Menu

6. Spine MCQs

Practice Set 118 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 2341

Topic: 6. Spine
A 42-year-old patient has had a fever and low back pain for several days. Laboratory studies show an elevated erythrocyte sedimentation rate and a WBC count of 9,500 mm3 with 75% neutrophils. A CT scan is shown in Figure 15. Examination will most likely reveal what other findings?
. Cauda equina syndrome
. Pain improved with hip flexion
. Pain in the lateral aspect of the thigh
. Pain in the sole of the foot
. Pain in the upper thoracic spine

Correct Answer & Explanation

. Pain improved with hip flexion

Explanation

DISCUSSION: The CT scan reveals a left-sided psoas abscess. Irritation of the saphenous division of the femoral nerve can cause paresthesias along the medial aspect of the knee. Pain is usually improved with hip flexion. REFERENCES: Cellier C, Gendre JP, Cosnes J, et al: Psoas abscess complication Crohn’s disease. Gastroenterol Clin Biol 1992;16:235-238. Netter FH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy, 1989, pp 470-471, 506.

Question 2342

Topic: 6. Spine
A 30-year-old man requires surgical stabilization of a hypermobile spondylolisthesis of L5 on S1. History reveals that he has smoked one pack of cigarettes a day for 15 years. During preoperative counseling, the patient should be advised to
. stop smoking immediately preoperatively and for at least 6 months postoperatively.
. stop smoking at least 3 months preoperatively and for 6 months postoperatively with the assistance of nicotine patches or gum.
. stop smoking postoperatively with the assistance of nicotine patches or gum.
. delay surgery to allow the patient to stop smoking for at least 6 months prior to surgery and for 6 months postoperatively.
. consider a different treatment because the rate of pseudarthrosis and clinical failure following fusion is unacceptable in smokers.

Correct Answer & Explanation

. stop smoking immediately preoperatively and for at least 6 months postoperatively.

Explanation

DISCUSSION: Many studies have shown the negative effects of cigarette smoking on the success of lumbar arthrodesis. Some have suggested preoperative cessation is a significant factor for good results. However, Deguchi and associates, in a review of spondylolisthesis fusions, and Glassman and associates, in a review of scoliosis fusions, showed no significant benefit from preoperative cessation of smoking. In every report, however, postoperative smoking correlated with a significantly increased rate of pseudarthrosis. Cessation of smoking with the use of nicotine substitutes would not be beneficial because animal studies and human clinical trials have shown that nicotine is a major factor in failure of fusion in patients who continue to smoke. REFERENCES: Silcox DH III, Daftari T, Boden SD, Schimandle JH, Hutton WC, Whitesides TE Jr: The effect of nicotine on spinal fusion. Spine 1995;20:1549-1553. Deguchi M, Rapoff AJ, Zdeblick TA: Posterolateral fusion for isthmic spondylolisthesis in adults: Analysis of fusion rate and clinical results. J Spinal Disord 1998;11:459-464. Glassman SD, Anagnost SC, Parker A, Burke D, Johnson JR, Dimar JR: The effect of cigarette smoking and smoking cessation on spinal fusion. Spine 2000;25:2608-2615.

Question 2343

Topic: 6. Spine
A 15-year-old diver has had persistent, activity-related low back pain for the past 2 months. He denies any history of trauma. Examination reveals that the pain is localized to the lumbosacral junction, and there are no radicular symptoms. The pain is worse with back extension. Neurologic examination is normal, as are AP, lateral, and oblique radiographs of the lumbosacral spine. Further evaluation should include:
. flexion and extension radiographs of the lumbosacral spine.
. diskography.
. an MRI scan of the lumbosacral spine.
. a bone scan with single photon emission computed tomography (SPECT).
. a renal ultrasound.

Correct Answer & Explanation

. a bone scan with single photon emission computed tomography (SPECT).

Explanation

DISCUSSION: Spondylolysis may develop as a stress fracture resulting from repetitive hyperextension during athletic activities. In young people, the pars interarticularis is thin, the neural arch has not yet reached maximum strength, and the intravertebral disk is less resistant to shear. While clinical symptoms may lead to the suspicion of spondylolysis, radiographic confirmation may be difficult in early cases. Plain radiographs may be negative initially, and the plain MRI scan may not offer good visualization of the pars. A bone scan with SPECT is very sensitive initially. CT scans with regular axial and reverse-gantry angled cuts may help determine the type of fracture and the course of treatment. REFERENCES: Congeni J, McCulloch J, Swanson K: Lumbar spondylolysis: A study of natural progression in athletes. Am J Sports Med 1997;25:248-253. Harvey CJ, Richenberg JL, Saifuddin A, Wolman RL: The radiological investigation of lumbar spondylolysis. Clin Radiol 1998;53:723-728.

