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Thoracolumbar Spine & Deformity MCQs

Practice Set 7 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 121

Topic: Thoracolumbar Spine & Deformity

A 19-year-old male presents after a lap-belt only motor vehicle collision. Radiographs show a horizontal fracture through the spinous process, pedicles, and vertebral body of T12. Which associated injury must be actively ruled out in this patient?

. Aortic dissection
. Diaphragmatic rupture
. Bowel perforation
. Renal laceration
. Splenic rupture

Correct Answer & Explanation

. Bowel perforation

Explanation

Chance fractures are flexion-distraction injuries commonly associated with seatbelt use. They have a high association (up to 40%) with intra-abdominal injuries, particularly hollow viscus perforations.

Question 122

Topic: Thoracolumbar Spine & Deformity

A patient has a T12 burst fracture. MRI shows indeterminate posterior ligamentous complex (PLC) status. The patient is neurologically intact. What is the total TLICS score, and what is the recommended management?

. Score 2, Non-operative
. Score 4, Surgeon's choice
. Score 5, Operative
. Score 3, Non-operative
. Score 6, Operative

Correct Answer & Explanation

. Score 4, Surgeon's choice

Explanation

The TLICS score is calculated as follows: Burst morphology (2 points), intact neurology (0 points), indeterminate PLC (2 points), yielding a total score of 4. A score of 4 means management can be either operative or non-operative based on surgeon preference.

Question 123

Topic: Thoracolumbar Spine & Deformity

A 12-year-old child wearing a lap belt sustains an L2 Chance fracture during a motor vehicle collision. Which of the following associated injuries is most commonly seen with this specific fracture pattern?

. Hepatic laceration
. Splenic rupture
. Hollow viscus injury
. Renal contusion
. Bladder rupture

Correct Answer & Explanation

. Hollow viscus injury

Explanation

Chance fractures are flexion-distraction injuries highly associated with seatbelt use. Due to the mechanism of sudden abdominal compression, there is a high incidence (up to 50%) of associated intra-abdominal hollow viscus injuries, such as bowel perforations.

Question 124

Topic: Thoracolumbar Spine & Deformity

A 45-year-old man presents with an L1 burst fracture demonstrating 60% canal compromise and progressive weakness in his lower extremities. What is the most appropriate surgical approach?

. Posterior laminectomy without fusion
. Anterior corpectomy and fusion
. Posterior short-segment pedicle screw fixation without decompression
. Translaminar screw fixation
. Stand-alone anterior interbody cage

Correct Answer & Explanation

. Anterior corpectomy and fusion

Explanation

Anterior corpectomy allows direct decompression of retropulsed bone fragments causing neurologic deficits in burst fractures. Laminectomy alone is contraindicated as it further destabilizes an already compromised anterior and middle column, leading to progressive kyphosis.

Question 125

Topic: Thoracolumbar Spine & Deformity

Which of the following radiographic parameters remains essentially fixed throughout life:

. Pelvic tilt
. Sacral slope
. Pelvic incidence
. T1 tilt
. Lumbar lordosis

Correct Answer & Explanation

. Pelvic incidence

Explanation

Pelvic incidence is a measure of the relationship between the superior sacral endplate and the hips. It does not change significantly during life unless there is a major pelvic fracture. Pelvic incidence is defined as the angle between a line connecting the hip center and the midpoint of the S1 endplate, and a perpendicular to the midpoint of the S1 endplate. This angle is fixed in bone. By contrast, all of the other angles vary with posture and age.

Question 126

Topic: Thoracolumbar Spine & Deformity

Which of the following treatment options is recommended for the patient shown in the image (Slide 1, Slide 2):

. Halo-vest immobilization
. Minerva cast immobilization
. Soft cervical collar
. Open reduction and internal fixation
. Atlantoaxial arthrodesis

Correct Answer & Explanation

. Open reduction and internal fixation

Explanation

Treatment must address the fracture of the C 2 pars interarticularis and the C 2-C 3 facet subluxation. Options include traction to reduce the subluxation followed by external immobilization, or open reduction of the facet subluxation, which includes the opportunity to internally fix the fracture. Traction failed in this patient because the fracture eliminates a means to pullon the arch of C 2. If facet subluxation is not present, then a cervicothoracic orthosis such as a Philadelphia collar is adequate for healing of the C 2 spondylolysis.

Question 127

Topic: Thoracolumbar Spine & Deformity

A 15-year-old gymnast presents with chronic lower back pain. Radiographs demonstrate a grade II isthmic spondylolisthesis at L5-S1. She has failed 6 months of conservative management. What is the most appropriate surgical intervention?

. L5-S1 anterior lumbar interbody fusion
. L5-S1 posterolateral in situ fusion
. Laminectomy without fusion
. L4-S1 posterolateral fusion
. Sacroiliac joint fusion

Correct Answer & Explanation

. L5-S1 posterolateral in situ fusion

Explanation

For symptomatic low-grade isthmic spondylolisthesis in adolescents failing conservative care, an in situ posterolateral fusion of L5-S1 is the standard surgical treatment. Decompression alone is contraindicated due to instability.

