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Thoracolumbar Spine & Deformity MCQs

Practice Set 42 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 821

Topic: Thoracolumbar Spine & Deformity

According to the Thoracolumbar Injury Classification and Severity Score (TLICS), which of the following cumulative scores serves as a definitive indication for operative management?

. A score of 2
. A score of 3
. A score of 4
. A score of 5 or greater
. TLICS relies solely on neurological status, not a cumulative score

Correct Answer & Explanation

. A score of 2

Explanation

The TLICS system guides treatment of thoracolumbar trauma based on morphology, neurological status, and the integrity of the posterior ligamentous complex (PLC). A score of 3 or less is typically treated non-operatively. A score of 4 is indeterminate and depends on surgeon preference/patient factors. A score of 5 or greater is a strong indication for operative stabilization.

Question 822

Topic: Thoracolumbar Spine & Deformity

A 35-year-old man falls from a 10-foot ladder. Imaging reveals an L1 burst fracture with widening of the interspinous distance, indicating a definite posterior ligamentous complex (PLC) disruption. He is neurologically intact. According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the score and appropriate management?

. TLICS is 2; conservative management
. TLICS is 3; conservative management
. TLICS is 5; operative management
. TLICS is 7; operative management
. TLICS is 1; conservative management

Correct Answer & Explanation

. TLICS is 2; conservative management

Explanation

The TLICS score is calculated as follows: Burst fracture morphology (2 points) + definite PLC injury (3 points) + neurologically intact (0 points) = 5 points. A score of 5 or greater is an indication for operative management.

Question 823

Topic: Thoracolumbar Spine & Deformity

In an adult patient presenting with an L5-S1 isthmic spondylolisthesis and unilateral radicular leg pain, which nerve root is most commonly compressed, and what is the primary anatomical site of this compression?

. L4 traversing root in the central canal
. L5 traversing root in the lateral recess
. L5 exiting root in the neural foramen
. S1 traversing root in the lateral recess
. S1 exiting root in the neural foramen

Correct Answer & Explanation

. L4 traversing root in the central canal

Explanation

In L5-S1 isthmic spondylolisthesis, the L5 exiting nerve root is most commonly compressed. The compression typically occurs in the neural foramen due to the pars interarticularis pseudarthrosis and hypertrophic fibrocartilage.

Question 824

Topic: Thoracolumbar Spine & Deformity

A 35-year-old male falls from a ladder and sustains an L1 burst fracture. He is neurologically intact. MRI confirms the posterior ligamentous complex (PLC) is completely intact. According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the best initial management?

. Urgent posterior spinal instrumented fusion
. Anterior corpectomy and stabilization
. Thoracolumbosacral orthosis (TLSO) bracing and early mobilization
. Strict bed rest for 8 weeks
. Laminectomy alone

Correct Answer & Explanation

. Urgent posterior spinal instrumented fusion

Explanation

The TLICS score for this patient is 2 (Morphology: Burst = 2, Neuro: Intact = 0, PLC: Intact = 0). A score of 3 or less indicates non-operative management, making a TLSO brace the most appropriate choice.

Question 825

Topic: Thoracolumbar Spine & Deformity

In the surgical planning for an adult patient with severe sagittal imbalance, achieving proper spinopelvic parameters is critical to postoperative clinical success. What is the universally accepted target for the mismatch between Pelvic Incidence (PI) and Lumbar Lordosis (LL)?

. PI-LL mismatch < 10 degrees
. PI-LL mismatch between 15 and 25 degrees
. PI-LL mismatch > 30 degrees
. LL should be exactly twice the PI
. PI should be less than 30 degrees regardless of LL

Correct Answer & Explanation

. PI-LL mismatch < 10 degrees

Explanation

In adult spinal deformity correction, restoring global sagittal balance correlates with improved clinical outcomes. The ideal postoperative target is a Pelvic Incidence to Lumbar Lordosis (PI-LL) mismatch of less than 10 degrees.

Question 826

Topic: Thoracolumbar Spine & Deformity

A 19-year-old female presents after a high-speed collision where she was wearing only a lap seatbelt. Imaging reveals a Chance fracture of L1. What concomitant injury must be highly suspected and urgently ruled out?

. Traumatic aortic dissection
. Intra-abdominal hollow viscus injury
. Bilateral diaphragmatic rupture
. Tension pneumothorax
. Renal artery avulsion

Correct Answer & Explanation

. Traumatic aortic dissection

Explanation

Chance fractures are flexion-distraction injuries commonly associated with lap seatbelt use. They carry a 40-50% incidence of concurrent intra-abdominal hollow viscus injuries (e.g., bowel perforations), which must be urgently evaluated.

