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Thoracolumbar Spine & Deformity MCQs

Practice Set 22 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 421

Topic: Thoracolumbar Spine & Deformity

A 14-year-old female gymnast presents with persistent lower back pain exacerbated by extension. Lateral radiographs reveal a grade I isthmic spondylolisthesis at L5-S1. She has failed 6 months of conservative management including physical therapy, rest, and bracing. What is the most appropriate surgical treatment?

. L5-S1 posterolateral instrumented fusion
. L5 laminectomy without fusion
. L4-S1 anterior lumbar interbody fusion (ALIF)
. Translaminar screw fixation
. Sacroiliac joint fusion

Correct Answer & Explanation

. L5-S1 posterolateral instrumented fusion

Explanation

For pediatric or adolescent patients with symptomatic isthmic spondylolisthesis who fail comprehensive nonoperative management, an in situ posterolateral instrumented fusion of the affected segment (L5-S1) is the gold standard surgical treatment. Laminectomy without fusion in a pediatric patient is contraindicated as it exacerbates instability. Interbody fusion is generally not required for low-grade slips in this age group.

Question 422

Topic: Thoracolumbar Spine & Deformity

What is the most significant radiographic risk factor for the progression of a dysplastic (isthmic) spondylolisthesis in a skeletally immature patient?

. High pelvic incidence
. Slip angle greater than 45 degrees
. Sacral slope less than 30 degrees
. Meyerding Grade I slip at presentation
. Presence of spina bifida occulta

Correct Answer & Explanation

. Slip angle greater than 45 degrees

Explanation

In skeletally immature patients with isthmic spondylolisthesis, a high slip angle (greater than 45-50 degrees) is the most significant radiographic risk factor for the progression of the slip. A high slip angle indicates a more vertical orientation of the L5-S1 disc space, placing higher shear forces across the lumbosacral junction. While high pelvic incidence is associated with the development of spondylolisthesis, the slip angle is the most predictive of progression.

Question 423

Topic: Thoracolumbar Spine & Deformity
According to the Wiltse classification of spondylolisthesis, which subtype is characterized by an elongated, but intact, pars interarticularis resulting from repeated micro-fractures and subsequent healing?
. Type I (Dysplastic)
. Type IIA (Lytic/Stress fracture)
. Type IIB (Elongated pars)
. Type IIC (Acute pars fracture)
. Type III (Degenerative)

Correct Answer & Explanation

. Type IIB (Elongated pars)

Explanation

The Wiltse classification categorizes spondylolisthesis. Type II is isthmic (pars defect). Type IIA is a stress fracture (lytic). Type IIB represents an elongated pars interarticularis secondary to repetitive micro-fracture and healing without complete separation. Type IIC is an acute fracture.

Question 424

Topic: Thoracolumbar Spine & Deformity

Which of the following is an essential radiographic criterion for the definitive diagnosis of typical Scheuermann's kyphosis (Sorensen criteria)?

. Anterior wedging of at least 5 degrees in three consecutive vertebrae
. Anterior wedging of at least 10 degrees in two consecutive vertebrae
. Schmorl's nodes in at least three non-consecutive vertebrae
. A regional thoracic kyphosis angle greater than 50 degrees without structural wedging
. Endplate irregularity isolated to the thoracolumbar junction

Correct Answer & Explanation

. Anterior wedging of at least 5 degrees in three consecutive vertebrae

Explanation

The classic Sorensen criteria for the diagnosis of Scheuermann's kyphosis require the presence of thoracic kyphosis greater than 40 degrees and at least three consecutive vertebrae demonstrating a minimum of 5 degrees of anterior wedging each.

Question 425

Topic: Thoracolumbar Spine & Deformity

According to the Thoracolumbar Injury Classification and Severity Score (TLICS), which is used to guide treatment for thoracolumbar trauma, a total score of 5 points generally indicates which of the following management strategies?

. Non-operative management is strictly indicated
. Operative management is indicated
. The choice between operative and non-operative management is equivocal (surgeon's choice)
. A definite fracture-dislocation pattern is present
. A purely ligamentous injury without fracture is present

Correct Answer & Explanation

. Operative management is indicated

Explanation

The TLICS system guides treatment based on three categories: injury morphology, neurological status, and integrity of the posterior ligamentous complex (PLC). A total score of 3 or less suggests non-operative management; a score of 4 is indeterminate (surgeon's choice); and a score of 5 or greater indicates that operative management is generally recommended due to instability or neurological compromise.

