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Thoracolumbar Spine & Deformity MCQs

Practice Set 27 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 521

Topic: Thoracolumbar Spine & Deformity

A 35-year-old man sustains an L1 burst fracture after falling from a ladder. He is neurologically intact. Imaging reveals 15 degrees of kyphosis, 30% canal compromise, and an intact posterior ligamentous complex (PLC). What is the most appropriate treatment?

. Thoracolumbosacral orthosis (TLSO) bracing and early mobilization
. Posterior instrumented spinal fusion
. Anterior corpectomy and fusion
. Percutaneous short-segment pedicle screws
. Laminectomy and facetectomy

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing and early mobilization

Explanation

Stable thoracolumbar burst fractures (neurologically intact, intact PLC, acceptable kyphosis < 20-30 degrees) are typically treated non-operatively with a TLSO brace. Outcomes for stable burst fractures treated with bracing are equivalent to surgical stabilization.

Question 522

Topic: Thoracolumbar Spine & Deformity

A 22-year-old man presents with chronic low back pain and radicular symptoms. Imaging reveals a bilateral L5 pars interarticularis defect (isthmic spondylolisthesis) with a Grade 2 slip. Which nerve root is most commonly compressed in this specific condition?

. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L5

Explanation

In isthmic spondylolisthesis at L5-S1, the fibrocartilaginous pseudarthrosis mass at the pars defect typically compresses the exiting L5 nerve root within the neural foramen. This differs from a paracentral disc herniation at L5-S1, which would affect the traversing S1 root.

Question 523

Topic: Thoracolumbar Spine & Deformity

A 68-year-old woman with severe back pain and forward-flexed posture is being evaluated for an adult spinal deformity correction. Her preoperative full-length standing radiographs demonstrate a Pelvic Incidence (PI) of 62 degrees. To achieve optimal postoperative sagittal balance and minimize the risk of adjacent segment disease or hardware failure, what should her target Lumbar Lordosis (LL) be?

. 32 degrees
. 42 degrees
. 52 degrees
. 62 degrees
. 82 degrees

Correct Answer & Explanation

. 62 degrees

Explanation

To achieve ideal sagittal balance, the Lumbar Lordosis (LL) should be matched to within 9 to 10 degrees of the patient's fixed Pelvic Incidence (PI). Therefore, for a PI of 62 degrees, a target LL of approximately 62 degrees is mathematically optimal.

Question 524

Topic: Thoracolumbar Spine & Deformity

A 42-year-old construction worker falls 10 feet and sustains an L1 burst fracture. He is neurologically intact on examination. CT and MRI show 40% anterior body height loss, 30% retropulsed bone causing canal compromise, and a completely intact posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the most appropriate treatment recommendation?

. Urgent posterior pedicle screw instrumentation and fusion
. Urgent anterior corpectomy with strut graft and plating
. Nonoperative management with a thoracolumbosacral orthosis (TLSO)
. Prophylactic lumbar subarachnoid drain placement
. Bed rest for 6 weeks followed by gradual mobilization without a brace

Correct Answer & Explanation

. Nonoperative management with a thoracolumbosacral orthosis (TLSO)

Explanation

The patient's TLICS score is 2 (Morphology: Burst = 2, Neurologic Status: Intact = 0, PLC: Intact = 0). A TLICS score of less than 4 is an indication for nonoperative management, typically utilizing a TLSO.

Question 525

Topic: Thoracolumbar Spine & Deformity

According to the Thoracolumbar Injury Classification and Severity (TLICS) score, which of the following injury characteristics assigns the highest independent point value toward the decision for surgical intervention?

. Compression morphology
. Disruption of the posterior ligamentous complex (PLC)
. Complete neurologic deficit
. Burst morphology
. Nerve root injury

Correct Answer & Explanation

. Disruption of the posterior ligamentous complex (PLC)

Explanation

In the TLICS system, an injured (disrupted) PLC is assigned 3 points, which is the highest individual score for a single category, alongside an incomplete neurologic deficit. A total score of 5 or more generally indicates surgical management.

