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 2201
Topic: Thoracolumbar Spine & Deformity
A patient who is an observant Jehovah’s Witness requires major surgery for scoliosis that will likely result in significant blood loss. Which of the following might the patient consider allowing the surgical team to use? Review Topic
Correct Answer & Explanation
. A cell saver with continuity maintained in a “closed circuit”
Explanation
Jehovah’s Witnesses will not accept the transfusion of blood or blood products such as packed red or white cells, platelets, or plasma. However, many Jehovah’s Witnesses will accept the use of a cell saver in a “closed circuit.”
Question 2202
Topic: 6. Spine
A 16-year-old female gymnast reports a 2-month history of back pain since falling off the parallel bars, and she has been unable to return to gymnastics. She has no numbness or tingling. Examination reveals lower back tenderness, some paravertebral muscle spasm, range of motion of the lumbosacral spine is 20 degrees of flexion and 20 degrees of extension, and an equivocal straight leg raise. Lumbosacral spine radiographs demonstrate Schmorl’s nodes but no evidence of spondylolisthesis. What is the next best step in management?
Correct Answer & Explanation
. MRI
Explanation
Injuries to the anterior and middle column in gymnasts occur but are far less common than posterior column injuries such as spondylolysis and spondylolisthesis. Long-term gymnastics exercise is associated with disk degeneration and other anterior and middle column abnormalities. Therefore, the differential diagnosis of back pain in these athletes should include abnormalities of the anterior and middle column. Although diagnostic imaging should begin with radiographs, MRI is the best way to diagnose these abnormalities.
Question 2203
Topic: 6. Spine
Figures 60a and 60b are the postmyelography CT images of a 62-year-old man who has had low-back and bilateral lower-extremity pain. His pain began approximately 1 year ago and there was no precipitating event. The location of the pain is in the lower lumbar region in the midline and it radiates into the buttocks and thighs bilaterally. The pain is exacerbated by standing and walking and relieved by forward spine flexion. He reports no pain while sitting or lying supine. Upright radiographs demonstrate 4 mm of anterolisthesis of L4 on L5. What is the most appropriate surgical procedure?
Correct Answer & Explanation
. Posterior decompression and fusion
Explanation
DISCUSSION: This patient radiographically has L4-5 degenerative stenosis and a low-grade spondylolisthesis. The axial images demonstrate a gap in the facet joint, more on the left than the right, which is highly suggestive of dynamic instability. Thus, this patient would most benefit from a laminectomy and fusion of L4-5. A microdiskectomy would not be helpful as this patient does not have a disk herniation. Patients undergoing posterior decompression alone experience an unacceptably high rate of recurrent stenosis and/or progression of spondylolisthesis. Early studies demonstrated that adding an intertransverse process fusion to posterior decompression significantly improved clinical outcomes. Anterior interbody fusion likely will not decompress the spinal canal sufficiently, though there is some thought that indirect decompression can be effective in some cases.
Question 2204
Topic: 6. Spine
A 32-year-old motorcycle rider is involved in a motor vehicle accident and radiographs show a burst fracture at L2 with 20 degrees of kyphosis. The neurologic examination is consistent with unilateral motor and sensory involvement of the L5, S1, S2, S3, and S4 nerve roots. He has no other injuries. CT demonstrates 20% anterior canal compromise with displaced laminar fractures at the level of injury. What is the best option for management of this patient?
Correct Answer & Explanation
. L2 laminectomy and posterior spinal fusion and instrumentation from T11 to L4
Explanation
DISCUSSION: The patient has a burst fracture with probable unilateral entrapment of the cauda equina within the elements of the fractured lamina. A dural tear is likely in this scenario as well. It is recommended that this type of burst fracture be treated surgically with laminectomy, freeing of the entrapped nerve roots, and dural repair followed by stabilization of the fracture by either a posterior or combined approach. The degree of kyphosis and the extent of anterior canal compromise does not warrant corpectomy in this patient. Therefore, after completing the laminectomy and dural repair, posterior fusion and instrumentation should be sufficient to stabilize the fracture.