Question 827

Topic: Thoracolumbar Spine & Deformity

A 68-year-old female is undergoing primary total hip arthroplasty. Preoperative standing and seated lateral spinopelvic radiographs reveal a change in pelvic tilt of only 4 degrees between standing and sitting, secondary to prior long-segment lumbar fusion. To minimize her risk of postoperative dislocation, how should the acetabular component positioning be adjusted relative to the standard Lewinnek 'safe zone'?

. Decreased anteversion and decreased inclination
. Increased anteversion and increased inclination
. Standard safe zone positioning (15 degrees anteversion, 40 degrees inclination)
. Decreased anteversion and increased inclination
. Increased anteversion and decreased inclination

Correct Answer & Explanation

. Decreased anteversion and decreased inclination

Explanation

Patients with a stiff spinopelvic junction (change in pelvic tilt < 10 degrees from stand to sit) fail to undergo the normal posterior pelvic tilt when sitting. Normally, posterior tilt increases functional acetabular anteversion, allowing clearance for the flexed femur. Without this compensatory mechanism, the patient is at a high risk for anterior impingement and subsequent posterior dislocation when seated. To compensate for a stiff spinopelvic junction, the acetabular component must be placed in relatively higher anteversion and inclination than the standard safe zone.

Question 828

Topic: Thoracolumbar Spine & Deformity

A 35-year-old male construction worker falls 10 feet from scaffolding. He complains of moderate low back pain but has full strength and normal sensation in his lower extremities.

CT imaging shows an L1 burst fracture with 40% loss of anterior vertebral body height and 50% retropulsion into the spinal canal. MRI confirms that the posterior ligamentous complex (PLC) is intact. Based on the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the appropriate score and recommended management?

. 2 points; nonoperative management
. 4 points; surgeon's choice
. 5 points; operative management
. 6 points; operative management
. 7 points; operative management

Correct Answer & Explanation

. 2 points; nonoperative management

Explanation

The TLICS system scores injuries based on three categories: morphology, neurologic status, and integrity of the posterior ligamentous complex (PLC). A burst fracture scores 2 points for morphology. A neurologically intact patient scores 0 points. An intact PLC scores 0 points. The total TLICS score is 2. A score of 3 or less indicates nonoperative management (e.g., bracing/mobilization).

Question 829

Topic: Thoracolumbar Spine & Deformity

A 16-year-old elite male gymnast complains of chronic low back pain that is distinctly worse with spinal extension. He has failed 6 months of rest, physical therapy, and bracing.

Radiographs demonstrate a Grade II L5-S1 isthmic spondylolisthesis. He remains symptomatic. What is the most appropriate surgical intervention?

. L5-S1 anterior lumbar interbody fusion (ALIF) alone
. L5-S1 posterior instrumented fusion with autograft
. L4-S1 posterolateral in situ fusion without instrumentation
. Laminectomy and bilateral L5 foraminotomies alone
. Direct pars interarticularis repair with pedicle screws and laminar hooks

Correct Answer & Explanation

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

Explanation

In adolescent patients with a symptomatic Grade I or II isthmic spondylolisthesis who fail conservative management, an in situ posterior/posterolateral instrumented fusion with autograft is the gold standard. Direct pars repair (e.g., Scott wiring or pedicle screw-hook construct) is typically reserved for young patients with a pars defect but no significant slip (Grade 0), usually at L4 or above. Decompression alone is contraindicated in pediatric isthmic spondylolisthesis due to the risk of progressive slip.

Question 830

Topic: Thoracolumbar Spine & Deformity

A 25-year-old female is involved in a motor vehicle collision while wearing only a lap belt. She presents with severe lower back pain and abdominal ecchymosis.

Radiographs and CT reveal a pure bony flexion-distraction injury (Chance fracture) extending through the spinous process, pedicles, and vertebral body of L2. She is neurologically intact. What is an acceptable nonoperative treatment modality?

. TLSO brace molded in flexion
. Extension orthosis or hyperextension casting
. Halo-pelvic traction
. Lumbar corset brace
. Strict bed rest for 6 weeks without bracing

Correct Answer & Explanation

. TLSO brace molded in flexion

Explanation

A purely bony Chance fracture (flexion-distraction injury) has an excellent healing potential because of the broad cancellous bony surfaces. Assuming there is no severe kyphotic deformity, anterior column compromise, or neurologic deficit, it can be treated nonoperatively with an extension orthosis (TLSO) or hyperextension cast. The extension maneuver closes the posterior hinge created by the injury.

Question 831

Topic: Thoracolumbar Spine & Deformity

A 65-year-old female presents with progressive stooped posture, early satiety, and severe low back pain. Radiographs reveal degenerative adult spinal deformity.