Question 426

Topic: Thoracolumbar Spine & Deformity

A 40-year-old male falls from a ladder and sustains an L1 burst fracture. Neurological examination is completely normal. MRI reveals a completely intact posterior ligamentous complex (PLC). Using the Thoracolumbar Injury Classification and Severity Score (TLICS), what is the total score and the most appropriate recommendation for treatment?

. Score 2; non-operative management
. Score 4; surgeon's choice (operative or non-operative)
. Score 5; operative management
. Score 7; operative management
. Score 3; non-operative management

Correct Answer & Explanation

. Score 2; non-operative management

Explanation

The TLICS system assigns points based on morphology, neurologic status, and integrity of the PLC. A burst fracture gets 2 points. A normal neurologic exam gets 0 points. An intact PLC gets 0 points. Total score = 2. A score of 3 or less indicates non-operative management is recommended. A score of 4 is indeterminate, and 5 or more suggests operative intervention.

Question 427

Topic: Thoracolumbar Spine & Deformity

A patient sustains a traumatic spondylolisthesis of the axis (Hangman fracture) classified as Levine-Edwards Type IIA. What is the classic mechanism of injury, and what is the appropriate initial closed management?

. Hyperextension and axial loading; traction
. Flexion-distraction; application of halo vest in slight extension and compression
. Flexion-distraction; application of heavy cervical traction
. Hyperextension and distraction; C1-C2 transarticular screws
. Axial loading; rigid cervical collar

Correct Answer & Explanation

. Flexion-distraction; application of halo vest in slight extension and compression

Explanation

Type IIA Hangman fractures exhibit minimal translation but severe angulation and are caused by a flexion-distraction mechanism. Crucially, they worsen with traction (unlike standard Type II fractures). The correct initial management is gentle reduction via extension, followed by placement in a halo vest under slight compression.

Question 428

Topic: Thoracolumbar Spine & Deformity

In evaluating a patient with adult spinal deformity, which of the following spino-pelvic parameters is a fixed morphologic parameter that does not change with patient position?

. Pelvic tilt (PT)
. Sacral slope (SS)
. Pelvic incidence (PI)
. Lumbar lordosis (LL)
. Sagittal vertical axis (SVA)

Correct Answer & Explanation

. Pelvic incidence (PI)

Explanation

Pelvic incidence (PI) is an anatomic parameter that is fixed after skeletal maturity. It is defined as the angle between a line perpendicular to the sacral endplate at its midpoint and a line connecting this point to the center of the bicoxofemoral axis. PI = PT + SS. PT and SS change with pelvic retroversion/anteversion.

Question 429

Topic: Thoracolumbar Spine & Deformity
A 45-year-old female presents with neurogenic claudication. Standing lateral radiographs reveal a Grade I L4-L5 spondylolisthesis without pars interarticularis defects. The facet joints appear sagittally oriented. Based on the Wiltse classification, what type of spondylolisthesis does this patient have?
. Type I (Dysplastic)
. Type II (Isthmic)
. Type III (Degenerative)
. Type IV (Traumatic)
. Type V (Pathologic)

Correct Answer & Explanation

. Type III (Degenerative)

Explanation

The Wiltse classification defines Type III as degenerative spondylolisthesis. It occurs secondary to intersegmental instability and facet arthropathy without a pars defect, and is most common at L4-L5 in middle-aged females with sagittally oriented facets.

Question 430

Topic: Thoracolumbar Spine & Deformity

A 16-year-old female presents with low back pain and a grade II L5-S1 isthmic spondylolisthesis. Which of the following spinopelvic parameters is highly correlated with the risk of progression in isthmic spondylolisthesis and is a fixed morphological parameter that does not change with patient positioning?

. Pelvic tilt
. Sacral slope
. Pelvic incidence
. Lumbar lordosis
. Sagittal vertical axis

Correct Answer & Explanation

. Pelvic incidence

Explanation

Pelvic incidence (PI) is a fixed anatomical parameter unique to each individual and does not change with posture (PI = Pelvic Tilt + Sacral Slope). A high pelvic incidence is strongly correlated with the development and progression of L5-S1 isthmic spondylolisthesis due to the resultant higher shear forces at the lumbosacral junction.