Question 2205
Topic: 6. Spine
A 22-year-old man sustained a cervical fracture-dislocation of the C5-6 level in a motor vehicle accident along with an associated spinal cord injury. Six months after his injury, he has 4 out of 5 biceps on the left, with 5 out of 5 biceps on the right. Deltoid is graded at 5 out of 5 bilaterally. There is 0 strength in the triceps, wrist flexors, wrist extensors, and digital extensors. He has neurogenic bowel and bladder with absent perianal sensation and no voluntary motor in the lower extremities. The patient's neurologic deficit is best categorized as which of the following? Review Topic
Correct Answer & Explanation
. Complete C5 spinal cord injury
Explanation
The patient has a complete spinal cord injury. The level of a spinal cord injury is determined by the most distal intact (5/5) function. The lowest motor intact level in this patient is C5 based on the described examination. Central spinal cord injury and Brown-STquard injuries are both incomplete patterns of spinal cord injury.
Question 2206
Topic: 6. Spine
A 22-year-old woman reports a 4-year history of worsening low back and left lower extremity pain following a motor vehicle accident. Management consisting of physical therapy, chiropractic manipulation, and interventional pain management, including sacroiliac joint injections and epidural steroid injections, has failed to provide relief. A sagittal T2-weighted MRI scan is shown in Figure 8. No nerve root compression is seen on axial images. She is currently working and lives with her fiancé. She smokes half a pack of cigarettes per day and reports depression on her health history. She is being maintained on narcotic analgesics and is having increasing difficulty performing her activities of daily living secondary to pain. What is the most appropriate management at this time?
Correct Answer & Explanation
. Cognitive intervention, exercise, and smoking cessation
Explanation
DISCUSSION: The MRI scan reveals a rudimentary disk at the L5-S1 level, suggesting transitional anatomy. There is a posterior disk bulge at L3-4. At L4-5, there is disk desiccation and loss of disk height, with a posterior disk bulge and a high intensity zone in the posterior annulus, suggesting an annular tear. While these and similar radiographic findings have been associated with the severity of a patient’s pain, they are also commonly found in cross-sectional studies of asymptomatic subjects. This patient’s non-specific pain pattern does not require further work-up as she is not a surgical candidate.
Question 2207
Topic: 6. Spine
A 9-year-old child sustained a fracture-dislocation of C-5 and C-6 with a complete spinal cord injury. What is the likelihood that scoliosis will develop during the remaining years of his growth?
Correct Answer & Explanation
. 100%
Explanation
DISCUSSION: The incidence of late spinal deformity after complete spinal cord injury in children depends on the level of the spinal cord injury and the age of the patient at the time of injury. If a cervical level injury occurs before age 10 years, paralytic scoliosis will develop in virtually 100% of patients.
Question 2208
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?
Correct Answer & Explanation
. Posterior fusion with instrumentation, with sagittal plane correction
Explanation
DISCUSSION: 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 2209
Topic: 6. Spine
Which of the following findings is considered a contraindication for posterior decompression (with or without fusion) for myelopathy?
Correct Answer & Explanation
. Fixed kyphosis of more than 10°
Explanation
DISCUSSION: Although cervical instability is a contraindication to posterior decompression alone, segmental instability in the myelopathic cervical spine can be addressed with concomitant posterior fusion with instrumentation. Cervical lordosis represents the ideal scenario for posterior decompressive procedures for myelopathy (laminectomy and laminoplasty) because compression from anterior osteophytes, if present, is relieved as the spinal cord migrates posteriorly. The anteroposterior diameter of the spinal canal does not have an impact on the selection of surgical approach. Posterior unroofing-type procedures in kyphotic cervical spines, however, are ineffective because anterior impingement on the spinal cord will remain; therefore, kyphosis of more than 10° is considered a contraindication for posterior decompression.