Which of the following spinopelvic parameters is most strongly correlated with poorer health-related quality of life (HRQOL) outcomes if it exceeds normative thresholds?

. Thoracic Kyphosis (TK)
. Coronal Cobb Angle
. Sagittal Vertical Axis (SVA)
. Sacral Slope (SS)
. Lumbar Lordosis (LL) independent of Pelvic Incidence

Correct Answer & Explanation

. Thoracic Kyphosis (TK)

Explanation

In adult spinal deformity, sagittal plane parameters correlate much more strongly with HRQOL outcomes than coronal plane parameters. The Sagittal Vertical Axis (SVA), defined by a plumb line dropped from the C7 vertebral body relative to the posterior superior corner of S1, is strongly correlated with clinical symptoms when it exceeds 5 cm. Other critical parameters include Pelvic Tilt (PT > 20 degrees) and PI-LL mismatch (>10 degrees).

Question 832

Topic: Thoracolumbar Spine & Deformity

A 16-year-old male is brought to the clinic by his mother, who is concerned about his "round back." He complains of dull mid-back pain after standing for long periods. Standing lateral radiographs reveal a thoracic kyphosis of 65 degrees.

According to the Sorensen criteria, what specific radiographic finding is required to confirm the diagnosis of classic Scheuermann's disease?

. Anterior wedging of at least 5 degrees in 3 or more consecutive vertebrae
. Anterior wedging of at least 10 degrees in 3 or more consecutive vertebrae
. The presence of Schmorl's nodes in at least 5 vertebrae
. Intervertebral disc space widening at the apex of the curve
. A rigid curve that corrects fully on a supine bolster

Correct Answer & Explanation

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

Explanation

The classic Sorensen criteria for diagnosing Scheuermann's kyphosis require the presence of anterior wedging of 5 degrees or more in at least 3 consecutive adjacent vertebrae. Other common findings include Schmorl's nodes, endplate irregularities, and narrowed disc spaces, but the multi-level wedging is the defining diagnostic criterion.

Question 833

Topic: Thoracolumbar Spine & Deformity

During a posterior instrumented fusion of the lumbar spine, the surgeon is preparing to place a pedicle screw at the L4 level.

Which of the following describes the most accurate anatomic landmarks for establishing the starting point for a standard lumbar pedicle screw?

. The intersection of the pars interarticularis and the inferior articular process
. The intersection of a horizontal line bisecting the transverse process and a vertical line at the lateral border of the superior articular process
. The medial border of the superior articular process and the base of the spinous process
. The inferior border of the transverse process and the medial facet joint line
. The tip of the mammillary process exclusively

Correct Answer & Explanation

. The intersection of the pars interarticularis and the inferior articular process

Explanation

The classic anatomic starting point for a lumbar pedicle screw is located at the intersection of two lines: a horizontal line that bisects the transverse process, and a vertical line that corresponds to the lateral border of the superior articular process (or the junction of the pars interarticularis). This intersection reliably leads to the center of the pedicle.

Question 834

Topic: Thoracolumbar Spine & Deformity

A 35-year-old male is involved in a motor vehicle collision. Examination reveals normal motor and sensory function throughout his upper and lower extremities. CT imaging shows an L1 burst fracture with 15 degrees of local kyphosis and 30% canal compromise. MRI confirms an intact posterior ligamentous complex. According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the indicated treatment?

. Thoracolumbosacral orthosis (TLSO) and early mobilization
. Short segment pedicle screw fixation one level above and below
. Anterior corpectomy and expandable cage placement
. Posterior laminectomy and non-instrumented fusion
. Long segment posterior fusion from T11 to L3

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) and early mobilization

Explanation

According to the TLICS system, a burst fracture scores 2 points for morphology. An intact posterior ligamentous complex (PLC) scores 0 points, and a neurologically intact exam scores 0 points. The total TLICS score is 2. A score of 3 or less is an indication for non-operative management, typically with a TLSO brace and early mobilization.

Question 835

Topic: Thoracolumbar Spine & Deformity

In adult spinal deformity surgery, the concept of spinopelvic harmony is critical to achieving successful outcomes and minimizing adjacent segment disease.

According to standard matching parameters, a patient's lumbar lordosis (LL) should ideally be restored to within how many degrees of their pelvic incidence (PI)?

. +/- 10 degrees
. +/- 20 degrees
. +/- 2 degrees
. LL should be exactly half of the PI
. LL should be exactly double the PI

Correct Answer & Explanation

. +/- 10 degrees

Explanation

Pelvic incidence (PI) is a fixed morphologic parameter (PI = Pelvic Tilt + Sacral Slope). To achieve spinopelvic harmony and optimal sagittal balance, the postoperative Lumbar Lordosis (LL) should be matched to within 10 degrees of the patient's PI (PI - LL < 10 degrees).