Question 2344

Topic: 6. Spine

Figure 109 is the radiograph of an 11-year-old boy who felt a snap in his right hip while jumping hurdles during track practice yesterday. He complains of pain to his right groin region and is walking with a limp. What physical examination test will cause the patient to experience the most discomfort?

. Resisted hip adduction
. Resisted hip abduction
. Resisted hip extension
. Resisted knee extension

Correct Answer & Explanation

. Resisted knee extension

Explanation

The radiograph shows an avulsion fracture from the right anterior inferior iliac spine. This is the site of origin of the rectus femoris tendon. Contraction of the rectus femoris is most pronounced with extension of the knee. The adductor muscles, which would be tested with resisted hip adduction, originate predominantly on the symphysis pubis. The abductors, which would be tested with resisted hip abduction, originate on the outer iliac crest. The hip extensors, which would be tested with resisted hip extension, originate on the posterior iliac crest.

Question 2345

Topic: 6. Spine
Figure 31 shows the radiograph of a 64-year-old woman who is seen in the emergency department following a motor vehicle accident. She has no voluntary motor function in her distal upper extremities or lower extremities. She does not have a bulbocavernosus reflex. She has a blood pressure of 80/50 mm Hg with a pulse of 50/min. Her hypotension does not improve with initial fluid resuscitation. Further treatment of her hypotension should consist of:
. continued rapid fluid infusion.
. administration of broad-spectrum antibiotics.
. administration of 30 mg/kg methylprednisolone over 1 hour.
. administration of pressors.
. cardioversion and implantation of a pacemaker.

Correct Answer & Explanation

. administration of pressors.

Explanation

DISCUSSION: The hallmark of neurogenic shock is hypotension without tachycardia. It is associated most commonly with high cervical spinal cord injuries and results from loss of function of the sympathetic nervous system. Because the peripheral vasculature is dilated due to loss of its sympathetic tone, continued rapid administration of fluid corrects the hypotension and can quickly lead to fluid overload and congestive heart failure. Therefore, neurogenic shock is best treated by the use of pressors. Cardioversion or administration of antibiotics or systemic steroids is not appropriate treatment for this patient’s hypotension. REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 179-187. Nockels RP: Nonoperative management of acute spinal cord injury. Spine 2001;26:S31-S37.

Question 2346

Topic: 6. Spine
A 46-year-old patient with cervical myelopathy undergoes a multilevel posterior cervical laminectomy from C3 to C7. The risk of postlaminectomy kyphosis is greatest with removal of which of the following structures?
. Greater than 80% of the lamina
. Greater than 50% of each facet joint
. Interspinous ligament
. Facet joint capsules
. Ligamentum flavum

Correct Answer & Explanation

. Greater than 50% of each facet joint

Explanation

DISCUSSION: Removal of more than 50% of a facet joint can lead to segmental instability and compromises the overall strength of the joint. Removal of the lamina, interspinous ligament, and ligamentum flavum are standard features of a cervical laminectomy. Most surgeons favor fusion with instrumentation of a laminectomized cervical spine. If the anterior part of the spine is already ankylosed from previous surgery or from degenerative conditions, or a posterior fusion with instrumentation is included, then the risk of kyphosis or instability is reduced. REFERENCE: Zdeblick TA, Abitol JJ, Kunz DN, et al: Cervical stabilization after sequential capsule resection. Spine 1993;18:2005-2008.

Question 2347

Topic: 6. Spine
Which of the following best describes the use of epidural morphine and steroid paste after laminectomy?
. Associated with an 11% rate of postoperative surgical site complications
. Associated with a less than 1% rate of surgical site infections
. Associated with a decreased rate of postoperative urinary retention
. Considered the standard for outpatient microdiskectomy
. Should only be used in the absence of radiculopathy

Correct Answer & Explanation

. Associated with an 11% rate of postoperative surgical site complications

Explanation

Kramer and associates conducted a retrospective review to identify the risk factors associated with a sudden increase in the rate of surgical site infections. They found in a multivariate analysis that the use of morphine nerve paste resulted in a 7.6-fold increase in postoperative surgical wound debridement and an 11% rate of surgical site complications.

Question 2348

Topic: Cervical Spine

During an ulnar collateral ligament (UCL) reconstruction using the docking technique, the sublime tubercle is utilized for the ulnar tunnel. The sublime tubercle serves as the anatomic insertion for which bundle of the UCL?

