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6. Spine MCQs

Practice Set 129 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 2561

Topic: 6. Spine

A 72-year-old male with long-standing diffuse idiopathic skeletal hyperostosis (DISH) presents with neck pain after a minor fall. Radiographs and CT reveal an isolated, non-displaced fracture through the C6 vertebral body. Which of the following is the most appropriate definitive management?

. Hard cervical collar for 6 weeks
. Soft cervical collar for comfort only
. Surgical stabilization via internal fixation
. Halo-vest immobilization
. Dynamic flexion-extension radiographs to confirm stability

Correct Answer & Explanation

. Hard cervical collar for 6 weeks

Explanation

Fractures through the ankylosed spine (such as in DISH or Ankylosing Spondylitis) act biomechanically like long bone fractures. Even if seemingly non-displaced, they are highly unstable and carry a significant risk of secondary neurologic deterioration or epidural hematoma. Surgical stabilization (often long-segment posterior fusion) is the standard of care to prevent catastrophic displacement.

Question 2562

Topic: Thoracolumbar Spine & Deformity

A 14-year-old female gymnast complains of persistent lower back pain that worsens with lumbar extension. Oblique radiographs of the lumbar spine demonstrate a 'Scottie dog with a collar' sign. The primary pathology is a stress fracture or defect of which of the following bony structures?

. Pedicle
. Pars interarticularis
. Spinous process
. Transverse process
. Superior articular facet

Correct Answer & Explanation

. Pedicle

Explanation

The 'Scottie dog with a collar' sign on an oblique lumbar radiograph represents a radiolucent defect in the pars interarticularis, indicating spondylolysis. This injury is a stress fracture resulting from repetitive hyperextension, commonly seen in young athletes like gymnasts and football linemen.

Question 2563

Topic: 6. Spine
A 72-year-old male with long-standing ankylosing spondylitis presents to the emergency department after a ground-level fall. He complains of severe neck pain. What is the most common mechanism of injury for cervical fractures in this patient population, and what is a highly associated critical complication?
. Hyperflexion; Vertebral artery dissection
. Hyperextension; Epidural hematoma
. Axial load; Syringomyelia
. Lateral bending; Brachial plexus neuropraxia
. Distraction; Brown-Sรฉquard syndrome

Correct Answer & Explanation

. Hyperextension; Epidural hematoma

Explanation

Patients with ankylosing spondylitis have rigid, osteopenic spines that behave like long bones, making them highly susceptible to fractures even from low-energy trauma. The most common mechanism in the cervical spine is hyperextension, resulting in an extension-distraction (through-and-through) fracture. These fractures are highly unstable and are strongly associated with spinal epidural hematomas, which can cause rapidly progressive neurologic deficits.

Question 2564

Topic: 6. Spine

A 22-year-old female is involved in a high-speed motor vehicle collision while wearing a lap-belt only. She sustains a severe flexion-distraction injury (Chance fracture) of the L2 vertebra. Which of the following concomitant injuries must be aggressively ruled out, as it is most highly associated with this specific spinal fracture pattern?

. Aortic transection
. Hollow viscus injury
. Splenic laceration
. Pelvic ring disruption
. Diaphragmatic rupture

Correct Answer & Explanation

. Aortic transection

Explanation

Chance fractures (flexion-distraction injuries) are historically associated with lap-belt use without shoulder harnesses. The fulcrum of flexion moves anteriorly to the abdominal wall, resulting in distraction forces through the middle and posterior columns of the spine. This mechanism strongly correlates with intra-abdominal injuries, most notably hollow viscus (bowel) injuries, which occur in up to 40-50% of patients with a lap-belt sign and a Chance fracture.

Question 2565

Topic: Cervical Spine

An 82-year-old male presents with a Type II odontoid fracture displaced 6 mm posteriorly following a low-energy fall. He is neurologically intact. In this specific elderly population, which of the following immobilization methods is associated with the highest rate of morbidity and mortality?

. Rigid cervical collar immobilization
. Halo vest immobilization
. Posterior C1-C2 instrumented fusion
. Anterior odontoid screw fixation
. Minerva cast application

Correct Answer & Explanation

. Rigid cervical collar immobilization

Explanation

In the elderly population (generally considered >75-80 years old), halo vest immobilization is poorly tolerated and is associated with exceptionally high rates of morbidity and mortality (respiratory compromise, pin site infections, cardiac events, and death). Standard of care for Type II odontoid fractures in elderly poor surgical candidates is typically a rigid cervical collar (accepting a stable fibrous nonunion), or posterior C1-C2 fusion if they are medically fit to undergo surgery.