Question 836

Topic: Thoracolumbar Spine & Deformity

In the surgical planning and evaluation of a patient undergoing correction for adult spinal deformity, what is the widely accepted target goal for the relationship between lumbar lordosis (LL) and pelvic incidence (PI) to achieve optimal sagittal balance?

. PI and LL should be within 10 degrees of each other.
. LL should be exactly 20 degrees greater than PI.
. PI and LL are independent parameters and do not need to correlate.
. Pelvic Tilt (PT) should be greater than 20 degrees to compensate for PI.
. Sacral Slope (SS) should be minimized to less than 10 degrees.

Correct Answer & Explanation

. PI and LL should be within 10 degrees of each other.

Explanation

The Pelvic Incidence (PI) is a fixed anatomical parameter (PI = Pelvic Tilt + Sacral Slope). To achieve a harmonious spino-pelvic alignment and reduce the risk of adjacent segment disease and mechanical failure, the Lumbar Lordosis (LL) should be matched to the Pelvic Incidence. The widely accepted goal, described by Schwab et al., is that PI minus LL should be less than or equal to 10 degrees.

Question 837

Topic: Thoracolumbar Spine & Deformity
A 14-year-old female gymnast presents with insidious onset lower back pain. Imaging confirms an L5-S1 spondylolisthesis secondary to bilateral stress fractures of the pars interarticularis. According to the Wiltse classification of spondylolisthesis, which type does this represent?
. Type I (Dysplastic)
. Type II (Isthmic)
. Type III (Degenerative)
. Type IV (Traumatic)
. Type V (Pathologic)

Correct Answer & Explanation

. Type II (Isthmic)

Explanation

The Wiltse classification categorizes spondylolisthesis by etiology. Type I is Dysplastic (congenital anomaly). Type II is Isthmic (lesion in the pars interarticularis, common in gymnasts). Type III is Degenerative. Type IV is Traumatic (fracture in areas other than the pars). Type V is Pathologic (generalized or localized bone disease). Type VI is Iatrogenic (post-surgical).

Question 838

Topic: Thoracolumbar Spine & Deformity

A 40-year-old male presents with severe mechanical back pain. Standing lateral radiographs reveal an isthmic spondylolisthesis at L5-S1. The L5 vertebral body has slipped anteriorly by 60% of the width of the S1 endplate. According to the Meyerding classification, what grade is this slip?

. Grade 1
. Grade 2
. Grade 3
. Grade 4
. Grade 5 (Spondyloptosis)

Correct Answer & Explanation

. Grade 1

Explanation

The Meyerding classification grades spondylolisthesis based on the percentage of anterior slip: Grade 1 (0-25%), Grade 2 (26-50%), Grade 3 (51-75%), Grade 4 (76-100%), and Grade 5 (>100%, also known as spondyloptosis). A 60% slip falls into the Grade 3 category.

Question 839

Topic: Thoracolumbar Spine & Deformity

A 40-year-old construction worker falls from a ladder and sustains an L1 burst fracture. He is neurologically intact. An MRI of the lumbar spine confirms complete disruption of the posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the most appropriate treatment recommendation?

. Mobilization in a Jewett brace
. Strict bed rest for 6 weeks
. Surgical stabilization
. Mobilization without bracing
. Serial casting

Correct Answer & Explanation

. Mobilization in a Jewett brace

Explanation

The TLICS score for this patient is 5 (Burst morphology = 2, PLC disruption = 3, Neurologically intact = 0). A TLICS score of 4 is indeterminate, while a score of 5 or greater is an indication for surgical stabilization. Non-operative management is generally reserved for a score of 3 or less.

Question 840

Topic: Thoracolumbar Spine & Deformity

In the preoperative planning for a 65-year-old female undergoing surgical correction for adult degenerative scoliosis, the surgeon calculates a pelvic incidence (PI) of 55 degrees. According to the SRS-Schwab classification, what is the ideal radiographic target for her postoperative lumbar lordosis (LL)?

. 10 to 20 degrees
. 25 to 35 degrees
. 45 to 65 degrees
. 70 to 85 degrees
. Equal to her sacral slope (SS)

Correct Answer & Explanation

. 10 to 20 degrees

Explanation

A key principle in adult spinal deformity surgery is restoring sagittal balance by minimizing the PI-LL mismatch. The ideal postoperative lumbar lordosis should be within 10 degrees of the patient's pelvic incidence (PI-LL < 10 degrees). Therefore, a target LL of approximately 45 to 65 degrees is optimal for a PI of 55 degrees.

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