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Thoracolumbar Spine & Deformity MCQs

Practice Set 32 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 621

Topic: Thoracolumbar Spine & Deformity

When evaluating a 65-year-old female for adult spinal deformity correction, which of the following radiographic parameters correlates most strongly with an improvement in health-related quality of life (HRQOL) scores postoperatively?

. Thoracic kyphosis < 40 degrees
. Pelvic tilt > 25 degrees
. Pelvic incidence minus lumbar lordosis (PI-LL) < 10 degrees
. Sagittal vertical axis (SVA) > 10 cm
. Coronal Cobb angle < 10 degrees

Correct Answer & Explanation

. Thoracic kyphosis < 40 degrees

Explanation

Achieving a PI-LL mismatch of less than 10 degrees is a primary goal in adult spinal deformity surgery. Along with an SVA < 5 cm and Pelvic Tilt < 20 degrees, this strongly correlates with improved postoperative HRQOL.

Question 622

Topic: Thoracolumbar Spine & Deformity

According to the Thoracolumbar Injury Classification and Severity (TLICS) score, which of the following injury patterns warrants a score of 3 for the morphology category?

. Compression fracture
. Burst fracture
. Translation/rotation injury
. Distraction injury
. Transverse process fracture

Correct Answer & Explanation

. Compression fracture

Explanation

In the TLICS system, morphology is scored as follows: compression (1), burst (2), translation/rotation (3), and distraction (4). These points are added to neurologic status and posterior ligamentous complex integrity to guide operative vs nonoperative management.

Question 623

Topic: Thoracolumbar Spine & Deformity

Which of the following radiographic criteria is strictly required to confirm the diagnosis of classic Scheuermann's disease?

. Thoracic kyphosis greater than 60 degrees
. Anterior wedging of at least 5 degrees in 3 or more consecutive vertebrae
. Presence of Schmorl's nodes in at least 5 levels
. Lumbar lordosis greater than 50 degrees
. Apical vertebral rotation of Grade II

Correct Answer & Explanation

. Thoracic kyphosis greater than 60 degrees

Explanation

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

Question 624

Topic: Thoracolumbar Spine & Deformity

A 66-year-old female undergoes surgical planning for adult spinal deformity. Her pelvic incidence (PI) is measured at 62 degrees. To achieve optimal sagittal balance and minimize the risk of adjacent segment disease, what should be her approximate target for postoperative lumbar lordosis (LL)?

. 20 degrees
. 35 degrees
. 45 degrees
. 55 degrees
. 75 degrees

Correct Answer & Explanation

. 20 degrees

Explanation

The formula for sagittal balance dictates that lumbar lordosis (LL) should be matched to within 9-10 degrees of the pelvic incidence (PI). Therefore, a PI of 62 degrees requires an LL target of approximately 52 to 62 degrees.

Question 625

Topic: Thoracolumbar Spine & Deformity

Pelvic incidence (PI) is a fundamental morphologic parameter in adult spinal deformity evaluation. What is the correct mathematical relationship between PI, pelvic tilt (PT), and sacral slope (SS)?

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

Correct Answer & Explanation

. PI = PT + SS

Explanation

Pelvic incidence is a fixed anatomical parameter defined as the algebraic sum of pelvic tilt and sacral slope (PI = PT + SS). It dictates the required lumbar lordosis for a patient, typically targeted at PI ± 9 degrees.

Question 626

Topic: Thoracolumbar Spine & Deformity

According to the Thoracolumbar Injury Classification and Severity (TLICS) score, which of the following injury patterns strictly warrants surgical stabilization (score > 4)?

. Compression fracture with intact posterior ligamentous complex and normal neurology
. Burst fracture with indeterminate posterior ligamentous complex and normal neurology
. Burst fracture with complete disruption of the posterior ligamentous complex and normal neurology
. Transverse process fractures with normal neurology
. Spinous process fracture with intact neurology

Correct Answer & Explanation

. Compression fracture with intact posterior ligamentous complex and normal neurology

Explanation

A burst fracture (2 points) with posterior ligamentous complex disruption (3 points) yields a TLICS score of 5, which dictates operative management. A score of 4 can be treated operatively or non-operatively, while < 4 is managed non-operatively.