Question 2566

Topic: 6. Spine

A 45-year-old male presents with severe lower back pain, bilateral sciatica, perineal numbness, and new-onset urinary retention with overflow incontinence. MRI reveals a massive L4-L5 central disc herniation. Based on the meta-analysis by Ahn et al., surgical decompression should ideally be performed within what timeframe from the onset of symptoms to maximize the chance of full neurologic recovery?

. Within 12 hours
. Within 24 hours
. Within 48 hours
. Within 72 hours
. Timing has been proven not to affect ultimate neurologic recovery

Correct Answer & Explanation

. Within 12 hours

Explanation

Cauda Equina Syndrome (CES) is a surgical emergency. The classic meta-analysis by Ahn et al. (2000) demonstrated a significant advantage in neurological outcomes, including motor, sensory, and urologic recovery, when surgical decompression is performed within 48 hours of symptom onset compared to after 48 hours. This remains the highly tested 'golden rule' on board exams, though many surgeons advocate for the earliest possible decompression.

Question 2567

Topic: Thoracolumbar Spine & Deformity

A 68-year-old female presents with severe 'flatback' syndrome and forward truncal inclination following prior long-segment lumbar fusion. She has exhausted nonoperative management. In evaluating her spinopelvic parameters to plan a corrective osteotomy, you note that she has a high Pelvic Incidence (PI). Which of the following best describes the expected compensatory changes in her Pelvic Tilt (PT) and Sacral Slope (SS) as her body attempts to maintain global sagittal balance?

. Decreased PT and decreased SS
. Decreased PT and increased SS
. Increased PT and increased SS
. Increased PT and decreased SS
. No change in PT or SS as PI is a fixed parameter

Correct Answer & Explanation

. Decreased PT and decreased SS

Explanation

Pelvic Incidence (PI) is a fixed morphological parameter representing the relationship between the sacrum and the femoral heads, defined by the equation PI = PT + SS. In conditions like flatback syndrome where there is a loss of lumbar lordosis, the patient shifts their center of gravity anteriorly. To compensate and bring the center of gravity back over the pelvis, the patient retroverts the pelvis. Pelvic retroversion corresponds to an increase in Pelvic Tilt (PT). Because PI is a constant, an increase in PT mathematically and anatomically mandates a decrease in Sacral Slope (SS).

Question 2568

Topic: 6. Spine

A 55-year-old male with progressive hand clumsiness and gait imbalance is diagnosed with cervical spondylotic myelopathy (CSM). He is scheduled for an anterior cervical discectomy and fusion (ACDF). Which of the following MRI findings is most predictive of a poor prognosis for postoperative neurologic recovery?

. T2 hyperintensity spanning one vertebral level
. Multilevel anterior osteophyte formation without posterior ligamentous buckling
. T1 hypointensity and T2 hyperintensity at the level of maximum compression
. Effacement of the ventral cerebrospinal fluid (CSF) signal alone
. Congenital cervical stenosis with a canal diameter of 12 mm

Correct Answer & Explanation

. T2 hyperintensity spanning one vertebral level

Explanation

In the setting of cervical spondylotic myelopathy (CSM), MRI changes within the spinal cord provide important prognostic information. The presence of T2 hyperintensity alone can indicate cord edema, which is potentially reversible and implies a moderate prognosis. However, the presence of T1 hypointensity combined with T2 hyperintensity represents myelomalacia, gliosis, or cystic necrosis of the spinal cord. This finding is a strong predictor of irreversible cord damage and poor functional recovery postoperatively.

Question 2569

Topic: 6. Spine

A 52-year-old male intravenous drug user presents with back pain and a fever. MRI reveals a spinal epidural abscess. In which of the following scenarios is nonoperative management with broad-spectrum intravenous antibiotics ALONE most appropriate?

