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Thoracolumbar Spine & Deformity MCQs

Practice Set 24 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 461

Topic: Thoracolumbar Spine & Deformity

A 35-year-old woman falls from a height and sustains a T12 burst fracture. Imaging reveals splaying of the spinous processes and an MRI shows disruption of the posterior ligamentous complex. She is neurologically intact. What is her Thoracolumbar Injury Classification and Severity (TLICS) score?

. 3
. 4
. 5
. 6
. 7

Correct Answer & Explanation

. 5

Explanation

The TLICS score is based on morphology (burst = 2 points), posterior ligamentous complex integrity (disrupted = 3 points), and neurologic status (intact = 0 points). A total score of 5 points indicates that surgical stabilization is the recommended treatment.

Question 462

Topic: Thoracolumbar Spine & Deformity

In planning a corrective surgery for adult spinal deformity, which of the following spinopelvic parameter relationships represents the primary goal to achieve optimal sagittal balance?

. Pelvic Incidence (PI) equals Pelvic Tilt (PT)
. Lumbar Lordosis (LL) equals Sacral Slope (SS)
. Pelvic Incidence (PI) minus Lumbar Lordosis (LL) is less than 10 degrees
. Pelvic Tilt (PT) minus Sacral Slope (SS) is greater than 10 degrees
. Thoracic Kyphosis (TK) matches Lumbar Lordosis (LL)

Correct Answer & Explanation

. Pelvic Incidence (PI) minus Lumbar Lordosis (LL) is less than 10 degrees

Explanation

A key goal in adult spinal deformity surgery is to restore the normal relationship between Pelvic Incidence (PI) and Lumbar Lordosis (LL). Matching PI and LL within 10 degrees (PI - LL < 10 degrees) minimizes compensatory mechanisms like increased pelvic tilt and improves clinical outcomes.

Question 463

Topic: Thoracolumbar Spine & Deformity

Which of the following anatomical factors is most strongly associated with the development of degenerative spondylolisthesis at L4-L5?

. Coronal orientation of the facet joints
. Sagittal orientation of the facet joints
. Increased sacral slope
. Decreased pelvic incidence
. Presence of a pars interarticularis defect

Correct Answer & Explanation

. Sagittal orientation of the facet joints

Explanation

Sagittal orientation of the facet joints at L4-L5 reduces their ability to resist anterior shear forces, strongly predisposing individuals to degenerative spondylolisthesis. Normal facet joints at this level are typically more coronally oriented, which mechanically blocks anterior translation.

Question 464

Topic: Thoracolumbar Spine & Deformity

A 25-year-old male is involved in a high-speed motor vehicle collision while wearing a lap seatbelt. Radiographs demonstrate a flexion-distraction injury (Chance fracture) at L1. Which of the following is the most commonly associated concomitant injury?

. Aortic tear
. Renal contusion
. Pelvic ring fracture
. Hollow viscus injury
. Splenic rupture

Correct Answer & Explanation

. Hollow viscus injury

Explanation

Chance fractures typically occur due to hyperflexion over a fulcrum (like a lap seatbelt), causing distraction of the posterior and middle columns. They are highly associated with intra-abdominal injuries, most notably hollow viscus injuries such as bowel perforations.

Question 465

Topic: Thoracolumbar Spine & Deformity

During the surgical planning for an adult patient with severe sagittal imbalance, the surgeon evaluates the spinopelvic parameters. Which of the following formulas correctly describes the fixed anatomic relationship of the pelvis?

. Pelvic Incidence = Pelvic Tilt + Sacral Slope
. Pelvic Tilt = Pelvic Incidence + Sacral Slope
. Sacral Slope = Pelvic Incidence + Pelvic Tilt
. Pelvic Incidence = Pelvic Tilt / Sacral Slope
. Pelvic Incidence = Sacral Slope - Pelvic Tilt

Correct Answer & Explanation

. Pelvic Incidence = Pelvic Tilt + Sacral Slope

Explanation

Pelvic Incidence (PI) is a fixed morphologic parameter that does not change with positioning. It is the algebraic sum of the position-dependent parameters: Pelvic Tilt (PT) and Sacral Slope (SS).