Question 526

Topic: Thoracolumbar Spine & Deformity

A 25-year-old man is brought to the ED after a lap-belt restrained motor vehicle collision. X-rays reveal a flexion-distraction injury (Chance fracture) at L2. Which of the following associated injuries must be actively ruled out?

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

Correct Answer & Explanation

. Intra-abdominal hollow viscus injury

Explanation

Chance fractures (flexion-distraction injuries) are highly associated with intra-abdominal injuries, particularly hollow viscus injuries like bowel perforations (up to 40-50% incidence). Prompt general surgery evaluation and abdominal CT are mandated.

Question 527

Topic: Thoracolumbar Spine & Deformity

A 14-year-old female gymnast complains of insidious onset lower back pain that worsens with back extension. Neurologic examination is entirely normal. Radiographs reveal a pars interarticularis defect at L5 bilaterally with 15% translation of L5 on S1. What is the most appropriate initial management?

. Activity modification and core-strengthening physical therapy
. Rigid TLSO bracing for 23 hours a day for 6 months
. Pars interarticularis repair (e.g., Buck's procedure)
. L5-S1 uninstrumented posterolateral fusion
. L5-S1 anterior lumbar interbody fusion (ALIF)

Correct Answer & Explanation

. Activity modification and core-strengthening physical therapy

Explanation

The patient has a Grade I isthmic spondylolisthesis. The first line of treatment for a symptomatic, low-grade isthmic spondylolisthesis in a neurologically intact adolescent is non-operative, focusing on activity modification and physical therapy to strengthen the core and stretch the hamstrings.

Question 528

Topic: Thoracolumbar Spine & Deformity

A 35-year-old man falls from a roof, sustaining an L1 burst fracture. His neurological examination is completely intact. MRI demonstrates an intact posterior ligamentous complex (PLC). The fracture exhibits 15 degrees of local kyphosis. Based on the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the recommended management?

. Posterior short-segment instrumented fusion
. Anterior corpectomy and fusion
. Thoracolumbosacral orthosis (TLSO) bracing
. Laminectomy alone
. Percutaneous pedicle screw fixation

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing

Explanation

The TLICS score is 2 (burst fracture morphology = 2, intact PLC = 0, intact neurological status = 0). A TLICS score of less than 4 indicates that non-operative management, such as TLSO bracing and early mobilization, is appropriate.

Question 529

Topic: Thoracolumbar Spine & Deformity

A 25-year-old woman involved in a high-speed motor vehicle collision presents with a transverse ecchymosis across her abdomen (seatbelt sign). Radiographs reveal an osseous flexion-distraction injury (Chance fracture) of L2. What associated injury must be most urgently and specifically ruled out?

. Aortic dissection
. Intra-abdominal hollow viscus injury
. Pelvic ring disruption
. Diaphragmatic rupture
. Renal laceration

Correct Answer & Explanation

. Intra-abdominal hollow viscus injury

Explanation

Flexion-distraction injuries (Chance fractures) are highly associated with intra-abdominal injuries, particularly hollow viscus injuries like bowel rupture, which occur in up to 40-50% of cases. A thorough abdominal evaluation, usually with CT, is strictly required.

Question 530

Topic: Thoracolumbar Spine & Deformity

A 72-year-old woman is planning to undergo reconstructive surgery for adult spinal deformity. To achieve optimal sagittal balance and minimize the risk of adjacent segment disease, her postoperative lumbar lordosis (LL) should be matched to which of the following pelvic parameters?

. Pelvic tilt
. Sacral slope
. Pelvic incidence
. Sagittal vertical axis
. T1 pelvic angle

Correct Answer & Explanation

. Pelvic incidence

Explanation

Pelvic incidence (PI) is a fixed morphologic parameter that dictates a patient's optimal spino-pelvic alignment. To achieve optimal sagittal balance, the postoperative lumbar lordosis (LL) should typically be within 10 degrees of the patient's pelvic incidence (PI - LL < 10 degrees).