. Anterior bundle
. Posterior bundle
. Transverse ligament
. Oblique bundle
. Superior bundle

Correct Answer & Explanation

. Anterior bundle

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow. It originates on the anterior inferior surface of the medial epicondyle and inserts distally on the sublime tubercle of the ulna.

Question 2349

Topic: 6. Spine

Figures 70a and 70b show the sagittal MRI scan and axial CT of a patient who has decreased range of motion in the cervical spine. In which of the following directions would the cervical motion be most significantly limited?

. Flexion
. Extension
. Axial rotation
. Left lateral bending
. Right lateral bending

Correct Answer & Explanation

. Flexion

Explanation

MRI and CT demonstrate an abnormality in the alantoaxial region (C1-C2). See chart in reference. “C1-C2 -Flexion/Extension 30 degrees - Sidebending 10 degrees - Rotation – 70 degrees”

Question 2350

Topic: 6. Spine
A 7-year-old boy is seen for follow-up for a scoliotic deformity. His parents are concerned because his deformity seems to have increased. He has no pain and is neurologically intact. A radiograph is shown in Figure 94, and measurement of his curve reveals that it has increased 10 degrees. What is the most appropriate recommendation for this patient at this time?
. Observation
. Bracing
. A growing rod
. Distraction instrumentation and posterior arthrodesis
. Hemivertebra excision and limited fusion

Correct Answer & Explanation

. Hemivertebra excision and limited fusion

Explanation

Nakamura and associates have reported good results in patients with resection for hemivertebra-related congenital scoliosis who have a progression of their deformity. Because of the progression, observation is not appropriate for this patient’s deformity. Bracing has not been shown to alter the progression of congenital scoliosis. The growing rod technique is also not effective in preventing progression related to hemivertebra. Distraction instrumentation carries an increased risk of neurologic complications in children with congenital spine deformities. Progression after posterior arthrodesis alone can occur through the so-called crankshaft phenomenon.

Question 2351

Topic: 6. Spine
A 32-year-old man sustained an L1 burst fracture with 90% canal compromise, intact posterior elements, and kyphosis of 25 degrees at the L1 level. He has an incomplete neurologic injury. Definitive management should consist of
. bed rest for 8 weeks, followed by mobilization in a total contact thoracolumbosacral orthosis.
. immediate laminectomy only.
. anterior decompression, vertebral body reconstruction, and stabilization.
. in situ posterior fusion.
. short segment posterior fixation and fusion.

Correct Answer & Explanation

. anterior decompression, vertebral body reconstruction, and stabilization.

Explanation

DISCUSSION: With an incomplete injury, the best chance for recovery occurs when the canal is cleared and the neural structures are decompressed. Anterior decompression, vertebral body reconstruction, and anterior stabilization have been shown to be highly effective in the treatment of burst-type injuries. Laminectomy alone is contraindicated because it increases the instability. Short segment posterior fixation has a high rate of failure in this type of injury at this level. REFERENCES: Kaneda K, Abumi K: Burst fractures with neurologic deficits of the thoracolumbar spine. J Bone Joint Surg Am 1997;79:69-83. McGuire R Jr: The role of anterior surgery in the treatment of thoracolumbar fractures. Orthopedics 1997;20:959-962.

Question 2352

Topic: 6. Spine
What would be the advantage of surgery for the patient described in this scenario?
. Shorter length of antibiotic therapy
. Reduced mortality risk
. Reduced risk for neurologic deterioration
. Reduced risk for chronic pain

Correct Answer & Explanation

. Reduced risk for neurologic deterioration

Explanation

DISCUSSION: The MR image of the lumbar spine postgadolinium contrast shows a ring-enhancing fluid collection. Ring-enhancing lesions within the spinal canal on postgadolinium MR images are indicative of epidural abscess. It is important to obtain a culture-specific diagnosis to inform the choice of antibiotics and educate patients regarding the likelihood of failure for standalone antibiotic therapy. Infection with MSSA, age younger than 65 years, the absence of neurologic deficit, and lumbar abscess location are all factors that point toward a patient being a reasonable candidate for a trial of culture-specific IV antibiotics. In this case, nafcillin is a suitable treatment for MSSA. The antibiotic should be initiated and closely observed with serial labs (WBC, ESR, CRP, repeat blood cultures) to ensure that the patient responds appropriately to therapy and that neurologic deficits do not develop. In the setting of epidural abscess, surgery is performed to evacuate the abscess and reverse or prevent neurologic deterioration. In the current scenario in which sepsis is not an issue, scant high-quality evidence shows that surgical intervention influences risk for mortality or chronic pain following epidural abscess.

