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Thoracolumbar Spine & Deformity MCQs

Practice Set 41 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 801

Topic: Thoracolumbar Spine & Deformity

In the assessment of spinopelvic parameters for a patient undergoing surgical correction for adult spinal deformity, Pelvic Incidence (PI) is considered a fixed morphological parameter once skeletal maturity is reached. PI is mathematically defined as the algebraic sum of which two parameters?

. Pelvic tilt + Lumbar lordosis
. Pelvic tilt + Sacral slope
. Sacral slope + Lumbar lordosis
. Thoracic kyphosis + Lumbar lordosis
. Sacral slope - Pelvic tilt

Correct Answer & Explanation

. Pelvic tilt + Lumbar lordosis

Explanation

Pelvic Incidence (PI) is a fundamental, fixed morphological parameter of the pelvis, defined as the angle between a line perpendicular to the sacral plate at its midpoint and a line connecting the same point to the center of the bicoxofemoral axis. Geometrically, PI is equal to the sum of Pelvic Tilt (PT) and Sacral Slope (SS). PI = PT + SS.

Question 802

Topic: Thoracolumbar Spine & Deformity

A 30-year-old construction worker falls from a height of 10 feet, sustaining an L1 burst fracture. Neurological examination is completely normal (intact). MRI demonstrates no disruption of the posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is this patient's total score?

. 0
. 2
. 4
. 5
. 7

Correct Answer & Explanation

. 0

Explanation

The TLICS score is calculated based on three categories: injury morphology, neurological status, and integrity of the PLC. For this patient: Morphology = Burst fracture (2 points); Neurological status = Intact (0 points); PLC = Intact (0 points). Total score = 2. A TLICS score of <= 3 suggests non-operative management, a score of 4 is indeterminate (operative vs. non-operative), and a score of >= 5 suggests operative management.

Question 803

Topic: Thoracolumbar Spine & Deformity

Which of the following describes the classic radiographic Sorensen criteria for the diagnosis of classic Scheuermann's Kyphosis?

. Anterior wedging of >= 5 degrees in 2 consecutive vertebrae
. Anterior wedging of >= 5 degrees in 3 consecutive vertebrae
. Anterior wedging of >= 10 degrees in 2 consecutive vertebrae
. Anterior wedging of >= 10 degrees in 3 consecutive vertebrae
. Schmorl's nodes in 5 consecutive vertebrae

Correct Answer & Explanation

. Anterior wedging of >= 5 degrees in 2 consecutive vertebrae

Explanation

The classic Sorensen criteria for the diagnosis of Scheuermann's Kyphosis requires structural kyphosis characterized by anterior wedging of 5 degrees or more in at least 3 adjacent (consecutive) vertebrae. Other common but non-diagnostic radiographic findings include Schmorl's nodes, endplate irregularities, and disc space narrowing.

Question 804

Topic: Thoracolumbar Spine & Deformity

A neurologically intact 30-year-old male presents with back pain after a fall from a height of 10 feet. CT and MRI demonstrate an L1 burst fracture with 40% loss of vertebral body height, 15 degrees of kyphosis, and 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 treatment with a TLSO brace
. Score 4; operative or non-operative treatment depending on surgeon preference
. Score 5; operative posterior spinal fusion
. Score 7; operative anterior corpectomy and fusion
. Score 2; operative posterior spinal fusion

Correct Answer & Explanation

. Score 2; non-operative treatment with a TLSO brace

Explanation

The TLICS score assigns points based on three categories: injury morphology, integrity of the PLC, and neurologic status. This patient has a burst fracture morphology (2 points), an intact PLC (0 points), and is neurologically intact (0 points), for a total TLICS score of 2. A score of <= 3 is a recommendation for non-operative management (e.g., TLSO brace). A score of >= 5 indicates operative management, and a score of 4 can be managed either operatively or non-operatively.

Question 805

Topic: Thoracolumbar Spine & Deformity

A 14-year-old female gymnast complains of insidious onset, mechanical lower back pain over the last 3 months. Plain radiographs of the lumbar spine are completely normal. However, an MRI reveals hyperintense signal (bone marrow edema) in the pars interarticularis of L5 bilaterally on T2/STIR sequences, with no discrete fracture line visible on CT. What is the most appropriate initial management?