Question 466

Topic: Thoracolumbar Spine & Deformity

A 14-year-old female gymnast complains of insidious onset, activity-related low back pain. Radiographs demonstrate a Grade 1 isthmic spondylolisthesis at L5-S1 with an identifiable pars interarticularis defect. She has no neurologic deficits. What is the most appropriate initial management?

. L5-S1 in situ fusion
. Activity modification and bracing
. L5 pars repair
. L5-S1 reduction and fusion
. Epidural steroid injection

Correct Answer & Explanation

. Activity modification and bracing

Explanation

Initial management for symptomatic, low-grade (Grade 1 or 2) isthmic spondylolisthesis in an adolescent is nonoperative. This includes a period of activity modification, physical therapy, and potentially bracing (TLSO) to allow symptoms to resolve.

Question 467

Topic: Thoracolumbar Spine & Deformity

When utilizing the Thoracolumbar Injury Classification and Severity (TLICS) score to determine the indication for surgery in a thoracolumbar burst fracture, which of the following radiographic parameters is heavily weighted and strongly drives the recommendation toward surgical stabilization?

. Posterior ligamentous complex integrity
. Loss of anterior vertebral height greater than 50%
. Spinal canal compromise greater than 50%
. Interpedicular widening
. Fracture of the transverse process

Correct Answer & Explanation

. Posterior ligamentous complex integrity

Explanation

In the TLICS system, disruption of the posterior ligamentous complex (PLC) assigns 3 points (if indeterminate, 2 points) and strongly pushes the score toward operative management. Degree of height loss and canal compromise are not directly scored in TLICS, distinguishing it from older classification systems.

Question 468

Topic: Thoracolumbar Spine & Deformity

A 45-year-old man falls from a roof and sustains an L1 burst fracture. Neurologic examination is normal. Radiographs and CT show 40% loss of anterior vertebral body height and 25% canal compromise. The posterior ligamentous complex is intact on MRI. According to the Thoracolumbar Injury Classification and Severity (TLICS) scale, what is his total score and recommended treatment?

. Score 2, Nonoperative management with an orthosis
. Score 4, Operative management
. Score 5, Operative management
. Score 3, Nonoperative management
. Score 2, Operative management

Correct Answer & Explanation

. Score 2, Nonoperative management with an orthosis

Explanation

The TLICS score assigns 2 points for a burst fracture, 0 points for intact neurologic status, and 0 points for an intact posterior ligamentous complex, totaling 2. A score of 3 or less is an indication for nonoperative management.

Question 469

Topic: Thoracolumbar Spine & Deformity

In planning surgical correction for adult degenerative scoliosis, the surgeon measures the pelvic incidence (PI). If the patient's PI is 55 degrees, what should be the approximate target for lumbar lordosis (LL) to achieve optimal sagittal balance?

. 20 to 30 degrees
. 35 to 45 degrees
. 45 to 55 degrees
. 60 to 70 degrees
. 75 to 85 degrees

Correct Answer & Explanation

. 45 to 55 degrees

Explanation

To achieve harmonious sagittal balance, the lumbar lordosis (LL) should match the pelvic incidence (PI) within 9 degrees (PI - LL < 10 degrees). Therefore, a target LL of 45 to 55 degrees is appropriate.

Question 470

Topic: Thoracolumbar Spine & Deformity

A 16-year-old boy presents with progressive mid-back pain and a cosmetic deformity. Radiographs reveal a thoracic kyphosis of 65 degrees. According to Sorensen's criteria, which radiographic finding is required for the diagnosis of Scheuermann's disease?

. Anterior wedging of greater than 5 degrees in at least three consecutive vertebrae
. Schmorl's nodes in at least four levels
. Thoracic kyphosis greater than 75 degrees
. Irregular endplates with loss of disc height at a single level
. Apophyseal ring fracture at the apex

Correct Answer & Explanation

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

Explanation

Sorensen's classic criteria for diagnosing Scheuermann's kyphosis require the presence of anterior wedging of greater than 5 degrees in at least three consecutive apical vertebrae.

