict bed rest
. Posterior C1-C2 instrumented fusion
. Occipitocervical fusion

Correct Answer & Explanation

. Posterior C1-C2 instrumented fusion

Explanation

In an elderly patient (e.g., >80 years old) with a displaced Type II odontoid fracture, posterior C1-C2 instrumented fusion provides the highest rate of fracture union and has lower morbidity compared to alternative surgical methods like an anterior odontoid screw (which relies on good bone quality, often poor in this demographic, and poses a higher risk of hardware failure or dysphagia). Halo vest immobilization in the elderly is associated with high nonunion rates and severe morbidity/mortality (pin site infection, pneumonia, cardiac arrest) and is generally avoided.

Question 165

Topic: Cervical Spine

An anterior cervical discectomy and fusion (ACDF) is planned via the Smith-Robinson approach. Which fascial interval is utilized, and why is the right-sided approach considered to have a higher risk to the recurrent laryngeal nerve?

. Between the sternocleidomastoid and the strap muscles; the right nerve loops around the aortic arch.
. Between the sternocleidomastoid and the strap muscles; the right nerve loops around the subclavian artery and enters the neck obliquely.
. Between the longus colli and the esophagus; the right nerve runs lateral to the carotid sheath.
. Between the strap muscles and the trachea; the right nerve loops around the subclavian artery.
. Between the platysma and the superficial fascia; the right nerve crosses the midline superiorly.

Correct Answer & Explanation

. Between the sternocleidomastoid and the strap muscles; the right nerve loops around the subclavian artery and enters the neck obliquely.

Explanation

The Smith-Robinson approach utilizes the interval between the sternocleidomastoid/carotid sheath (lateral) and the strap muscles/trachea/esophagus (medial). The right recurrent laryngeal nerve is more vulnerable because it loops around the subclavian artery and ascends more obliquely than the left.

Question 166

Topic: Cervical Spine

An 82-year-old male presents after a low-energy fall with neck pain. CT reveals a Type II odontoid fracture with 2 mm of posterior displacement. He is neurologically intact. What is the most appropriate management, considering his age and fracture characteristics?

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

Correct Answer & Explanation

. Rigid cervical collar for 6-12 weeks.

Explanation

In the elderly population (>80 years), nonoperative management with a rigid cervical collar has been shown to have lower morbidity and mortality compared to surgery or halo vest immobilization for Type II odontoid fractures. While nonunion rates are high, a stable fibrous nonunion is typically well tolerated. Halo vests carry an unacceptably high risk of pulmonary complications and mortality in this age group.

Question 167

Topic: Cervical Spine

A 65-year-old male presents with progressive clumsiness in his hands and a broad-based gait. Physical examination reveals a positive Hoffmann's sign bilaterally and hyperreflexia in the lower extremities. MRI of the cervical spine demonstrates multi-level spondylotic cord compression from C3 to C6. Sagittal alignment is neutral, and the patient denies any significant neck pain. What is the most appropriate surgical intervention?

. Anterior cervical discectomy and fusion (ACDF) C3-C6
. Cervical laminectomy without fusion
. Cervical laminoplasty
. Posterior cervical fusion without decompression
. Cervical disc arthroplasty C3-C6

Correct Answer & Explanation

. Cervical laminoplasty

Explanation

Cervical laminoplasty is ideal for multi-level compression in patients with neutral or lordotic alignment and absent/minimal mechanical neck pain. Laminectomy alone in adults has an unacceptably high rate of post-laminectomy kyphosis.

Question 168

Topic: Cervical Spine

A 20-year-old collegiate pitcher undergoes ulnar collateral ligament (UCL) reconstruction using a palmaris longus autograft. Which functional bundle of the UCL is the primary restraint to valgus stress and is the primary target of this reconstruction?

. Posterior bundle
. Transverse ligament
. Anterior band of the anterior bundle
. Posterior band of the anterior bundle
. Annular ligament

Correct Answer & Explanation

. Anterior band of the anterior bundle

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow. The anterior band is taut in extension, while the posterior band is taut in flexion; reconstructions primarily focus on restoring the stabilizing properties of the anterior bundle.

Question 169

Topic: Cervical Spine

An 82-year-old male sustains a Type II odontoid fracture with 2 mm of displacement after a low-energy fall. A decision is made regarding non-operative treatment. Compared to a rigid cervical collar, the use of a halo vest in this specific age group is most strongly associated with:

. Higher rates of fracture union
. Significantly increased mortality and morbidity
. Decreased risk of pin-site infection
. Improved patient compliance
. Lower rates of dysphagia

Correct Answer & Explanation

. Significantly increased mortality and morbidity

Explanation

Halo vest immobilization in the elderly (generally >65 years) is poorly tolerated and associated with high rates of morbidity and mortality (up to 20-30%), primarily due to respiratory complications (pneumonia) and falls. Studies have shown no significant improvement in union rates compared to rigid cervical collars in elderly patients; thus, a rigid collar is often the preferred non-operative treatment.