Question 128

Topic: Thoracolumbar Spine & Deformity

Which of the following factors predicts a lesser degree of impairment of pulmonary function in patients with adolescent idiopathic scoliosis:

. Increased C obb angle
. Decreased number of vertebrae in the curve
. Increased cephalad apex of the curve
. Decreased thoracic kyphosis
. Pectus excavatum in addition to the scoliosis

Correct Answer & Explanation

. Decreased number of vertebrae in the curve

Explanation

An increased Cobb angle, increased cephalad apex of the curve, decreased thoracic kyphosis, and pectus excavatum in addition to the scoliosis are factors that predict a greater degree of pulmonary impairment. A lower number of vertebrae in the curve signals less impairment.

Question 129

Topic: Thoracolumbar Spine & Deformity

A 15-year-old girl is experiencing progressive weakness. She is unable to abduct her arms above 100° (pic). She has a progressive lordosis. Her facial expression is flat, and she cannot smile. Her mother has the same constellation of findings. No scoliosis is present. She and her mother are able to walk independently. The most likely diagnosis is:

. Parsonage-Turner syndrome
. Friedreich ataxia
. Facioscapulohumeral dystrophy
. Bells palsy
. Nemaline rod myopathy

Correct Answer & Explanation

. Facioscapulohumeral dystrophy

Explanation

This patient most likely has facioscapulohumeral dystrophy. With a frequency of 1:20,000, it is a rare disorder inherited in an autosomal- dominant fashion. The genetic abnormality is found on chromosome 4, with a decreased number of D4Z4 tandem repeats, but this does not appear to code for a protein product. Scoliosis is not present. In this condition, selective weakness of the serratus anterior, trapezius, and rhomboid muscles is present. Therefore, the scapula is not effectively stabilized against the trunk during use.

Question 130

Topic: Thoracolumbar Spine & Deformity

Which of the following is not a common finding in patients with Prader- Willi syndrome:

. Short stature
. Developmental delay
. Scoliosis
. Osteopenia
. Arachnodactyly

Correct Answer & Explanation

. Arachnodactyly

Explanation

Prader-Willi syndrome is characterized by early hypotonia, short stature, severe obesity, developmental delay, scoliosis, and osteopenia.

Question 131

Topic: Thoracolumbar Spine & Deformity
This radiograph shows a 9-year-old boy with scoliosis. From which of the following conditions is the boy's scoliosis likely to have resulted?
. Marfan syndrome
. Osteogenesis imperfecta
. Neurofibromatosis
. Fibrous dysplasia
. Juvenile idiopathic scoliosis

Correct Answer & Explanation

. Neurofibromatosis

Explanation

The patient's scoliosis is the result of neurofibromatosis. A sharp focal curve over few vertebrae, thinning of apical pedicles, and spindling of the ribs are symptoms of neurofibromatosis that are indicated in the radiograph.

Question 132

Topic: Thoracolumbar Spine & Deformity
Loeys-Dietz syndrome is caused by a mutation in:
. Fibrillin-1
. Fibrillin-2
. TGF-beta receptor
. Collagen type III
. Decorin

Correct Answer & Explanation

. TGF-beta receptor

Explanation

Loeys-Dietz syndrome is an autosomal dominant syndrome characterized by arterial tortuosity, aneurysms, hypertelorism, and bifid uvula or cleft palate. Scoliosis, foot deformities, ligamentous laxity, and other findings are often present. The aneurysms have particular risk for rupture at small diameters. This disorder is caused by mutations in genes encoding TGF-beta receptor 1 and 2.

Question 133

Topic: Thoracolumbar Spine & Deformity

The mean age of triradiate cartilage closure in girls and boys is:

. 10 years for girls and 12 years for boys
. 11 years for girls and 12 years for boys
. 12 years for girls and 13 years for boys
. 12.5 years for girls and 13.5 years for boys
. 13.5 years for girls and 14.5 years for boys

Correct Answer & Explanation

. 12.5 years for girls and 13.5 years for boys

Explanation

The triradiate cartilage closes at a mean of 12.5 years in girls and 13.5 years in boys. The closure of the triradiate cartilage signals the end of the peak height velocity (growth spurt). This is important for timing of scoliosis treatment and for signaling a change in pelvic fracture patterns from pediatric to adult.

Question 134

Topic: Thoracolumbar Spine & Deformity

A 14-year-old gymnast presents with lower back pain radiating to the posterior thighs. Radiographs show a Grade 3 (75%) isthmic spondylolisthesis at L5-S1 with a high slip angle. What is the best surgical approach?

