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6. Spine MCQs

Practice Set 103 of 379

This practice set contains high-yield board review questions covering key concepts in 6. Spine. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 2041

Topic: 6. Spine

A 17-year-old girl with a history of Scheuermann's kyphosis has a fixed thoracic deformity of 80 degrees. There was no correction of her deformity on supine hyperextension radiographs. What is the most appropriate treatment? Review Topic

. Posterior arthrodesis
. Anterior interbody arthrodesis
. Smith-Petersen osteotomies with posterior arthrodesis
. Vertebral column resection with posterior arthrodesis
. Pedicle subtraction osteotomy with posterior arthrodesis

Correct Answer & Explanation

. Posterior arthrodesis

Explanation

The Smith-Petersen osteotomy is most appropriate for long, sweeping, global kyphosis, such as Scheuermann's kyphosis. It can achieve approximately 10 degrees of correction in the sagittal plane at each spinal level at which it is performed. The pedicle subtraction osteotomy is the preferred osteotomy for patients with ankylosing spondylitis, who have a sagittal plane imbalance. It can achieve approximately 30 degrees to 40 degrees of correction in the sagittal plane at each spinal level at which it is performed. Vertebral column resections are extensive procedures, thus they are most appropriately applied to pathologies with sharp angular kyphosis, anterior fusions, and when maximal visualization and decompression of the spinal cord is required. Sagittal curves were reduced an average of 50 degrees, with a lumbosacral deformity treated via vertebral column resection. Anterior arthrodesis alone will not provide sufficient correction and stabilization of the deformity. Posterior arthrodesis alone, while providing stabilization, will not correct the fixed deformity.

Question 2042

Topic: 6. Spine
If a surgeon inadvertently burrs through the midlateral wall of C5 during an anterior corpectomy, what structure is at greatest risk for injury?
. C5 root
. C6 root
. Internal carotid artery
. Vertebral artery
. Vagus nerve

Correct Answer & Explanation

. Vertebral artery

Explanation

DISCUSSION: The vertebral artery is contained within the vertebral foramen and thus tethered alongside the vertebral body, making it vulnerable to injury if a drill penetrates the lateral wall. The C5 root passes over the C5 pedicle and is not in the vicinity. The C6 root passes under the C5 pedicle but is posterior to the vertebral artery and is only vulnerable at the very posterior-inferior corner. The carotid artery and the vagus nerve are both within the carotid sheath and well anterior. REFERENCES: Pfeifer BA, Freidberg SR, Jewell ER: Repair of injured vertebral artery in anterior cervical procedures. Spine 1994;19:1471-1474. Gerszten PC, Welch WC, King JT: Quality of life assessment in patients undergoing nucleoplasty-based percutaneous discectomy. J Neurosurg Spine 2006;4:36-42.

Question 2043

Topic: 6. Spine
What arterial vessel is most prone to injury during posterior iliac crest bone graft harvest?
. Superior gluteal
. Deep circumflex iliac
. Iliolumbar
. Ascending branch of the lateral femoral circumflex
. Fourth lumbar

Correct Answer & Explanation

. Superior gluteal

Explanation

The superior gluteal artery is most at risk with a posterior iliac crest bone graft harvest. The artery leaves the pelvis through the sciatic notch and can be injured by retractors or other sharp instruments entering the sciatic notch area. The deep circumflex iliac, iliolumbar, and fourth lumbar arteries supply the iliacus and iliopsoas muscles and can be damaged during anterior bone graft harvest. The ascending branch of the lateral femoral circumflex artery is at risk during the anterior approach to the hip.

Question 2044

Topic: 6. Spine
In providing culturally competent care to a Muslim woman with a cervical spine injury, which of the following most accurately describes the steps a male orthopaedist should take to respect her religious beliefs during his examination?
. No one should be in the exam room except the patient and the physician.
. Another woman should be in the exam room and only the affected body part should be exposed.
. A chaperone of either gender should be in the exam room and no skin should be exposed.
. No particular steps need to be taken in this case.
. The patient’s closest male relative should be in the exam room but a standard hospital gown may be used.

Correct Answer & Explanation

. Another woman should be in the exam room and only the affected body part should be exposed.