Question 170

Topic: Cervical Spine

A 75-year-old male presents to the emergency department after a mechanical fall from standing height, complaining of neck pain. CT scan of the cervical spine reveals a Type II odontoid fracture with 2 mm of posterior displacement. He is neurologically intact. What is the most appropriate initial management for this patient?

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

Correct Answer & Explanation

. Rigid cervical collar

Explanation

In elderly patients (generally defined as >65 or >70 years) with a Type II odontoid fracture, treatment is debated, but a rigid cervical collar is often preferred as initial management. This is because halo vest immobilization and operative interventions carry disproportionately high morbidity and mortality in this population. Although nonunion rates are higher with a collar, the nonunions are frequently stable and asymptomatic (fibrous nonunion).

Question 171

Topic: Cervical Spine

A 60-year-old Asian male presents with progressive clumsiness in his hands and difficulty walking. Radiographs and CT of the cervical spine reveal a continuous band of ossification along the posterior aspect of the C3-C6 vertebral bodies. MRI shows spinal cord compression with T2 signal change. Which of the following is the most appropriate surgical approach, assuming neutral cervical sagittal alignment?

. Anterior cervical discectomy and fusion (ACDF)
. Anterior cervical corpectomy and fusion (ACCF)
. Posterior cervical laminectomy without fusion
. Posterior cervical laminoplasty
. Combined anterior-posterior decompression and fusion

Correct Answer & Explanation

. Posterior cervical laminoplasty

Explanation

The diagnosis is Ossification of the Posterior Longitudinal Ligament (OPLL). For multi-level (>3 levels) OPLL with neutral or lordotic cervical alignment, a posterior approach such as laminoplasty (or laminectomy with fusion) is preferred to avoid the high complication rates (e.g., dural tears, CSF leak) associated with anterior resection of the ossified mass.

Question 172

Topic: Cervical Spine

An 82-year-old male with multiple medical comorbidities sustains a Type II odontoid fracture after a ground-level fall. The fracture is displaced 2 mm anteriorly. His neurologic exam is completely intact. What is the most appropriate initial management considering his age and fracture pattern?

. Halo vest immobilization
. Surgical stabilization with an anterior odontoid screw
. Posterior C1-C2 instrumental fusion
. Rigid cervical collar immobilization
. Cervical traction and prolonged bed rest

Correct Answer & Explanation

. Rigid cervical collar immobilization

Explanation

In elderly patients (>80 years) with multiple comorbidities, a rigid cervical collar is often the most appropriate management for a minimally displaced Type II odontoid fracture. Halo vest immobilization is poorly tolerated and associated with high mortality in the elderly. While surgical stabilization (posterior fusion) may increase union rates, the perioperative risk is high. A stable, fibrous nonunion treated in a collar is frequently asymptomatic and acceptable in this population.

Question 173

Topic: Cervical Spine

During the physical examination of a patient with suspected cervical spondylotic myelopathy, the examiner supports the patient's hand and firmly flicks the distal phalanx of the middle finger downward. A positive response is noted as reflex flexion of the interphalangeal joint of the thumb. What is the name of this clinical sign?

. Lhermitte's sign
. Wartenberg's sign
. Hoffmann's sign
. Spurling's sign
. Babinski reflex

Correct Answer & Explanation

. Hoffmann's sign

Explanation

Hoffmann's sign is an upper motor neuron sign elicited by flicking the distal phalanx of the middle finger, leading to reflex flexion of the thumb and/or index finger. It indicates cervical cord compression or other upper motor neuron pathology.

Question 174

Topic: Cervical Spine

A 70-year-old male sustains a Type II odontoid fracture after a ground-level fall. Which of the following radiographic findings is most strongly associated with a high risk of non-union if treated conservatively with a rigid cervical collar?

. Anterior displacement of 3 mm
. Fracture line extending into the vertebral body
. Posterior displacement of 6 mm
. An impacted fracture with 2 degrees of angulation
. Presence of an isolated, non-displaced C1 arch fracture

Correct Answer & Explanation

. Posterior displacement of 6 mm

Explanation

Type II odontoid fractures (fractures at the base of the dens) have a high rate of non-union due to tenuous blood supply. Risk factors for non-union include: age > 50 years, initial displacement > 5 mm (anterior or posterior), angulation > 10 degrees, and posterior displacement direction. Therefore, posterior displacement of 6 mm is a major risk factor for non-union, often warranting surgical stabilization.

Question 175

Topic: Cervical Spine

An 82-year-old man presents with neck pain following a ground-level fall. Imaging reveals a Type II odontoid fracture with 3 mm of posterior displacement. He is neurologically intact but suffers from severe osteoporosis and frailty. What is the most appropriate management?

