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6. Spine MCQs

Practice Set 11 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 201

Topic: 6. Spine
A 21-year-old man presented to the emergency department after sustaining a low-velocity gunshot wound to his midback resulting in grade 0 (out of 5) weakness in his quadriceps and tibialis anterior muscles. His extensor hallucis longus and gastrocnemius/soleus muscles were grade 3 (out of 5) bilaterally. His sensation remained intact. An intradural bullet fragment was seen at T12. No fracture was seen on computed tomography (CT) scan. Management should consist of:
. Administration of methylprednisolone 30 mg/kg bolus followed by an infusion of 5.4 mg/kg for 24 hours.
. Application of a thoracolumbosacral orthosis (TLSO).
. Administration of broad-spectrum antibiotics for 14 days.
. Removal of the bullet fragment.
. Removal of the bullet fragment and instrumented fusion from T10 to L2.

Correct Answer & Explanation

. Removal of the bullet fragment.

Explanation

In complete and incomplete lesions from T12 to L4, removal of the bullet fragment from the canal has been associated with significant motor recovery. This improvement is not seen in other regions of the spine. High-dose steroids have not been shown to offer improvement in patients with spinal cord injury after a gunshot wound, and the complications of high-dose steroids have been documented in this population. The majority of gunshot wounds to the spine are stable injuries. This patient's CT scan does not demonstrate any instability. Therefore, neither nonoperative (e.g., TLSO bracing) nor operative (instrumented fusion) stabilization is indicated. While infection after transalimentary bullet wounds to the spine is a well-documented complication, this patient's injury was sustained from the back, thereby avoiding the alimentary canal and obviating the need for intravenous antibiotics.

Question 202

Topic: 6. Spine

Common indications for lumbar pedicle screw fixation include:

. Rigid stabilization for patients undergoing arthrodesis or interbody fusion
. Correction of lumbar spinal deformity
. Stabilization after trauma to the lumbar spine
. Rigid stabilization for patients undergoing arthrodesis or interbody fusion, and correction of lumbar spinal deformity
. Rigid stabilization for patients undergoing arthrodesis or interbody fusion, correction of lumbar spinal deformity and stabilization

Correct Answer & Explanation

. Rigid stabilization for patients undergoing arthrodesis or interbody fusion, correction of lumbar spinal deformity and stabilization

Explanation

after trauma to the lumbar spine Common indications for pedicle screw fixation include rigid stabilization for patients undergoing arthrodesis or interbody fusion, correction of deformity, and stabilization after trauma.

Question 203

Topic: 6. Spine

A 16-year-old boy presents with a painful, rigid thoracic scoliosis. Imaging confirms an osteoid osteoma in the T8 vertebra. Which of the following best describes the typical curve pattern in relation to the lesion?

. The lesion is located on the convexity of the curve
. The lesion is located on the concavity of the curve
. The apex of the curve is typically three levels above the lesion
. The curve is predominantly a structural, non-flexible kyphosis
. The curve invariably progresses despite resection of the lesion

Correct Answer & Explanation

. The lesion is located on the concavity of the curve

Explanation

In spinal osteoid osteomas, muscle spasm typically causes the spine to curve away from the lesion, placing the tumor on the concavity of the scoliotic curve. Excision of the nidus usually leads to resolution of the scoliosis if treated within 15 months of onset.

Question 204

Topic: 6. Spine

An asymptomatic 50-year-old woman undergoes a lumbar spine X-ray revealing prominent vertical trabeculae in the L2 vertebral body. Axial CT shows a 'polka-dot' appearance. What is the recommended management?

. Marginal resection
. Radiation therapy
. Kyphoplasty
. Observation
. Preoperative embolization and curettage

Correct Answer & Explanation

. Observation

Explanation

The classic 'corduroy cloth' (vertical striations) on X-ray and 'polka-dot' sign on CT are pathognomonic for a vertebral hemangioma. Most are benign, completely asymptomatic, and require only observation.

Question 205

Topic: 6. Spine

Which of the following scoring systems is specifically designed to estimate survival in patients with spinal metastatic disease to guide surgical decision-making?

. Mirels score
. Enneking staging system
. Tokuhashi score
. Spine Instability Neoplastic Score (SINS)
. Frankel grade

Correct Answer & Explanation

. Tokuhashi score

Explanation

The Tokuhashi score estimates life expectancy in patients with spinal metastases based on performance status, primary tumor site, and other metastases. The SINS system evaluates mechanical stability, not primarily survival.

