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6. Spine MCQs

Practice Set 107 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 2121

Topic: 6. Spine

Which clinical signs are consistent with the diagnosis of cauda equina syndrome?

. Saddle anesthesia, hyperreflexia, quadriceps weakness
. Decreased motor function in the quadriceps and gastrocnemius, hyperreflexia,? and saddle anesthesia
. More than 5 beats of clonus, saddle anesthesia, and bowel incontinence
. Urinary retention, saddle anesthesia, and extensor hallucis longus weakness

Correct Answer & Explanation

. Saddle anesthesia, hyperreflexia, quadriceps weakness

Explanation

DISCUSSIONCauda equina syndrome is a lower-motor neuron deficit. Hyperreflexia, clonus, and other upper-motor neuron findings would not be seen. Saddle anesthesia, motor weakness, and neurogenic bladder are elements critical to the diagnosis of cauda equina syndrome.RECOMMENDED READINGSKostuik JP, Harrington I, Alexander D, Rand W, Evans D. Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg Am. 1986 Mar;68(3):386-91. PubMed PMID: 2936744.ViewAbstract at PubMedSpector LR, Madigan L, Rhyne A, Darden B 2nd, Kim D. Cauda equina syndrome. J Am Acad Orthop Surg. 2008 Aug;16(8):471-9. Review. PubMed PMID: 18664636.View Abstract atPubMedCLINICAL SITUATION FOR QUESTIONS 78 THROUGH 80Figures 78a and 78b are the axial and sagittal MR images of an otherwise healthy 24-year-old woman who has had 8 weeks of severe leg pain without weakness.A B

Question 2122

Topic: 6. Spine

Figures 129a through 129b are the radiographs and MRI and CT scans of the lumbar spine of a 10-yearold premenarchal girl who has back pain and scoliosis. What is the most likely etiology of her scoliosis?

. Olisthetic
. Idiopathic
. Tethered cord
. Myelodysplasia
. Osteoid osteoma

Correct Answer & Explanation

. Olisthetic

Explanation

Question 2123

Topic: 6. Spine

Where is the most common site for tuberculosis (TB) spondylitis in children? Review Topic

. Anterior aspect of the lower thoracic region
. Anterior aspect of the cervical spine
. Posterior elements of the lower thoracic region
. Posterior elements of the cervical spine
. Transverse process of the lower lumbar spine

Correct Answer & Explanation

. Anterior aspect of the lower thoracic region

Explanation

In children, the main route of infection in skeletal TB is through hematogenous spread from a primary source. The mycobacterium is deposited in the end arterials in the vertebral body adjacent to the anterior aspect of the vertebral end plate. Thus, the anterior portion of the vertebral body is most commonly involved. The lower thoracic region is the most common segment; next in decreasing order of frequency are the lumbar, upper thoracic, cervical, and sacral regions.

Question 2124

Topic: 6. Spine

A 3-year-old boy sustains a complete paralysis following a high thoracic spinal cord injury consistent with a SCIWORA-type injury (spinal cord injury without radiographic abnormality). Subsequent progressive spinal deformity will develop in what percent of patients with this injury?

. 10%
. 25%
. 50%
. 75%
. Greater than 75%

Correct Answer & Explanation

. 10%

Explanation

DISCUSSION: Spinal cord injury in skeletally immature patients almost always leads to the development of paralytic spinal deformity.  The age at injury is the most important factor affecting the development of scoliosis.  Spinal cord injury that occurs more than 1 year prior to skeletal maturity is almost always followed by the development of scoliosis.  In one study, scoliosis developed in 100% of children who were younger than age 10 years at the time of spinal cord injury.  Scoliosis can occur after injury at any level.  Spasticity is often a contributing factor.  Up to two thirds of patients who have paralytic scoliosis prior to skeletal maturity will eventually require surgery for curve control.REFERENCES: Mayfield JK, Erkkila JC, Winter RB: Spine deformity subsequent to acquired childhood spinal cord injury. J Bone Joint Surg Am 1981;63:1401-1411.Lancourt JE, Dickson JH, Carter RE: Paralytic spinal deformity following traumatic spinal cord injury in children and adolescents. J Bone Joint Surg Am 1981;63:47-53.Dearolf WW III, Betz RR, Vogel LC, Levin J, Clancy M, Steel HH: Scoliosis in pediatric spinal cord injured patients.  J Pediatr Orthop 1990;10:214-218.