. Halo vest immobilization for 12 weeks
. Hard cervical collar for 6 to 12 weeks
. Anterior odontoid screw fixation
. Posterior C1-C2 transarticular screw fixation
. Cervical traction followed by Minerva cast

Correct Answer & Explanation

. Hard cervical collar for 6 to 12 weeks

Explanation

In frail elderly patients (>80 years) with Type II odontoid fractures, both surgery and halo vest immobilization carry very high morbidity and mortality rates. The current standard of care for these patients often leans toward a hard cervical collar, accepting a stable fibrous nonunion, which is typically asymptomatic and allows for early mobilization with significantly fewer complications.

Question 176

Topic: Cervical Spine

A 75-year-old male is evaluated after a low-energy fall. Cervical spine CT reveals a displaced Type II odontoid fracture. He has no neurologic deficits. His past medical history is significant for severe COPD and osteoporosis. Which of the following is the most appropriate definitive management?

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

Correct Answer & Explanation

. Posterior C1-C2 instrumental fusion

Explanation

Type II odontoid fractures in the elderly have an unacceptably high rate of nonunion. Halo vest immobilization is poorly tolerated and carries high morbidity/mortality, especially with severe COPD. Anterior odontoid screw fixation requires good bone quality and is often contraindicated in severe osteoporosis. Posterior C1-C2 fusion provides the highest union rates and immediate stability, making it the preferred surgical choice for elderly patients.

Question 177

Topic: Cervical Spine

According to the Grauer modification of the Anderson and D'Alonzo classification for odontoid fractures, a Type IIB fracture is best described as:

. An undisplaced transverse fracture through the waist of the odontoid
. A fracture extending from the anterior-inferior base to the posterior-superior tip
. A fracture extending from the anterior-superior tip to the posterior-inferior base
. A highly comminuted fracture through the base of the odontoid
. An avulsion fracture of the tip of the odontoid process

Correct Answer & Explanation

. A fracture extending from the anterior-inferior base to the posterior-superior tip

Explanation

The Grauer modification helps dictate treatment for Type II odontoid fractures. Type IIA is undisplaced/minimally displaced (<1mm) and treated externally. Type IIB features a displaced transverse fracture or an oblique fracture from anterior-superior to posterior-inferior. This pattern is ideal for an anterior odontoid screw because the fracture line is perpendicular to the screw trajectory, allowing for compression. Type IIC is an anterior-inferior to posterior-superior oblique fracture (or comminuted base), which parallels the screw trajectory, risks shearing, and thus requires posterior C1-C2 fusion.

Question 178

Topic: Cervical Spine

A 22-year-old male is evaluated for neck pain following an axial loading injury. Radiographs show a C1 burst fracture (Jefferson fracture). Which of the following findings on an open-mouth odontoid view is indicative of a complete rupture of the transverse atlantal ligament?

. Combined lateral mass displacement > 6.9 mm
. Combined lateral mass displacement > 3.0 mm
. Atlantodental interval (ADI) > 3 mm
. Atlantodental interval (ADI) > 5 mm
. Basion-dental interval > 12 mm

Correct Answer & Explanation

. Combined lateral mass displacement > 6.9 mm

Explanation

According to the rule of Spence, a combined lateral mass overhang (displacement) of C1 on C2 of greater than 6.9 mm on an open-mouth AP radiograph indicates a rupture of the transverse atlantal ligament, rendering the C1 ring fracture unstable.

Question 179

Topic: Cervical Spine
An 82-year-old male presents with neck pain after a low-energy fall. Radiographs and CT show a displaced Type II odontoid fracture. He has multiple medical comorbidities (ASA III). What is the most appropriate management?
. Halo vest immobilization for 12 weeks
. Rigid cervical collar for 6-8 weeks
. Anterior odontoid screw fixation
. Posterior C1-C2 fusion
. Minerva cast application

Correct Answer & Explanation

. Rigid cervical collar for 6-8 weeks

Explanation

In elderly patients (especially >80 years) with significant comorbidities, the morbidity and mortality of halo vest immobilization or surgical intervention (like C1-C2 fusion) are prohibitively high. Evidence supports treating Type II odontoid fractures in this population with a rigid cervical collar, prioritizing life and comfort over fracture union, as nonunion is typically well-tolerated if fibrous stability is achieved.

Question 180

Topic: Cervical Spine

A 78-year-old male falls from a standing height and sustains a Type II odontoid fracture. Computed tomography reveals an anteriorly displaced fracture with an oblique fracture line running from anterior-inferior to posterior-superior. Which of the following is the most appropriate surgical management?

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

Correct Answer & Explanation

. Posterior C1-C2 fusion

Explanation

In elderly patients with Type II odontoid fractures, conservative management (collar/halo) carries a high rate of nonunion and halo vests have significant morbidity/mortality. Surgical fixation is preferred. An anterior odontoid screw is contraindicated in this scenario because of the 'reverse obliquity' of the fracture line (anterior-inferior to posterior-superior), which would cause the fragment to shear anteriorly upon screw compression. Additionally, poor bone quality in an elderly patient is a relative contraindication for an anterior screw. Therefore, posterior C1-C2 fusion is the treatment of choice.

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