Question 627

Topic: Thoracolumbar Spine & Deformity

A 65-year-old woman presents with severe back pain and a progressive inability to stand up straight following a previous L4-S1 fusion. Radiographs reveal a pelvic incidence (PI) of 65 degrees and a lumbar lordosis (LL) of 20 degrees. If surgical correction is planned, what is the generally accepted target lumbar lordosis to optimize her sagittal alignment?

. 10 degrees
. 25 degrees
. 40 degrees
. 55 degrees
. 75 degrees

Correct Answer & Explanation

. 10 degrees

Explanation

For optimal sagittal balance, the lumbar lordosis (LL) should be matched to within 10 degrees of the pelvic incidence (PI). With a PI of 65 degrees, the target LL should be approximately 55 degrees to prevent flatback syndrome and adjacent segment disease.

Question 628

Topic: Thoracolumbar Spine & Deformity

A 40-year-old man falls from a height of 10 feet and sustains an L1 burst fracture. He is neurologically intact. MRI confirms an intact posterior ligamentous complex (PLC).

According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the score and recommended management?

. TLICS score of 2; nonoperative management
. TLICS score of 4; surgical management
. TLICS score of 4; operative or nonoperative management
. TLICS score of 5; surgical management
. TLICS score of 2; surgical management

Correct Answer & Explanation

. TLICS score of 2; nonoperative management

Explanation

The TLICS score assigns 2 points for a burst fracture morphology, 0 points for being neurologically intact, and 0 points for an intact PLC. A total score of 2 indicates nonoperative management with a brace.

Question 629

Topic: Thoracolumbar Spine & Deformity

Which of the following anatomical variations is most strongly associated with the development of a degenerative spondylolisthesis at L4-L5 rather than an isthmic spondylolisthesis?

. Pars interarticularis defect
. Coronal facet joint orientation
. Sagittally oriented facet joints
. Elongated pedicles
. Spina bifida occulta

Correct Answer & Explanation

. Pars interarticularis defect

Explanation

Degenerative spondylolisthesis most commonly occurs at L4-L5 and is strongly associated with sagittally oriented facet joints, which provide less resistance to anterior shear forces. Isthmic spondylolisthesis involves a pars interarticularis defect and is most common at L5-S1.

Question 630

Topic: Thoracolumbar Spine & Deformity

A 22-year-old woman is involved in a high-speed motor vehicle collision while wearing a lap belt. Radiographs show a flexion-distraction injury (Chance fracture) at L2. Which of the following concomitant injuries must be ruled out most urgently?

. Aortic dissection
. Hollow viscus injury
. Renal artery avulsion
. Diaphragmatic rupture
. Pelvic ring disruption

Correct Answer & Explanation

. Aortic dissection

Explanation

Chance fractures (flexion-distraction injuries) are frequently caused by lap seatbelts and have a high association (up to 40-50%) with intra-abdominal injuries, particularly hollow viscus (bowel) rupture. Urgent general surgery evaluation is required.

Question 631

Topic: Thoracolumbar Spine & Deformity

A 15-year-old boy presents with progressive mid-back pain and a noticeable rounding of his upper back. Standing lateral radiographs reveal a thoracic kyphosis of 65 degrees. According to the Sorensen criteria, what specific radiographic finding confirms the diagnosis of Scheuermann's kyphosis?