Question 2125

Topic: 6. Spine

Up to what time frame are the risks minimized in anterior revision disk replacement surgery?

. 3 days
. 1 week
. 10 days
. 2 weeks
. 6 weeks

Correct Answer & Explanation

. 3 days

Explanation

DISCUSSION: Revision anterior exposure within 2 weeks of total disk replacement incurs relatively little additional morbidity because adhesion formation is minimal.  Surgeons should have a low threshold for revising implants that are clearly dangerously malpositioned or show early migration within this 2-week window.  Beyond this time period, a revision strategy must be individualized to the particular clinical situation.  A posterior fusion with instrumentation with or without a laminectomy is currently the most effective salvage procedure.REFERENCE: Tortolani JP, McAfee PC, Saiedy S: Failures of lumbar disc replacement.  Sem Spine Surg 2006;18:78-86.

Question 2126

Topic: 6. Spine

What method of spinal fixation requires the largest force to disrupt the bone-implant interface?

. Sublaminar cables
. Laminar hooks
. Pedicle hooks
. Pedicle screws

Correct Answer & Explanation

. Sublaminar cables

Explanation

Pedicle screws have been established to produce a superior bone-implant interface in the nonosteoporotic spine according to numerous studies, but, interestingly, clinical outcomes using the varied implants have not been different.

Question 2127

Topic: 6. Spine

An otherwise healthy 45-year-old woman reports the onset of severe right leg pain. Figure 20a shows an axial MRI scan of the L4-5 level, and Figure 20b shows a sagittal view with the arrow at the L4-5 level. What nerve root is the most likely source of her pain?

. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L3

Explanation

DISCUSSION: The scans show a disk herniation in the far lateral region of the disk.  In particular, the sagittal view shows the herniation adjacent to the exiting L4 nerve root.  Disk herniations in this area that cause symptoms are more likely to compress the nerve exiting at the same level rather than the next most caudal level.REFERENCES: McCulloch JA: Microdiscectomy, in Frymoyer JW (ed): The Adult Spine: Principles and Practice.  New York, NY, Raven Press, 1991, vol 2, pp 1765-1783.Hodges SD, Humphreys SC, Eck JC, Covington LA: The surgical treatment of far lateral L3-L4 and L4-L5 disc herniations: A modified technique and outcomes analysis of 25 patients.  Spine 1999;24:1243-1246.

Question 2128

Topic: 6. Spine

Figures 54a and 54b show the radiograph and MRI scan of a 7-year-old boy who has a painful right thoracic scoliosis that measures 35°. Neurologic examination is normal. Management should consist of

. repeat radiographs in 6 months.
. a technetium Tc 99m bone scan.
. posterior spinal fusion.
. anterior and posterior spinal fusion.
. a neurosurgical consultation.

Correct Answer & Explanation

. a neurosurgical consultation.

Explanation

DISCUSSION: Because hydrosyringomyelia, with or without an Arnold-Chiari malformation, is now being recognized as the etiology of many infantile and juvenile idiopathic scolioses, management should consist of a neurosurgical consultation.  Observation with follow-up radiographs is not an option in curves of this magnitude.  A technitium Tc 99m bone scan is unnecessary because the etiology of the curve has been identified.  Although spinal fusion may be needed in the future, it should not be undertaken before the neurosurgical problem has been addressed.REFERENCES: Zadeh HG, Sakka SA, Powell MP, Mehta MH: Absent superficial abdominal reflexes in children with scoliosis: An early indicator of syringomyelia.  J Bone Joint Surg Br 1995;77:762-767.Schwend RM, Hennrikus W, Hall JE, Emans JB: Childhood scoliosis: Clinical indications for magnetic resonance imaging.  J Bone Joint Surg Am 1995;77:46-53.Farley FA, Song KM, Birch JG, Browne R: Syringomyelia and scoliosis in children.  J Pediatr Orthop 1995;15:187-192.

