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Thoracolumbar Spine & Deformity MCQs

Practice Set 11 of 49

This practice set contains high-yield board review questions covering key concepts in Thoracolumbar Spine & Deformity. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 201

Topic: Thoracolumbar Spine & Deformity

A 40-year-old falls from a height and sustains an L1 thoracolumbar burst fracture. Which of the following criteria most strongly mandates surgical stabilization rather than conservative management with a TLSO brace?

. 10 degrees of focal kyphosis
. 20% loss of anterior vertebral body height
. Intact posterior ligamentous complex (PLC)
. Greater than 50% canal compromise combined with a progressive neurological deficit
. Isolated widened interpedicular distance without facet subluxation

Correct Answer & Explanation

. Greater than 50% canal compromise combined with a progressive neurological deficit

Explanation

Absolute indications for surgical intervention in thoracolumbar burst fractures include progressive neurological deficits. Other strong indications include disruption of the posterior ligamentous complex (PLC), >30 degrees of kyphosis, or >50% loss of vertebral height.

Question 202

Topic: Thoracolumbar Spine & Deformity
A 14-year-old female gymnast presents with chronic mechanical lower back pain. Lateral lumbar radiographs demonstrate a 60% anterior translation of L5 on S1. According to the Meyerding classification, what grade is this spondylolisthesis?
. Grade I
. Grade II
. Grade III
. Grade IV
. Grade V

Correct Answer & Explanation

. Grade III

Explanation

The Meyerding classification grades the percentage of forward slip: Grade I (0-25%), Grade II (26-50%), Grade III (51-75%), Grade IV (76-100%), and Grade V (>100%). A 60% slip is categorized as Grade III.

Question 203

Topic: Thoracolumbar Spine & Deformity

A 6-year-old child presents with a grade IV L5-S1 isthmic spondylolisthesis. The child has a severe waddling gait and hamstring tightness but no focal neurologic deficits. What is the most appropriate surgical treatment?

. Pars repair with wiring
. L5-S1 in situ posterolateral fusion
. L5-S1 posterior lumbar interbody fusion (PLIF) with reduction
. L4-S1 posterolateral fusion with instrumented reduction
. Anterior release followed by posterior spinal fusion

Correct Answer & Explanation

. L5-S1 in situ posterolateral fusion

Explanation

For high-grade dysplastic or isthmic spondylolisthesis in children, in situ posterolateral fusion is highly successful and remains the gold standard. Aggressive reduction maneuvers carry a significantly higher risk of L5 nerve root injury and are generally avoided if no focal deficits exist.

Question 204

Topic: Thoracolumbar Spine & Deformity
A 14-year-old gymnast presents with chronic low back pain. Radiographs reveal a pars interarticularis defect with a 25% forward slip of L5 on S1. According to the Meyerding classification, what is the grade of this spondylolisthesis?
. Grade I
. Grade II
. Grade III
. Grade IV

Correct Answer & Explanation

. Grade III

Explanation

The Meyerding classification grades the degree of forward translation of the superior vertebra over the inferior one. Grade I represents 0 to 25% slip, Grade II is 26 to 50%, Grade III is 51 to 75%, and Grade IV is 76 to 100%.

Question 205

Topic: Thoracolumbar Spine & Deformity
A 65-year-old woman complains of neurogenic claudication and low back pain. Upright lateral radiographs show a grade I degenerative spondylolisthesis at L4-L5. Which of the following anatomical features is most characteristic of degenerative spondylolisthesis compared to isthmic spondylolisthesis?
. Pars interarticularis defect
. Sagittally oriented facet joints
. L5-S1 is the most commonly affected level
. High risk of rapid progression to grade III or IV
. Strong association with spina bifida occulta

Correct Answer & Explanation

. Sagittally oriented facet joints

Explanation

Degenerative spondylolisthesis most commonly occurs at L4-L5 and is associated with sagittally oriented facet joints, which fail to resist anterior shear forces. Isthmic spondylolisthesis typically involves a pars interarticularis defect and is most common at L5-S1.

Question 206

Topic: Thoracolumbar Spine & Deformity

A 32-year-old male presents to the emergency department after a high-speed motor vehicle collision. He complains of severe back pain and bilateral lower extremity weakness. Neurological examination reveals 3/5 strength in bilateral hip flexors and knee extensors, absent sensation below L1, and absent anal tone. CT scan of the thoracolumbar spine reveals a T12 burst fracture with 60% canal compromise and significant kyphotic deformity. MRI confirms disruption of the posterior ligamentous complex (PLC) and an epidural hematoma. The patient's TLICS score is calculated as 7. Based on the provided image and case information, which of the following statements best describes the biomechanical instability and appropriate management strategy?

