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6. Spine MCQs

Practice Set 117 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 2321

Topic: 6. Spine
What normal tissue has a low signal intensity (appears black) on both T1- and T2-weighted images?
. Tendon
. Fat
. Joint fluid
. Intervertebral disk
. Bone marrow

Correct Answer & Explanation

. Tendon

Explanation

DISCUSSION: Tendons, cortical bone, ligaments, menisci, and fibrous tissue will show low signal intensity (SI) on both T1- and T2-weighted images. Fat-containing tissues, such as subcutaneous fat and bone marrow, will show high SI on T1-weighted images and low SI on T2-weighted images. Tissues with high water content, such as joint fluid, intervertebral disk, and edema, will show low SI on T1-weighted images and high SI on T2-weighted images.

Question 2322

Topic: 6. Spine

A 24-year-old man sustained a bilateral C5-6 facet dislocation in a car accident and was intubated at the scene. He remains sedated in the intensive care unit

. mm rostral caudal cord edema
. Disruption of the anterior longitudinal ligament
. Edema in the soft tissue anterior to the spine
. Diffuse cord edema
. mm cord hematoma

Correct Answer & Explanation

. mm rostral caudal cord edema

Explanation

The MRI finding that most consistently corresponds with a complete spinal injury is a hematoma within the cord. Cord edema can predict a poor prognosis if it is more extensive but is not considered as consistent a finding. Ligamentous injury about the neck can indicate musculoskeletal instability but it does not in and of itself indicate the presence or predict the severity of spinal cord injury. Likewise, soft-tissue edema anterior to the spine may indicate musculoskeletal injury but does not offer specific information regarding the presence or absence of cord injury.

Question 2323

Topic: 6. Spine
Surgical restoration of sagittal balance of an adult spinal deformity will have which effect on outcome?
. No effect
. Improve leg-related symptoms but not back pain
. Improve quality of life and back pain
. Improve quality of life and leg-related symptoms

Correct Answer & Explanation

. Improve quality of life and back pain

Explanation

DISCUSSION: The influence of sagittal balance on outcomes following fusion-based procedures for degenerative conditions of the lumbar spine has only recently been appreciated. Restoration of sagittal spinal balance improves low-back-pain outcomes and quality of life. Sagittal spinal balance has not been shown to relieve neurogenic claudication attributable to spinal stenosis.

Question 2324

Topic: Thoracolumbar Spine & Deformity
A 14-year-old boy is seen for back pain. Radiographic evaluation reveals a grade III isthmic spondylolisthesis. What measurement is most useful in predicting the likelihood of progression?
. Pelvic incidence
. Slip angle
. Sacral inclination
. Lumbosacral joint angle
. Sagittal rotation

Correct Answer & Explanation

. Slip angle

Explanation

Slip angle has been shown to be highly predictive of the risk for increased slippage in patients with spondylolisthesis. None of the other radiographic parameters listed has been shown to be predictive of the risk for increased slippage.

Question 2325

Topic: 6. Spine
A 2-year-old boy has complete absence of the sacrum and lower lumbar spine. What is the most likely long-term outcome if no spinal pelvic stabilization is performed?
. Progressive paralysis
. Neck extension contracture
. Inability to sit without using the hands for support
. Progressive hip dislocation
. Sexual dysfunction

Correct Answer & Explanation

. Inability to sit without using the hands for support

Explanation

DISCUSSION: Without stabilization, progressive kyphosis will develop between the spine and pelvis. The kyphosis progresses to the point that the child must use his or her hands to support the trunk, and therefore is unable to use his or her hands for other activities. Neck extension contracture does not usually develop. Neurologic deficit, including sexual dysfunction, is generally present at birth and static.

Question 2326

Topic: 6. Spine
A 15-year-old dancer who has had brief episodes of back pain over the past 2 years now reports a 3-month history of low back pain and a decreased tolerance for dance. Figure 22a-c show flexion and extension x-rays and CT scan. She reports no leg pain, nor any bowel or bladder difficulties. Management should now consist of
. Post spinal fusion from L5 to S1
. Primary repair with an iliac bone graft
. Post spinal fusion of L4-5
. A pantaloon body cast and 6 weeks of bed rest
. Rest, NSAIDs, and limited dancing

Correct Answer & Explanation

. Rest, NSAIDs, and limited dancing

Explanation

The radiographs show a Grade I spondylolisthesis. Studies have shown that patients with Grade 1 or 2 spondylolisthesis have significant relief of pain with conservative treatment. Conservative treatment includes rest, NSAIDs, abdominal strengthening exercises, hamstring stretching exercises, or traction.