Explanation

In examining a traditional Muslim woman, a male physician should have another woman present, and the patient’s husband, if possible. Only the affected limb or area needing examination should be exposed.

Question 2045

Topic: 6. Spine
A 24-year-old man who was involved in a high-speed motor vehicle accident is transferred for definitive care after having been diagnosed with an acute spinal cord injury from a fracture-dislocation at C6-7. He has a complete C6 neurologic level and it is now approximately 10 hours from his injury. What is the most appropriate pharmacologic treatment at this time?
. No pharmacologic intervention is recommended at this time
. Administration of methylprednisolone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 24 hours
. Administration of methylprednisolone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 48 hours
. Administration of naloxone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 24 hours
. Administration of naloxone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 48 hours

Correct Answer & Explanation

. No pharmacologic intervention is recommended at this time

Explanation

The standard practice in the pharmacologic treatment of a spinal cord injury in the United States has been the administration of methylprednisolone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 24 hours, in accordance with the findings of the second and third National Acute Spinal Cord Injury Studies (NASCIS). Although the studies have subsequently drawn criticism for their methodology and outcomes, it has been generally accepted that beneficial neurologic outcomes were anticipated in patients who were able to start the protocol within 8 hours of their initial injury. Further improvement was noted in patients receiving the methylprednisolone within 3 hours of their injury and continuing an infusion for 48 hours. In this patient, who is outside the 8-hour treatment window, no studies have supported starting the methylprednisolone protocol at this time.

Question 2046

Topic: 6. Spine
What structure is most at risk with anterior penetration of C1 lateral mass screws?
. Vertebral artery
. External carotid artery
. Internal carotid artery
. Pharynx
. Glossopharyngeal nerve

Correct Answer & Explanation

. Internal carotid artery

Explanation

DISCUSSION: Posterior screw fixation of the upper cervical spine has gained a great deal of popularity due to its stable fixation, obviating the use of halo vest immobilization, and its high fusion rates. The use of screws in this location, however, has introduced a whole new set of potential complications. Vertebral artery injury is one of the most feared complications associated with screws in the C1/C2 region. This structure, however, is lateral and posterior at the C2 level and then penetrates the foramen transversarium of C1 to lie cephalad to the arch of C1 before entering the foramen magnum. It is the internal carotid artery that lies immediately anterior to the arch of C1 that is particularly at risk by anterior penetration of C1 lateral mass or C1-C2 transarticular screws as demonstrated by Currier and associates. The internal carotid artery lies posterior to the pharynx. The external carotid artery and the glossopharyngeal nerve are not at risk with this method of fixation. REFERENCES: Currier BL, Todd LT, Maus TP, et al: Anatomic relationship of the internal carotid artery to the C1 vertebra: A case report of cervical reconstruction for chordoma and pilot study to assess the risk of screw fixation of the atlas. Spine 2003;28:E461-E467. Grant JC: Grant’s Atlas of Anatomy, ed 6. Baltimore, MD, Williams & Wilkins, 1972. Harms J, Melcher RP: Posterior C1-C2 fusion with polyaxial screw and rod fixation. Spine 2001;26:2467-2471.

Question 2047

Topic: 6. Spine
The risk of progression with congenital kyphosis is greatest with which of the following?
. Anterior unsegmented bar
. Block vertebra
. Posterior hemivertebra
. Anterolateral bar and contralateral quadrant vertebrae
. Butterfly vertebra

Correct Answer & Explanation

. Anterolateral bar and contralateral quadrant vertebrae

Explanation

DISCUSSION: The risk of neurologic compromise associated with congenital kyphosis is normally secondary to risk of progression. The classic study of the natural history of congenital spinal deformity by McMaster and Singh confirms that an anterolateral bar with contralateral quadrant vertebrae has the greatest risk. REFERENCES: McMaster MJ, Singh H: Natural history of congenital kyphosis and kyphoscoliosis: A study of one hundred and twelve patients. J Bone Joint Surg Am 1999;81:1367-1383. Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, p 351.