. Schmorl's nodes in at least 2 consecutive vertebrae
. Anterior wedging of ≥ 5 degrees in 3 or more consecutive vertebrae
. Thoracic kyphosis > 45 degrees resolving on a hyperextension bolster
. Pedicle narrowing in the apical thoracic vertebrae
. Intervertebral disc space widening at the apex of the deformity

Correct Answer & Explanation

. Schmorl's nodes in at least 2 consecutive vertebrae

Explanation

The classic Sorensen criteria define Scheuermann's disease radiographically as anterior wedging of 5 degrees or more in at least three consecutive vertebrae. Rigid kyphosis, Schmorl's nodes, and endplate irregularities are also supportive findings.

Question 632

Topic: Thoracolumbar Spine & Deformity

A 65-year-old female presents with severe neurogenic claudication and an L4-L5 degenerative spondylolisthesis as demonstrated on her MRI.

She has failed conservative management. Which of the following factors most strongly supports performing a decompression with fusion rather than an isolated decompression?

. Presence of severe mechanical back pain
. Sagittal orientation of the facet joints
. Preoperative dynamic instability >3 mm on flexion/extension radiographs
. A preoperative visual analog scale (VAS) leg pain score > 8
. Presence of a pars interarticularis defect

Correct Answer & Explanation

. Presence of severe mechanical back pain

Explanation

Decompression with fusion is indicated over decompression alone in degenerative spondylolisthesis when there is clear evidence of dynamic instability (e.g., >3 mm of translation on flexion/extension films) to prevent postoperative progression of the slip.

Question 633

Topic: Thoracolumbar Spine & Deformity

In the evaluation of adult spinal deformity, which of the following sagittal radiographic parameters correlates most closely with poor health-related quality of life (HRQOL) scores?

. Coronal Cobb angle > 40 degrees
. High pelvic incidence
. Sagittal vertical axis (SVA) > 5 cm
. Lumbar lordosis exceeding pelvic incidence by > 10 degrees
. Thoracic kyphosis < 20 degrees

Correct Answer & Explanation

. Coronal Cobb angle > 40 degrees

Explanation

Positive sagittal imbalance is the most critical driver of disability in adult spinal deformity. A Sagittal Vertical Axis (SVA) greater than 5 cm is the most reliable radiographic predictor of clinical symptoms and poor HRQOL outcomes.

Question 634

Topic: Thoracolumbar Spine & Deformity

A 68-year-old female presents with severe back pain and inability to stand upright. Radiographs reveal a pelvic incidence (PI) of 62 degrees, pelvic tilt (PT) of 35 degrees, and lumbar lordosis (LL) of 20 degrees. When planning a corrective osteotomy for this adult spinal deformity, achieving a PI-LL mismatch of less than which of the following values is most highly correlated with favorable health-related quality of life (HRQOL) scores?

. 10 degrees
. 20 degrees
. 30 degrees
. 40 degrees
. 50 degrees

Correct Answer & Explanation

. 10 degrees

Explanation

The primary goal of sagittal realignment in adult spinal deformity is to restore an optimal spino-pelvic relationship. Achieving a Pelvic Incidence minus Lumbar Lordosis (PI-LL) mismatch of less than 10 degrees is strongly associated with improved HRQOL outcomes.

Question 635

Topic: Thoracolumbar Spine & Deformity

A 40-year-old male sustains a T12 burst fracture from a fall. He is neurologically intact. MRI demonstrates definitive disruption of the posterior ligamentous complex (PLC). Using the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his total score and the corresponding treatment recommendation?

. 2 points; Nonoperative management
. 4 points; Surgeon preference for operative versus nonoperative management
. 5 points; Operative management
. 7 points; Operative management
. 3 points; Nonoperative management

Correct Answer & Explanation

. 2 points; Nonoperative management

Explanation

In the TLICS system, a burst fracture morphology scores 2 points, definitive PLC injury scores 3 points, and intact neurology scores 0 points, yielding a total of 5 points. A score of 5 or greater indicates operative management.

Question 636

Topic: Thoracolumbar Spine & Deformity

A 25-year-old man is involved in a motor vehicle accident. CT reveals a traumatic spondylolisthesis of the axis with C2 pars fractures. There is 4 mm of translation and 15 degrees of angulation of C2 on C3. What is the Levine-Edwards classification and the most appropriate initial management?