Question 2327

Topic: 6. Spine

A 70-year-old female with a history of a long posterior spinal fusion from T10 to the pelvis for adult spinal deformity is scheduled for a primary total hip arthroplasty. Her spinopelvic parameters indicate a 'stiff' spine. How does this condition biomechanically alter her risk for dislocation during activities such as sitting?

. Her pelvis excessively tilts posteriorly during sitting, increasing the risk of anterior dislocation.
. Her pelvis fails to tilt posteriorly during sitting, resulting in relative anterior acetabular uncoverage and an increased risk of posterior dislocation.
. Her lumbar spine hyper-flexes during sitting, decreasing the risk of impingement.
. Her acetabular anteversion dynamically increases by more than 20 degrees from standing to sitting.
. Her pelvis abnormally tilts anteriorly upon standing, increasing the risk of posterior dislocation while upright.

Correct Answer & Explanation

. Her pelvis fails to tilt posteriorly during sitting, resulting in relative anterior acetabular uncoverage and an increased risk of posterior dislocation.

Explanation

In a normal patient moving from standing to sitting, the lumbar spine flexes and the pelvis tilts posteriorly. This posterior pelvic tilt effectively increases acetabular anteversion, allowing the femoral neck to clear the anterior rim of the socket. In patients with a stiff spine (e.g., long spinal fusion to the pelvis), the pelvis fails to tilt posteriorly upon sitting. Consequently, the acetabulum remains relatively 'closed' anteriorly. When the hip is flexed during sitting, the femoral neck strikes the anterior rim of the cup, levering the femoral head out posteriorly. Thus, they are at significantly higher risk for posterior dislocation.

Question 2328

Topic: 6. Spine

A 56-year-old man has had a 2-year history of slowly progressive neck pain and bilateral arm aching. Over the past year, he has noticed intermittent, diffuse numbness in both hands, with decreased grip strength and mild hand clumsiness. He denies any problems with balance. Examination shows a wide-based gait, intrinsic wasting, and a postive Hoffman's sign bilaterally. An MRI scan of the cervical spine is shown in Figure 16. What is the most appropriate treatment? Review Topic

. Anterior diskectomy without fusion at C4-C5
. Epidural injections
. Anterior diskectomy and fusion at C4-C5 and C5-C6
. Multilevel laminectomy and fusion
. Multilevel posterior foraminotomies

Correct Answer & Explanation

. Anterior diskectomy without fusion at C4-C5

Explanation

The patient has classic symptoms of myelopathy with upper motor neuron signs on examination. His symptoms have been present for years, and are getting worse. The cervical spine MRI scan shows spinal stenosis with multilevel spondylosis causing spinal cord compression at multiple levels. With the longstanding duration of the patient's signs and symptoms, combined with involvement of multiple levels in the cervical spine, posterior multilevel laminectomy and fusion is the best treatment option. Two-level anterior diskectomy and fusion would address the two areas of most severe narrowing, but it would fail to decompress the other stenotic areas which also require decompression. Posterior cervical foraminotomies would only address radicular symptoms, which are not present in this patient, and would not succeed in decompression of the spinal cord. Cervical epidural injections are not indicated for myelopathy symptoms, and may in fact place this patient at risk for neurologic deterioration.

Question 2329

Topic: 6. Spine
What is the most common complication of halo vest immobilization in adults?
. Neurologic deterioration
. Pin loosening
. Pressure sores under the vest
. Psychosis
. Dural puncture

Correct Answer & Explanation

. Pin loosening

Explanation

Although pin loosening generally has not been considered a major problem, it has been cited as the most common complication in two published series of halo vest complications. The other possible complications are all significantly less common.