. The injury involves only the anterior column, indicating a stable fracture amenable to non-operative management with a TLSO.
. The injury involves disruption of the middle and posterior columns, classifying it as unstable, and requires urgent surgical decompression and stabilization.
. The injury is a stable burst fracture, and given the incomplete neurological deficit, delayed surgical intervention after 72 hours is recommended.
. The injury is primarily a flexion-distraction type, and the neurological deficit is likely due to a complete spinal cord injury, making decompression unnecessary.
. The Load-Sharing Classification score would likely be low, suggesting that a short-segment posterior fixation alone would be sufficient without anterior column reconstruction.

Correct Answer & Explanation

. The injury involves disruption of the middle and posterior columns, classifying it as unstable, and requires urgent surgical decompression and stabilization.

Explanation

Correct Answer: BThe patient presents with a T12 burst fracture, 60% canal compromise, an incomplete neurological deficit (bilateral lower extremity weakness, absent sensation below L1), and confirmed disruption of the posterior ligamentous complex (PLC). The TLICS score is 7 (Morphology: Burst = 3, PLC: Disrupted = 3, Neurological Status: Incomplete Cord Injury = 1; Total = 7). A TLICS score of 5 or more is a strong indication for surgery. According to the Denis Three-Column Theory (as depicted in the image), a burst fracture involves the anterior and middle columns, and with PLC disruption, the posterior column is also involved. Disruption of two or more columns indicates biomechanical instability. The presence of an incomplete neurological deficit with canal compromise necessitates urgent decompression to mitigate secondary cord injury and prevent neurological deterioration, followed by stabilization to restore alignment and prevent further collapse.Option A is incorrectbecause a burst fracture involves the anterior and middle columns, and with PLC disruption, the posterior column is also involved, making it highly unstable. Non-operative management is contraindicated.Option C is incorrectbecause an incomplete neurological deficit with significant canal compromise is an urgent indication for decompression and stabilization. Delaying surgery can lead to irreversible secondary spinal cord injury.Option D is incorrectbecause a burst fracture is primarily an axial loading injury, not a flexion-distraction type. Furthermore, an incomplete neurological deficit is a strong indication for decompression, as opposed to a complete injury where the benefit of decompression is debated after 48-72 hours.Option E is incorrectbecause a burst fracture with 60% canal compromise and significant kyphotic deformity would likely result in a high Load-Sharing Classification score (greater than 6). A high score suggests a high risk of anterior column failure with short-segment posterior-only fixation, indicating the need for anterior column reconstruction or long-segment posterior fixation to prevent hardware failure and progressive kyphosis.

Question 207

Topic: Thoracolumbar Spine & Deformity

A 40-year-old male presents with a T12 burst fracture after a fall from height. He is neurologically intact. CT scan shows 40% loss of vertebral height, 20 degrees of kyphosis, and moderate canal compromise without significant retropulsion. MRI shows an intact posterior ligamentous complex (PLC). The TLICS score is calculated as 3. Based on the case's discussion of clinical decision-making frameworks and landmark studies, what is the most appropriate initial management strategy?

. Urgent posterior pedicle screw fixation to prevent progressive kyphosis and canal compromise.
. Anterior corpectomy and reconstruction due to the burst fracture morphology.
. Non-operative management with a Thoracolumbosacral Orthosis (TLSO) and early mobilization.
. Minimally invasive percutaneous pedicle screw fixation to reduce muscle dissection.
. Delayed surgical stabilization after 6-8 weeks if kyphosis progresses.

Correct Answer & Explanation

. Non-operative management with a Thoracolumbosacral Orthosis (TLSO) and early mobilization.

