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Thoracolumbar Spine & Deformity MCQs

Practice Set 6 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 101

Topic: Thoracolumbar Spine & Deformity

According to the Thoracolumbar Injury Classification and Severity Score (TLICS), which of the following findings contributes the most points towards the indication for surgical intervention?

. Burst fracture morphology
. Complete neurologic deficit
. Suspected posterior ligamentous complex injury
. Incomplete neurologic deficit

Correct Answer & Explanation

. Incomplete neurologic deficit

Explanation

In the TLICS system, an incomplete neurologic deficit awards the highest points (3 points). Complete deficit is 2 points, burst morphology is 2 points, and suspected PLC injury is 2 points.

Question 102

Topic: Thoracolumbar Spine & Deformity

A 22-year-old woman sustained an injury to her low back 1 year ago while playing rugby. She now complains of excruciating low back pain with numbness and tingling into her left buttock. This pain is affecting her daily living activities. The patient underwent 6 months of conservative management consisting of restriction of activities, physical therapy, and anti- inflammatory medication with little relief. Based on the image below, the next appropriate step in the management of this patient is:

. C ontinued conservative management
. Posterolateral fusion at the L5/S1 level with bone graft
. Laminectomy at the L2/L3 level
. Laminectomy at the L3/L4 level
. Diskectomy at the L3/L4 level

Correct Answer & Explanation

. Posterolateral fusion at the L5/S1 level with bone graft

Explanation

The patient has an L5/S1 spondylysis with a grade 1 spondylolisthesis. This patient has undergone a sufficient attempt at conservative management with continued unrelenting low back pain. The next most appropriate step in the management of this condition is a posterolateral fusion at the L5/S1 level with autologous bone graft.

Question 103

Topic: Thoracolumbar Spine & Deformity

A 19-year-old female is involved in a high-speed motor vehicle collision while wearing only a lap belt. She sustains a Chance fracture of L2. Which of the following associated injuries must be highly suspected and ruled out?

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

Correct Answer & Explanation

. Hollow viscus injury

Explanation

Chance fractures are flexion-distraction injuries highly associated with lap belt use. Approximately 40-50% of these patients have concomitant intra-abdominal injuries, particularly to hollow viscous organs like the small bowel.

Question 104

Topic: Thoracolumbar Spine & Deformity

A 15-year-old female gymnast complains of persistent mechanical lower back pain. Lateral radiographs show a grade 1 anterolisthesis of L5 on S1. Oblique views demonstrate a 'Scotty dog with a collar' appearance. What is the initial treatment of choice?

. L5-S1 anterior lumbar interbody fusion
. Pars repair using pedicle screws and hooks
. Rigid bracing and activity modification
. Laminectomy and decompression
. Epidural steroid injections

Correct Answer & Explanation

. L5-S1 anterior lumbar interbody fusion

Explanation

The patient has a symptomatic isthmic spondylolisthesis secondary to a pars interarticularis defect, common in adolescent athletes. Initial management for low-grade slips is non-operative, focusing on activity modification, physical therapy, and bracing.

Question 105

Topic: Thoracolumbar Spine & Deformity

A 68-year-old woman presents with severe low back pain and neurogenic claudication. Plain radiographs reveal a grade 1 spondylolisthesis at L4-L5. Which of the following best describes the pathogenesis of this specific condition?

. Bilateral defects in the pars interarticularis
. Facet joint osteoarthritis and ligamentum flavum hypertrophy
. A congenital defect in the superior articular facet
. Traumatic fracture of the pedicles
. Pathologic destruction by a metastatic lesion

Correct Answer & Explanation

. Bilateral defects in the pars interarticularis

Explanation

Degenerative spondylolisthesis most commonly occurs at L4-L5 due to facet joint incompetence and degenerative changes. Unlike isthmic spondylolisthesis, the pars interarticularis remains intact.

