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Thoracolumbar Spine & Deformity MCQs

Practice Set 23 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 441

Topic: Thoracolumbar Spine & Deformity

A 40-year-old male sustains an isolated thoracolumbar fracture at T12 following a fall. Neurological examination is completely normal. CT imaging demonstrates a burst fracture of T12 with 30% loss of anterior vertebral body height and splaying of the pedicles. MRI reveals the posterior ligamentous complex (PLC) is intact. According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his total score and the generally recommended treatment pathway?

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

Correct Answer & Explanation

. Score 2; nonoperative management

Explanation

The TLICS scoring system considers three parameters: injury morphology, neurological status, and integrity of the posterior ligamentous complex (PLC). Morphology: burst fracture = 2 points. Neurological status: intact = 0 points. PLC: intact = 0 points. Total score = 2. A score of less than 4 implies nonoperative management is indicated.

Question 442

Topic: Thoracolumbar Spine & Deformity

A 16-year-old gymnast with an L5-S1 isthmic spondylolisthesis develops progressively worsening radicular leg pain. Imaging reveals an L5 pars defect with a Grade II slip and significant foraminal stenosis. Which nerve root is most likely compressed, and where does the compression occur?

. L4 root, in the lateral recess
. L5 root, in the neural foramen
. S1 root, in the lateral recess
. S1 root, in the neural foramen
. S2 root, centrally

Correct Answer & Explanation

. L5 root, in the neural foramen

Explanation

In L5-S1 isthmic spondylolisthesis, the exiting L5 nerve root is most commonly compressed within the neural foramen. The compression is typically caused by the hypertrophic fibrocartilaginous mass at the pars interarticularis defect (the 'Gill lesion').

Question 443

Topic: Thoracolumbar Spine & Deformity
A 15-year-old gymnast complains of chronic low back pain that worsens with hyperextension. Radiographs confirm a grade I L5-S1 spondylolisthesis secondary to bilateral pars interarticularis defects. According to the Wiltse classification of spondylolisthesis, which type does this represent?
. Type I (Dysplastic)
. Type II (Isthmic)
. Type III (Degenerative)
. Type IV (Traumatic)
. Type V (Pathologic)

Correct Answer & Explanation

. Type II (Isthmic)

Explanation

The Wiltse classification defines five major types of spondylolisthesis: Type I is Dysplastic (congenital abnormality of the upper sacrum/arch of L5); Type II is Isthmic (defect in the pars interarticularis, typical in young athletes like gymnasts); Type III is Degenerative (due to chronic instability without a pars defect); Type IV is Traumatic (fracture of the neural arch other than the pars); Type V is Pathologic.

Question 444

Topic: Thoracolumbar Spine & Deformity

A 35-year-old male sustains a T12 burst fracture after a fall. Neurological examination is completely intact. Radiographs and an MRI demonstrate splaying of the spinous processes and complete disruption of the posterior ligamentous complex (PLC). Based on the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his total score and the recommended treatment strategy?

. Score 3; non-operative treatment with a TLSO brace
. Score 4; surgeon's choice between operative and non-operative management
. Score 5; surgical stabilization is indicated
. Score 7; surgical stabilization is indicated
. Score 2; non-operative treatment with early mobilization

Correct Answer & Explanation

. Score 5; surgical stabilization is indicated

Explanation

The TLICS score assigns points based on morphology, neurologic status, and PLC integrity. Burst morphology = 2 points. Intact neurologic status = 0 points. Disrupted PLC = 3 points. Total score = 5 points. A TLICS score of 3 or less is typically treated non-operatively, 4 is indeterminate (surgeon's choice), and 5 or more indicates surgical stabilization.

Question 445

Topic: Thoracolumbar Spine & Deformity

In adult spinal deformity surgery, achieving optimal sagittal balance is critical. The goal for restoring lumbar lordosis (LL) is typically based on the patient's pelvic incidence (PI). What is the generally accepted target relationship between PI and LL?