Question 2210
Topic: 6. Spine
A 26-year-old woman who noted right-sided lumbosacral pain 10 days ago while vacuuming now reports that the pain has intensified. She denies any history of back problems. No radicular component is present, and her neurologic examination is normal. The next most appropriate step in management should consist of
Correct Answer & Explanation
. a brief (2 to 3 days) period of bed rest and nonsteroidal anti-inflammatory drugs.
Explanation
DISCUSSION: The initial management of a lumbar strain should consist of 2 to 3 days of bed rest when symptoms are severe, activity restrictions, and nonsteroidal anti-inflammatory drugs. It has been estimated that 60% to 80% of the adult population experiences back pain, with 2% to 5% affected yearly. Spontaneous improvement generally will occur within 4 weeks. Further study is indicated by the presence of radiculopathy, weakness, trauma, or suspicion of malignancy.
Question 2211
Topic: 6. Spine
A 40-year-old woman sustains a flexion injury to her neck. Physical examination is normal. A lateral radiograph of the cervical spine is shown in Figure 57a. MRI scans of the cervical spine are shown in Figures 57b and 57c. Treatment should include
Correct Answer & Explanation
. skeletal traction, closed reduction, and posterior fixation/fusion.
Explanation
DISCUSSION: This is a classic bilateral facet dislocation. When there is no evidence of a disk herniation, treatment should include careful skeletal traction, closed reduction, and posterior fusion. There is no role for anterior procedures. These fractures are unstable and require surgical intervention.
Question 2212
Topic: 6. Spine
When treating thoracic disk herniations, which of the following surgical approaches has the highest reported rate of neurologic complications?
Correct Answer & Explanation
. Posterior
Explanation
DISCUSSION: Numerous surgical approaches have been used for thoracic diskectomy, including the most recent VATS. One of the first approaches described, posterior laminectomy, involves manipulation of the spinal cord, which the other approaches avoid. The posterior approach had dismal results, including further neurologic deterioration and even paralysis. REFERENCES: Belanger TA, Emery SE: Thoracic disc disease and myelopathy, in Frymoyer JW, Wiesel SW (eds): The Adult and Pediatric Spine. Philadelphia, PA, Lippincott Williams and Wilkins, 2004, pp 855-864. Benjamin V: Diagnosis and management of thoracic disc disease. Clin Neurosurg 1983;30:577-605. Russell T: Thoracic intervertebral disc protrusion: Experience of 67 cases and review of the literature. Br J Neurosurg 1989;3:153-160. Fessler RG, Sturgill M: Review: Complications of surgery for thoracic disc disease. Surg Neurol 1998;49:609-618.
Question 2213
Topic: 6. Spine
A 6-year-old girl has a painless spinal deformity. Examination reveals 2+ and equal knee jerks and ankle jerks, negative clonus, and a negative Babinski. The straight leg raising test is negative. Abdominal reflexes are asymmetrical. PA and lateral radiographs are shown in Figures 15a and 15b. What is the next most appropriate step in management? Review Topic
Correct Answer & Explanation
. MRI of the spinal axis
Explanation
The patient has an abnormal neurologic exam as shown by the abnormal abdominal reflexes. Furthermore, she has a significant curve and is younger than age 10 years. These findings are not consistent with idiopathic scoliosis. MRI will best rule out syringomyelia or an intraspinal tumor. Bracing and surgery are not indicated for this small curvature prior to obtaining an MRI scan.
Question 2214
Topic: 6. Spine
A tall, thin 17-year-old basketball player and his parents request an evaluation of his flexible (hypermobile) pes planus/planovalgus foot deformities. As part of his evaluation, the orthopaedic surgeon notes pectus excavatum, disproportionately long arms, and scoliosis. In addition to providing treatment of his feet, what test or evaluation should the patient be referred for? Review Topic
Correct Answer & Explanation
. Cardiovascular evaluation
Explanation
The current diagnostic criteria for Marfan syndrome, called the Ghent criteria, are based on clinical findings and family history. The role of genetic testing in establishing the diagnosis is limited, because testing for FBN1 mutations is neither sensitive nor specific for Marfan syndrome. By making the diagnosis and arranging for cardiovascular evaluation, the orthopaedic surgeon can help prevent sudden death in these patients. The cardiovascular manifestations, including dissection and dilation of the ascending aorta and mitral valve prolapse, are responsible for nearly all of the precocious deaths of patients with Marfan syndrome. Patients with Marfan syndrome do have problems with protrusio acetabuli, scoliosis, and opthalmologic problems but the life-threatening problem that must be considered is the risk of cardiovascular sudden death.