. Direct pars repair with pedicle screw and sublaminar wire (Scott wiring)
. L5-S1 anterior lumbar interbody fusion (ALIF)
. Restriction of sports and application of a TLSO brace
. Diagnostic bilateral L5 pars injections
. Observation and immediate continuation of gymnastics

Correct Answer & Explanation

. Direct pars repair with pedicle screw and sublaminar wire (Scott wiring)

Explanation

This patient has an acute/early stress reaction of the pars interarticularis (early spondylolysis) before a true cortical defect has formed, indicated by isolated marrow edema on MRI and negative plain films/CT. This stage has a very high potential for complete bony healing if treated aggressively with rest and immobilization. The standard of care is immediate restriction from offending sports (gymnastics) and bracing (e.g., TLSO or Boston brace) until symptoms resolve and serial imaging confirms healing. Surgical repair is reserved for chronic, symptomatic defects that fail 6 months of non-operative management.

Question 806

Topic: Thoracolumbar Spine & Deformity

A 30-year-old male sustains a T12 burst fracture in a fall. He is neurologically intact. Imaging shows a 25% loss of vertebral body height, 15 degrees of local kyphosis, and an intact posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his total score?

. TLICS 2
. TLICS 3
. TLICS 4
. TLICS 5
. TLICS 7

Correct Answer & Explanation

. TLICS 2

Explanation

The TLICS score assigns points for morphology (Burst = 2), neurologic status (Intact = 0), and PLC integrity (Intact = 0). A total score of 2 generally warrants non-operative management.

Question 807

Topic: Thoracolumbar Spine & Deformity

A 15-year-old male presents with thoracic back pain and a prominent, rigid thoracic kyphosis. Radiographs are obtained to evaluate for Scheuermann's disease. According to Sorensen's criteria, the radiographic diagnosis requires anterior wedging of at least how many degrees in how many consecutive vertebrae?

. 3 degrees in 2 consecutive vertebrae
. 5 degrees in 2 consecutive vertebrae
. 5 degrees in 3 consecutive vertebrae
. 10 degrees in 2 consecutive vertebrae
. 10 degrees in 3 consecutive vertebrae

Correct Answer & Explanation

. 3 degrees in 2 consecutive vertebrae

Explanation

Sorensen's criteria define classical Scheuermann's kyphosis as structural anterior wedging of 5 degrees or more in at least 3 consecutive thoracic vertebrae.

Question 808

Topic: Thoracolumbar Spine & Deformity

In surgical planning for adult spinal deformity, achieving specific spinopelvic parameters is highly correlated with improved Health-Related Quality of Life (HRQOL) outcomes. According to the SRS-Schwab classification, which of the following represents an optimal alignment goal?

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

Correct Answer & Explanation

. Sagittal Vertical Axis (SVA) < 10 cm

Explanation

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

Question 809

Topic: Thoracolumbar Spine & Deformity

A 30-year-old male falls from a height of 10 feet. CT demonstrates an L1 burst fracture. His neurological examination is completely normal. MRI confirms that the posterior ligamentous complex (PLC) is intact. What is his Thoracolumbar Injury Classification and Severity (TLICS) score, and what is the recommended treatment?

. TLICS Score 2, recommend non-operative management
. TLICS Score 4, recommend operative management
. TLICS Score 5, recommend operative management
. TLICS Score 2, recommend operative management
. TLICS Score 4, recommend non-operative management

Correct Answer & Explanation

. TLICS Score 2, recommend non-operative management

Explanation

The TLICS score is 2 (Burst fracture morphology = 2, intact PLC = 0, neurologically intact = 0). A TLICS score of 3 or less is generally an indication for non-operative management.

Question 810

Topic: Thoracolumbar Spine & Deformity

A 14-year-old gymnast presents with an L5-S1 isthmic spondylolisthesis with a 20% slip (Meyerding Grade I). She has severe, mechanically limiting back pain that has failed 6 months of comprehensive conservative management. Which of the following is the most appropriate surgical intervention?