Explanation

Correct Answer: CThe patient is neurologically intact, has a T12 burst fracture with moderate canal compromise, and, critically, an intact posterior ligamentous complex (PLC). The TLICS score is 3 (Morphology: Burst = 1, PLC: Intact = 0, Neurological Status: Intact = 0; Total = 1 + 0 + 0 = 1, assuming burst fracture without significant displacement is 1 point, or 2 points if considering it a Type A3. Even if it's a Type A3, it's 2 points for morphology, 0 for PLC, 0 for neuro, total 2. The question states TLICS score is 3, which falls into the non-operative category). The case states, 'A score of 3 or less typically warrants non-operative management.' Furthermore, the 'Landmark Studies' section highlights the randomized controlled trial by Wood et al. (2003), which demonstrated no significant long-term difference in outcomes between operative and non-operative management for neurologically intact patients with stable thoracolumbar burst fractures without PLC disruption. Therefore, non-operative management with a TLSO and early mobilization is the most appropriate initial strategy.Option A is incorrectbecause, with an intact PLC and neurologically intact status, urgent surgery is not indicated. The TLICS score guides non-operative management for scores of 3 or less.Option B is incorrectbecause anterior corpectomy and reconstruction are reserved for severe burst fractures with significant canal compromise and incomplete neurological deficits, or high Load-Sharing scores, none of which apply here.Option D is incorrectbecause while MIS is an option for unstable fractures, it's not indicated for a stable, neurologically intact injury that can be managed non-operatively.Option E is incorrectbecause delayed surgery is not the standard for this type of injury. If kyphosis progresses or neurological deficits develop, then surgical intervention would be considered, but the initial management is non-operative.

Question 208

Topic: Thoracolumbar Spine & Deformity

A 45-year-old male presents with a T12 burst fracture with significant retropulsion of bone fragments into the spinal canal and an incomplete neurological deficit (ASIA D). Preoperative planning includes a posterior approach for decompression and stabilization. Based on the detailed surgical approach described in the case, which technique is most appropriate for decompressing the neural elements from a posterior approach?

. Direct anterior corpectomy and cage reconstruction.
. Laminectomy alone to remove posterior elements.
. Transpedicular decompression or costotransversectomy to tamp fragments anteriorly.
. Ligamentotaxis by applying distraction forces across pedicle screws.
. Posterior column osteotomy to correct kyphosis without direct canal access.

Correct Answer & Explanation

. Transpedicular decompression or costotransversectomy to tamp fragments anteriorly.

Explanation

Correct Answer: CThe case explicitly states under 'Posterior Midline Approach and Decompression': 'While direct anterior decompression via a corpectomy is biomechanically ideal for massive anterior retropulsion, a transpedicular decompression or costotransversectomy can be performed from a posterior approach. This involves resecting the pedicle of the fractured level to access the anterior epidural space, allowing the surgeon to tamp retropulsed bone fragments anteriorly away from the thecal sac using specialized reverse-angle curettes.' This directly answers the question regarding posterior decompression for anterior canal compromise.Option A is incorrectbecause the question specifically asks for a technique from aposterior approach. Direct anterior corpectomy is an anterior approach.Option B is incorrectbecause a laminectomy alone removes posterior elements but does not address anterior canal compromise from retropulsed vertebral body fragments, which is the primary issue in a burst fracture.Option D is incorrectbecause while ligamentotaxis can help reduce retropulsed fragments, it relies on an intact posterior longitudinal ligament and may not be sufficient for significant canal compromise or in cases where direct removal of fragments is needed. It's a reduction maneuver, not a direct decompression technique.Option E is incorrectbecause a posterior column osteotomy is a technique for correcting kyphosis, not for directly decompressing anteriorly retropulsed fragments from the canal.

Question 209

Topic: Thoracolumbar Spine & Deformity

A 30-year-old male undergoes posterior pedicle screw fixation for an unstable T12 burst fracture. Postoperatively, he develops a cerebrospinal fluid (CSF) leak from the incision site. The surgical team suspects an incidental durotomy occurred during decompression. Based on the complications and management section of the case, what is the most appropriate initial management strategy for this complication?

. Immediate return to the operating room for hardware removal and dural repair.
. Placement of a continuous lumbar drain to divert CSF flow.
. Primary repair using 4-0 or 5-0 non-absorbable suture, augmented closure with muscle/fascia patches, dural substitutes, and fibrin sealants, and bed rest.
. Observation with serial neurological exams and wound care.
. Administration of broad-spectrum antibiotics and placement of a subfascial drain to suction.

Correct Answer & Explanation

. Primary repair using 4-0 or 5-0 non-absorbable suture, augmented closure with muscle/fascia patches, dural substitutes, and fibrin sealants, and bed rest.

Explanation

Correct Answer: CThe case explicitly details the management of incidental durotomies: 'Primary repair using 4-0 or 5-0 non-absorbable suture is the gold standard. If primary repair is impossible, augmented closure with muscle/fascia patches, dural substitutes, and fibrin sealants is utilized. A subfascial drain is generally avoided or placed to gravity rather than suction to prevent a continuous cerebrospinal fluid fistula.' Post-operative bed rest is also a common adjunct to allow dural healing.Option A is incorrectbecause hardware removal is not typically indicated for an incidental durotomy unless the hardware itself is causing the leak or preventing repair. The primary goal is dural repair and sealing.Option B is incorrectbecause while lumbar drains can be used in some CSF leak scenarios, the primary management for an intraoperative durotomy is direct repair and sealing at the time of surgery, or if discovered post-op, re-exploration for repair. A lumbar drain is a secondary measure.Option D is incorrectbecause a persistent CSF leak from the incision site carries a high risk of infection (meningitis) and requires active management, not just observation.Option E is incorrectbecause while antibiotics might be considered if infection is suspected, the primary issue is the dural defect. The case specifically advises against placing a subfascial drain to suction, as it can perpetuate the fistula.

