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6. Spine MCQs

Practice Set 133 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 2641

Topic: Thoracolumbar Spine & Deformity

A 15-year-old boy presents with progressive back pain and a prominent thoracic kyphosis. Standing lateral radiographs reveal anterior wedging of multiple consecutive thoracic vertebrae. According to Sorensen's criteria, what is the strict radiographic definition of classic Scheuermann's disease?

. Anterior wedging of at least 5 degrees in 2 or more consecutive vertebrae
. Anterior wedging of at least 5 degrees in 3 or more consecutive vertebrae
. Anterior wedging of at least 10 degrees in 2 or more consecutive vertebrae
. Anterior wedging of at least 10 degrees in 3 or more consecutive vertebrae
. Anterior wedging of at least 15 degrees in 3 or more consecutive vertebrae

Correct Answer & Explanation

. Anterior wedging of at least 5 degrees in 2 or more consecutive vertebrae

Explanation

Sorensen's criteria for classic Scheuermann's kyphosis require anterior wedging of at least 5 degrees in 3 or more consecutive vertebrae. Other common findings include Schmorl's nodes and narrowed disc spaces.

Question 2642

Topic: Cervical Spine

An 82-year-old man sustains a Type II odontoid fracture after a ground-level fall. He is neurologically intact. Radiographs show a 3 mm posterior displacement. He has severe medical comorbidities (ASA IV). What is the most appropriate management?

. Halo vest immobilization
. Hard cervical collar immobilization
. Anterior odontoid screw fixation
. Posterior C1-C2 fusion
. Cervical traction followed by open reduction

Correct Answer & Explanation

. Halo vest immobilization

Explanation

In elderly patients with severe comorbidities (ASA IV) and Type II odontoid fractures, rigid cervical collar immobilization is generally preferred over a Halo vest (due to high morbidity/mortality) or surgery. While nonunion rates are high, the resulting fibrous nonunions are typically stable and well-tolerated.

Question 2643

Topic: 6. Spine

A 60-year-old man with a 20-year history of ankylosing spondylitis presents to the ED after a minor rear-end motor vehicle collision. He complains of severe lower cervical pain. Plain radiographs show marked osteopenia and bridging syndesmophytes, but no obvious fracture. What is the most appropriate next step?

. Discharge with a soft collar and NSAIDs
. Flexion-extension cervical radiographs
. CT scan of the entire cervical spine
. Bone scintigraphy
. Diagnostic facet injections

Correct Answer & Explanation

. Discharge with a soft collar and NSAIDs

Explanation

Patients with ankylosing spondylitis are at an extremely high risk for unstable, occult spinal fractures even after minor trauma. A CT scan of the entire cervical spine is mandatory when plain radiographs are negative or inadequate.

Question 2644

Topic: 6. Spine

A 14-year-old non-ambulatory boy with spastic quadriplegic cerebral palsy presents with progressive scoliosis. His Cobb angle is 85 degrees and he has 30 degrees of pelvic obliquity causing severe seating difficulties and ischial skin breakdown. When planning posterior spinal fusion, what is the most appropriate distal extent of fixation?

. L3
. L4
. L5
. S1
. Pelvis (Ilium)

Correct Answer & Explanation

. L3

Explanation

In non-ambulatory patients with neuromuscular scoliosis and significant pelvic obliquity (>15 degrees), fusion must typically extend to the pelvis (ilium). This effectively corrects the obliquity, restores a level sitting balance, and helps prevent pressure sores.

Question 2645

Topic: Thoracolumbar Spine & Deformity

A 16-year-old female gymnast complains of mechanical low back pain for 6 months. Imaging reveals a bilateral L5 pars defect with a Grade I anterior slip of L5 on S1. Conservative treatment has failed. Which of the following pelvic parameters is the strongest predictor for progression of the spondylolisthesis?

. Low pelvic incidence
. High pelvic incidence
. Low sacral slope
. High pelvic tilt
. Negative sagittal vertical axis

Correct Answer & Explanation

. Low pelvic incidence

Explanation

A high pelvic incidence increases the shear stress at the lumbosacral junction. It is considered a strong anatomical predictor for the development and progression of L5-S1 isthmic spondylolisthesis.

Question 2646

Topic: 6. Spine

A 45-year-old man presents with acute onset of severe low back pain, bilateral sciatica, saddle anesthesia, and urinary retention with overflow incontinence. MRI reveals a massive L4-L5 herniated disc. To maximize the chance of full neurologic recovery, surgical decompression should ideally be performed within what timeframe from the onset of autonomic symptoms?