Question 531

Topic: Thoracolumbar Spine & Deformity

A 25-year-old man sustains a seatbelt-type injury in a high-speed motor vehicle collision. Radiographs demonstrate a flexion-distraction (Chance) fracture of L2. Which of the following associated injuries must be carefully evaluated for?

. Traumatic aortic rupture
. Intra-abdominal hollow viscus injury
. Diaphragmatic rupture
. Renal artery thrombosis
. Splenic rupture

Correct Answer & Explanation

. Intra-abdominal hollow viscus injury

Explanation

Chance fractures (flexion-distraction injuries) are classically associated with lap seatbelt use in motor vehicle collisions. There is a high incidence (up to 40%) of concomitant intra-abdominal injuries, most commonly hollow viscus perforations.

Question 532

Topic: Thoracolumbar Spine & Deformity

A 45-year-old man fell from 10 feet. CT reveals an L1 burst fracture with 40% canal compromise. He is neurologically intact. MRI demonstrates an intact posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the recommended treatment?

. Anterior corpectomy and fusion
. Posterior short-segment pedicle screw fixation
. Posterior long-segment pedicle screw fixation
. Thoracolumbosacral orthosis (TLSO) and early mobilization
. Laminectomy and non-instrumented fusion

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) and early mobilization

Explanation

The patient's TLICS score is 2 (burst fracture = 2, intact PLC = 0, neuro intact = 0). A score less than 4 is a strong indication for non-operative management, typically with a TLSO.

Question 533

Topic: Thoracolumbar Spine & Deformity

A 15-year-old gymnast presents with persistent lower back pain unresponsive to 6 months of conservative management. Radiographs show a grade II isthmic spondylolisthesis at L5-S1. What is the most appropriate surgical treatment?

. L5 laminectomy alone
. L5-S1 anterior lumbar interbody fusion (ALIF) alone
. L5-S1 instrumented posterolateral fusion
. L4-S1 instrumented posterolateral fusion
. Sacroiliac joint fusion

Correct Answer & Explanation

. L5-S1 instrumented posterolateral fusion

Explanation

In symptomatic pediatric patients with low-grade isthmic spondylolisthesis who fail conservative care, an in situ single-level (L5-S1) instrumented posterolateral fusion is the surgical treatment of choice.

Question 534

Topic: Thoracolumbar Spine & Deformity

A 30-year-old neurologically intact male sustains an L1 burst fracture. CT shows 30% canal compromise and 15 degrees of local kyphosis. MRI confirms an intact posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his total score and the recommended management?

. Score 2, non-operative management
. Score 4, operative management
. Score 5, operative management
. Score 7, operative management
. Score 3, non-operative management

Correct Answer & Explanation

. Score 2, non-operative management

Explanation

The TLICS score assigns 2 points for burst morphology, 0 points for intact neurology, and 0 points for an intact PLC, yielding a total score of 2. A score of 3 or less is an indication for non-operative management.

Question 535

Topic: Thoracolumbar Spine & Deformity

Which of the following represents the classic Sorensen radiographic criteria required for the diagnosis of typical Scheuermann's kyphosis?

. Anterior wedging of at least 5 degrees in 3 consecutive vertebrae
. Schmorl's nodes in at least 2 consecutive vertebrae
. Endplate irregularities in 5 consecutive vertebrae
. Thoracic kyphosis greater than 60 degrees
. Loss of intervertebral disc height in 2 non-consecutive vertebrae

Correct Answer & Explanation

. Anterior wedging of at least 5 degrees in 3 consecutive vertebrae

Explanation

The classic Sorensen criteria for Scheuermann's kyphosis require anterior wedging of 5 degrees or more in at least 3 consecutive thoracic vertebrae. Associated findings like Schmorl's nodes and endplate irregularities are common but not the defining strict criteria.

Question 536

Topic: Thoracolumbar Spine & Deformity

In the preoperative surgical planning for an adult spinal deformity, restoring sagittal balance is critical to improving clinical outcomes. The optimal postoperative lumbar lordosis (LL) should be matched to which of the following spinopelvic parameters?