Question 2129

Topic: 6. Spine

A 78-year-old man has a history of worsening bilateral calf pain with activity. MRI scans are shown in Figures 31a through 31d. His symptoms are not improved with forward flexion of the lumbar spine. His lower extremity pain is relieved when he sits or ceases activity. Which of the following tests would be most helpful in establishing a diagnosis? Review Topic

. Selective nerve root blocks
. Electromyography and a nerve conduction velocity study of the lower extremities
. Ankle-brachial index (ABI)
. Bilateral hip radiographs
. Post-myelography CT scan

Correct Answer & Explanation

. Ankle-brachial index (ABI)

Explanation

The differential diagnosis of degenerative lumbar stenosis is extensive. Vascular and neurogenic claudication frequently coexist in the older population. Therefore, it is important to determine the specific etiology of a patient's lower extremity claudication prior to any surgical intervention. Vascular claudication is relieved with cessation of activity, whereas neurogenic claudication requires that the patient sit down or flex the lumbar spine forward to increase the canal diameter. Because this patient does not experience improvement in his symptoms with sitting or forward flexion, it is likely that he is experiencing vascular claudication. The ankle-brachial index (ABI) is the ratio of the blood pressure in the lower legs to the blood pressure in the arms. Compared with the arm, lower blood pressure in the leg is a sign of peripheral vascular disease. The ABI is calculated by dividing the systolic blood pressure in the arteries at the ankle and foot by the higher of the two systolic blood pressures in the arms. An ABI value between 0.40 to 0.80 is moderately decreased and such patients often experience symptoms such as intermittent claudication. Selective nerve root blocks prove to be more useful in identifying specific level(s) of involvement in patients experiencing radicular pain and paresthesias. Their utility is less helpful in lower extremity claudication. Electrophysiologic studies are rarely useful, except in identifying the presence and source of a peripheral neuropathy. About 80% of patients with symptomatic lumbar stenosis will demonstrate electromyographic changes. Osteoarthritis of the hip may be associated with buttock, groin, hip, and thigh pain.Decreased range of motion and hip joint pain, especially in internal rotation and abduction, are common findings in patients with degenerative arthritis of the hip. While post-myelography CT has been found superior to MRI as a single study for the preoperative planning of decompression for lumbar spinal stenosis, it will not assist in differentiating vascular from neurogenic claudication.

Question 2130

Topic: 6. Spine

A 64-year-old man who underwent an L4-5 decompression approximately 1 year ago reported relief of his claudicatory leg pain initially, but he now has increasing low back pain and recurrent neurogenic claudication despite nonsurgical management. Radiographs show new asymmetric collapse and spondylolisthesis at the decompressed segment, and MRI scans show lateral recess stenosis. The next most appropriate step in management should consist of

. L4-5 diskectomy.
. L4-5 diskectomy and lateral recess decompression.
. revision posterior decompression.
. revision posterior decompression and posterolateral fusion.
. anterior lumbar interbody fusion with cages.

Correct Answer & Explanation

. revision posterior decompression and posterolateral fusion.

Explanation

DISCUSSION: When radiographic findings reveal postlaminectomy instability, procedures that do not include some type of fusion will fail to solve the problem.  In fact, wider decompression or diskectomy alone will only further destabilize the segment.  Because there is radiographic evidence of recurrent lateral recess stenosis and symptomatic neurogenic claudication, a revision decompression should be included.  Since access to the canal involves a posterior approach, the stabilization should be performed through that same approach.REFERENCES: Herkowitz HN, Kurz LT: Degenerative lumbar spondylolisthesis with spinal stenosis: A prospective study comparing decompression with decompression and intertransverse process arthrodesis.  J Bone Joint Surg Am 1991;73:802-808.Hansraj KK, O’Leary PF, Cammisa FP Jr, et al: Decompression, fusion, and instrumentation surgery for complex lumbar spinal stenosis.  Clin Orthop 2001;384:18-25.