Question 431

Topic: Thoracolumbar Spine & Deformity

A 35-year-old man falls from a height and sustains a T12 burst fracture. He is neurologically intact. MRI demonstrates complete disruption of the posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his total score and the recommended management?

. 2 points; non-operative management
. 4 points; operative or non-operative management
. 5 points; operative management
. 7 points; operative management
. 8 points; operative management

Correct Answer & Explanation

. 5 points; operative management

Explanation

The TLICS system scores three categories: Morphology (Burst = 2 points), Neurological Status (Intact = 0 points), and PLC Integrity (Disrupted = 3 points). Total score = 2 + 0 + 3 = 5. A TLICS score of >4 points is an indication for operative management. A score of <4 indicates non-operative, and 4 is at the surgeon's discretion.

Question 432

Topic: Thoracolumbar Spine & Deformity

A 14-year-old gymnast presents with persistent lower back pain exacerbated by extension. Radiographs reveal a Grade II L5-S1 isthmic spondylolisthesis. After 6 months of conservative management including bracing and physical therapy, her pain remains debilitating. What is the most appropriate surgical intervention?

. L5-S1 anterior lumbar interbody fusion (ALIF) without posterior instrumentation
. L5 laminectomy and pars interarticularis repair (Buck's procedure)
. L5-S1 posterior instrumented fusion with autogenous bone graft
. L4-S1 posterior instrumented fusion
. In situ uninstrumented posterolateral fusion of L5-S1

Correct Answer & Explanation

. L4-S1 posterior instrumented fusion

Explanation

In an adolescent with a symptomatic Grade II isthmic spondylolisthesis that has failed conservative management, the standard surgical treatment is an L5-S1 posterior instrumented fusion. Pars repairs are reserved for defects with no significant slip (Grade 0 or early Grade I).

Question 433

Topic: Thoracolumbar Spine & Deformity

In the Thoracolumbar Injury Classification and Severity Score (TLICS), which of the following variables is assigned the highest individual point value?

. Burst fracture morphology
. Complete neurologic deficit
. Disruption of the posterior ligamentous complex
. Distraction morphology
. Incomplete neurologic deficit

Correct Answer & Explanation

. Distraction morphology

Explanation

The TLICS system assigns points based on morphology, neurologic status, and posterior ligamentous complex (PLC) integrity. Distraction morphology is assigned 4 points, making it the highest single point value in the scoring system. For comparison: translation/rotation morphology is 3 points, burst is 2; complete neurologic deficit is 2, incomplete is 3; and definite PLC disruption is 3 points.

Question 434

Topic: Thoracolumbar Spine & Deformity

A 14-year-old female gymnast complains of mechanical lower back pain and bilateral L5 radicular symptoms. Lateral lumbar radiographs demonstrate a Grade II forward slip of L5 on S1. What is the most likely pathological mechanism underlying this specific type of spondylolisthesis?

. Degeneration of the L5-S1 facet joints and intervertebral disc
. Congenital dysplasia of the superior sacral articular facets
. Fatigue stress fracture of the pars interarticularis
. Acute traumatic bilateral pedicle fractures
. Pathologic destruction of the pars by an underlying tumor

Correct Answer & Explanation

. Fatigue stress fracture of the pars interarticularis

Explanation

Isthmic spondylolisthesis is the most common type of spondylolisthesis in children and adolescents, particularly in athletes subjected to repetitive hyperextension forces (e.g., gymnastics, football linemen). It is caused by a fatigue stress fracture or elongation (spondylolysis) of the pars interarticularis, almost exclusively at the L5 level.

Question 435

Topic: Thoracolumbar Spine & Deformity

A 34-year-old construction worker falls 10 feet, sustaining a T12 burst fracture. He is neurologically intact. CT and MRI scans reveal a burst morphology with 25% canal compromise and an intact posterior ligamentous complex (PLC). Using the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his total score and the most appropriate treatment recommendation?

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

Correct Answer & Explanation

. Score 2; Non-operative management

Explanation

The TLICS system scores injuries based on three categories: Morphology, Neurologic Status, and PLC integrity. For this patient: Morphology is a burst fracture (2 points). Neurologic status is intact (0 points). PLC is intact (0 points). Total score = 2. A score of 3 or less dictates non-operative management. A score of 4 is equivocal, and 5 or more indicates surgery.