. Laminectomy alone
. Pars repair with bone grafting
. In situ posterolateral fusion from L5 to S1
. Reduction and circumferential fusion of L5-S1
. Anterior lumbar interbody fusion alone

Correct Answer & Explanation

. Reduction and circumferential fusion of L5-S1

Explanation

For high-grade (>50%) isthmic spondylolisthesis with a high slip angle or signs of sagittal imbalance, reduction and circumferential (anterior/posterior) fusion or instrumented posterior fusion with interbody support is indicated.

Question 135

Topic: Thoracolumbar Spine & Deformity
A 15-year-old girl experienced an injury of L1 during a sledding accident. Her neurologic examination is normal. The best treatment is:
. Thoracolumbosacral orthosis
. Hyperextension cast
. Reduction and posterior fusion of T12-L1 with pedicle screws
. Corpectomy of T12 and anteroposterior instrumented fusion
. Reduction and posterior fusion of T12-L2 with pedicle screws

Correct Answer & Explanation

. Reduction and posterior fusion of T12-L2 with pedicle screws

Explanation

This patient has a Chance fracture of L1, which is indicated by the compression of the anterior portion of L1 and the distraction of the posterior portion of L1. A hyperextension cast will not treat the patient's Chance fracture completely. Operative treatment is needed to remove residual kyphosis at the thoracolumbar junction. Posterior column compression will also likely reduce the presence of residual kyphosis. Posterior fusion of T12-L2 with pedicle screws results in the best angular correction for a patient with a Chance fracture of L1. T12-L1 with hooks is an optional treatment for patients with a Chance fracture of L1 because residual kyphosis may persist even if the inferior lamina of L1 is intact.

Question 136

Topic: Thoracolumbar Spine & Deformity

A 10-year-old boy sustains a flexion-distraction injury of the lumbar spine (Chance fracture) while wearing a lap belt. Which associated injury must be specifically evaluated for?

. Aortic dissection
. Renal artery thrombosis
. Hollow viscus injury
. Pulmonary contusion
. Pelvic ring fracture

Correct Answer & Explanation

. Hollow viscus injury

Explanation

Chance fractures in children are highly associated with intra-abdominal injuries, particularly hollow viscus injuries like bowel perforations, due to the fulcrum of the lap belt over the abdomen.

Question 137

Topic: Thoracolumbar Spine & Deformity

A 12-year-old gymnast complains of chronic low back pain. Radiographs reveal a bilateral pars interarticularis defect at L5 with a 60% anterior slip of L5 on S1. What is the most appropriate definitive management?

. Activity modification and rigid bracing
. Physical therapy and NSAIDs
. In situ posterolateral L5-S1 fusion
. Laminectomy without fusion
. Pars repair with lag screws

Correct Answer & Explanation

. In situ posterolateral L5-S1 fusion

Explanation

Symptomatic high-grade spondylolisthesis (>50% slip) in a growing child is an indication for surgical stabilization. An in situ posterolateral L5-S1 fusion is the standard of care to prevent progression and relieve symptoms.

Question 138

Topic: Thoracolumbar Spine & Deformity

A 14-year-old girl with neurofibromatosis type 1 is diagnosed with scoliosis. Her curve is short-segment and sharply angulated. Which radiographic finding suggests a dystrophic type of curve with a high risk of progression?

. Hemivertebrae
. Unilateral unsegmented bar
. Penciling of the ribs
. Bilateral pars defects
. Apophyseal ring avulsion

Correct Answer & Explanation

. Penciling of the ribs

Explanation

Dystrophic scoliosis in NF-1 is characterized by short, sharp curves, penciling of ribs, dural ectasia, and severe vertebral scalloping. These curves have a high rate of progression and pseudarthrosis.

Question 139

Topic: Thoracolumbar Spine & Deformity

A 12-year-old girl is involved in a severe motor vehicle accident wearing a lap belt. Radiographs demonstrate the injury shown.

What associated injury must be urgently ruled out?

. Aortic dissection
. Splenic laceration
. Hollow viscus injury
. Diaphragmatic rupture
. Renal contusion

Correct Answer & Explanation

. Hollow viscus injury

Explanation

The image represents a Chance fracture, a flexion-distraction injury highly associated with lap belt use. Approximately 40-50% of these pediatric patients have concurrent intra-abdominal injuries, most commonly hollow viscus perforations.

Question 140

Topic: Thoracolumbar Spine & Deformity

In a neurologically intact patient with a thoracolumbar burst fracture, which of the following features most strongly indicates the need for operative stabilization?

. 10 degrees of focal kyphosis
. 20% loss of anterior vertebral body height
. Disruption of the posterior ligamentous complex (PLC)
. Isolated fracture of the spinous process
. 15% spinal canal compromise by retropulsed bone

Correct Answer & Explanation

. Disruption of the posterior ligamentous complex (PLC)

Explanation

In the Thoracolumbar Injury Classification and Severity Score (TLICS), a disrupted posterior ligamentous complex (PLC) indicates a highly unstable injury. This structural failure typically requires operative stabilization even without neurological deficits.

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