Question 2131

Topic: 6. Spine

A 73-year-old woman reports a 4-month history of severe left-sided posterior buttock pain and left leg pain. The leg pain radiates into the left lateral thigh and posterior calf with cramping. Examination reveals mild difficulty with a single-leg toe raise on the left side and a diminished ankle reflex. There is also a significant straight leg raise test at 45 degrees which exacerbates symptoms. An MRI scan is shown in Figure 4. What is the most appropriate treatment at this time? Review Topic

. Lumbar laminectomy with synovial cyst excision
. Repeat epidural steroid injection
. Microdiskectomy at L4-5
. Nonsteroidal medication and outpatient physical therapy
. Left-sided facet blocks at L4-5 and L5-S1

Correct Answer & Explanation

. Lumbar laminectomy with synovial cyst excision

Explanation

Lumbar spinal stenosis with lumbar radiculopathy can be commonly caused by a synovial cyst arising from the facet joints. Lyons and associates reported on the surgical treatment of synovial cysts in 194 patients. Of the 147 with follow-up data, 91% reported good pain relief and 82% had improvement of their motor deficits. Epstein reported a 58% to 63% incidence of good/excellent results and a 38 to 42point improvement on the SF-36 Physical Function Scale. It was also suggested that since the presence of a synovial cyst indicates facet pathology, possible fusion should be considered in these patients, especially those with underlying spondylolisthesis.(SBQ12SP.20) Amphotericin B is most appropriate for the treatment of which type of spine infection?Review TopicFungal osteomyelitisBacterial osteomyelitis with a gram-positive organismBacterial osteomyelitis with a gram-negative organismTuberculous osteomyelitisViral meningomyelitisAmphotericin B would be most appropriate for the treatment of fungal infections of the spine.Amphotericin B is a broad-spectrum anti-fungal medication. It is commonly used as the first-line agent for treatment of fungal infections of the spine. The most common fungi involving the spine include cryptococcus, candida, and aspergillus. The indications for débridement and stabilization with spinal fusion, includes resistance to antibiotic therapy, spinal instability, and/or neurologic deficits.Kim et al. reviewed fungal infections of the spine. They comment that fungus infections are most commonly spread by hematogenous or direct spread. Access to the vascular system may include intravenous lines, during implantation of prosthetic devices, or during surgery.Frazier et al. retrospectively reviewed 11 patients with fungal osteomyelitis of the spine. Nine of the patients were immunocompromised secondary to diabetes mellitus, corticosteroid use, chemotherapy for a tumor, or malnutrition. All were treated with anti-fungal medication. 10 of 11 patients were also treated with surgical debridement. Paralysis secondary to the spine infection developed in eight patients. After an average of 6.3 years of follow-up, the infection had resolved in all nine surviving patients.Illustration A shows the mechanism of action of Amphotericin. Illustration B shows T1- (Image A and B) and T2-weighted (Image C) images of the lower thoracic and lumbar spine. There are hypointense signals within the T12 and L1 vertebral bodies (Images A and B) indicative of fungal osteomyelitis.IncorrectAnswers:

Question 2132

Topic: 6. Spine

A B C Figures 30a through 30c are the radiograph and MR images of a 54-year-old woman who has severe leg pain with walking. Her treatment has included 12 weeks of physical therapy, anti-inflammatory medications, and narcotic pain relievers, and she is interested in surgery. Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) is recommended. When compared with open TLIF, MIS TLIF is associated with

. shorter hospital stay.
. lower rates of fusion.
. higher complication rates.
. worse long-term outcomes.