Question 2353

Topic: 6. Spine

A 60-year-old man is evaluated in the ICU after a rollover motor vehicle accident 3 days ago. He has multiple upper and lower extremity trauma and was found unresponsive at the accident scene. Surgery is planned for the extremity trauma once the patient is medically stable. He remains intubated and the cervical spine is immobilized in a semi-rigid collar. Examination reveals mild erythema in the posterior occipital cervical region. Initial AP and lateral radiographs of the cervical spine have not revealed any obvious fracture. What is the most appropriate treatment option at this time? Review Topic

. Continued semi-rigid immobilization until the extremity surgeries are completed
. Halo skeletal fixation prior to the extremity surgery
. Definitive clearance of the cervical spine with CT and/or MRI
. Removal of the semi-rigid collar and physical examination when the patient is responsive
. Soft collar immobilization and local wound care

Correct Answer & Explanation

. Continued semi-rigid immobilization until the extremity surgeries are completed

Explanation

Ackland and associates demonstrated that the failure to achieve early spinal clearance in an unconscious blunt trauma patient predisposed the patient to increased morbidity secondary to the prolonged used of cervical immobilization. They demonstrated that the four significant predictors of collar-related ulcers were ICU admission, mechanical ventilation, the necessity for cervical MRI, and the time to cervical spine clearance and collar removal. The risk of pressure-related ulceration increased by 66% for every 1-day increase in Philadelphia collar time and this highlights the need for definitive C-spine clearance.

Question 2354

Topic: 6. Spine
Which intervention most effectively prevents surgical-site infections following spine surgery?
. Bathing the day of surgery
. Intravenous (IV) vancomycin
. Preincision IV antibiotics
. Vancomycin powder in wound

Correct Answer & Explanation

. Preincision IV antibiotics

Explanation

DISCUSSION: The use of IV antibiotics for prophylaxis of surgical-site infection is supported by Level 1 evidence in spine surgery. It has been given a "B" recommendation by the North American Spine Society. The use of specific bathing solutions the day of surgery may be beneficial, but the evidence in spine surgery is lacking. Similarly, evidence for use of vancomycin (either topically or IV) is not supported by high-level studies, although retrospective and basic science studies support topical vancomycin use.

Question 2355

Topic: 6. Spine

A 56-year-old man has a chief complaint of leg weakness and inability to walk. Examination reveals 5 out of 5 motor strength in all lower extremity muscle groups tested and normal sensation to light touch in both lower extremities. The patient is slow in getting up from a seated position and has an unsteady wide-based

. Electromyography and nerve conduction velocity studies of bilateral lower extremities
. Multilevel lumbar laminectomy
. MRI of the thoracic and cervical spine
. MRI of the brain
. Epidural steroid injections

Correct Answer & Explanation

. Electromyography and nerve conduction velocity studies of bilateral lower extremities

Explanation

The patient is having gait problems suspicious for spinal cord compression. MRI of the thoracic and cervical spine should be performed to evaluate for spinal cord compression. Reports of leg weakness in the absence of discrete motor weakness on manual testing, and the appearance of an unsteady wide-based gait are more consistent with myelopathy as a cause of the gait difficulty rather than lumbar stenosis. Although the MRI scan of the lumbar spine shows multilevel spinal stenosis that is mild to moderate, it does not clearly explain the patient's signs and symptoms. Electromyography and nerve conduction velocity studies of the lower extremities are unlikely to add significantly to the diagnosis. Epidural steroid injections are not indicated. Lumbar decompression is unlikely to help the patient because the source of the patient's problem does not originate in the lumbar spine. MRI of the brain could be considered as a secondary imaging study if the cervical and thoracic MRI scans fail to identify an obvious cause for gait instability.

Question 2356

Topic: 6. Spine
When posterior fusion with instrumentation to the sacrum is used to treat adult scoliosis, what instrumentation technique best increases the chance of a successful lumbosacral fusion?
. Addition of sublaminar wires to the midlumbar spine
. Cross-linking of the longitudinal rods
. Use of multiple claw hook fixation in the upper thoracic spine
. Use of large-diameter rods and pedicle screws
. Fixation into both the ilium and the sacrum

Correct Answer & Explanation

. Fixation into both the ilium and the sacrum

Explanation

As the chance of success of lumbosacral fusion increases with the stiffness and rigidity of the construct, fixation and stiffness improve with fixation into both the upper sacrum and the ilium. In a review of individuals treated with long constructs to the pelvis for adult scoliosis, Islam and associates reported that the rate of pseudarthrosis was significantly lower with sacral and iliac fixation compared with sacral fixation alone or iliac fixation alone.