Question 436

Topic: Thoracolumbar Spine & Deformity
According to the Wiltse classification of spondylolisthesis, which subtype is characterized by an elongation or attenuation of the pars interarticularis without a frank bony defect or acute fracture?
. Dysplastic (Type I)
. Isthmic (Type IIa)
. Isthmic (Type IIb)
. Degenerative (Type III)
. Traumatic (Type IV)

Correct Answer & Explanation

. Isthmic (Type IIb)

Explanation

The Wiltse classification categorizes spondylolisthesis by etiology. Type II is isthmic (involving the pars interarticularis). Type IIa involves a pars fatigue fracture (lytic). Type IIb involves an elongated, attenuated pars without a complete separation, believed to result from repeated microfractures that heal in an elongated state. Type IIc is an acute traumatic pars fracture.

Question 437

Topic: Thoracolumbar Spine & Deformity
A 14-year-old gymnast presents with lower back pain exacerbated by extension. Lateral lumbar radiographs show a pars interarticularis defect at L5 with a 30% anterior translation of L5 on S1. According to the Meyerding classification, what grade of spondylolisthesis does this patient have?
. Grade I
. Grade II
. Grade III
. Grade IV
. Grade V

Correct Answer & Explanation

. Grade II

Explanation

The Meyerding classification grades the severity of spondylolisthesis based on the percentage of anterior translation of the superior vertebral body over the inferior one. Grade I is 0-25%, Grade II is 26-50%, Grade III is 51-75%, Grade IV is 76-100%, and Grade V (spondyloptosis) is >100%. A 30% slip falls into Grade II.

Question 438

Topic: Thoracolumbar Spine & Deformity
In the Wiltse classification of spondylolisthesis, a slip secondary to an elongated but intact pars interarticularis is classified as:
. Type I (Dysplastic)
. Type IIA (Lytic)
. Type IIB (Elongated)
. Type III (Degenerative)
. Type IV (Traumatic)

Correct Answer & Explanation

. Type IIA (Lytic)

Explanation

The Wiltse classification defines Type II as Isthmic. It is subdivided into IIA (lytic fatigue fracture of the pars), IIB (elongated but intact pars, due to repeated healed microfractures), and IIC (acute pars fracture). Type I is dysplastic, Type III is degenerative, and Type IV is traumatic (fracture other than pars).

Question 439

Topic: Thoracolumbar Spine & Deformity

According to the Thoracolumbar Injury Classification and Severity Score (TLICS), a patient presents with an L1 burst fracture, intact neurology, and an MRI indicating a confirmed disruption of the posterior ligamentous complex (PLC). What is the patient's total TLICS score and the recommended management?

. Score 3; non-operative management
. Score 4; surgeon preference (operative or non-operative)
. Score 5; operative management
. Score 6; operative management
. Score 7; operative management

Correct Answer & Explanation

. Score 5; operative management

Explanation

The TLICS system scores three categories: Morphology, Neurologic Status, and PLC Integrity. A burst fracture = 2 points. Intact neurologic status = 0 points. Confirmed disruption of the PLC = 3 points. Total score = 2 + 0 + 3 = 5 points. A TLICS score of > 4 represents an indication for operative management. A score of < 4 indicates non-operative management, and a score of exactly 4 is indeterminate (surgeon preference).

Question 440

Topic: Thoracolumbar Spine & Deformity
A 15-year-old female gymnast presents with chronic low back pain. Radiographs reveal a grade II L5-S1 spondylolisthesis. Oblique radiographs demonstrate bilateral defects in the pars interarticularis. According to the Wiltse classification of spondylolisthesis, which type does this patient have?
. Dysplastic (Type I)
. Isthmic (Type II)
. Degenerative (Type III)
. Traumatic (Type IV)
. Pathologic (Type V)

Correct Answer & Explanation

. Isthmic (Type II)

Explanation

The Wiltse classification categorizes spondylolisthesis into five types. Type II is Isthmic, which involves a defect, elongation, or acute fracture of the pars interarticularis. It is the most common type seen in young athletes (e.g., gymnasts). Type I is dysplastic, Type III is degenerative, Type IV is traumatic (fracture other than pars), and Type V is pathologic.

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