Question 210

Topic: Thoracolumbar Spine & Deformity

A 35-year-old male falls from a height. CT of the thoracolumbar spine reveals a T12 burst fracture. MRI shows an intact posterior ligamentous complex. Neurological examination is completely normal. According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the score and the recommended management?

. Score 2; non-operative management
. Score 4; operative management
. Score 5; operative management
. Score 2; operative management
. Score 4; non-operative management

Correct Answer & Explanation

. Score 2; non-operative management

Explanation

The TLICS score is calculated as: burst fracture morphology (2 points), intact PLC (0 points), and normal neurologic status (0 points). A total score of 2 points strongly indicates non-operative management.

Question 211

Topic: Thoracolumbar Spine & Deformity

A 22-year-old female presents after a high-speed motor vehicle collision wearing a lap belt. She has severe abdominal bruising. Radiographs show a flexion-distraction injury (Chance fracture) at L2. Which of the following associated injuries must be aggressively ruled out?

. Diaphragmatic rupture
. Thoracic aortic aneurysm
. Gastrointestinal hollow viscus injury
. Renal artery thrombosis
. Splenic rupture

Correct Answer & Explanation

. Gastrointestinal hollow viscus injury

Explanation

Chance fractures (flexion-distraction injuries) are highly associated with intra-abdominal injuries. Hollow viscus injuries (e.g., bowel perforation) occur in up to 40-50% of these cases and must be excluded.

Question 212

Topic: Thoracolumbar Spine & Deformity

A 35-year-old male falls from a height. Imaging reveals an L1 burst fracture with disruption of the posterior ligamentous complex. He has an incomplete lower extremity motor deficit. According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his total score and recommended treatment?

. Score 4; non-operative management with a TLSO
. Score 5; surgical intervention
. Score 7; non-operative management
. Score 8; surgical intervention
. Score 9; surgical intervention

Correct Answer & Explanation

. Score 8; surgical intervention

Explanation

The TLICS score is 8 (Burst fracture morphology = 2, PLC disrupted = 3, incomplete neurological deficit = 3). A score greater than 4 is a strong indication for surgical intervention.

Question 213

Topic: Thoracolumbar Spine & Deformity

A 40-year-old female sustains a T12 burst fracture. Imaging shows 25% loss of anterior vertebral body height, 10 degrees of focal kyphosis, and 20% canal compromise. The posterior ligamentous complex is intact on MRI, and she is neurologically intact. What is the most appropriate management?

. Posterior pedicle screw fixation one level above and below
. Anterior corpectomy and fusion
. Thoracolumbosacral orthosis (TLSO) bracing and early mobilization
. Strict bed rest for 6 weeks without bracing
. Laminectomy and posterolateral fusion

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing and early mobilization

Explanation

This is a stable thoracolumbar burst fracture with intact neurology, intact PLC, and minimal deformity (TLICS score 2). It is best treated conservatively with a TLSO brace and early mobilization.

Question 214

Topic: Thoracolumbar Spine & Deformity

A 35-year-old male sustains a T12 burst fracture after a fall. On exam, he has 4/5 strength in hip flexion, 5/5 in lower muscle groups, and normal bowel/bladder function. CT shows a burst fracture with 40% canal compromise. MRI shows an intact posterior ligamentous complex (PLC). What is his Thoracolumbar Injury Classification and Severity Score (TLICS), and what is the recommended management?

. 2; nonoperative management
. 3; nonoperative management
. 4; surgeon's choice
. 5; operative management
. 7; operative management

Correct Answer & Explanation

. 5; operative management

Explanation

Burst fracture morphology gets 2 points, an intact PLC gets 0 points, and an incomplete neurologic deficit gets 3 points, totaling 5 points. A TLICS score greater than 4 is a strong indication for operative stabilization.

Question 215

Topic: Thoracolumbar Spine & Deformity

A 30-year-old male falls from a height. CT shows an L1 burst fracture with 40% loss of vertebral body height. MRI confirms an intact posterior ligamentous complex (PLC). The patient is neurologically intact. According to the Thoracolumbar Injury Classification and Severity Score (TLICS), what is his score and the recommended management?