. 6 hours
. 24 to 48 hours
. 72 hours
. 96 hours
. 1 week

Correct Answer & Explanation

. 6 hours

Explanation

Cauda equina syndrome with urinary retention is a surgical emergency. Decompression ideally performed within 24 to 48 hours from the onset of autonomic/sphincter symptoms offers the best chance for significant urological and neurological recovery.

Question 2647

Topic: 6. Spine

A 40-year-old intravenous drug user presents with T10-T11 discitis and a small ventral epidural abscess. He is neurologically completely intact. Blood cultures are positive for Methicillin-sensitive Staphylococcus aureus (MSSA). What is the standard initial management?

. Immediate surgical decompression and stabilization
. Intravenous oxacillin/cefazolin without surgery
. CT-guided aspiration followed by oral antibiotics
. Posterior spinal fusion alone
. Anterior debridement without antibiotics

Correct Answer & Explanation

. Immediate surgical decompression and stabilization

Explanation

In the absence of neurologic deficits, spinal instability, or gross deformity, most spinal epidural abscesses and discitis cases can be treated successfully with a prolonged course of culture-directed intravenous antibiotics. Surgery is reserved for neurologic decline or failure of medical management.

Question 2648

Topic: 6. Spine
A 50-year-old woman requires surgical decompression for a large, central, calcified T8-T9 disc herniation causing severe myelopathy. Which of the following surgical approaches is contraindicated due to an unacceptably high risk of iatrogenic spinal cord injury?
. Costotransversectomy
. Lateral extracavitary approach
. Transthoracic anterior approach
. Posterior laminectomy
. Thoracoscopic decompression

Correct Answer & Explanation

. Posterior laminectomy

Explanation

Posterior laminectomy alone is strongly contraindicated for central or calcified thoracic disc herniations. Retracting the thoracic spinal cord to access an anterior central lesion via a standard posterior laminectomy carries a very high risk of catastrophic paraplegia.

Question 2649

Topic: 6. Spine
A 13-year-old boy is comatose and has irregular breathing after being struck by a car while riding his bicycle. Auscultation suggests a pneumothorax on the right side and swelling about the right arm and leg. Initial management should consist of
. careful neurologic evaluation because of suspected brain injury.
. CT of the brain because of suspected subdural hematoma.
. insertion of an internal jugular vein central line for vascular access.
. airway control, placement of vascular access lines, and cervical spine radiographs.
. a chest tube and chest radiograph.

Correct Answer & Explanation

. airway control, placement of vascular access lines, and cervical spine radiographs.

Explanation

The first priority is to gain control of the airway with intubation. Following intubation, management should consist of ventilation and placement of a chest tube if needed, vascular access and circulatory stabilization, radiographs of the cervical spine and chest, and CT of the brain.

Question 2650

Topic: 6. Spine
An 18-year-old man sustained a knife injury to his midback, with the entry wound 2 cm to the left of the midline. He has been diagnosed with a hemicord transection. Neurologic examination will most likely reveal left-sided loss of
. vibratory and light touch sensation and motor function, and right-sided loss of pain and temperature sensation.
. pain and temperature sensation and motor function, and right-sided loss of vibratory and light touch sensation.
. pain, temperature, vibratory, and light touch sensation and motor function.
. motor function, and right-sided loss of pain, temperature, vibratory, and light touch sensation.
. light touch and pain sensation and motor function, and right-sided loss of vibratory and temperature sensation.

Correct Answer & Explanation

. vibratory and light touch sensation and motor function, and right-sided loss of pain and temperature sensation.

Explanation

Brown-Sequard syndrome results from an injury to one half of the spinal cord and is characteristically seen in penetrating injuries. The spinothalamic fibers cross the midline below the level of the lesion, resulting in contralateral loss of pain and temperature sensation. The posterior columns and corticospinal tracts carry vibratory, position, and light touch sensation, as well as motor function from the ipsilateral side of the body.

Question 2651

Topic: 6. Spine
A 21-year-old woman with scoliosis reports no pain, and her examination is unremarkable except for the scoliosis. Preoperative radiographs, including bending views, are shown in Figures 14a through 14e. The thoracic curve measures 62 degrees. Treatment should consist of
. posterior fusion from T2 to L3.
. posterior fusion from T4 to L1.
. posterior fusion from T4 to L4.
. anterior fusion from T6 to L1.
. anterior fusion from T9 to T11.