. A neurologically intact patient with an abscess extending from T2 to L3 (pan-spinal involvement)
. A patient with 3/5 lower extremity weakness that began 12 hours ago
. A neurologically intact patient with a well-circumscribed focal abscess at L2 with severe mechanical back pain and dynamic instability
. A patient with an isolated cervical epidural abscess who presents with new-onset urinary retention
. A patient whose blood cultures are negative and who has a progressive neurologic deficit

Correct Answer & Explanation

. A neurologically intact patient with an abscess extending from T2 to L3 (pan-spinal involvement)

Explanation

Surgical decompression (laminectomy/evacuation) and concurrent antibiotics is the gold standard for most spinal epidural abscesses. Absolute indications for surgery include progressive neurologic deficit, presence of spinal instability/deformity, and failure of medical management. Medical management alone (IV antibiotics) is generally reserved for patients who are medically unfit for surgery, patients completely paralyzed for >48-72 hours, or neurologically intact patients with extensive pan-spinal (multilevel) epidural abscesses where wide laminectomies would induce massive spinal instability and morbidity.

Question 2570

Topic: 6. Spine

A 72-year-old male presents with bilateral lower extremity pain, heaviness, and cramping that occurs after walking for 10 minutes. He is evaluated for both lumbar spinal stenosis (neurogenic claudication) and peripheral arterial disease (vascular claudication). Which of the following historical features is the most reliable discriminator pointing toward a diagnosis of neurogenic claudication?

. Pain that ascends from the calves to the buttocks
. Pain that is rapidly relieved by standing still and remaining upright
. Pain relief when leaning forward over a shopping cart while walking
. Decreased pedal pulses on physical examination
. Skin changes including hair loss and dependent rubor

Correct Answer & Explanation

. Pain that ascends from the calves to the buttocks

Explanation

Neurogenic claudication secondary to lumbar spinal stenosis is classically exacerbated by lumbar extension (which narrows the spinal canal and neuroforamina) and relieved by lumbar flexion (which increases canal volume). Therefore, leaning forward over a shopping cart, sitting, or walking up an incline typical relieves neurogenic claudication. Vascular claudication is dependent on muscle oxygen demand; it is relieved by simply stopping and resting (standing still) and does not require a change in posture (flexion) for relief. Vascular claudication also tends to ascend (distal to proximal), whereas neurogenic claudication descends (proximal to distal).

Question 2571

Topic: Thoracolumbar Spine & Deformity
A 40-year-old male construction worker falls 15 feet and complains of severe back pain. Neurologic examination of the lower extremities is completely intact (ASIA E). A CT scan demonstrates a T12 burst fracture with 40% loss of anterior height and retropulsion into the canal. MRI reveals high T2 signal in the interspinous ligaments but an intact ligamentum flavum, representing an 'indeterminate' posterior ligamentous complex (PLC) injury. Utilizing the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the patient's calculated score and the corresponding treatment recommendation?
. Score of 2; Nonoperative treatment
. Score of 3; Nonoperative treatment
. Score of 4; Operative or Nonoperative treatment
. Score of 5; Operative treatment
. Score of 7; Operative treatment

Correct Answer & Explanation

. Score of 4; Operative or Nonoperative treatment

Explanation

The Thoracolumbar Injury Classification and Severity (TLICS) score determines treatment based on three categories: 1) Morphology: Burst fracture = 2 points. 2) Neurologic status: Intact = 0 points. 3) PLC integrity: Indeterminate (suspected) = 2 points. Total score = 2 + 0 + 2 = 4 points. According to TLICS, a score of โ‰ค 3 suggests nonoperative management, a score of โ‰ฅ 5 suggests operative management, and a score of exactly 4 is an equivocal indication where either operative or nonoperative management may be chosen based on surgeon preference and patient factors.

Question 2572

Topic: 6. Spine

A 45-year-old male is brought to the emergency department after a high-speed motor vehicle collision. He complains of severe neck pain. A cervical spine CT scan demonstrates a traumatic spondylolisthesis of the axis (Hangman's fracture) with severe angulation, minimal translation, and widening of the posterior disc space (Levine-Edwards Type IIA). Which of the following standard cervical interventions is strictly contraindicated in the acute management of this specific fracture pattern?

. Cervical traction
. Application of a hard cervical collar
. Application of a halo vest
. Surgical posterior C1-C2 fusion
. Surgical anterior C2-C3 discectomy and fusion

Correct Answer & Explanation

. Cervical traction

Explanation

The Levine-Edwards classification of Hangman's fractures dictates specific treatments. A Type IIA fracture is characterized by significant angulation and minimal translation, with widening of the posterior C2-C3 disc space. The mechanism of injury is flexion-distraction. Because the injury represents a distraction vector with severe posterior ligamentous compromise, the application of cervical traction is strictly contraindicated, as it will exacerbate the distraction, worsen the deformity, and potentially cause neurologic compromise. Treatment typically involves reduction in extension under fluoroscopy followed by halo immobilization.