Question 2330

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?
. MRI of the spinal axis
. Physical therapy
. A brace for scoliosis
. Observation, with reevaluation in 6 to 12 months
. Posterior spinal fusion from T6 to T12

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 2331

Topic: 6. Spine
A 40-year-old patient who has a type II odontoid fracture is placed in a halo vest for 12 weeks; however, current radiographs show no evidence of healing. The next most appropriate step in management should consist of:
. Removal of the halo vest, followed by observation if the patient remains asymptomatic.
. Use of the halo vest for an additional 4 weeks, followed by repeat radiographs.
. Placement of one odontoid screw and the addition of bone graft.
. Placement of two odontoid screws.
. Posterior fusion at C1-2.

Correct Answer & Explanation

. Posterior fusion at C1-2.

Explanation

Because nonsurgical management has failed and a significant number of type II odontoid fractures will go on to a nonunion, the salvage treatment of choice is posterior fusion at C1-2. Odontoid screws are contraindicated in patients with a chronic nonunion, which this patient has at the end of 3 months.

Question 2332

Topic: 6. Spine
A 12-year-old female is referred to the office by a community orthopaedic surgeon concerned that her shoulders appear to be at different heights. With Adam's forward bending, she is noted to have a significant right thoracic rib prominence. She denies pain. A detailed neurological examination reveals no abnormalities. Radiographs of her spine show an apex left lumbar curve measuring 32 degrees and an apex right thoracic curve measuring 28 degrees. She had her first menses last month and her Tanner-Whitehouse staging is consistent with an adolescent steady state. The most appropriate treatment would be?
. Posterior spinal fusion
. Spinal manipulations
. Observation and referral to an endocrinologist
. Thoracolumbosacral orthosis
. Halo-gravity traction

Correct Answer & Explanation

. Thoracolumbosacral orthosis

Explanation

A growing child presenting with a curve of 25°–40° or a curve 20-25° with documented progression should be treated first with a thoracolumbosacral orthosis. Assessing a child's skeletal maturity has important clinical implications when treating patients with idiopathic scoliosis. The Tanner-Whitehouse III method specifically uses the distal radial and ulnar epiphyses, as well as the metacarpal and phalangeal epiphyses of the first, third, and fifth digits for determination of skeletal age. A Tanner-Whitehouse Stage in 'adolescent steady-state' means she is past peak height velocity. However, as she is before skeletal maturity, and her lumbar and thoracic curvatures are > 25 deg., these curvatures may continue to progress. Therefore, bracing would be the best treatment option at this time.

Question 2333

Topic: 6. Spine

A 65-year-old woman presents with neck pain for 18 months. She has taken NSAIDs and undergone physical therapy without improvement. Over the past 6 months, she has also noticed progressive hand clumsiness and difficulty with gait. Sagittal and axial MRI images are shown in figures A and B, respectively. What is the most appropriate next step in management? Review Topic

. Physical therapy with emphasis on neck muscle strengthening and posture improvement
. Epidural steroid injection
. Anterior cervical discectomy and fusion
. Laminectomy alone
. Multi-level laminectomy and fusion

Correct Answer & Explanation

. Anterior cervical discectomy and fusion

Explanation

This patient presents with clinical and radiographic evidence of cervical myelopathy with progression of gait imbalance and hand clumsiness. The most appropriate management is anterior cervical discectomy and fusion (ACDF).Cervical myelopathy is typically caused compression on the spinal cord and classically present with neck pain, parasthesias, clumsiness, gait imbalance, and/or urinary retention. Nonoperative management is reserved for patients without functional impairment. ACDF is the treatment of choice for focal compression from anterior disc-ostephyte changes. Posterior decompression is indicated in patients with multi-level disease. It is important to note in patients with significant kyphosis, the kyphosis must be reversed in order for decompression alone to be effective.Hsu reviewed posterior decompression techniques in the cervical spine. They state that the choice of anterior versus posterior approach is determined based on sagittal spine alignment, extent and location of pathological involvement, and patient preference. They recommend laminectomy and fusion for cervical stenosis and kyphosis <10 degrees. The use of BMP-2 as an adjunct in the cervical spine is not recommended by the author.Emery reviewed cervical spondylotic myelopathy and recommend nonoperative treatment in patients with minimal symptoms without pathologic reflexes or gait imbalances. They suggest that the preferred posterior techniques are now laminectomy and fusion or laminoplasty.Figure A and B are sagittal and axial T2 MRI sequences showing a degenerative disc osteophyte complex at C5-C6 with resultant canal stenosis and cord compression. Illustration A is a lateral C spine radiograph in a patient who is status post ACDF at C5-C6.Incorrect Answers:

Question 2334

Topic: 6. Spine
A 14-year-old boy reports a 4-month history of increasing backache with difficulty walking long distances. His parents state that he walks with his knees slightly flexed and is unable to bend forward and get his hands to his knees. He denies numbness, tingling, and weakness in his legs and denies loss of bladder and bowel control. A lateral radiograph of the lumbosacral spine is shown in Figure 18. What is the best surgical management for this condition?
. Vertebrectomy of L5
. Posterior spinal fusion with or without instrumentation from L4 to S1
. Posterior spinal fusion without instrumentation from L5 to S1
. Anterior spinal fusion from L4 to L5
. Direct repair of the spondylolysis defect

Correct Answer & Explanation

. Posterior spinal fusion with or without instrumentation from L4 to S1

Explanation

The patient has a grade 4 spondylolisthesis. Optimal surgical management is posterior spinal fusion from L4 to the sacrum. The use of instrumentation is controversial. Vertebrectomy is typically reserved for spondylo-optosis (grade 5) cases. Spinal fusion from L5 to S1 usually is not successful for a slip that is greater than 50%. Isolated anterior spinal fusion has not been successful, and direct repair of the pars defect is only useful for spondylolysis without spondylolisthesis.

Question 2335

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?
. 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

DISCUSSION: 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 42 point 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.

Question 2336

Topic: Thoracolumbar Spine & Deformity

What is the minimum hours per day of wear that has been correlated with the effectiveness of bracing on curve progression in idiopathic scoliosis? Review Topic

. Prescribed brace wear 23 hours/day
. Prescribed brace wear 16 hours/day
. Actual brace wear more than 12 hours/day
. Actual brace wear 6 hours/day

Correct Answer & Explanation

. Actual brace wear more than 12 hours/day

Explanation

The efficacy of brace treatment for patients with adolescent idiopathic scoliosis is controversial because its effectiveness remains unproven. One of the challenges is patient noncompliance with prescribed bracing regimens. A recent study investigated curve progression based on actual brace wear using a temperature sensor to accurately assess brace wear. The total hours of brace wear correlated with lack of curve progression with a dose-response effect noted. Curves did not progress in 82% of patients who actually wore the brace more than 12 hours per day. For those who wore the brace for fewer than 7 hours per day, curves progressed in 69%. Prescribed bracing regimens (eg, 16 hours/day or 23 hours/day) had no effect on actual brace wear or curve progression.

Question 2337

Topic: 6. Spine
A 12-year-old girl has scoliosis at T5-T10 that measures 62°. A clinical photograph of the axilla is shown in Figure 56. Management should consist of
. a thoracolumbosacral orthosis.
. in situ posterior spinal fusion.
. posterior spinal fusion with segmental instrumentation.
. anterior spinal fusion with instrumentation.
. anterior and posterior spinal fusion with posterior segmental instrumentation.

Correct Answer & Explanation

. anterior and posterior spinal fusion with posterior segmental instrumentation.

Explanation

DISCUSSION: Neurofibromatosis type 1 (NF-1) is an autosomal-dominant disorder affecting about 1 in 4,000 people. NF-1 causes tumors to grow along various types of nerves and affects the development of non-nervous tissues, such as bone and skin. The gene for NF-1 is located on the long arm of chromosome 17 and codes the protein neurofibromin. Research indicates that NF-1 acts as a tumor-suppressor gene and, as such, plays an important role in the control of cell growth and differentiation. Axillary and inguinal freckling is considered a good diagnostic marker for NF-1. The hyperpigmented spots that measure from 2 mm to 4 mm may be congenital, but these typically appear and increase later in life. Scoliosis is the most common musculoskeletal disorder of NF-1. The curves are frequently dystrophic, kyphotic, and have a high risk of pseudarthrosis following spinal fusion. Anterior and posterior spinal fusion with rigid posterior segmental instrumentation is the treatment of choice.