. LL should equal PI plus 20 degrees
. LL should be within 10 degrees of PI
. PI should be half of the LL
. LL should be twice the pelvic tilt (PT)
. LL should be independent of PI but exactly match thoracic kyphosis

Correct Answer & Explanation

. LL should be within 10 degrees of PI

Explanation

In sagittal plane deformity correction, the target is a PI-LL mismatch of less than 10 degrees (ideally LL = PI +/- 9 degrees). This helps ensure that the patient can maintain an upright posture with minimal energy expenditure and reduces the risk of adjacent segment disease and mechanical failure.

Question 446

Topic: Thoracolumbar Spine & Deformity

A 32-year-old male falls from a height and presents neurologically intact. CT imaging shows an L1 burst fracture with 30% canal compromise. An MRI clearly demonstrates a wide disruption of the interspinous ligaments and facet capsules with significant edema (definite Posterior Ligamentous Complex disruption). Based on the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the score and corresponding recommendation?

. Score 2; Non-operative management
. Score 4; Surgeon preference for operative vs non-operative
. Score 5; Surgical intervention indicated
. Score 7; Surgical intervention indicated
. Score 3; TLSO bracing

Correct Answer & Explanation

. Score 5; Surgical intervention indicated

Explanation

The TLICS score is calculated from three categories: Morphology (Burst = 2 points), Neurologic status (Intact = 0 points), and Posterior Ligamentous Complex (PLC) status (Definite disruption = 3 points). Total score = 2 + 0 + 3 = 5. A TLICS score >4 indicates surgical intervention is the recommended treatment.

Question 447

Topic: Thoracolumbar Spine & Deformity

A 32-year-old male sustains a T12 burst fracture after a fall. He is neurologically intact. MRI is obtained, and the status of the posterior ligamentous complex (PLC) is deemed 'indeterminate'. According to the Thoracolumbar Injury Classification and Severity (TLICS) score, how many points are assigned specifically to the PLC component in this scenario?

. 0
. 1
. 2
. 3
. 4

Correct Answer & Explanation

. 3

Explanation

In the TLICS scoring system, the integrity of the Posterior Ligamentous Complex (PLC) is scored as follows: Intact = 0 points; Indeterminate (or suspected injury) = 2 points; Disrupted (definite injury) = 3 points. Total score dictates management (<=3 non-operative, 4 is surgeon's choice, >=5 operative).

Question 448

Topic: Thoracolumbar Spine & Deformity

A 35-year-old female falls from a height and sustains an L1 burst fracture. She is neurologically intact. MRI demonstrates an intact posterior ligamentous complex (PLC). Radiographs show 25% loss of anterior vertebral body height and CT shows 30% canal compromise. Based on 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 follows: Morphology (Burst = 2 points), Neurologic status (Intact = 0 points), PLC status (Intact = 0 points). The total score is 2. A score of 3 or less is an indication for non-operative management (e.g., orthosis/bracing). A score of 4 is indeterminate, and 5 or more indicates surgery.

Question 449

Topic: Thoracolumbar Spine & Deformity
A 16-year-old elite female gymnast presents with insidious onset lower back pain that worsens with extension activities. Oblique radiographs of the lumbar spine demonstrate a 'collar on the Scotty dog'. According to the Wiltse classification of spondylolisthesis, what type of defect does this patient have?
. Type I (Dysplastic)
. Type II (Isthmic)
. Type III (Degenerative)
. Type IV (Traumatic)
. Type V (Pathologic)

Correct Answer & Explanation

. Type II (Isthmic)

Explanation

The patient has a pars interarticularis defect (spondylolysis), classically seen as a 'collar on the Scotty dog' on oblique radiographs. In the Wiltse classification of spondylolisthesis, a pars defect (often a stress/fatigue fracture common in gymnasts) is classified as Type II (Isthmic). Type I is Dysplastic (congenital abnormality of the upper sacrum or L5 arch), Type III is Degenerative, Type IV is Traumatic (fractures of the posterior arch other than the pars), and Type V is Pathologic.

Question 450

Topic: Thoracolumbar Spine & Deformity

A 12-year-old female presents with back pain and a slip angle of 55 degrees on standing lateral radiographs, consistent with high-grade dysplastic spondylolisthesis. Which of the following is the most characteristic physical exam finding associated with this condition?