. L5-S1 anterior lumbar interbody fusion (ALIF) standalone
. Direct pars interarticularis repair
. L5-S1 posterior instrumented fusion
. L5 laminectomy without fusion
. L4-S1 posterior instrumented fusion

Correct Answer & Explanation

. L5-S1 anterior lumbar interbody fusion (ALIF) standalone

Explanation

For a symptomatic low-grade isthmic spondylolisthesis failing conservative care in an adolescent, L5-S1 posterior instrumented fusion is the gold standard. Direct pars repair is generally reserved for young patients with acute pars defects and no significant slip or disc degeneration.

Question 811

Topic: Thoracolumbar Spine & Deformity
A 14-year-old gymnast presents with severe lower back pain and radicular pain in the L5 distribution. Radiographs demonstrate a Grade III L5-S1 isthmic spondylolisthesis. The surgeon is planning reduction and fusion. Which nerve root is at highest risk of injury during the surgical reduction of this high-grade slip?
. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L5

Explanation

During the reduction of a high-grade L5-S1 spondylolisthesis, the L5 nerve root is placed under significant tension and is at the highest risk of stretch injury. Many surgeons opt for in situ fusion or partial reduction to minimize this specific neurological risk.

Question 812

Topic: Thoracolumbar Spine & Deformity

A 12-year-old girl with a high-grade isthmic spondylolisthesis (Meyerding Grade IV) at L5-S1 undergoes surgical reduction and instrumented fusion. Postoperatively, she develops new-onset weakness in ankle dorsiflexion and extensor hallucis longus function. Injury to which nerve root is most likely responsible?

. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L4

Explanation

The L5 nerve root is at the greatest risk for traction injury during the reduction of a high-grade L5-S1 spondylolisthesis. This typically presents with weakness in ankle dorsiflexion and great toe extension.

Question 813

Topic: Thoracolumbar Spine & Deformity

A 14-year-old gymnast presents with persistent low back pain exacerbated by extension. Oblique radiographs demonstrate a "collar on the Scotty dog" at L5. If the patient has a grade 2 isthmic spondylolisthesis, what defines a grade 2 slip according to the Meyerding classification?

. 0-25% translation
. 26-50% translation
. 51-75% translation
. 76-100% translation
. >100% translation (spondyloptosis)

Correct Answer & Explanation

. 0-25% translation

Explanation

The Meyerding classification categorizes spondylolisthesis based on the percentage of forward translation of the superior vertebral body over the inferior one. Grade 2 corresponds to 26% to 50% translation.

Question 814

Topic: Thoracolumbar Spine & Deformity

When preparing the entry point for a thoracic pedicle screw, the standard anatomic landmark is best described as the intersection of the:

. Mid-portion of the facet joint and the superior border of the transverse process
. Lateral border of the superior articular facet and the midline of the transverse process
. Medial border of the superior articular facet and the inferior border of the transverse process
. Lateral border of the pars interarticularis and superior border of the lamina
. Spinous process and the inferior articular facet

Correct Answer & Explanation

. Mid-portion of the facet joint and the superior border of the transverse process

Explanation

The standard free-hand entry point for a thoracic pedicle screw is located at the intersection of the lateral border of the superior articular facet and a line bisecting the transverse process (midline of the transverse process).

Question 815

Topic: Thoracolumbar Spine & Deformity

A 14-year-old gymnast presents with lower back pain exacerbated by extension. Radiographs show a grade II spondylolisthesis at L5-S1. What is the most likely pathological mechanism?

. Repetitive stress causing pars interarticularis microfractures
. Degenerative changes of the facet joints
. Congenital dysplastic facets
. Traumatic fracture of the pedicle
. Pathological fracture from an underlying cyst

Correct Answer & Explanation

. Repetitive stress causing pars interarticularis microfractures

Explanation

Isthmic spondylolisthesis in young athletes (especially gymnasts and football linemen) is typically due to repetitive hyperextension leading to stress fractures of the pars interarticularis (spondylolysis) which may progress to spondylolisthesis.

Question 816

Topic: Thoracolumbar Spine & Deformity

A 35-year-old male falls from a height and sustains an L1 burst fracture. He is neurologically intact. Radiographs and CT show 20 degrees of kyphosis, 50% loss of vertebral body height, and 40% canal compromise. What is the most appropriate initial treatment?