Question 106

Topic: Thoracolumbar Spine & Deformity
A 12-year-old girl presents to the clinic with scoliosis detected by school screening. Her past medical history includes ophthalmologic observation for Lisch nodules of the iris. She has just started her menstrual periods. On physical exam, she has axillary freckles and normal neurological function. Standing radiographs of the spine illustrate a 32° right thoracic curve from T4 to T10 and rib pencilling. In the sagittal plane, she has a thoracic kyphosis of 30°. The most likely diagnosis is:
. Adolescent idiopathic scoliosis
. Congenital kyphoscoliosis
. Neurofibromatosis-1 (NF-1)
. Neurofibromatosis-2 (NF-2)
. Stickler disease

Correct Answer & Explanation

. Neurofibromatosis-1 (NF-1)

Explanation

Neurofibromatosis (von Recklinghausen disease) is an autosomal dominant disorder that affects connective tissue. The most common type is NF-1, and is associated with primary skeletal disorders such as scoliosis, cortical thinning and pseudarthrosis of the tibia. It is the result of an abnormality on chromosome 17, and is also associated with: Café au lait spots, Neurofibromas, Axillary or inguinal freckling, Iris hamartomata (Lisch nodules). Scoliosis in NF-1 can occur in 2 patterns. The first is similar to idiopathic scoliosis. The second, or dystrophic type is marked by short, sharper deformities, scalloping of the vertebral bodies, rib pencilling, enlarged foramina and severe apical vertebral body rotation. Some authors have demonstrated that curves characterized as idiopathic in childhood can take on dystrophic characteristics later in life and progress rapidly. Treatment is usually surgical.

Question 107

Topic: Thoracolumbar Spine & Deformity

A 13-year-old female gymnast presents with progressive lower back pain and a waddling gait. On physical examination, she walks with a peculiar gait with her hips and knees flexed, and she has severe hamstring tightness and a vertical sacrum. Radiographs confirm a high-grade L5-S1 isthmic spondylolisthesis. The gait abnormality described is known as:

. Trendelenburg gait
. Steppage gait
. Phalen-Dickson sign
. Gowers' sign
. Ollier's sign

Correct Answer & Explanation

. Phalen-Dickson sign

Explanation

The Phalen-Dickson sign is characterized by a waddling gait with flexed knees and hips due to severe hamstring tightness and pelvic retroversion (vertical sacrum). It is a classic clinical finding in high-grade spondylolisthesis.

Question 108

Topic: Thoracolumbar Spine & Deformity

When evaluating a pediatric patient with an L5-S1 isthmic spondylolisthesis, which of the following combinations of risk factors is most strongly associated with an increased risk of slip progression?

. High slip angle, dysplastic sacral dome, and prepubertal age
. Low slip angle, flat sacral dome, and postpubertal age
. Male gender, low pelvic incidence, and Risser 5
. High pelvic incidence, spina bifida occulta, and asymptomatic presentation
. L4-L5 location, low slip angle, and adult age

Correct Answer & Explanation

. High slip angle, dysplastic sacral dome, and prepubertal age

Explanation

Risk factors for progression of a spondylolisthesis include youth (significant growth remaining), a high slip angle (>40-50 degrees), a dysplastic (dome-shaped) sacrum, a trapezoidal L5 body, and high pelvic incidence.

Question 109

Topic: Thoracolumbar Spine & Deformity

A 10-year-old boy with known neurofibromatosis type 1 (NF1) presents with a 45-degree right thoracic scoliosis. Which of the following radiographic findings is most specifically associated with a high risk for rapid, unrelenting curve progression (dystrophic curve)?

. Apical vertebral rotation
. Vertebral scalloping
. Interpedicular narrowing
. Thickened ribs
. Spondylolysis at L5

Correct Answer & Explanation

. Vertebral scalloping

Explanation

Dystrophic curves in NF1 have a high propensity for rapid progression. Radiographic markers include vertebral scalloping (often due to dural ectasia), rib pencilling, spindling of transverse processes, and severe apical rotation.

Question 110

Topic: Thoracolumbar Spine & Deformity

A 13-year-old female presents with severe back pain, hamstring tightness, and a waddling gait. Radiographs show a Grade IV isthmic spondylolisthesis of L5 on S1. Which of the following physical examination findings is most characteristic of this condition?