Question 2215
Topic: 6. Spine
Which of the following pharmacologic agents is most likely to adversely affect the success rate of bony union after lumbar arthrodesis?
Correct Answer & Explanation
. Ketorolac
Explanation
Glassman and associates reported a significantly higher pseudarthrosis rate when ketorolac was used postoperatively compared to a similar group of patients who were not given ketorolac. To reduce narcotic dosage, nonsteroidal anti-inflammatory drugs (NSAIDs) have been promoted as an adjunct for postoperative analgesia in patients undergoing spinal fusion. However, a high failure rate of arthrodesis has been associated with postoperative use of NSAIDs.
Question 2216
Topic: 6. Spine
A 45-year-old female returns to your clinic with 10-weeks of severe pain that starts in her back and extends down her right leg to the top of her foot. On physical exam she has decreased sensation on the dorsal aspect of her foot and 4/5 strength in her EHL. She has a positive straight leg raise on the right. The remaining physical exam is unremarkable, including normal achilles and patellar reflexes bilaterally, no clonus, and a down-going Babinski sign. Her pain has not been relieved by NSAIDs, epidural steroids or physical therapy. Figure A is a sagittal MRI and figure B is a axial MRI through the L4/5 disc space. What is the best treatment option at this time? Review Topic
Correct Answer & Explanation
. Continued oral anti-inflammatories
Explanation
The patient has a herniated L4/5 disc leading to right L5 radicular pain. She continues to have severe symptoms despite 10 weeks of nonoperative treatment, so the next step is a right sided L4/5 microdiscectomy.Patients with paracentral herniated lumbar discs present with radicular pain affecting the traversing (caudal) nerve root. Unless the patient develops progressive neurologic decline, patients with herniated lumbar discs should undergo no less than 6 weeks of conservative treatment consisting of anti-inflammatory medications, rest and therapy. Most patients improve with nonoperative modalities. If appropriate conservative care fails, the correct surgical option is a unilateral microdiscectomy.In the Spine Patient Outcomes Research Trial (SPORT) Weinstein et al. reported on the results of 501 patients with herniated lumbar discs who had failed at least six weeks of non-operative care. The patients were randomized to operative or nonoperative care, however there was a high amount of crossover between the two groups. Because of this, there was no difference reported between the two groups at final follow-up using an intent-to-treat analysis.Weinstein et al., because of the flaws with the intent-to-treat analysis, also published an observational study on 528 patients who received surgery and 191 who received nonoperative care for a herniated lumbar disc. They reported that while both groups had an improvement from baseline, at two years, patients who elected to undergo surgery had significantly better outcomes than those who chose conservative care.Lurie et al. reported the eight-year results from the observational group of the SPORT data, and found that the patients who underwent surgery continued to have statistically superior outcomes compared to those who underwent conservative care at long-term follow-up.Figure A is a T2 sagittal MRI of the lumbar spine demonstrating a right sided L4/5 disc herniation, and Figure B is an axial image again demonstrating a paracentral L4/5 disc herniation.Incorrect answers:
Question 2217
Topic: 6. Spine
A 32-year-old professional football player has disabling left arm pain in the C7 dermatome that has been increasing in severity for the past 2 months. Examination shows a positive Spurling test on the left side, but no changes in motor, sensory, or deep tendon reflexes. Because nonsurgical management has failed to provide relief, he has chosen surgery to allow him to complete his season. The MRI scan and myelogram shown in Figures 19a and 19b show minimal disk bulge, but a root cutoff is noted at the left C7 foramen. Electromyography demonstrates C7 nerve root irritation. Which of the following procedures will best optimize his chances for completing the season?
