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Thoracolumbar Spine & Deformity MCQs

Practice Set 3 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 41

Topic: Thoracolumbar Spine & Deformity

When surgically correcting adult spinal deformity, which of the following postoperative spino-pelvic parameters is associated with the best health-related quality of life (HRQOL) scores according to the SRS-Schwab criteria?

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

Correct Answer & Explanation

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

Explanation

The SRS-Schwab criteria for optimal HRQOL outcomes include a Sagittal Vertical Axis (SVA) < 5 cm, Pelvic Tilt (PT) < 20 degrees, and a PI-LL mismatch of < 10 degrees.

Question 42

Topic: Thoracolumbar Spine & Deformity

A 65-year-old patient presents with a progressive positive sagittal vertical axis (SVA). Which of the following represents the body's initial primary compensatory mechanism to maintain horizontal gaze and standing balance?

. Knee flexion
. Hip flexion
. Pelvic retroversion (increased pelvic tilt)
. Cervical kyphosis
. Thoracic hyperkyphosis

Correct Answer & Explanation

. Pelvic retroversion (increased pelvic tilt)

Explanation

The initial compensatory mechanism for a positive SVA is pelvic retroversion, which manifests radiographically as an increased Pelvic Tilt (PT). As this mechanism exhausts, patients subsequently resort to knee flexion and hip extension.

Question 43

Topic: Thoracolumbar Spine & Deformity

In patients with developmental L5-S1 high-grade spondylolisthesis, which spino-pelvic parameter is characteristically significantly elevated compared to the normal population?

. Pelvic Tilt
. Sacral Slope
. Pelvic Incidence
. Thoracic Kyphosis
. C7 SVA

Correct Answer & Explanation

. Pelvic Incidence

Explanation

Patients with isthmic or dysplastic spondylolisthesis characteristically have a high Pelvic Incidence (PI). A higher PI leads to greater sacral slope and higher shear forces at the lumbosacral junction, predisposing to slip progression.

Question 44

Topic: Thoracolumbar Spine & Deformity
What is the formula for the target lumbar lordosis (LL) based on pelvic incidence (PI) to minimize the risk of adjacent segment disease and sagittal imbalance?
. LL = PI + 20 degrees
. LL = PI ± 10 degrees
. LL = PI / 2
. LL = PT + SS
. LL = PI - 20 degrees

Correct Answer & Explanation

. LL = PI ± 10 degrees

Explanation

To maintain harmonious sagittal balance and reduce the risk of adjacent segment breakdown, the target lumbar lordosis should ideally be within 10 degrees of the patient's fixed pelvic incidence (PI - LL ≤ 10 degrees).

Question 45

Topic: Thoracolumbar Spine & Deformity

A 45-year-old falls from a height and sustains an L1 burst fracture. MRI demonstrates an intact posterior ligamentous complex (PLC) and the patient has no neurologic deficit. According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the patient's score and recommended management?

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

Correct Answer & Explanation

. TLICS 2, non-operative management

Explanation

The TLICS system assigns 2 points for a burst fracture morphology, 0 points for an intact PLC, and 0 points for an intact neurologic status, totaling 2 points. A score of 3 or less is an indication for non-operative management.

Question 46

Topic: Thoracolumbar Spine & Deformity

A 30-year-old involved in a motor vehicle accident sustains a flexion-distraction injury (Chance fracture) at L2. Which of the following concomitant injuries is most highly associated with this fracture pattern?

. Aortic transection
. Gastrointestinal tract injury
. Splenic rupture
. Bladder rupture
. Renal avulsion

Correct Answer & Explanation

. Gastrointestinal tract injury

Explanation

Chance fractures are caused by a flexion-distraction mechanism, commonly associated with lap seatbelts. They have a high association (up to 40-50%) with intra-abdominal injuries, particularly hollow viscus and mesenteric tears.

Question 47

Topic: Thoracolumbar Spine & Deformity

A 14-year-old competitive gymnast complains of chronic, localized lower back pain that worsens with extension. Radiographs reveal a pars interarticularis defect at L5 without anterior slippage. What is the correct terminology for this condition?

. Spondylosis
. Spondylolysis
. Spondylolisthesis
. Spondyloptosis
. Spondyloarthropathy

Correct Answer & Explanation

. Spondylolysis

Explanation

Spondylolysis refers specifically to a defect or stress fracture in the pars interarticularis. If anterior translation (slippage) of the vertebral body occurs as a result, it becomes isthmic spondylolisthesis.