Correct Answer & Explanation

. shorter hospital stay.

Explanation

DISCUSSIONMIS TLIF involves a steep learning curve but is associated with similar longterm outcomes as open TLIF, arguably comparable or possibly lower complication rates, and equivalent fusion rates. The major distinguishing feature comparing open to minimally invasive surgery for this and other spinal diagnoses has been shorter hospital stays.RECOMMENDED READINGSPeng CW, Yue WM, Poh SY, Yeo W, Tan SB. Clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion. Spine (Phila Pa 1976). 2009 Jun 1;34(13):1385-9. doi: 10.1097/BRS.0b013e3181a4e3be. PubMed PMID: 19478658.ViewAbstract at PubMedLee KH, Yue WM, Yeo W, Soeharno H, Tan SB. Clinical and radiological outcomes of open versus minimally invasive transforaminal lumbar interbody fusion. Eur Spine J. 2012 Nov;21(11):2265-70. doi: 10.1007/s00586-012-2281-4. Epub 2012 Mar 28. PubMed PMID:

Question 2133

Topic: 6. Spine

A 27-year-old man sustained a gunshot wound to the lumbar spine and undergoes an exploratory laparotomy. An injury to the cecum is identified and treated. Management should now include

. no antibiotics.
. oral broad-spectrum antibiotics for 7 days.
. intravenous broad-spectrum antibiotics for 48 hours.
. intravenous broad-spectrum antibiotics for 7 days.
. intravenous antibiotics specific for Staphylococcus for 7 days.

Correct Answer & Explanation

. no antibiotics.

Explanation

DISCUSSION: Gunshot wounds to the spine present relatively little risk of infection in most cases.  When there has been an injury to the colon, the risk of infection can be minimized witha 7-day course of broad-spectrum antibiotics.  Fragment removal is not indicated.REFERENCES: Roffi RP, Waters RL, Adkins RH: Gunshot wounds to the spine associated with a perforated viscus.  Spine 1989;14:808-811.Velmahoos GC, Demetriades D: Gunshot wounds of the spine: Should retained bullets be removed to prevent infection?  Ann R Coll Surg Engl 1976;94:85-87.

Question 2134

Topic: 6. Spine

Which of the following is the most sensitive parameter to detect the increased inflammatory response seen with both postoperative infection and the use of instrumentation in spinal surgery?

. Patient temperature
. WBC count
. Erythrocyte sedimentation rate
. C-reactive protein
. Rheumatoid Factor

Correct Answer & Explanation

. C-reactive protein

Explanation

CORRECTDISCUSSION: The most sensitive parameter to detect inflammation elicited by implants and infection is the C-reactive protein (CRP).CRP is an acute phase reactant that increases sharply immediately after surgery within 6 hours after tissue damage. CRP then peaks 2-3 days later and returns to normal levels 5-21 days after the inciting event. In contrast, ESR reaches its peak on days 4-11, then remains elevated for a prolonged period of time.Takahashi et al performed a Level 3 study of patients who had undergone spinal surgery with and without instrumentation, with a primary outcome of infection. They concluded that renewed elevation of C-reactive protein, white blood cell count, and body temperature after postoperative days 4 to 7 may be a key indicator of postoperative infection.

Question 2135

Topic: 6. Spine

Which of the following is considered the most common long-term effect on the spine of a professional race horse jockey?

. Thoracic spondylosis
. Lumbar spondylosis
. Cervical spondylosis
. Cervical and thoracic spondylosis
. Cervical and lumbar spondylosis

Correct Answer & Explanation

. Cervical and lumbar spondylosis

Explanation

DISCUSSION: Horseback riding is a sport that directly affects the jockey’s spine.  Tsirikos and associates reported the results of a study of 32 jockeys.  They found that equestrian sports, especially professional horseback riding, apart from the increased risk of direct spinal injury caused by a fall from the horse, can lead to progressive spinal degeneration as a result of repetitive trauma and increased physical stress on the spine.  It is associated with spondylosis of the cervical spine and lumbar spine.REFERENCES: Tsirikos A, Papagelopoulos PJ, Giannakopoulos PN, et al:  Degenerative spondyloarthropathy of the cervical and lumbar spine in jockeys.  Orthop 2001;24:561-564.Hordegen KM: The spine and horseback riding.  Schweiz Med Wochenschr 1975;105:668-675.