. Pelvic tilt (PT)
. Sacral slope (SS)
. Pelvic incidence (PI) within 10 degrees
. Pelvic incidence (PI) within 25 degrees
. Sacral vertical axis (SVA)

Correct Answer & Explanation

. Pelvic incidence (PI) within 10 degrees

Explanation

Pelvic incidence (PI) is a fixed morphologic parameter. To achieve optimal sagittal balance, the lumbar lordosis (LL) must be matched to the pelvic incidence such that PI minus LL is less than 10 degrees.

Question 537

Topic: Thoracolumbar Spine & Deformity

When evaluating a patient with adult spinal deformity, achieving appropriate sagittal balance is a primary surgical goal. Which of the following spinopelvic parameter relationships correlates most closely with favorable health-related quality of life (HRQOL) scores?

. Pelvic incidence (PI) minus Lumbar lordosis (LL) < 10 degrees
. Pelvic tilt (PT) > 25 degrees
. Sacral slope (SS) < 20 degrees
. Thoracic kyphosis (TK) > 50 degrees
. Sagittal vertical axis (SVA) > 10 cm

Correct Answer & Explanation

. Pelvic incidence (PI) minus Lumbar lordosis (LL) < 10 degrees

Explanation

A PI-LL mismatch of less than 10 degrees is strongly correlated with improved HRQOL scores in adult spinal deformity patients. Other goals include a sagittal vertical axis (SVA) of < 5 cm and a pelvic tilt (PT) of < 20 degrees.

Question 538

Topic: Thoracolumbar Spine & Deformity

A 35-year-old man sustains an L1 burst fracture in a motor vehicle collision. He is neurologically intact. Radiographs and CT show 20 degrees of local kyphosis, 40% loss of anterior vertebral body height, and 30% retropulsion of the posterior cortex into the canal. The posterior ligamentous complex is intact on MRI. What is the most appropriate treatment?

. Strict bed rest for 6 weeks
. Thoracolumbosacral orthosis (TLSO) brace
. Anterior corpectomy and fusion
. Posterior pedicle screw fixation
. Laminectomy alone

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) brace

Explanation

In a neurologically intact patient with a stable burst fracture (intact posterior ligamentous complex), nonoperative management with a TLSO or hyperextension brace yields clinical outcomes equivalent to surgery. The degree of canal compromise does not strictly correlate with late neurologic deterioration.

Question 539

Topic: Thoracolumbar Spine & Deformity

A 15-year-old female gymnast complains of 6 months of low back pain that is exacerbated by extension activities. Radiographs demonstrate a pars interarticularis defect at L5 bilaterally and a 15% anterior translation of L5 on S1. Her neurologic examination is normal. What is the most appropriate initial management?

. In situ posterolateral fusion of L5-S1
. L5 laminectomy
. Activity modification, core strengthening, and physical therapy
. Transforaminal lumbar interbody fusion (TLIF)
. Epidural steroid injection

Correct Answer & Explanation

. Activity modification, core strengthening, and physical therapy

Explanation

This patient has a symptomatic Grade 1 isthmic spondylolisthesis. Initial management for low-grade, symptomatic isthmic spondylolisthesis in adolescents is nonoperative, focusing on activity modification (avoiding hyperextension) and core strengthening physical therapy.

Question 540

Topic: Thoracolumbar Spine & Deformity

A 35-year-old man falls from a height of 10 feet and sustains an L1 burst fracture. He is neurologically intact with normal perianal tone. MRI demonstrates an intact posterior ligamentous complex (PLC). His Thoracolumbar Injury Classification and Severity (TLICS) score is calculated. What is the most appropriate management?

. Short-segment posterior pedicle screw fixation
. Long-segment posterior pedicle screw fixation
. Anterior corpectomy and strut grafting
. Thoracolumbosacral orthosis (TLSO) bracing and early mobilization
. Posterolateral uninstrumented fusion in situ

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing and early mobilization

Explanation

This patient has a TLICS score of 2 (1 point for compression morphology, 0 for neurologically intact, 1 for intact PLC). A score of 3 or less is an absolute indication for nonoperative management, typically with a TLSO brace and early mobilization.

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