Correct Answer & Explanation

. posterior fusion from T4 to L1.

Explanation

The patient has a King type III curve with a very flexible lumbar spine that derotates and levels well on side bending. The fractional upper thoracic curve is also quite flexible and will not need to be addressed; therefore, treatment should consist of posterior spinal fusion from T4 to L1.

Question 2652

Topic: 6. Spine

Of the following, what is the most reliable method of assessing spinal fusion? Review Topic

. Radiographs
. MRI
. Flexion/extension radiographs
. CT
. CT myelography

Correct Answer & Explanation

. Radiographs

Explanation

Despite the ease of attainment, radiographs only accurately diagnose failed arthrodesis in 60% to 80% of uninstrumented cases and these numbers are even lower in cases with posterior instrumentation. The role of dynamic radiographs remains unclear because of the paucity of normative data values after lumbar spine fusion. CT scans provide excellent bony detail and their images are not affected by metal components as in MRI. Post-myelogram CT is useful for identifying neurologic compression.

Question 2653

Topic: Thoracolumbar Spine & Deformity

A 14-year-old gymnast presents with progressive lower back pain and is diagnosed with an L5-S1 isthmic spondylolisthesis. Which of the following statements regarding her spino-pelvic parameters is most accurate concerning the etiology of her condition?

. Pelvic incidence is generally lower than the normal population.
. High pelvic incidence is a predisposing factor due to increased shear forces at L5-S1.
. Pelvic tilt typically decreases to compensate for the sagittal imbalance.
. Sacral slope is typically decreased in patients with high-grade isthmic spondylolisthesis.
. Pelvic incidence changes significantly after skeletal maturity.

Correct Answer & Explanation

. Pelvic incidence is generally lower than the normal population.

Explanation

High pelvic incidence (PI = Pelvic Tilt + Sacral Slope) is strongly correlated with the development of isthmic spondylolisthesis. A higher PI leads to an increased sacral slope, which in turn increases the anterior shear forces acting across the pars interarticularis at the L5-S1 junction. Pelvic incidence is considered a fixed morphological parameter after skeletal maturity.

Question 2654

Topic: 6. Spine

A 45-year-old man presents with right arm pain radiating to his thumb. Examination reveals weakness in wrist extension and an absent brachioradialis reflex. A clinical image representing his pathology is shown. Which of the following cervical nerve roots is most likely compressed?

. C4
. C5
. C6
. C7
. C8

Correct Answer & Explanation

. C4

Explanation

The clinical presentation is classic for a C6 radiculopathy. Findings include pain or numbness radiating to the thumb and index finger (radial aspect of the forearm and hand), weakness in wrist extension (extensor carpi radialis longus and brevis), and an absent or diminished brachioradialis reflex. C5 radiculopathy typically affects the deltoid and biceps; C7 affects the triceps, wrist flexion, and finger extension; C8 affects finger flexors.

Question 2655

Topic: 6. Spine

A 22-year-old male sustains a traumatic cervical spine injury. On examination 48 hours later, he has motor function graded as 3/5 or higher in more than half of the key muscles below the neurological level of injury. He has intact light touch and pinprick sensation in the sacral segments (S4-S5). Based on the ASIA (American Spinal Injury Association) Impairment Scale, how is this injury classified?

. ASIA A
. ASIA B
. ASIA C
. ASIA D
. ASIA E

Correct Answer & Explanation

. ASIA A

Explanation

ASIA D is defined as a motor incomplete injury where motor function is preserved below the neurological level, and at least half or more of key muscle functions below the neurological level have a muscle grade of 3 or greater. ASIA C indicates motor preservation but more than half of key muscles below the neurological level have a muscle grade less than 3. ASIA B is sensory incomplete (sacral sparing but no motor preservation). ASIA A is complete.

Question 2656

Topic: Cervical Spine

An 82-year-old male with severe COPD, coronary artery disease, and prior myocardial infarction falls and sustains a Type II odontoid fracture with 2 mm of posterior displacement. He is neurologically intact. A representative image is shown. Which of the following is the most appropriate treatment to minimize mortality while managing this fracture?

. Halo vest immobilization
. Rigid cervical collar
. Anterior odontoid screw fixation
. Posterior C1-C2 transarticular screw fixation
. Occipitocervical fusion

Correct Answer & Explanation

. Halo vest immobilization

Explanation

In elderly patients (typically >80 years) with significant medical comorbidities, rigid cervical collar immobilization is the safest approach for isolated, minimally displaced Type II odontoid fractures. Halo vest immobilization in this age group is associated with high morbidity and mortality (up to 40%) due to respiratory complications and pin site issues. While surgical fusion provides better union rates, the perioperative risks are prohibitive in severely medically compromised elderly patients. Fibrous nonunion in this population is frequently asymptomatic and clinically stable.