. Type I; rigid collar
. Type II; reduction with traction and halo vest
. Type IIA; reduction with traction and halo vest
. Type IIA; halo vest in slight extension (traction contraindicated)
. Type III; rigid collar

Correct Answer & Explanation

. Type I; rigid collar

Explanation

A Levine-Edwards Type IIA fracture is characterized by severe angulation with minimal translation. Cervical traction is strictly contraindicated as it can cause over-distraction and neurologic injury; management involves gentle extension and halo vest immobilization.

Question 637

Topic: Thoracolumbar Spine & Deformity

A 65-year-old woman presents with classic neurogenic claudication. Radiographs reveal a grade 1 degenerative spondylolisthesis at L4-L5 with intact pars interarticularis. Which anatomic factor is the primary stabilizer preventing the progression of this specific slip?

. The iliolumbar ligament
. The coronal orientation of the facet joints
. The robust intervertebral disc height
. The ligamentum flavum
. The sagittal orientation of the facet joints

Correct Answer & Explanation

. The iliolumbar ligament

Explanation

Sagittally oriented facet joints are a primary anatomic risk factor and determinant in the development and progression of degenerative spondylolisthesis, which most frequently occurs at the L4-L5 level.

Question 638

Topic: Thoracolumbar Spine & Deformity

A 45-year-old female presents with persistent, severe lower back and bilateral L5 radicular pain that has failed 6 months of conservative management. Radiographs demonstrate a Grade II isthmic spondylolisthesis at L5-S1. What is the most appropriate surgical intervention?

. L5 laminectomy and Gill procedure alone
. L5-S1 anterior lumbar interbody fusion (ALIF) without posterior instrumentation
. L5-S1 posterior decompression and instrumented posterolateral fusion
. Pars interarticularis repair (Buck's or Scott wiring)
. L4-S1 uninstrumented posterolateral fusion

Correct Answer & Explanation

. L5 laminectomy and Gill procedure alone

Explanation

In adult patients with symptomatic low-grade isthmic spondylolisthesis failing conservative care, the standard surgical treatment is decompression of the neural elements combined with an instrumented posterolateral fusion (with or without interbody fusion). Pars repair is generally reserved for young patients (under 20) with minimal slip.

Question 639

Topic: Thoracolumbar Spine & Deformity

A 22-year-old male is involved in a rugby tackle resulting in a neck injury. Lateral cervical radiographs demonstrate a unilateral facet dislocation at C5-C6. What is the typical radiographic appearance of a unilateral facet dislocation regarding vertebral body translation?

. Anterior translation of the superior vertebral body by less than 25% of the vertebral body width
. Anterior translation of the superior vertebral body by approximately 50% of the vertebral body width
. Posterior translation of the superior vertebral body by 25%
. Anterior translation of the superior vertebral body by greater than 75%
. No translation, only angular kyphosis

Correct Answer & Explanation

. Anterior translation of the superior vertebral body by less than 25% of the vertebral body width

Explanation

Unilateral facet dislocations typically exhibit less than 25% anterior translation of the superior vertebral body over the inferior body on lateral radiographs. Bilateral facet dislocations typically present with 50% or greater anterior translation.

Question 640

Topic: Thoracolumbar Spine & Deformity

A 50-year-old male undergoes posterior lumbar decompression and fusion for degenerative spondylolisthesis. When placing pedicle screws, understanding the pedicle anatomy is critical. What anatomical structure forms the medial border of the lumbar pedicle?

. The traversing nerve root
. The exiting nerve root
. The dural sac
. The superior articular process
. The pars interarticularis

Correct Answer & Explanation

. The traversing nerve root

Explanation

The medial border of the lumbar pedicle is adjacent to the dural sac. The superior border is the exiting nerve root, the inferior border is the traversing nerve root, and the lateral border is the paraspinal musculature and retroperitoneal space.

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