Question 48

Topic: Thoracolumbar Spine & Deformity

Which of the following radiographic parameters is the most important biomechanical predictor of adjacent segment disease following a multi-level lumbar fusion?

. Failure to restore sagittal lumbar lordosis
. Use of pedicle screws larger than 6.5mm in diameter
. The specific choice of interbody graft material
. Preoperative disc space height at the adjacent level
. Presence of lumbar scoliosis less than 10 degrees

Correct Answer & Explanation

. Failure to restore sagittal lumbar lordosis

Explanation

Sagittal imbalance, specifically the failure to restore physiological lumbar lordosis matching the patient's pelvic incidence, significantly increases mechanical stress on adjacent segments. This is a primary driver of adjacent segment degeneration.

Question 49

Topic: Thoracolumbar Spine & Deformity
A 14-year-old gymnast presents with lower back pain. Radiographs reveal a pars interarticularis defect at L5 with 35% forward 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 II

Explanation

The Meyerding classification grades spondylolisthesis based on the percentage of forward slip: Grade I (0-25%), Grade II (26-50%), Grade III (51-75%), and Grade IV (76-100%). A 35% slip falls into the Grade II category.

Question 50

Topic: Thoracolumbar Spine & Deformity

A 15-year-old male athlete presents with axial lower back pain. Imaging confirms an acute, bilateral L5 pars interarticularis defect (spondylolysis) without spondylolisthesis. What is the initial recommended treatment?

. Immediate L5-S1 in situ posterolateral fusion
. Pars interarticularis repair (Buck's procedure)
. Restriction from sports and use of an antilordotic brace
. Epidural steroid injections
. Total disc replacement

Correct Answer & Explanation

. Restriction from sports and use of an antilordotic brace

Explanation

Acute, symptomatic spondylolysis in an adolescent athlete is initially managed non-operatively. Treatment consists of rest, restriction from athletic activities, and typically an antilordotic (TLSO) brace until the patient is pain-free.

Question 51

Topic: Thoracolumbar Spine & Deformity

A 25-year-old man sustains a flexion-distraction injury (Chance fracture) of L1 during a motor vehicle collision. What is the most common associated non-orthopedic injury in this setting?

. Aortic tear
. Small bowel or hollow viscus injury
. Splenic rupture
. Renal contusion
. Diaphragmatic hernia

Correct Answer & Explanation

. Small bowel or hollow viscus injury

Explanation

Chance fractures, or flexion-distraction injuries, are frequently caused by lap seatbelts and are highly associated with intra-abdominal injuries, particularly hollow viscus and small bowel ruptures. A high index of suspicion and general surgery consultation are essential.

Question 52

Topic: Thoracolumbar Spine & Deformity

A 34-year-old patient has a T12 burst fracture. On evaluation, the patient is neurologically intact, and MRI confirms an intact posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity Score (TLICS), what is the total score and recommended management?

. TLICS score 2; Nonoperative management with a brace
. TLICS score 4; Posterior spinal fusion
. TLICS score 5; Anterior corpectomy
. TLICS score 6; Short segment percutaneous fixation
. TLICS score 3; Laminectomy

Correct Answer & Explanation

. TLICS score 2; Nonoperative management with a brace

Explanation

The patient scores 2 points for a burst fracture, 0 points for being neurologically intact, and 0 points for an intact PLC, yielding a TLICS score of 2. A score of 3 or less is an indication for nonoperative management, typically with an orthosis.

Question 53

Topic: Thoracolumbar Spine & Deformity

In a pediatric patient with an L5-S1 isthmic spondylolisthesis, which of the following radiographic parameters is considered the strongest predictor of slip progression?

. Pelvic incidence
. High slip angle
. Sacral slope
. Decreased lumbar lordosis
. Grade of the initial slip alone

Correct Answer & Explanation

. High slip angle

Explanation

A high slip angle (kyphosis at the lumbosacral junction) is the strongest predictor of progression in isthmic spondylolisthesis. It reflects the local destabilizing shear forces acting on the L5-S1 motion segment.

Question 54

Topic: Thoracolumbar Spine & Deformity

In an adult patient with degenerative lumbar scoliosis, which of the following radiographic parameters is the strongest predictor of future curve progression?