. Anterior corpectomy and fusion
. Posterior spinal instrumentation and fusion
. TLSO brace and early mobilization
. Bed rest for 6 weeks followed by bracing
. Laminectomy and short-segment fusion

Correct Answer & Explanation

. Anterior corpectomy and fusion

Explanation

Neurologically intact patients with thoracolumbar burst fractures and stable posterior ligamentous complexes can typically be treated non-operatively with a TLSO brace. Canal compromise itself (even up to 50%) will frequently remodel, and without neurological deficit or severe kyphosis (>30 degrees), nonoperative management is the standard of care.

Question 817

Topic: Thoracolumbar Spine & Deformity
A 16-year-old boy presents with an increasingly prominent mid-back curvature and aching pain after prolonged sitting. Lateral radiographs reveal a thoracic kyphosis of 65 degrees. What radiographic finding is necessary to confirm the diagnosis of Scheuermann's disease?
. Spondylolysis at the L5 pars interarticularis
. Anterior wedging of ≥5 degrees in 3 consecutive vertebrae
. Decreased interpedicular distance
. Complete absence of the pedicles (winking owl sign)
. Calcification of the anterior longitudinal ligament

Correct Answer & Explanation

. Anterior wedging of ≥5 degrees in 3 consecutive vertebrae

Explanation

Sorensen's criteria for the diagnosis of Scheuermann's kyphosis require the presence of structural kyphosis > 45 degrees, and anterior wedging of at least 5 degrees in 3 or more consecutive vertebral bodies.

Question 818

Topic: Thoracolumbar Spine & Deformity

In evaluating a patient for adult spinal deformity correction, which of the following spinopelvic parameters is morphological, established at skeletal maturity, and remains fixed regardless of patient positioning or pelvic retroversion?

. Pelvic Tilt (PT)
. Sacral Slope (SS)
. Pelvic Incidence (PI)
. Lumbar Lordosis (LL)
. Sagittal Vertical Axis (SVA)

Correct Answer & Explanation

. Pelvic Tilt (PT)

Explanation

Pelvic Incidence (PI) is a morphological parameter that describes the anatomical relationship between the sacrum and the pelvis. It is calculated as the sum of Pelvic Tilt (PT) and Sacral Slope (SS). Because the sacroiliac joint is essentially immobile, PI becomes fixed at skeletal maturity and does not change with posture, making it the fundamental baseline measurement when calculating target lumbar lordosis (LL) during deformity correction (goal PI-LL mismatch < 10 degrees).

Question 819

Topic: Thoracolumbar Spine & Deformity

A 14-year-old gymnast presents with chronic low back pain. Conservative management for 6 months has failed.

Radiographs demonstrate a Grade II isthmic spondylolisthesis at L5-S1. What is the recommended surgical treatment?

. L5-S1 anterior lumbar interbody fusion without posterior fixation
. L5-S1 laminectomy and bilateral foraminal decompression alone
. Direct pars interarticularis repair (e.g., Buck's or Scott wiring)
. L5-S1 posterior instrumented fusion
. L4-S1 posterior instrumented fusion to ensure adequate stabilization

Correct Answer & Explanation

. L5-S1 anterior lumbar interbody fusion without posterior fixation

Explanation

For pediatric or adolescent patients with a symptomatic Grade I or II isthmic spondylolisthesis failing conservative management, the gold standard treatment is an in-situ or partially reduced L5-S1 posterior instrumented fusion (with or without interbody support). Direct pars repairs are generally reserved for L1-L4 defects or very early-stage L5 defects with minimal to no slip, not for a Grade II slip. Laminectomy alone would further destabilize the spine.

Question 820

Topic: Thoracolumbar Spine & Deformity

A 19-year-old female is involved in a high-speed motor vehicle collision wearing only a lap belt. Radiographs show a transverse fracture through the spinous process, pedicles, and vertebral body of L2. Based on the mechanism of injury, what is the most commonly associated concomitant pathology?

. Traumatic aortic transection
. Intra-abdominal hollow viscus injury
. Diaphragmatic rupture
. Pneumothorax
. Closed head injury

Correct Answer & Explanation

. Traumatic aortic transection

Explanation

The patient has a Chance fracture, which is a flexion-distraction injury classically associated with lap-belt use in motor vehicle collisions. These injuries are highly associated with concurrent intra-abdominal pathology (up to 40-50% of cases), particularly traumatic rupture or ischemia of hollow viscera (e.g., small bowel). A high index of suspicion and general surgery evaluation is critical.

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