Question 2338

Topic: 6. Spine
A 79-year-old woman reports a history of left leg pain with walking. Her pain is exacerbated with walking and stair climbing, and her symptoms are improved by standing after she stops walking. Lumbar flexion does not provide any significant improvement of the symptoms and sitting does not significantly change symptoms. Her leg pain is worse at night and she obtains relief by hanging her leg over the side of the bed. The neurologic examination is essentially normal. Examination of the lower extremities demonstrates mild early trophic changes, and her pulses distally are palpable but are diminished bilaterally. Radiographs are shown in Figures 15a and 15b. What is the next most appropriate step in management?
. Decompression and posterior fusion at L4-L5
. Epidural steroid injection at L4-5
. Nonsteroidal medications and physical therapy for 6 weeks
. Measurement of the ankle-brachial index
. CT myelogram

Correct Answer & Explanation

. Measurement of the ankle-brachial index

Explanation

DISCUSSION: The patient has symptoms that are more consistent with vascular claudication than with the pseudoclaudication anticipated from lumbar spinal stenosis. Therefore, the patient is a candidate for further vascular work-up. The radiographs reveal early spinal stenosis and spondylolisthesis at L4-5 but also show significant calcification of the iliac arteries, suggestive of peripheral vascular disease. Vascular claudication is a manifestation of peripheral vascular disease and presents with crampy leg pain that is exacerbated by physical exertion. The pain is easily relieved by standing still or sitting. Unlike pseudoclaudication, a forward-flexed posture and/or sitting does not improve the symptoms. Night pain is common in vascular claudication due to the elevation of the extremities and patients often report pain improvement by hanging their extremities in a dependent position. In evaluation of a patient with suspected vascular claudication, the five “P’s” of vascular insufficiency should be monitored, including pulselessness, paralysis, paresthesia, pallor, and pain. While pain and paresthesias can be common in both vascular claudication and pseudoclaudication, the presence of any of the remaining symptoms is suggestive of vascular disease.

Question 2339

Topic: 6. Spine
What region of the thoracic curve is most dangerous for pedicle screw insertion while performing a posterior fusion for adolescent idiopathic scoliosis?
. Concave side at the stable vertebra
. Concave side at the apex of the curve
. Convex side at the stable vertebra
. Convex side at the apex of the curve
. Thoracolumbar junction

Correct Answer & Explanation

. Concave side at the apex of the curve

Explanation

DISCUSSION: Morphologic and anatomic studies confirm the pedicle is smaller on the concave side of thoracic curves. The dura is also closer to the pedicle on the concave side of the curves. REFERENCES: Liljenqvist U, Allkemper T, Hackenberg L, et al: Analysis of vertebral morphology in idiopathic scoliosis with use of magnetic resonance imaging and multiplanar reconstruction. J Bone Joint Surg Am 2002;84:359-368. Parent S, Labelle H, Skalli W, et al: Thoracic pedicle morphometry in vertebrae from scoliotic spines. Spine 2004;29:239-248.

Question 2340

Topic: 6. Spine

A 4-month-old infant is referred for evaluation of congenital scoliosis. The child has no congenital heart anomalies, and a renal ultrasound shows that he has one kidney. Examination reveals mild scoliosis and a large hairy patch on the child’s back. Neurologic evaluation is normal for his age. A clinical photograph and radiograph are shown in Figures 19a and 19b. Initial management should consist of Review Topic

. referral to a plastic surgeon to remove the hairy patch.
. MRI of the entire spine.
. physical therapy and repeat evaluation and radiographs in 1 year.
. anterior and posterior fusion of the anomalous regions of the spine to prevent deformity.
. voiding cystourethrography.

Correct Answer & Explanation

. MRI of the entire spine.

Explanation

Congenital anomalies of the spine, including failure of formation and failure of segmentation, are associated with other anomalies in other organ systems that develop at the same time. These include anomalies in the genitourinary system, cardiac anomalies, Sprengel’s deformity, radial hypoplasia, and gastrointestinal anomalies including imperforate anus and trachealesophageal fistula. Spinal dysraphism is the most common associated abnormality. McMaster found an 18% incidence before the common use of MRI. Bradford and associates reported on 16 of 42 patients with congenital spinal anomalies and spinal dysraphism using MRI. Neural axis lesions may be associated with visible midline abnormalities such as a hairy patch or nevus. The child has already had a cardiac and renal work-up, and based on the findings of the hairy patch and congenital vertebral anomalies, MRI of the entire spine is prudent at this time. Spinal fusion is indicated for progressive congenital scoliosis or kyphosis. Physical therapy does not affect the natural history of congenital scoliosis.

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