. Phalen's test positivity
. Iliopsoas contracture
. Hamstring tightness
. Quadriceps weakness
. Ankle clonus

Correct Answer & Explanation

. Hamstring tightness

Explanation

High-grade spondylolisthesis in children is classically accompanied by severe hamstring tightness. This leads to a typical waddling gait with knees bent and a retroverted pelvis, known as the Phalen-Dickson sign.

Question 451

Topic: Thoracolumbar Spine & Deformity

A 15-year-old male presents with increasing middle back pain and a visible rounding of his spine. Standing lateral radiographs reveal thoracic kyphosis of 60 degrees. According to the Sorensen criteria, which of the following radiographic findings must be present to establish a definitive diagnosis of Scheuermann's kyphosis?

. Decreased kyphosis on active extension
. Presence of Schmorl's nodes on MRI
. Anterior wedging of >5 degrees in 3 consecutive vertebrae
. Apophyseal ring fractures at multiple levels
. A defect in the pars interarticularis of the lower thoracic vertebrae

Correct Answer & Explanation

. Anterior wedging of >5 degrees in 3 consecutive vertebrae

Explanation

Scheuermann's disease is a rigid structural thoracic or thoracolumbar kyphosis. The Sorensen criteria mandate that there must be anterior wedging of greater than 5 degrees in at least three consecutive vertebrae. While Schmorl's nodes and apophyseal ring irregularities are commonly associated radiographic findings, they are not strictly required by the diagnostic criteria.

Question 452

Topic: Thoracolumbar Spine & Deformity
A 14-year-old gymnast presents with chronic low back pain that worsens with extension. Lateral lumbar radiographs reveal a grade I spondylolisthesis at L5-S1 with a visible pars interarticularis defect. According to the Wiltse classification, which 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 II (Isthmic)

Explanation

The Wiltse classification of spondylolisthesis is: Type I: Dysplastic (congenital abnormalities of the upper sacrum or L5 arch). Type II: Isthmic (lesion in the pars interarticularis, typical in young athletes like gymnasts). Type III: Degenerative (secondary to long-standing segmental instability). Type IV: Traumatic (fractures in areas other than the pars). Type V: Pathologic (generalized or localized bone disease). Type VI: Iatrogenic.

Question 453

Topic: Thoracolumbar Spine & Deformity

A 40-year-old man has intractable pain following 2 years of nonsurgical management for high-grade spondylolisthesis. What is the best surgical option?

Orthopedic Surgery Board Review 2026 | High-Yield MCQs - Set 9 - Figure 36

. Posterolateral fusion
. Posterolateral fusion with instrumentation
. Circumferential fusion
. Transforaminal lumbar interbody fusion
. Anterior lumbar interbody fusion

Correct Answer & Explanation

. Circumferential fusion

Explanation

Circumferential fusion is the preferred choice for patients undergoing revision surgery following failed posterolateral fusions for isthmic spondylolisthesis as well as for those patients having primary surgery for high-grade isthmic spondylolisthesis.

Question 454

Topic: Thoracolumbar Spine & Deformity

Which of the following morphological fracture patterns is assigned the highest point value in the Thoracolumbar Injury Classification and Severity (TLICS) system?

. Compression fracture
. Burst fracture
. Translational/rotational injury
. Distraction injury
. Flexion-teardrop fracture

Correct Answer & Explanation

. Distraction injury

Explanation

In the TLICS system, morphology is scored as follows: compression (1), burst (2), translation/rotation (3), and distraction (4). Distraction morphology carries the highest point value as it implies severe instability.

Question 455

Topic: Thoracolumbar Spine & Deformity

In adult spinal deformity surgery, achieving proper sagittal balance is highly correlated with improved Health-Related Quality of Life (HRQOL) outcomes. Which of the following radiographic targets is generally recommended?