Question 2048

Topic: 6. Spine
A 25-year-old man has chronic back pain that has been slowly worsening. He has no constitutional symptoms, and he denies any previous medical problems. Examination shows a tall lean build with no objective neurologic findings or skin lesions. Figure 32 shows a T2-weighted sagittal MRI scan. What is the most likely diagnosis?
. Marfan syndrome
. Ankylosing spondylitis
. Lumbar disk herniation
. Arnold-Chiari malformation
. Ehlers-Danlos syndrome

Correct Answer & Explanation

. Marfan syndrome

Explanation

DISCUSSION: The MRI scan shows significant dural ectasia, which is seen in more than 60% of patients with Marfan syndrome. It is also relatively common in patients with neurofibromatosis, but this patient has no skin lesions. It has also been described in Ehlers-Danlos syndrome but is less common. REFERENCES: Ahn NU, Sponseller PD, Ahn UM, Nallamshetty L, Kuszyk BS, Zinreich SJ: Dural ectasia is associated with back pain in Marfan’s syndrome. Spine 2000;25:1562-1568. Villeirs GM, Van Tongerloo AJ, Verstraete KL, Kunnen MF, De Paepe AM: Widening of the spinal canal and dural ectasia in Marfan’s syndrome: Assessment by CT. Neuroradiology 1999;41:850-854.

Question 2049

Topic: 6. Spine

A 27-year-old professional football player complains of acute onset neck and radiating left arm pain after making a tackle. For approximately 1 week after injury his left deltoid strength was 4/5. An MRI is performed, which demonstrates a C4-5 disc herniation without evidence of cord compression. He was treated with a brief course of oral steroids followed by aggressive physical therapy. At this time he is asymptomatic and his neurologic exam is normal. If the patient returns to professional football play, what is his increased risk of sustaining a catastrophic spinal cord injury? Review Topic

. There is no increased risk for spinal cord injury.
. 10%
. 25%
. 35%
. Greater than 50%

Correct Answer & Explanation

. There is no increased risk for spinal cord injury.

Explanation

This patient is a professional football player who likely is suffering from an acute left sided C4-5 cervical disc herniation causing a C5 radiculopathy. After non-operative treatment and return to sport, his likelihood of sustaining a catastrophic spinal cord injury is less than 5%.A C5 radiculopathy from an acute disc herniation can manifest as pain in the neck and affected arm, as well as weakness in the affected myotome. The natural history of this pathology is symptomatic improvement over time. In professional athletes, there are few studies to guide treatment, but oral methylprednisolone has been shown to improve symptoms and expedite return to play. The risk of sustaining catastrophic spinal cord injury after return to play is considered low, and has been reported to be 0%.Wong et. al. performed a systematic review of the literature identifying the natural history, clinical course, and prognostic factors of symptomatic cervical disc herniations with radiculopathy. They found substantial symptomatic improvement within the first 4-6 months after onset, with maintained improvements for 2-3 years. No patients in their review developed progressive neurological deficits or myelopathyatanypointduringfollowup.Meredith et. al. performed a retrospective chart review of 16 professional football players with cervical disc herniations. The authors recommended surgery if patients had MRI with cord compression and signal change within the cord, but otherwise encouraged nonoperative treatment with return to sports after symptoms improved and repeat MRI demonstrated no cord compression. Symptoms generally improved with a course of anti-inflammatory medications including NSAIDs, oral methylprednisolone, and epidural steroid injections. Nine of the 16 patients were able to return to play, and at one year after return to play there were no catastrophic spinal cord injuries among the group.Incorrect

Question 2050

Topic: 6. Spine
A 44-year-old man reports persistent left leg pain following an L5-S1 hemilaminotomy and partial diskectomy. Examination shows a grade 4 weakness of the left extensor hallucis longus and a positive left straight leg raise. A radiograph is shown in Figure 1a, and sagittal and axial MRI scans are shown in Figures 1b and 1c. Nonsurgical management consisting of medication, physical therapy, and injections has failed to provide relief. Surgical management should consist of
. revision L5-S1 hemilaminotomy.
. L5-S1 total disk arthroplasty.
. L5 Gill laminectomy.
. posterior foraminal decompression and fusion at L5-S1 with instrumentation and bone graft.
. stand-alone posterior lumbar interbody fusion.