Question 2357

Topic: 6. Spine
A 24-year-old professional football player underwent surgery for a symptomatic cervical disk herniation with radiculopathy 9 months ago. A current radiograph is shown in Figure 17. He has normal neurologic findings, no pain, and full range of motion. A CT scan shows a solid fusion. When can he expect to return to play?
. Immediately
. In three games
. After anterior plate removal
. Next season
. Cannot return

Correct Answer & Explanation

. Immediately

Explanation

The radiograph shows that the two-level anterior cervical diskectomy and fusion has healed. In addition, the patient has good range of motion and the neurologic examination is normal. Based on these findings, the patient can return to play immediately. Patients with one- or two-level anterior cervical diskectomies and fusions that have healed fully can return to play. Any loss of motion, persistent neurologic deficit, or significant adjacent segment degeneration may preclude a player from returning.

Question 2358

Topic: 6. Spine
A 53-year-old woman has severe neck and left shoulder pain after a rollover motor vehicle accident. Radiographs and a CT scan of the cervical spine are shown in Figures 34a through 34c. Management should consist of
. a soft cervical collar.
. a rigid cervical collar.
. halo vest immobilization for 3 months.
. simple midline (Rogers) wiring.
. lateral mass plate fixation at C4-C6.

Correct Answer & Explanation

. lateral mass plate fixation at C4-C6.

Explanation

DISCUSSION: The plain radiographs show a horizontal orientation of the C5 facet joint. The CT scan through C5 reveals an ipsilateral pedicle and lamina fracture (floating facet). This injury involves two adjacent motion segments and is extremely unstable. Lateral mass plates, with or without the purchase of the “floating facet,” provide the best means of stabilization and should include the facet above (C4) and below (C6) the level of injury. Orthotic immobilization is insufficient for this particular injury. Halo vest treatment does not control the subaxial spine well and is of limited value. While simple midline (Rogers) wiring provides some tension band restoration, it is not optimal for rotational control. The use of lateral mass plates provides rotational stability. Another option would be anterior fusion and plating, which would save cervical segments. REFERENCES: Levine AM, Mazel C, Roy-Camille R: Management of fracture separations of the articular mass using posterior cervical plating. Spine 1992;17:S447-S454. Levine AM: Facet fractures and dislocations, in Levine AM, Eismont FJ, Garfin S, Zigler JE (eds): Spine Trauma. Philadelphia, PA, WB Saunders, 1998, pp 360-362. Whitehill R, Richman JA, Glaser JA: Failure of immobilization of the cervical spine by the halo vest: A report of five cases. J Bone Joint Surg Am 1986;68:326-332. Garvey TA, Eismont FJ, Roberti LJ: Anterior decompression, structural bone grafting, and Caspar plate stabilization for unstable cervical spine fractures and/or dislocations. Spine 1992;17:S431-S435.

Question 2359

Topic: 6. Spine
A 56-year-old woman sustained the fracture shown in Figures 30a and 30b in a motor vehicle accident. What mechanism is most likely responsible for the injury?
. Flexion distraction
. Vertical shear
. Extension distraction
. Flexion compression
. Axial load

Correct Answer & Explanation

. Axial load

Explanation

DISCUSSION: The CT scans show a burst fracture that results from an axial load injury. The radiographic hallmark of a burst fracture is compression of the posterior cortex of the vertebral body with retropulsion of bone into the spinal canal. AP radiographs often show widening of the interpedicular distance with a fracture of the lamina.

Question 2360

Topic: 6. Spine
A 69-year-old man has nonpainful weakness in the upper and lower extremities. He also notes progressive instability in his gait and increasing difficulty ambulating, as well as manipulating small objects with his hands. MRI scans of his cervical spine are shown in Figures 85a and 85b. When would be the most appropriate time to proceed with surgical treatment?
. When the patient is medically stable for surgery
. When the MRI scans show multisegmental high-intensity intramedullary signal changes on T2-weighted sequences
. When he reaches a Nurick grade of IV for his preoperative neurologic function
. When he reports neck and/or extremity pain that becomes intolerable or not controlled by medication
. When he develops bowel or bladder incontinence

Correct Answer & Explanation

. When the patient is medically stable for surgery

Explanation

The natural history of cervical myelopathy is one of slow deterioration over time, typically in a stepwise fashion with a variable period of stable neurologic function. Surgery should be performed as soon as possible when cervical spondylotic myelopathy has been diagnosed. It is desirable to operate when the patient is functioning with a Nurick grade of I or II to preserve and restore function.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page