. Positive Trendelenburg test
. Phalen sign
. Heart-shaped pelvis
. Palpable step-off and pelvic retroversion
. Absent patellar reflexes

Correct Answer & Explanation

. Palpable step-off and pelvic retroversion

Explanation

High-grade spondylolisthesis typically presents with hamstring tightness, a crouched or waddling gait, pelvic retroversion (a vertical sacrum), and a palpable step-off at the lumbosacral junction.

Question 111

Topic: Thoracolumbar Spine & Deformity

A 16-year-old male gymnast presents with a 3-month history of axial low back pain exacerbated by extension. Plain radiographs are normal. What is the most sensitive imaging modality to detect an early, acute stress reaction of the pars interarticularis?

. CT scan
. MRI with STIR sequences
. Bone scintigraphy
. Dynamic flexion-extension radiographs
. Ultrasound

Correct Answer & Explanation

. MRI with STIR sequences

Explanation

MRI with fluid-sensitive sequences (STIR or T2 fat-suppressed) is highly sensitive for detecting marrow edema indicative of an early/acute pars stress reaction. This detects the pathology before a frank fracture line is visible on CT.

Question 112

Topic: Thoracolumbar Spine & Deformity

A major indication for surgical decompression of an L1 burst fracture is:

. Loss of anterior body height of 60%
. Retropulsion of canal fragments to 50% of canal size
. Kyphosis of 15°
. Post-void residual of 450 mL
. Presence of a posterior lamina fracture

Correct Answer & Explanation

. Post-void residual of 450 mL

Explanation

Generalized treatment algorithms for burst fractures involving upper lumbar spine have relative indications for surgery that include 50% loss of height, 25% of kyphosis, and 50% canal compromise. Absolute indications for decompression include neurological deficits including a potential conus injury. Post-void residual of > 450 mL is suggestive of sacral root injury at the level of conus. Bradford suggests that anterior decompression of this injury has favorable outcome with frequent resolution or improvement of symptoms.

Question 113

Topic: Thoracolumbar Spine & Deformity

A type 3 traumatic spondylolisthesis of the axis, as classified by Levine and Edwards, is best treated with which of the following:

. Soft collar immobilization
. Hard Philadelphia cervical orthosis
. Halo vest immobilization
. Open reduction and operative posterior stabilization
. Gardner-Wells tongs application and awake reduction, then posterior stabilization

Correct Answer & Explanation

. Open reduction and operative posterior stabilization

Explanation

The Levine classification of traumatic spondylolisthesis or Hangman fractures involving C 2 in the type 3 injury has a combined bilateral facet dislocation at C 2-C 3 as well as the traumatic spondylolisthesis of the axis. Closed reduction could not be performed secondary to the traumatic spondylolisthesis at the C 2 isthmus.

Question 114

Topic: Thoracolumbar Spine & Deformity
The following can be found in the examination and radiographs of a child with Scheuermann disease:
. Schmorl nodes
. Back pain
. Anterior wedging 3 or more vertebrae
. Thoracic kyphosis
. All of the above

Correct Answer & Explanation

. All of the above

Explanation

Scheuermann disease is increased thoracic kyphosis, usually rigid, occurring in adolescent males. The etiology is unknown, but has included theories dealing with avascular necrosis of the ring apophysis, growth plate abnormalities, biologic and mechanical causes. The classic definition is increased thoracic kyphosis (>45°) with 5° or more of anterior wedging at 3 sequential vertebrae. Other radiographic abnormalities include: Endplate irregularities, Spondylolysis, Compensatory lumbar hyperlordosis, Schmorl's nodes. Hamstring tightness and rigid thoracic kyphosis is noted on physical examination, and neurological function is normal. Treatment consists of bracing in skeletally immature patients with a thoracolumbosacral orthosis, but many adolescent male patients are noncompliant with bracing. In the skeletally mature patient with pain and severe deformity (>65° of kyphosis), posterior spinal fusion with instrumentation is indicated. Occasionally, anterior diskectomy and interbody fusion with posterior fusion and instrumentation are required for severe deformity correction. Postural kyphosis is also common in adolescent males, but the vertebral changes are not present, and the deformities are usually more supple. Treatment is hyperextension exercises.