Correct Answer & Explanation

. posterior foraminal decompression and fusion at L5-S1 with instrumentation and bone graft.

Explanation

The patient has a grade I isthmic spondylolisthesis at L5-S1. He has an L5 radiculopathy with foraminal stenosis. Any further treatment needs to include an arthrodesis and foraminal decompression. Isolated interbody fusion is contraindicated in patients with spondylolisthesis, as is total disk arthroplasty. Therefore, the best procedure is a posterior fusion with instrumentation and bone graft along with a foraminal decompression.

Question 2051

Topic: 6. Spine
When performing the exposure for an anterior approach to the cervical spine, the surgical dissection should not enter the plane between the trachea and the esophagus and excessive retraction should be avoided to prevent injury to the
. vagus nerve.
. recurrent laryngeal nerve.
. superior laryngeal nerve.
. hypoglossal nerve.
. sympathetic trunk.

Correct Answer & Explanation

. recurrent laryngeal nerve.

Explanation

The recurrent laryngeal nerve lies between the trachea and the esophagus. The vagus nerve lies in the carotid sheath. The sympathetic trunk lies anterior to the longus colli muscles. The hypoglossal and superior laryngeal nerves are both at risk during the exposure but are not located between the trachea and the esophagus.

Question 2052

Topic: 6. Spine

A 45-year-old man reports a history of a popping sensation and pain in the right shoulder while lifting boxes 6 months ago. The pain has persisted with loss of motion of the shoulder. Radiographs and MRI scans are shown in Figures 47a through 47d. Which of the following studies is likely to produce a significant positive result? Review Topic

. Rheumatoid factor
. HLA-B27
. Synovial fluid analysis
. MRI of the upper cervical spine
. Urine screen for tetrahydrocannabinol (THC)

Correct Answer & Explanation

. Rheumatoid factor

Explanation

The patient has a neuropathic joint secondary to syringomyelia that can be seen on a cervical MRI scan. The patient sustained minimal trauma that lead to a chronic anterior glenohumeral dislocation. He did not seek treatment for several months and has a massive rotator cuff tear and hygroma on MRI in addition to the chronic dislocation. Rheumatoid arthritis does not present with a neuropathic picture, except theoretically as the result of numerous intra-articular cortisone injections. This Charcot picture is inconsistent with ankylosing spondylitis or gout. Cannabis use is not typically associated with seizures that could produce anterior as well as posterior shoulder dislocations.

Question 2053

Topic: 6. Spine
  • A 15-year-old girl has a thoracic kyphosis that causes mild pain. Examination reveals a sagittal curve measuring 55 degrees and wedging of the eighth through tenth vertebrae. The iliac apophyses are Risser 4. Management should include
. observation and exercises
. bracing with a thoracolumbar orthosis
. fusion of the posterior spine
. fusion of the anterior spine
. fusion of the anterior and posterior spine

Correct Answer & Explanation

. observation and exercises

Explanation

Scheuermann’s Disease classically presents with >45o thoracic kyphosis and anterior wedging (5o or more) at three sequential vertebrae. Disc narrowing, end-plate irregularities, scoliosis, spondylosis, and Schmorl’s nodes are also seen. It’s more common in adolescents and males. Normally, these patients are treated (1) in a brace if the curve is progressive and Risser 3 or less,(2) with surgical fusion if >75o and Risser 3 or less, (3) with surgical fusion if >65o and Risser 4/5 if necessary or symptomatic. Posterior instrumentation, anterior release and interbody fusion is the treatment of choice for curves >75o, or those >55o on hyperextension. Other causes of kyphosis include trauma, infection, spondylitis, bone dysplasia, neoplasia, neurofibromatosis.