Correct Answer & Explanation
. Posterior keyhole foraminotomy on the left side at C6-7
Explanation
DISCUSSION: Because the patient has chronic pain, a possible lateral recess stenosis of the C7 root, and no neurologic deficits, keyhole foraminotomy is the treatment of choice for decompressing the exiting nerve root and offering an early return to play, especially when using a muscle-splitting posterior approach. Henderson and associates reported excellent results with posterolateral foraminotomy in patients with radicular symptoms. Although anterior cervical diskectomy and fusion is equally effective in the long term, a period of 6 to 12 weeks is required to allow the anterior fusion to heal prior to a return to play. Chen and associates reported that keyhole foraminotomy maintains cervical motion segment dynamics better than compared to anterior limited diskectomy and foraminotomy or anterior diskectomy with fusion.
Question 2218
Topic: 6. Spine
Figures 128a and 128b show the radiograph and MRI scan of a 74-year-old woman with severe neck pain and upper extremity numbness, tingling, and clumsiness. She also reports that she has balance problems and sustained a distal radius fracture in a fall 6 months ago. Examination reveals hyperreflexia in bilateral quadriceps and Achilles reflexes, bilateral Hoffman's signs, and eight beats of clonus in both lower extremities. What is the best treatment option? Review Topic
Correct Answer & Explanation
. Combined anteroposterior decompression and fusion
Explanation
The patient has cervical spondylosis and symptomatic myelopathy. The radiograph reveals multilevel spinal cord compression and, most importantly, a fixed kyphosis of the cervical spine. In the setting of cord compression and kyphotic deformity, a combined anteroposterior approach allows for ventral and dorsal decompression, kyphosis correction, and stabilization. Observation in the setting of severe myelopathy will likely lead to further disease progression. In the setting of cervical kyphosis, posterior-only treatment options will not adequately address cord deformation and, therefore, not improve symptoms as reliably.
Question 2219
Topic: 6. Spine
The most common neurologic injury following an anterior cervical diskectomy and fusion (ACDF) is injury to which of the following structures? Review Topic
Correct Answer & Explanation
. Recurrent laryngeal nerve
Explanation
The most common neurologic injury in ACDF is injury to the recurrent laryngeal nerve. It is most vulnerable on the right because it crosses from lateral to midline more cephalad in the incision after it passes under the subclavian artery; conversely, on the left the course is more caudal because it passes under the aortic arch, a more caudal structure. The superior laryngeal nerve runs along with the superior thyroid artery in the upper cervical spine, putting it at risk during surgical procedures on the upper cervical spine which are less commonly performed. A C5 root palsy more commonly occurs as a result of multilevel posterior decompressive procedures, possibly because of its short transverse take-off from the cord. The sympathetic chain lies on top of the longus colli and can be injured if retractors are not placed under the longus colli muscle.
Question 2220
Topic: 6. Spine
A 24-year-old man sustains the injury shown in Figures 19a through 19e in a paragliding accident. He is neurologically intact. He also sustained fractures of his left femur and right distal radius. Which of the following represents the best option for management of the spinal injury?
Correct Answer & Explanation
. Posterior spinal fusion and instrumentation
Explanation
The injury pattern is that of a burst fracture at L1 contiguous with a compression fracture at T12. There is associated kyphosis and slight spondylolisthesis of T12 on L1. Treatment of this type of burst fracture in neurologically intact patients is somewhat controversial, with at least one study demonstrating equal long-term results comparing nonsurgical treatment to surgical treatment. In this study, however, body casts were used initially in the nonsurgical group. Moreover, because this patient has multiple fractures, spinal fracture stabilization should be considered to facilitate early mobilization. Surgical stabilization and fusion via a posterior approach is the best treatment option in this patient. Anterior decompression is not necessary since the patient is neurologically intact.
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