Question 2136

Topic: 6. Spine

A patient with rheumatoid arthritis has an unstable pseudarthrosis after undergoing C1-2 posterior fusion. No neurologic deficits are noted, and repair with posterior transarticular fixation screws and a posterior wiring technique at C1-2 is planned. Which of the following preoperative studies offers the best visualization?

. Lateral flexion-extension radiographs centered over C1-2
. Cervical MRI
. Thin-cut CT through the C1-2 and C2-3 segments
. Vertebral artery angiography
. Electromyography of the cervical roots and spinal cord

Correct Answer & Explanation

. Thin-cut CT through the C1-2 and C2-3 segments

Explanation

DISCUSSION: Dickman and associates reported a greater than 10% incidence of vertebral artery anomalies at the C1-2 junction that would preclude the use of either unilateral or bilateral transarticular screw placement.  They noted that 13 of 105 patients had a high-riding transverse foramen that precluded bilateral screw placement.  In another series, 17 of 94 patients had unilateral high-riding transverse foramina and three had bilateral anomalies.  Thin-cut CT with sagittal reconstructions offers the best visualization of the anomalous position of the vertebral artery.  They noted that single screw placement in combination with posterior C1-2 fusion was an effective means to secure C1-2 stability.  MRI gives excellent visualization of soft tissues and spinal cord compression but is not as clear as thin-cut CT for visualization of the vertebral artery foramina.  Vertebral artery angiography is an invasive study with an inherent potential for complications.  Electromyography does not correlate with vertebral artery anatomy.REFERENCES: Paramore CG, Dickman CA, Sonntag VK: The anatomic suitability of the C1-2 complex for transarticular screw fixation.  J Neurosurg 1996;85:221-224.Dickman CA, Sonntag VK: Posterior C1-C2 transarticular screw fixation for atlantoaxial arthrodesis.  Neurosurgery 1998;43:275-280.Song GS, Theodore N, Dickman CA, Sonntag VK: Unilateral posterior atlantoaxial transarticular Screw fixation.  J Neurosurg 1997;87:851-855.

Question 2137

Topic: 6. Spine

A 12-year-old girl has back pain after falling 20 feet and landing in the sitting position. She has no fractures or other injuries, and her neurologic examination is normal. A lateral radiograph, transverse CT scan, and reformatted sagittal CT scan are shown in Figures 25a through 25c. Which of the following methods is associated with the best long-term outcome? Review Topic


. Hyperextension casting of the thoracolumbar spine for 6 weeks
. In situ posterior fusion with instrumentation
. Posterior fusion with instrumentation, with sagittal plane correction
. Posterior decompression, followed by posterior fusion with instrumentation, with sagittal plane correction
. Anterior decompression and partial corpectomy, with anterior instrumentation

Correct Answer & Explanation

. Posterior fusion with instrumentation, with sagittal plane correction

Explanation

The patient has a displaced burst fracture. Fusion with instrumentation has shown better results than casting alone. Posterior fusion with instrumentation, with sagittal plane correction, yields the best results. Decompression occurs indirectly with correction of the kyphosis. Anterior decompression is unnecessary.