Question 2054

Topic: 6. Spine

A 55-year-old man presents with low back pain that has progressed over the last year. He reports the pain is worse with activity, especially when bending forward and lifting objects. He denies any pain in the buttocks or lower extremities. On physical he has age-appropriate motion in the lumbar spine. He is neurologically intact in the lower extremities. Figure A shows his axial and sagittal T2-weighted MRI scans. A histological sample of this lesion would most likely show Review Topic

. dense, compact concentric lamellae of fibrocollagenous tissue with occasional fibroblast-like chondrocytes
. semifluid gelatinous matrix with oval chondrocytes
. ossified nidus surrounded by a radiolucent halo, in turn surrounded by dense, reactive osteosclerosis
. irregular fascicles of collagenous stroma with pleomorphic cells with foamy cytoplasm and marked atypia in a storiform pattern
. synovial cells covering a stroma with vascular granulation tissue

Correct Answer & Explanation

. synovial cells covering a stroma with vascular granulation tissue

Explanation

The clinical presentation is consistent with a synovial cyst. Histology would most likely show synovial cells covering a stroma with vascular granulation tissue.Juxtafacet cysts may include synovial cysts or ganglion cysts. Synovial cysts are lined with epithelium (cuboid synovial cells) and contain clear or xanthochromic fluid. Ganglion cysts which have no synovial lining, and contain gelatinous material from myxoid degeneration of the fibrous adventitial tissue.Xu et al. reviewed the treatment of 195 synovial cysts. They found that patients treated with laminectomy had the highest risk of cyst recurrence (3%). In contrast, decompression with instrumented fusion had the lowest incidences of cyst recurrence (0%) or back pain (although they had the longest hospital stay, and greatest blood loss).Figure A is a T2-weighted MRI (left, axial; right, sagittal) showing a facet synovial cyst arising from an arthritic left L3-4 facet joint. It occupies much of the space in the spinal canal and indents and displaces the thecal sac. Illustration A shows a hemorrhagic synovial cyst showing synovial cell lining, fibroconnective tissue with widespread hemorrhage, neoangiogenesis, and hemosiderin microdeposits.Incorrect Answer Answer Answer1:2:3:Described histology is characteristic of Described histology is characteristic ofDescribedhistologyischaracteristic

Question 2055

Topic: 6. Spine

5 mm of change in the atlanto-dens interval (ADI) between flexion and extension views

. Posterior atlanto-dens interval (PADI) <14 mm
. Progressive myelopathy
. ADI > 10 mm with no change on flexion/extension views

Correct Answer & Explanation

. Posterior atlanto-dens interval (PADI) <14 mm

Explanation

The patient has been treated with agents for rheumatoid arthritis (RA) and is developing symptoms concerning for rheumatoid cervical spondylitis. All of the answers are indications for surgical intervention EXCEPT >3.5 mm change in ADI on flexion/extension views.With the introductions of disease-modifying antirheumatic agents (DMARDs), the incidence of RA patients undergoing cervical spine surgery has decreased significantly. Basilar invagination, atlantoaxial instability, and subaxial subluxation are the three most common manifestations of cervical disease. Multiple studies in RA patients with untreated or poorly controlled disease have led to the development of a set of measurements that identify patients who require surgical intervention and predict outcome after surgery. Additionally, progressive neurological compromise andrefractorypainareindicationsforintervention.Kim and Hilibrand reviewed management of the rheumatoid cervical spine and outline parameters for surgical intervention. These include a PADI < 14 mm, cervicomedullary angle <135 degrees, progressive neurological deficit, refractory pain, atlantoaxial impaction as determined by migration >5 mm rostral to McGregor's line, and subaxial canal diameter < 14 mm.Boden et al. analyzed 73 patients followed for rheumatoid cervical spine disease with an average follow up of 7 years. They found that the PADI correlated with paralysis. Patients with PADI less than 10 mm had no recovery, and all patients with PADI greater than 14 mm had full recovery.Illustration A demonstrates the measurement of the ADI and PADI. Illustration B demonstrates how to measure the cervicomedullary angle (as marked by A), which is typically determined on MRIIncorrect

Question 2056

Topic: 6. Spine
An inverted radial reflex is associated with
. spinal cord compression with myelopathy.
. acute cervical radiculopathy.
. chronic cervical radiculopathy.
. Parsonage-Turner syndrome.
. peripheral neuropathy.

Correct Answer & Explanation

. spinal cord compression with myelopathy.

Explanation

An inverted radial reflex is a hypoactive brachioradialis reflex in combination with involuntary finger flexion. It is a spinal cord “release” sign and is associated with upper motor neuron pathology as seen in cervical stenosis with myelopathy. Radiculopathy is characterized by a diminished reflex but no finger flexion. Peripheral neuropathy is not associated with any reflex change. Parsonage-Turner syndrome is an idiopathic brachial neuritis.