Question 206

Topic: 6. Spine

When an osteoid osteoma is situated in the lumbar pedicle near the neural foramen, what is a common initial misdiagnosis due to its clinical presentation?

. Lumbar radiculopathy from disc herniation
. Inflammatory bowel disease
. Renal colic
. Hip osteoarthritis
. Ankylosing spondylitis

Correct Answer & Explanation

. Lumbar radiculopathy from disc herniation

Explanation

Osteoid osteomas in the lumbar spine can cause severe localized inflammation, leading to adjacent nerve root irritation. This often presents as referred pain down the leg, clinically mimicking sciatica from a disc herniation.

Question 207

Topic: 6. Spine

Which of the following factors contributes the highest number of points to the Spine Instability Neoplastic Score (SINS)?

. Pain character (mechanical vs. non-mechanical)
. Lesion location (junctional vs. non-junctional)
. Radiographic alignment (subluxation or translation)
. Bone lesion type (lytic vs. blastic)
. Posterolateral element involvement

Correct Answer & Explanation

. Radiographic alignment (subluxation or translation)

Explanation

In the SINS criteria, radiographic alignment showing subluxation or translation contributes 4 points, which is the highest single scoring category. A total score of 13-18 indicates instability warranting surgical consultation.

Question 208

Topic: 6. Spine

An 18-year-old female presents with a rigid, painful thoracic scoliosis. An osteoid osteoma is identified in the spine. Which of the following best describes the typical relationship between the lesion and the scoliotic curve?

. The lesion is located at the apex of the convexity.
. The lesion is located at the apex of the concavity.
. The lesion is located in the vertebral body causing kyphoscoliosis.
. The curve typically progresses rapidly despite complete tumor excision.
. The lesion invariably involves the anterior elements of the spine.

Correct Answer & Explanation

. The lesion is located at the apex of the concavity.

Explanation

Spinal osteoid osteomas typically present with a painful, rigid scoliosis. The lesion is almost always located in the posterior elements on the concave side of the apex of the curve due to asymmetric muscle spasms.

Question 209

Topic: 6. Spine

Which of the following is NOT a component of the Spinal Instability Neoplastic Score (SINS) used to evaluate metastatic spinal lesions?

. Location of the lesion
. Pain characteristics
. Bone lesion quality (lytic vs. blastic)
. Patient life expectancy
. Posterolateral involvement

Correct Answer & Explanation

. Patient life expectancy

Explanation

The SINS score evaluates mechanical instability using six criteria: location, pain, bone lesion quality, radiographic spinal alignment, degree of vertebral body collapse, and posterolateral involvement. Patient life expectancy is part of the Tokuhashi or Tomita scores, not SINS.

Question 210

Topic: 6. Spine

A 25-year-old male has an expansile, lytic lesion in the posterior elements of L3 causing progressive lower extremity weakness. Biopsy confirms osteoblastoma. What is the most appropriate definitive surgical management?

. En bloc resection or aggressive curettage with spinal stabilization
. Radiation therapy alone
. Chemotherapy followed by local excision
. Radiofrequency ablation
. Observation as the lesion is self-limiting

Correct Answer & Explanation

. En bloc resection or aggressive curettage with spinal stabilization

Explanation

Surgical resection (intralesional curettage or en bloc depending on staging/morbidity) is the treatment of choice for spinal osteoblastomas causing neurologic deficit. Because of the size and destruction, spinal stabilization is often required.

Question 211

Topic: 6. Spine

Which of the following regions of the spine is normally straight:

. T1 to T6
. T7 to T12
. T10 to L2
. L1 to L4
. T12 to S1

Correct Answer & Explanation

. T10 to L2

Explanation

The normal range of thoracic kyphosis is 20° to 50°. The mean in normal adults is 35°. The normal range of lumbar lordosis is 40° to 80°. The mean in normal adults is approximately 60°. The spine is usually straight in the sagittal plane between T10 and L2. The majority of lumbar lordosis occurs between L4 and S1.