. Cobb angle > 30 degrees with apical rotation > Grade II
. Thoracic hyperkyphosis > 40 degrees
. Intervertebral disc height loss > 50%
. Pelvic tilt < 10 degrees
. L5-S1 facet arthropathy

Correct Answer & Explanation

. Cobb angle > 30 degrees with apical rotation > Grade II

Explanation

Risk factors for progression in adult degenerative scoliosis include a Cobb angle > 30 degrees, apical vertebral rotation greater than Grade II, lateral listhesis > 6 mm, and the L5 vertebral body seated above the intercrestal line.

Question 55

Topic: Thoracolumbar Spine & Deformity

In sagittal balance evaluation of the spine, the pelvic incidence (PI) is a constant morphological parameter. Which of the following accurately describes the relationship between pelvic incidence, pelvic tilt (PT), and sacral slope (SS)?

. PI = PT - SS
. PI = SS - PT
. PI = PT + SS
. PI = (PT + SS) / 2
. PI = PT x SS

Correct Answer & Explanation

. PI = PT + SS

Explanation

Pelvic incidence is an anatomical constant for each individual and is defined as the sum of the pelvic tilt and the sacral slope (PI = PT + SS). It dictates the amount of lumbar lordosis required to maintain sagittal balance.

Question 56

Topic: Thoracolumbar Spine & Deformity

A 12-year-old boy restrained by a lap belt sustains a flexion-distraction injury (Chance fracture) of L2 during a motor vehicle collision. Which of the following associated injuries has the highest incidence in this scenario?

. Aortic transection
. Renal artery thrombosis
. Hollow viscus organ injury
. Pulmonary contusion
. Splenic rupture

Correct Answer & Explanation

. Hollow viscus organ injury

Explanation

Lap-belt flexion-distraction injuries (Chance fractures) are highly associated with concurrent intra-abdominal injuries, most commonly hollow viscus gastrointestinal tears. Up to 40% of patients with this fracture pattern will have an associated abdominal injury.

Question 57

Topic: Thoracolumbar Spine & Deformity

A 35-year-old female presents with an L1 burst fracture following a fall. She is neurologically intact. MRI demonstrates an intact posterior ligamentous complex (PLC). Based on the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the total score and recommended treatment?

. Score 2, non-operative management
. Score 3, non-operative management
. Score 4, surgeon's preference
. Score 5, operative management
. Score 7, operative management

Correct Answer & Explanation

. Score 2, non-operative management

Explanation

In the TLICS system, a burst fracture is scored 2 points for morphology. An intact neurologic status is 0 points, and an intact PLC is 0 points, yielding a total score of 2 which indicates non-operative management.

Question 58

Topic: Thoracolumbar Spine & Deformity

Which of the following is the most common type of spondylolisthesis seen in the adult population:

. Degenerative
. Isthmic
. C ongenital
. Traumatic
. Pathologic

Correct Answer & Explanation

. Degenerative

Explanation

The prevalence of degenerative spondylolisthesis is 2% to 5%; the prevalence increases with age. Symptomatic patients usually present in the fourth decade of life or later. The disease is five times more common in the female sex. The African American population, diabetics, and patients with sacralization of the L5 vertebrae are also at increased risk for developing symptomatic spondylolisthesis.

Question 59

Topic: Thoracolumbar Spine & Deformity

Which of the following is the most common location of adult degenerative spondylolisthesis:

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

Correct Answer & Explanation

. L4-L5 interspace

Explanation

The L4-L5 interspace is the most common location of adult degenerative spondylolisthesis.

Question 60

Topic: Thoracolumbar Spine & Deformity

Which of the following statements is true regarding lumbar degenerative scoliosis:

. Lumbar degenerative scoliosis is most commonly distributed to the left.
. Lumbar degenerative scoliosis is most commonly distributed to the right.
. Lumbar degenerative scoliosis is most commonly evenly distributed between left and right.
. The distribution of lumbar degenerative scoliosis depends on age of patient at the time of onset.
. No data are available.

Correct Answer & Explanation

. Lumbar degenerative scoliosis is most commonly evenly distributed between left and right.

Explanation

Degenerative lumbar scoliosis occurs in approximately the same number of women as men. Lumbar curves are generally smaller than those in idiopathic scoliosis and are more evenly distributed between left and right, also in contrast to idiopathic curves that occur predominantly to the left.

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