Question 2057

Topic: 6. Spine
A 7-year-old boy sustained a head contusion and small bowel injuries in a motor vehicle accident in which he was wearing a lap belt. He subsequently required a bowel resection. Six weeks after the accident, his parents note a painful mass in his lower back. His neurologic examination is normal. A radiograph and CT scans are shown in Figures 47a through 47c. Definitive management should now consist of
. transcutaneous electrical stimulation and a lumbar corset.
. transforaminal interbody fusion.
. posterior instrumented L2-L3 reduction and fusion.
. anterior interbody fusion with a cage.
. spine extension bracing.

Correct Answer & Explanation

. posterior instrumented L2-L3 reduction and fusion.

Explanation

The posttraumatic lumbar kyphotic deformity will not remodel and is likely to worsen with time because the central line of gravity lies anterior to the deformity and the ligamentous disruption will not heal. The worsening deformity also puts the patient at some risk for future neurologic damage.

Question 2058

Topic: 6. Spine
Six weeks after onset, what is the most clearly accepted indication for surgical management for lumbar disk herniation?
. Stable sensory loss
. Stable motor weakness
. Refractory radicular pain
. Size of the herniation
. Lost time at work

Correct Answer & Explanation

. Refractory radicular pain

Explanation

In the absence of a cauda equina syndrome or progressive weakness, the best indication for surgical management is refractory radicular pain. When intractable radicular pain is the strict indication for surgery, surgical intervention provides substantial and more rapid pain relief than nonsurgical care.

Question 2059

Topic: 6. Spine
A 45-year-old woman has idiopathic scoliosis. Surgery is to include an anterior thoracic release through an open left thoracotomy. The thoracotomy will have what effect on the patient’s pulmonary function postoperatively?
. Unaffected
. Transiently reduced postoperatively but ultimately improves to greater than preoperative function
. Transiently reduced immediately postoperatively but then quickly returns to preoperative levels
. Improves postoperatively due to correction of the scoliosis and is maintained long term
. Reduced postoperatively and often remains reduced long term

Correct Answer & Explanation

. Reduced postoperatively and often remains reduced long term

Explanation

DISCUSSION: A thoracotomy in an adult with idiopathic scoliosis causes a reduction in pulmonary function that often does not return to preoperative levels. What pulmonary function that does recover, recovers over many months. Long-term improvement in pulmonary function, compared to preoperative function, is rarely seen.

Question 2060

Topic: 6. Spine
A 15-year-old boy reports a 2-day history of progressive left buttock pain and severe limping. He denies any history of trauma or radiation of the pain. He has an oral temperature of 100.4 degrees F (38 degrees C). Examination reveals that the lumbar spine and left hip have unguarded motion. The abdomen is nontender. There is moderate tenderness of the left sacroiliac region with no palpable swelling. Pain is elicited when the left lower extremity is placed in the figure-4 position (FABER test). Laboratory studies show a peripheral WBC count of 11,500/mm^3 (normal to 10,500/mm^3) and an erythrocyte sedimentation rate of 38 mm/h (normal up to 20 mm/h). Radiographs of the pelvis, hips, and lumbar spine are normal. A nucleotide bone scan (posterior view) is shown in Figure 44. Initial management should consist of
. oral nonsteroidal anti-inflammatory drugs.
. intravenous antistaphylococcal antibiotics.
. incision and debridement of the retroperitoneal abscess.
. incision and debridement of the left sacroiliac joint.
. arthrotomy and irrigation of the left hip joint.

Correct Answer & Explanation

. intravenous antistaphylococcal antibiotics.

Explanation

DISCUSSION: The symptoms, physical findings, and laboratory studies are most consistent with a diagnosis of infectious sacroiliitis, usually caused by Staphylococcus aureus. Initial radiographs will be normal, and the diagnosis of sacroiliitis is often delayed. Needle aspiration of the sacroiliac joint is difficult; therefore, antibiotic selection is usually empiric or based on blood cultures.

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