Question 2573

Topic: 6. Spine

A 64-year-old male with cervical myelopathy undergoes a posterior C3-C6 laminectomy and instrumented fusion. On postoperative day 4, he suddenly develops profound weakness in bilateral shoulder abduction and elbow flexion, while hand intrinsic function and lower extremity strength remain full. MRI shows adequate decompression with no hematoma or new cord signal. What is the most appropriate initial management and expected natural history for this complication?

. Immediate return to the operating room for exploration; poor long-term recovery
. High-dose intravenous methylprednisolone for 48 hours; minimal recovery expected
. Emergent anterior cervical discectomy and fusion at C4-C5; spontaneous recovery within 2 weeks
. Observation and physical therapy; spontaneous recovery of motor function within 6 months in the majority of patients
. Placement of a lumbar subarachnoid drain; complete recovery within 72 hours

Correct Answer & Explanation

. Immediate return to the operating room for exploration; poor long-term recovery

Explanation

The patient has developed a C5 palsy, a well-recognized complication occurring in up to 10% of patients following posterior cervical decompression (laminectomy/fusion or laminoplasty). The exact etiology is multifactorial and heavily debated, potentially involving spinal cord shifting/tethering, reperfusion injury, or foraminal stenosis. It classically presents 2 to 5 days postoperatively with deltoid and biceps weakness. If imaging confirms adequate decompression and no correctable cause (like a hematoma), the standard of care is conservative management (observation and PT to prevent stiffness). The prognosis is generally favorable, with the majority of patients experiencing spontaneous recovery within 6 months.

Question 2574

Topic: 6. Spine

A 65-year-old female with degenerative spondylolisthesis at L4-L5 and severe neurogenic claudication elects to undergo surgical intervention after failing conservative management. Based on the Spine Patient Outcomes Research Trial (SPORT), what is the expected long-term outcome compared to non-operative treatment?

. No significant difference in pain or function at 4 years
. Operative treatment provides significantly greater improvement in pain and function at 4 years
. Non-operative treatment shows superior function but equal pain relief
. Operative treatment has a higher rate of permanent neurological deficit
. Both groups show equal rates of progression to spinal arthrodesis

Correct Answer & Explanation

. No significant difference in pain or function at 4 years

Explanation

The SPORT trial demonstrated that patients treated surgically for degenerative spondylolisthesis with spinal stenosis maintained significantly greater improvements in pain and function at 4 years compared to those treated non-operatively.

Question 2575

Topic: 6. Spine

A 55-year-old male presents with severe cervical myelopathy. Imaging demonstrates continuous ossification of the posterior longitudinal ligament (OPLL) from C3 to C6, with a K-line negative alignment on the sagittal radiograph. What is the most appropriate surgical strategy?

. Cervical laminoplasty without fusion
. Posterior laminectomy and instrumented fusion
. Stand-alone cervical disc arthroplasty
. Poster cervical foraminotomy
. Interlaminar decompression

Correct Answer & Explanation

. Cervical laminoplasty without fusion

Explanation

A negative K-line indicates that the OPLL mass exceeds the line connecting the midpoints of the spinal canal at C2 and C7, typically due to kyphosis. Laminoplasty alone is contraindicated; posterior laminectomy with instrumented fusion or an anterior approach is required to decompress the cord effectively.

Question 2576

Topic: 6. Spine

A 24-year-old female sustains a Levine-Edwards Type IIa traumatic spondylolisthesis of the axis (Hangman's fracture) after a high-speed motor vehicle collision. The fracture demonstrates significant angulation with minimal translation. What is the primary contraindication in the initial non-operative management of this specific fracture pattern?

. Use of a rigid cervical collar
. Application of cervical traction
. Closed reduction under fluoroscopy
. Use of a halo vest
. Administration of high-dose corticosteroids

Correct Answer & Explanation

. Use of a rigid cervical collar

Explanation

Levine-Edwards Type IIa Hangman's fractures involve significant angulation with minimal translation and are caused by a flexion-distraction mechanism. Cervical traction is strictly contraindicated as it can cause over-distraction and catastrophic neurological injury.