Question 2138

Topic: 6. Spine

A 75-year-old woman who sustained a fall now reports neck pain and upper extremity weakness. Examination reveals 4 of 5 strength in the upper extremities and 5 of 5 strength in the lower extremities. Radiographs show multilevel degenerative disk disease. An MRI scan is shown in Figure 96. Her clinical presentation is most compatible with which of the following? Review Topic

. Brachial plexus injury
. Anterior cord syndrome
. Posterior cord syndrome
. Central cord syndrome
. Brown-Séquard syndrome

Correct Answer & Explanation

. Brachial plexus injury

Explanation

The MRI scan shows advanced multilevel degenerative changes and moderate to severe stenosis at C3-C4 and C4-C5 with associated cord signal change. The patient has greater weakness in the upper extremities than in the lower extremities. This pattern is most compatible with central cord syndrome. Patients with brachial plexus injury will have unilateral weakness. Patients with anterior cord syndrome will have greater weakness in the legs than in the arms, and those with Brown-Séquard syndrome will have ipsilateral motor deficits and contralateral pain and temperature deficits.

Question 2139

Topic: 6. Spine

An otherwise healthy 54-year-old man who underwent a successful multilevel lumbar decompression and fusion 4 years ago now reports increasingly severe bilateral thigh claudication with paresthesia and severe back pain for the past 12 months. Physical therapy, bracing, and epidural steroids have failed to provide relief. A radiograph and MRI scans are shown in Figures 15a through 15c. He is afebrile, and laboratory studies show an erythrocyte sedimentation rate of 5 mm/h and a normal WBC count. What is the best course of action?

. Referral to the pain clinic to consider insertion of a morphine pump
. L1-2 laminectomy
. L1-2 anterior lumbar interbody fusion via a minimally invasive technique
. Posterior laminectomy and uninstrumented fusion
. Posterior decompression and instrumented fusion

Correct Answer & Explanation

. Referral to the pain clinic to consider insertion of a morphine pump

Explanation

DISCUSSION: The patient has degeneration of an adjacent segment with resultantkyphosis and stenosis.  Because he is healthy, has responded well to previous surgery,|and has a potentially correctable lesion, he is not a good candidate for an end-stage failedback procedure such as a morphine pump.  The stenosis is exacerbated by the deformity; therefore, a simple decompression will contribute to instability.  Because of the kyphosis and the patient’s relatively young age, the treatment of choice is restoration of sagittal alignment and posterior decompression.REFERENCE: Eck JC, Humphreys SC, Hodges SD: Adjacent-segment degeneration after lumbar fusion: A review of clinical, biomechanical, and radiographic studies.  Am J Orthop 1999;28:336-340.

Question 2140

Topic: 6. Spine

A 10-year-old girl has been referred for evaluation of a prominence at the lower cervical spine. The patient is asymptomatic, and the examination reveals no evidence of neurologic abnormality. A radiograph and CT scans are shown in Figures 12a through 12c. What is the most likely diagnosis?

. Tuberculosis
. Congenital kyphosis
. Blastomycosis
. Aneurysmal bone cyst
. Osteoblastoma

Correct Answer & Explanation

. Tuberculosis

Explanation

DISCUSSION: Tuberculosis is uncommon in the cervical spine but has a relatively greater incidence in young children.  In a review of 40 patients with lower cervical spine involvement (C2 to C7), 24 were younger than age 10 years at presentation.  In children, the disease is characterized by more extensive involvement with the formation of large abscesses.  In older patients with lower cervical tuberculosis, the disease is more localized but is more likely to cause paraplegia.  Four-drug antituberculosis therapy should be used.  For patients with pain or neurologic dysfunction, anterior excision of diseased bone and grafting are indicated.  Whether vertebral body excision and grafting should be done in an asymptomatic 10-year-old child is debatable.  The CT scan shows a large “cold” abscess that is partially calcified.REFERENCES: Hsu LC, Leong JC: Tuberculosis of the lower cervical spine (C2 to C7): A report on 40 cases.  J Bone Joint Surg Br 1984;66:1-5.Loder RT: The cervical spine, in Morrissy RT, Weinstein SL (eds):  Lovell & Winter’s Pediatric Orthopaedics, ed 4.  Philadelphia, Pa, Lippincott-Raven, 1996, pp 739-789.

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