Question 471

Topic: Thoracolumbar Spine & Deformity

During surgical correction of a complex adult degenerative scoliosis, restoring sagittal balance is a primary goal to optimize postoperative function and pain relief. According to the Schwab criteria, what is the ideal postoperative target relationship between Pelvic Incidence (PI) and Lumbar Lordosis (LL)?

. PI and LL should be equal to within 10 degrees (PI - LL < 10°)
. LL should exceed PI by at least 20 degrees
. PI should exceed LL by at least 20 degrees
. Pelvic Tilt (PT) should be greater than 25 degrees
. Sacral Slope (SS) should be less than 10 degrees

Correct Answer & Explanation

. PI and LL should be equal to within 10 degrees (PI - LL < 10°)

Explanation

In adult spinal deformity surgery, optimal sagittal balance is achieved when the patient's lumbar lordosis matches their innate pelvic incidence. The Schwab classification targets a PI-LL mismatch of less than 10 degrees to improve functional outcomes and minimize the risk of adjacent segment disease.

Question 472

Topic: Thoracolumbar Spine & Deformity

A 16-year-old gymnast presents with persistent, localized low back pain that worsens with extension activities. She has failed 6 months of rest and physical therapy. Radiographs and a CT scan reveal a bilateral pars interarticularis defect at L5 with a Grade II spondylolisthesis. If surgical intervention is pursued, what is the standard treatment of choice?

. Pars repair with lag screws
. L5 laminectomy without fusion
. Posterolateral in situ fusion of L5-S1
. Anterior-only L5-S1 interbody fusion
. Sacroiliac joint fusion

Correct Answer & Explanation

. Posterolateral in situ fusion of L5-S1

Explanation

For a symptomatic adolescent with a high-grade (Grade II or above) isthmic spondylolisthesis that fails conservative management, L5-S1 posterolateral in situ fusion (often with instrumentation) is the gold standard. Pars repair is generally reserved for patients with defects but minimal to no slip (Grade 0 or early Grade I) at higher lumbar levels.

Question 473

Topic: Thoracolumbar Spine & Deformity

A 30-year-old male construction worker falls from scaffolding, sustaining a T12 burst fracture. He is neurologically intact. Review of his CT and MRI shows a comminuted burst fracture with 20% canal compromise and an intact posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his score and recommended treatment?

. TLICS 2; Nonoperative treatment with TLSO
. TLICS 4; Operative or nonoperative treatment
. TLICS 5; Operative treatment
. TLICS 6; Operative treatment
. TLICS 7; Operative treatment

Correct Answer & Explanation

. TLICS 2; Nonoperative treatment with TLSO

Explanation

The TLICS score for this injury is 2: Morphology is burst (2 points), Neurology is intact (0 points), and PLC is intact (0 points). A score of 3 or less indicates nonoperative management, typically with a TLSO brace or early mobilization depending on pain and mechanical stability.

Question 474

Topic: Thoracolumbar Spine & Deformity

A 14-year-old boy is brought to the emergency department after a high-speed motor vehicle collision in which he was a rear-seat, lap-belted passenger. He complains of severe lower back pain. Radiographs and a CT scan reveal a flexion-distraction injury (Chance fracture) at L2. Given this injury pattern, what additional evaluation is most critical for this patient?

. MRI to evaluate for epidural hematoma
. CT angiography of the lower extremities
. Evaluation for intra-abdominal hollow viscus injury
. Urodynamic testing for neurogenic bladder
. DEXA scan

Correct Answer & Explanation

. Evaluation for intra-abdominal hollow viscus injury

Explanation

Chance fractures (flexion-distraction injuries) are frequently sustained by lap-belted passengers in motor vehicle collisions and are highly associated with concurrent intra-abdominal injuries. Approximately 30% to 50% of these cases present with a concomitant hollow viscus injury.

Question 475

Topic: Thoracolumbar Spine & Deformity

A 68-year-old woman with adult degenerative scoliosis is undergoing evaluation for corrective surgery. Her pelvic incidence (PI) is 60 degrees. To achieve optimal sagittal balance and minimize the risk of adjacent segment disease and mechanical failure, her lumbar lordosis (LL) should be reconstructed to approximately what value?