Question 115

Topic: Thoracolumbar Spine & Deformity

A 19-year-old restrained passenger in a high-speed collision sustains a flexion-distraction injury (Chance fracture) of L2. Which of the following associated injuries must be actively ruled out due to its high incidence?

. Aortic tear
. Renal artery thrombosis
. Hollow viscus injury
. Diaphragmatic rupture
. Pulmonary contusion

Correct Answer & Explanation

. Hollow viscus injury

Explanation

Chance fractures (flexion-distraction injuries) are frequently associated with lap-belt usage. Up to 50% of these patients have an associated hollow viscus or bowel injury that requires urgent general surgery evaluation.

Question 116

Topic: Thoracolumbar Spine & Deformity

A 30-year-old male falls 15 feet, sustaining an L1 burst fracture. He is neurologically intact. MRI confirms severe disruption of the posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity (TLICS) system, what is his total score and management recommendation?

. Score 2: Non-operative management
. Score 4: Non-operative management
. Score 5: Operative management
. Score 7: Operative management
. Score 3: Surgeon's preference

Correct Answer & Explanation

. Score 5: Operative management

Explanation

The TLICS score is calculated as follows: Burst fracture morphology (2) + Intact neurology (0) + PLC disrupted (3) = Total score of 5. A score of 5 or greater is an indication for operative management.

Question 117

Topic: Thoracolumbar Spine & Deformity

A 14-year-old gymnast complains of chronic lower back pain exacerbated by extension. Oblique lumbar radiographs demonstrate a "Scotty dog with a collar" sign. What is the underlying pathology?

. Spondyloptosis
. Spondylolysis
. Herniated nucleus pulposus
. Scheuermann's disease
. Sacroiliitis

Correct Answer & Explanation

. Spondylolysis

Explanation

The "Scotty dog with a collar" sign on oblique lumbar radiographs represents a defect or stress fracture in the pars interarticularis, known as spondylolysis.

Question 118

Topic: Thoracolumbar Spine & Deformity

A 30-year-old male sustains a T12 burst fracture. He is neurologically intact, and the posterior ligamentous complex (PLC) is indeterminate on MRI. What is his TLICS score and recommended management?

. Score 2: Non-operative management
. Score 4: Operative or non-operative management
. Score 5: Operative management
. Score 7: Operative management
. Score 3: Non-operative management

Correct Answer & Explanation

. Score 4: Operative or non-operative management

Explanation

The Thoracolumbar Injury Classification and Severity (TLICS) score assigns 2 points for a burst fracture, 0 points for intact neurology, and 2 points for an indeterminate PLC, totaling 4 points. A score of 4 can be treated operatively or non-operatively based on surgeon preference and patient factors.

Question 119

Topic: Thoracolumbar Spine & Deformity

A 25-year-old restrained passenger in a high-speed MVC presents with a bony Chance fracture of L2. Which of the following is the most commonly associated concomitant injury?

. Aortic tear
. Hollow viscus injury
. Diaphragmatic rupture
. Splenic laceration
. Pelvic ring disruption

Correct Answer & Explanation

. Hollow viscus injury

Explanation

Chance fractures are flexion-distraction injuries commonly referred to as seatbelt injuries. They have a high association (up to 40-50%) with intra-abdominal injuries, particularly of hollow viscous organs.

Question 120

Topic: Thoracolumbar Spine & Deformity
A patient presents with a traumatic spondylolisthesis of the axis. CT shows severe angulation and >3mm translation, with C2-C3 facet capsules disrupted. According to Levine and Edwards, what is the classification and recommended non-operative treatment?
. Type I: Rigid cervical collar
. Type II: Halo vest immobilization in neutral
. Type IIA: Halo vest with compression
. Type IIA: Halo vest with gentle traction
. Type III: Surgical stabilization is strictly mandated

Correct Answer & Explanation

. Type IIA: Halo vest with compression

Explanation

Type IIA Hangman fractures show severe angulation with minimal translation and are caused by a flexion-distraction mechanism. Traction is contraindicated as it exacerbates the deformity; they must be treated with reduction under compression in a halo vest.

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