Question 2577

Topic: 6. Spine

A 17-year-old high school football player sustains a neck injury in a game. During the initial on-field assessment, the team physician removes his helmet, and the athlete is log-rolled to the supine position while the physician manually stabilizes his cervical spine. An examination demonstrates tenderness to palpation over the cervical spine and neurologic deficits in bilateral upper and lower extremities. Shoulder pads prohibit proper placement of a hard cervical collar, and the athlete is immobilized on a spine board and transported to the emergency department via ambulance. Comprehensive evaluation in the emergency department reveals a bilateral facet dislocation of C5 on C6. The on-field intervention most likely to cause a neurologic injury is

. failure to place a hard cervical collar.
. helmet removal prior to examination.
. transfer to a spine board prior to transport.
. log-rolling the athlete to the supine position.

Correct Answer & Explanation

. failure to place a hard cervical collar.

Explanation

DISCUSSIONComplete immobilization of the cervical spine is critical for athletes with a suspected cervical spine or spinal cord injury. The spinal cord in the subaxial spine is especially sensitive to motion, and removal of protective gear such as the helmet and shoulder pads presents an unacceptable risk for progressive neurologic injury in the setting of a potentially unstable cervical spine injury. Removal of the face mask alone is typically performed to improve access to an athlete's airway. Protective equipment often prevents proper placement of a hard cervical collar, and the spine board offers a variety of options for safe cervical spine immobilization of helmeted athletes without a hard cervical collar. The log-roll and lift-and-slide techniquesallow for the safe transfer of an athlete to a spine board while maintaining appropriate manual stabilization of the cervical spine.

Question 2578

Topic: 6. Spine

What is one of the principle concerns when a fracture such as the one seen in Figure 18 is encountered? Review Topic

. Fractures of the lower extremities
. Paroxysmal hypertension
. Infection
. Epidural hematoma
. Gastrointestinal bleeding

Correct Answer & Explanation

. Fractures of the lower extremities

Explanation

The injury shown is a fracture-dislocation and it is highly unstable. In addition to this concern, spinal epidural hematomas have a much higher incidence in people with ankylosing spondylitis following spine fracture. It is felt to be due to disrupted epidural veins, with hypervascular epidural soft tissue in the setting of a rigid spinal canal. Patients with ankylosing spondylitis may have other significant comorbidities, especially cardiac and pulmonary, and these should be carefully assessed.

Question 2579

Topic: 6. Spine
What is the typical axial plane transverse angulation of the thoracic pedicles?
. 5 degrees medial at T1 and T2; 10 degrees from T3 to T10
. 5 degrees lateral at T1; neutral at T2; 5 degrees medial from T3 to T12
. 10 degrees medial from T1 to T10; 15 degrees medial at T11 and T12
. 10 degrees medial from T1 to T12
. 25 degrees medial at T1; 15 degrees at T2; and 10 degrees medial from T3 to T10

Correct Answer & Explanation

. 25 degrees medial at T1; 15 degrees at T2; and 10 degrees medial from T3 to T10

Explanation

DISCUSSION: Thoracic pedicles typically are angled 25 degrees medially at T1 so the starting point is more lateral. T2 angles about 15 degrees, and then the pedicles average about 5 to 7 degrees down to T10. At T11 and 12, the angulation is minimal. REFERENCES: Weinstein L: Pediatric Spine Principles and Practice. New York, NY, Raven Press, 1994, pp 1659-1681. Lenke LG, Orchowski J: Segmental posterior spinal instrumentation: Thoracic spine to sacrum, in Frymoyer JW, Wiesel SW (eds): The Adult and Pediatric Spine, ed 3. Philadelphia, PA, Lippincott Williams and Wilkins, 2004, pp 537-552.

Question 2580

Topic: 6. Spine
In patients with neurofibromatosis, what is the most important sign of impending rapid progression of a spinal deformity?
. Apical curve rotation
. Anterior vertebral body erosions
. Cervical spine involvement
. Penciling of three or more ribs
. Curve magnitude of greater than 50 degrees

Correct Answer & Explanation

. Penciling of three or more ribs

Explanation

DISCUSSION: Neurofibromatosis can progress very rapidly. Rib penciling is the only singular prognostic factor. Significant progression has been observed in 87% of the curves with three or more penciled ribs. The other factors are often present but do not have a high correlation with rapid, severe progression. REFERENCES: Crawford AH, Schorry EK: Neurofibromatosis in children: The role of the orthopaedist. J Am Acad Orthop Surg 1999;7:217-230. Durrani AA, Crawford AH, Chouhdry SN, Saifuddin A, Morley TR: Modulation of spinal deformities in patients with neurofibromatosis type 1. Spine 2000;25:69-75.

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