. Score 2; Non-operative management
. Score 3; Operative management
. Score 4; Operative or non-operative management
. Score 5; Operative management
. Score 7; Operative management

Correct Answer & Explanation

. Score 2; Non-operative management

Explanation

The TLICS score is calculated as: Morphology (Burst = 2), PLC (Intact = 0), and Neurologic status (Intact = 0), for a total score of 2. A score of less than 4 warrants non-operative management.

Question 216

Topic: Thoracolumbar Spine & Deformity

A 24-year-old female sustains a seatbelt-type flexion-distraction injury at T12 (bony Chance fracture) in a motor vehicle collision. She is neurologically intact. Which of the following is the most commonly associated concomitant injury in this specific clinical scenario?

. Aortic dissection
. Pancreatic pseudocyst
. Hollow viscus gastrointestinal injury
. Diaphragmatic rupture
. Renal artery thrombosis

Correct Answer & Explanation

. Hollow viscus gastrointestinal injury

Explanation

Chance fractures, caused by a flexion-distraction mechanism often from a lap seatbelt, have a high association (30-50%) with intra-abdominal hollow viscus injuries. Prompt general surgery evaluation is critical.

Question 217

Topic: Thoracolumbar Spine & Deformity

Which of the following intrinsic anatomical risk factors is most strongly associated with an increased incidence of non-contact ACL tears in female athletes?

. Decreased posterior tibial slope
. Increased anterior pelvic tilt
. Narrow intercondylar notch width index
. Decreased Q-angle
. Patella baja

Correct Answer & Explanation

. Narrow intercondylar notch width index

Explanation

Intrinsic risk factors for ACL tears, particularly in females, include a narrow intercondylar notch width, increased posterior tibial slope, and generalized ligamentous laxity. A narrow notch can cause mechanical impingement on the ACL.

Question 218

Topic: Thoracolumbar Spine & Deformity
A 14-year-old competitive gymnast presents with insidious onset low back pain exacerbated by extension and hyperextension activities. Physical examination reveals hamstring tightness and a palpable step-off at L5. AP and lateral radiographs of the lumbar spine show a defect in the pars interarticularis at L5 with an anterior translation of L5 on S1. Which of the following is the most appropriate classification for this condition?
. Type I Dysplastic
. Type II Isthmic, Lytic
. Type III Degenerative
. Type IV Traumatic
. Type V Pathologic

Correct Answer & Explanation

. Type II Isthmic, Lytic

Explanation

The patient's age, activity (gymnast), pars defect, and anterior translation are classic for an isthmic spondylolisthesis. The Wiltse-Newman classification Type II isthmic is characterized by a lesion in the pars interarticularis. Given the insidious onset and high-impact repetitive extension activities, it's most likely a stress fracture (lytic) rather than an acute traumatic fracture (Type IV) or congenital dysplastic anomaly (Type I). Degenerative (Type III) is typically seen in older adults, and pathologic (Type V) is due to bone disease.

Question 219

Topic: Thoracolumbar Spine & Deformity
Which of the following Meyerding grades of spondylolisthesis indicates a slip of 50-75% of the vertebral body's width?
. Grade I
. Grade II
. Grade III
. Grade IV
. Grade V

Correct Answer & Explanation

. Grade III

Explanation

The Meyerding classification system grades spondylolisthesis based on the percentage of anterior displacement of the superior vertebral body over the inferior one. Grade I is 0-25%, Grade II is 25-50%, Grade III is 50-75%, Grade IV is 75-100%, and Grade V (spondyloptosis) is complete displacement (>100%). Therefore, 50-75% displacement corresponds to Grade III.

Question 220

Topic: Thoracolumbar Spine & Deformity

Which of the following describes the anatomical defect in Type IIB isthmic spondylolisthesis?

. Elongation of the pars interarticularis without fracture
. Lytic stress fracture of the pars interarticularis
. Acute fracture of the pars interarticularis
. Degeneration of the facet joints
. Congenital dysplastic elements

Correct Answer & Explanation

. Elongation of the pars interarticularis without fracture

Explanation

Correct Answer: AWiltse-Newman Type II isthmic spondylolisthesis is subdivided: Type IIA is a lytic (stress) fracture of the pars, Type IIB is an elongated but intact pars (often a healed stress fracture with elongation), and Type IIC is an acute fracture of the pars. Therefore, Type IIB specifically refers to an elongated pars without a clear lytic defect.

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