. 20 degrees
. 40 degrees
. 50 degrees
. 60 degrees
. 80 degrees

Correct Answer & Explanation

. 50 degrees

Explanation

Optimal sagittal balance requires the lumbar lordosis (LL) to be within 10 degrees of the pelvic incidence (PI). Therefore, for a PI of 60 degrees, the LL should be reconstructed to approximately 50-60 degrees to prevent flatback deformity.

Question 476

Topic: Thoracolumbar Spine & Deformity

A 30-year-old unrestrained driver is involved in an MVC. CT of the lumbar spine shows a flexion-distraction injury (Chance fracture) at L1. Which of the following associated injuries must be carefully ruled out?

. Aortic transection
. Intra-abdominal hollow viscus injury
. Diaphragmatic rupture
. Splenic laceration
. Renal contusion

Correct Answer & Explanation

. Intra-abdominal hollow viscus injury

Explanation

Chance fractures are flexion-distraction injuries commonly associated with seatbelt use. Up to 50% of patients with these fractures have concomitant intra-abdominal injuries, most commonly involving hollow viscous organs like the small bowel.

Question 477

Topic: Thoracolumbar Spine & Deformity

A 24-year-old man wearing a lap belt is involved in a high-speed motor vehicle collision. Radiographs demonstrate a flexion-distraction injury (Chance fracture) at L1. Which of the following associated injuries is most critical to rule out in this patient?

. Aortic dissection
. Diaphragmatic rupture
. Gastrointestinal hollow viscus injury
. Splenic laceration
. Reninal artery thrombosis

Correct Answer & Explanation

. Gastrointestinal hollow viscus injury

Explanation

Chance fractures (flexion-distraction injuries) are highly associated with intra-abdominal injuries, particularly to hollow viscous organs like the bowel, due to the acute compression from the lap belt. A thorough abdominal evaluation is mandatory.

Question 478

Topic: Thoracolumbar Spine & Deformity

A 22-year-old woman is involved in a high-speed motor vehicle collision while wearing a lap belt. She complains of severe back pain. Radiographs reveal a flexion-distraction injury (Chance fracture) at L2. Which of the following associated injuries must be carefully evaluated for in this patient?

. Diaphragmatic rupture
. Hollow viscus bowel injury
. Aortic transection
. Renal artery thrombosis
. Splenic laceration

Correct Answer & Explanation

. Hollow viscus bowel injury

Explanation

Chance fractures are flexion-distraction injuries commonly caused by lap seatbelts acting as a fulcrum. They have a high association (up to 50%) with intra-abdominal injuries, particularly to hollow viscus organs such as the small bowel.

Question 479

Topic: Thoracolumbar Spine & Deformity

A 65-year-old woman presents with neurogenic claudication. Imaging reveals a Grade I degenerative spondylolisthesis. What is the most common anatomic level for this specific pathology to occur?

. L2-L3
. L3-L4
. L4-L5
. L5-S1
. T12-L1

Correct Answer & Explanation

. L4-L5

Explanation

Degenerative spondylolisthesis occurs most frequently at the L4-L5 level. This is in contrast to isthmic spondylolisthesis, which most commonly affects the L5-S1 level.

Question 480

Topic: Thoracolumbar Spine & Deformity

A 35-year-old male sustains a T12 burst fracture after a fall from a height of 10 feet. He is neurologically intact. MRI demonstrates an indeterminate posterior ligamentous complex (PLC) injury. According to the Thoracolumbar Injury Classification and Severity (TLICS) scale, what is the most appropriate management recommendation?

. Immediate surgical decompression and stabilization
. Strict bed rest for 6 weeks followed by bracing
. Nonoperative management with a TLSO exclusively
. Management may be either surgical or nonoperative based on surgeon discretion
. Kyphoplasty of the T12 vertebral body

Correct Answer & Explanation

. Management may be either surgical or nonoperative based on surgeon discretion

Explanation

This patient has a TLICS score of 4 (Morphology: Burst = 2; Neuro: Intact = 0; PLC: Indeterminate = 2). A score of 4 signifies that either operative or nonoperative management is acceptable based on surgeon preference.

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