Question 212

Topic: 6. Spine

The endplates and pedicles of which of the following vertebra are normally parallel to the ground in a standing individual:

. L1
. L3
. S1
. T1
. T12

Correct Answer & Explanation

. L3

Explanation

The alignment of the spine is important in normal upright posture. There is a normal degree of lordosis in the cervical and lumbar spines and a moderate degree of kyphosis in the thoracic spine. The head, spine, and pelvis are connected and balanced. If the spine is out of balance, then a deformity can develop causing fatigue of the paraspinal muscles. The normal sagittal alignment in the upright patient is as follows: Plumb line The sagittal plumb line falls from the odontoid process through the C 7-T1 intervertebral disk and then anterior to the thoracic spine. The plumb line then crosses the spine at the T12-L1 intervertebral disk, and then travels posterior to the spine. The plumb line crosses at the posterior corner of the S1 vertebra. The endplates and pedicles of the L3 vertebra are normally parallel to the ground.

Question 213

Topic: 6. Spine

Which of the following is true regarding the alignment of the spine with aging:

. Thoracic kyphosis decreases; lumbar lordosis increases
. Thoracic kyphosis decreases; lumbar lordosis decreases
. Thoracic kyphosis increases; lumbar lordosis decreases
. Thoracic kyphosis increases; lumbar lordosis increases
. The alignment of the spine undergoes no significant changes with aging.

Correct Answer & Explanation

. Thoracic kyphosis increases; lumbar lordosis decreases

Explanation

The normal range of thoracic kyphosis is 20° to 50°. The mean in normal adults is 35°. The normal range of lumbar lordosis is 40° to 80°. The mean in normal adults is approximately 60°. The spine is usually straight in the sagittal plane between T10 and L2. The majority of lumbar lordosis occurs between L4 and S1. With aging, due to changes in the intervertebral disks, thoracic kyphosis increases and lumbar lordosis increases. There is loss of height of the intervertebral disks.

Question 214

Topic: 6. Spine

In reference to the normal sagittal vertical axis (sagittal plumb line), the axis normally falls from the odontoid process through the C 7-T1 intervertebral disk and anterior to the thoracic vertebra. This normal axis crosses the spinal column at which of the following levels before crossing the spinal column at the posterior superior border of the S1 vertebral body:

. T3-T4 intervertebral disk
. T6-T7 intervertebral disk
. T8-T10 intervertebral disk
. T12-L1 intervertebral disk
. L3-L4 intervertebral disk

Correct Answer & Explanation

. T12-L1 intervertebral disk

Explanation

The alignment of the spine is important in normal upright posture. There is a normal degree of lordosis in the cervical and lumbar spines and a moderate degree of kyphosis in the thoracic spine. The head, spine, and pelvis are connected and balanced. If the spine is out of balance, then a deformity can develop causing fatigue of the paraspinal muscles. The normal sagittal alignment in an upright patient is as follows: Plumb line The sagittal plumb line falls from the odontoid process through the C 7-T1 intervertebral disk and then anterior to the thoracic spine. The plumb line then crosses the spine at the T12-L1 intervertebral disk, and then travels posterior to the spine. The plumb line crosses at the posterior corner of the S1 vertebra The endplates and pedicles of the L3 vertebra are normally parallel to the ground.

Question 215

Topic: 6. Spine

The vertebral artery on the right side of the body arises from the subclavian artery and enters the lateral mass foramen of which of the following cervical vertebra (the first one it enters) before ascending to the brain:

. C 3
. C 4
. C 5
. C 6
. C 7

Correct Answer & Explanation

. C 6

Explanation

The vertebral artery arises from the subclavian artery on the right side of the body and the aortic arch on the left side. The vertebral artery enters the lateral mass foramen of the sixth cervical vertebra before ascending to the brain.

Question 216

Topic: 6. Spine

To avoid damages to the vertebral arteries when exposing the posterior aspect of the first cervical vertebra, dissection should be limited to __ mm from the midline on the superior aspect of C 1 and ___ mm from the midline on the posterior aspect of C 1.

. 8 mm; 12 mm
. 10 mm; 14 mm
. 12 mm; 16 mm
. 14 mm; 20 mm
. 16 mm; 22 mm

Correct Answer & Explanation

. 8 mm; 12 mm

Explanation

One must be careful not to damage the vertebral artery when exposing the posterior and superior aspect of the C1 vertebra. It is especially important when using a Cobb elevator or an electrocautery not to dissect too far from the midline. The vertebral artery lies close to the midline. On the superior aspect, the groove for the vertebral artery lies 8 mm to12 mm from the midline. On the posterior aspect of the vertebral body, the vertebral artery lies 12 mm to 23 mm from the midline.