. Sagittal Vertical Axis (SVA) < 10 cm
. Pelvic Incidence minus Lumbar Lordosis (PI-LL) < 10 degrees
. Pelvic Tilt (PT) > 25 degrees
. Thoracic Kyphosis > 60 degrees
. Sacral Slope < 20 degrees

Correct Answer & Explanation

. Pelvic Incidence minus Lumbar Lordosis (PI-LL) < 10 degrees

Explanation

Favorable outcomes in adult spinal deformity are associated with an SVA < 5 cm, PT < 20 degrees, and a PI-LL mismatch of less than 10 degrees. These parameters optimize standing posture and minimize energy expenditure.

Question 456

Topic: Thoracolumbar Spine & Deformity

A 40-year-old male falls from a height and sustains an L1 burst fracture. He is neurologically intact.

Which of the following parameters is the strongest indication for operative stabilization over nonoperative management?

. 15 degrees of focal kyphosis
. 20% anterior vertebral body height loss
. 30% spinal canal compromise
. Posterior ligamentous complex (PLC) injury
. Pedicle widening of 2 mm

Correct Answer & Explanation

. Posterior ligamentous complex (PLC) injury

Explanation

Injury to the posterior ligamentous complex (PLC) indicates a highly unstable injury pattern (earning 3 points on the TLICS scale) and is a strong indication for surgical stabilization in thoracolumbar burst fractures.

Question 457

Topic: Thoracolumbar Spine & Deformity

In surgical planning for adult spinal deformity, achieving optimal spinopelvic harmony is critical. Which formula represents the ideal relationship between pelvic incidence (PI) and lumbar lordosis (LL)?

. PI = LL ± 10 degrees
. LL = PI ± 10 degrees
. PI = Pelvic Tilt + Sacral Slope
. LL = Pelvic Tilt - Sacral Slope
. PI = LL + 20 degrees

Correct Answer & Explanation

. PI = LL ± 10 degrees

Explanation

For optimal spinopelvic harmony and improved functional outcomes, the lumbar lordosis (LL) should match the pelvic incidence (PI) within 10 degrees (PI = LL ± 10 degrees).

Question 458

Topic: Thoracolumbar Spine & Deformity

A 16-year-old female wearing a lap belt in an MVA sustains a flexion-distraction injury (Chance fracture) of L2.

Which of the following associated injuries must be aggressively ruled out?

. Aortic transection
. Renal artery thrombosis
. Intra-abdominal hollow viscus injury
. Pulmonary contusion
. Pelvic ring disruption

Correct Answer & Explanation

. Intra-abdominal hollow viscus injury

Explanation

Chance fractures are highly associated with intra-abdominal injuries, particularly hollow viscus injuries (e.g., bowel perforations), which occur in up to 50% of cases due to extreme lap-belt compression.

Question 459

Topic: Thoracolumbar Spine & Deformity

In planning for adult spinal deformity correction, which of the following radiographic relationships is the primary goal to achieve a well-balanced spine?

. Lumbar Lordosis (LL) equals Pelvic Incidence (PI) ± 9 degrees
. Pelvic Tilt (PT) greater than 20 degrees
. Sagittal Vertical Axis (SVA) greater than 5 cm
. Thoracic Kyphosis (TK) equals Lumbar Lordosis (LL)
. Sacral Slope (SS) less than 20 degrees

Correct Answer & Explanation

. Lumbar Lordosis (LL) equals Pelvic Incidence (PI) ± 9 degrees

Explanation

A fundamental goal of adult spinal deformity surgery is to restore sagittal balance. This is best achieved by correcting the Lumbar Lordosis to within 9-10 degrees of the patient's fixed Pelvic Incidence.

Question 460

Topic: Thoracolumbar Spine & Deformity

Which of the following is an absolute indication for surgical intervention in a patient with a traumatic thoracolumbar burst fracture?

. 30% loss of anterior vertebral body height
. 40% canal compromise without neurologic deficit
. Progressive neurologic deficit
. 15 degrees of local kyphosis
. Concomitant transverse process fractures

Correct Answer & Explanation

. Progressive neurologic deficit

Explanation

The development of a progressive neurologic deficit is an absolute indication for urgent surgical decompression and stabilization in the setting of a thoracolumbar burst fracture.

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