Question 217

Topic: 6. Spine

Which of the following levels most significantly contributes to the blood supply of the cervical spinal cord:

. C 2 (accompanying the left C 2 spinal nerve)
. C 4 (accompanying the right C 4 spinal nerve)
. C 6 (accompanying the left C 6 spinal nerve)
. C 7 (accompanying the right C 7 spinal nerve)
. T1 (accompanying the right T1 spinal nerve)

Correct Answer & Explanation

. C 6 (accompanying the left C 6 spinal nerve)

Explanation

The major blood supply to the cervical spinal cord comes from the anterior spinal artery, which arises from the deep cervical artery. This vessel most commonly accompanies the left C 6 spinal nerve.

Question 218

Topic: 6. Spine
Patients with Brown-Séquard syndrome usually present with:
. Ipsilateral paralysis, loss of contralateral vibration and touch sensation, and loss of ipsilateral pain and temperature sensation
. Ipsilateral paralysis and loss of contralateral vibration, and touch, pain, and temperature sensation
. Ipsilateral paralysis, loss of ipsilateral vibration and touch sensation, and loss of contralateral pain and temperature sensation
. Contralateral paralysis, loss of ipsilateral vibration and touch sensation, and loss of contralateral pain and temperature sensation
. Contralateral paralysis, loss of contralateral vibration and touch sensation, and loss of ipsilateral pain and temperature sensation

Correct Answer & Explanation

. Ipsilateral paralysis, loss of ipsilateral vibration and touch sensation, and loss of contralateral pain and temperature sensation

Explanation

Brown-Séquard syndrome usually results from hemisection of the spinal cord, which is often a result of trauma (e.g., penetrating stab wounds). Clinical presentation usually consists of: Ipsilateral paralysis, loss of ipsilateral vibration and touch sensation, and loss of contralateral pain and temperature sensation.

Question 219

Topic: 6. Spine

Central cord syndrome is typically due to:

. An axial compression injury with resultant injury to the central gray matter
. A hyperextension injury with compression of the cord by herniated disk material anteriorly
. A hyperextension injury with compression of the cord by osteophytes anteriorly and infolded ligamentum flavum posteriorly
. A hyperflexion injury with compression of the cord by herniated disk material anteriorly
. A hyperflexion injury compression of the cord by the anterior longitudinal ligament anteriorly and osteophytes posteriorly

Correct Answer & Explanation

. A hyperextension injury with compression of the cord by osteophytes anteriorly and infolded ligamentum flavum posteriorly

Explanation

Central cord syndrome is the most common incomplete spinal cord lesion and is usually seen in patients with preexisting cervical spondylosis who then sustain a hyperextension injury to the cervical spine. This mechanism causes compression of the cord by osteophytes anteriorly and the infolded ligamentum flavum posteriorly with resulting injury to the central gray matter. The clinical presentation is variable but usually consists of: Greater loss of motor neurons to the upper extremities than the lower extremities often resulting in profound weakness in the arms and hands, and some weakness in the legs and feet Variable sensory loss Patients with central cord syndrome have variable return of function but are usually left with some degree of residual deficit and spasticity.

Question 220

Topic: 6. Spine

A patient with cauda equina syndrome and the full spectrum of symptons presents with:

. Severe low back pain, sciatica, saddle anesthesia, and preservation of bladder vesicular control
. Severe low back pain, sciatica, urinary retention, and preservation of perianal sensation
. Severe low back pain, saddle anesthesia, loss of motor and sensation in the lower extremities, and preservation of bulbocavernosus reflex.
. Severe low back pain, loss of motor and sensation in the lower extremities, and preservation of bladder vesicular control
. Severe low back pain, sciatica, saddle anesthesia, urinary retention, and loss of bulbocavernosus reflex

Correct Answer & Explanation

. Severe low back pain, sciatica, saddle anesthesia, urinary retention, and loss of bulbocavernosus reflex

Explanation

Cauda equina syndrome is a severe neurologic disorder that results from an injury to the neural elements within the thecal sac between the conus medullaris and the lumbosacral nerve roots (ie, cauda equina or "horse's tail"). Cauda equina syndrome usually occurs as a result of lumbar disk herniation with compression of the cauda equina and requires urgent surgical decompression. Clinical presentation includes: Severe low back pain Bilateral or unilateral sciatica Saddle anesthesia Motor or sensory deficit Bladder and bowel vesicular involvement (classically leading to urinary retention) With a complete lesion, a loss of bulbocavernosus reflex, anal wink, and reflexes in the lower extremities

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