Question 2657

Topic: 6. Spine

A 68-year-old male complains of bilateral leg and buttock pain that worsens with prolonged standing and walking. His symptoms improve when he leans forward over a shopping cart. Examination reveals normal lower extremity pulses. Which of the following characteristics most reliably differentiates his neurogenic claudication from vascular claudication?

. Pain that reliably resolves immediately upon cessation of walking, while remaining standing
. Worsening of pain when walking uphill compared to downhill
. Pain relief requiring sitting or lumbar flexion, rather than merely stopping walking
. Absent pedal pulses
. Decreased ankle-brachial index (ABI)

Correct Answer & Explanation

. Pain that reliably resolves immediately upon cessation of walking, while remaining standing

Explanation

Neurogenic claudication (due to lumbar spinal stenosis) is exacerbated by lumbar extension (which decreases canal volume) and relieved by lumbar flexion (such as leaning on a shopping cart or sitting), which opens the spinal canal and foramina. A key distinguishing feature is that mere cessation of walking while remaining standing (in lumbar extension) does not quickly relieve neurogenic pain. In contrast, vascular claudication is relieved rapidly by simply resting (stopping muscle exertion), even while standing upright.

Question 2658

Topic: 6. Spine

A 65-year-old man with type 2 diabetes presents with neck stiffness and mild dysphagia. Radiographs demonstrate flowing ossification along the anterolateral aspect of four contiguous vertebral bodies in the cervical spine. The intervertebral disc spaces are preserved, and the sacroiliac joints are normal. A representative image is shown. What is the most likely diagnosis?

. Ankylosing spondylitis
. Diffuse idiopathic skeletal hyperostosis (DISH)
. Ossification of the posterior longitudinal ligament (OPLL)
. Cervical spondylotic myelopathy
. Psoriatic arthritis

Correct Answer & Explanation

. Ankylosing spondylitis

Explanation

Diffuse idiopathic skeletal hyperostosis (DISH), or Forestier disease, is characterized by flowing ossification of the anterolateral aspect of at least four contiguous vertebral bodies. Diagnostic criteria include the preservation of intervertebral disc height and the absence of sacroiliac joint erosion or ankylosis (which distinguishes it from ankylosing spondylitis). Large anterior cervical osteophytes can impinge on the esophagus, causing dysphagia. It is strongly associated with metabolic syndrome and type 2 diabetes.

Question 2659

Topic: Thoracolumbar Spine & Deformity
A 35-year-old female falls from a horse and sustains a T12 burst fracture. On CT, there is 40% canal compromise, but the posterior ligamentous complex (PLC) is intact. She has 5/5 strength in all lower extremity myotomes, normal sensation, and intact bowel/bladder function. What is her Thoracolumbar Injury Classification and Severity (TLICS) score, and what is the recommended treatment based on this score?
. Score 2; Nonoperative treatment with a TLSO brace
. Score 4; Operative or Nonoperative treatment
. Score 5; Operative fixation
. Score 7; Emergent operative decompression and fixation
. Score 3; Nonoperative treatment

Correct Answer & Explanation

. Score 2; Nonoperative treatment with a TLSO brace

Explanation

The Thoracolumbar Injury Classification and Severity (TLICS) score determines treatment for thoracolumbar fractures based on three categories. 1) Morphology: Burst fracture = 2 points. 2) Neurological status: Intact = 0 points. 3) Posterior ligamentous complex (PLC) integrity: Intact = 0 points. The total score is 2. A score of ≤3 indicates nonoperative management (e.g., TLSO brace). A score of 4 is indeterminate, and ≥5 suggests operative management.

Question 2660

Topic: 6. Spine

A 35-year-old male is brought to the trauma bay after a high-speed motor vehicle collision. He is intubated and sedated. A lateral cervical spine radiograph shows a Basion-Dens Interval (BDI) of 14 mm and Basion-Axial Interval (BAI) of 15 mm. What is the most appropriate definitive management?

. Rigid cervical collar and upright mobilization
. Halo vest immobilization for 12 weeks
. Occipitocervical fusion
. C1-C2 posterior fusion
. Anterior odontoid screw fixation

Correct Answer & Explanation

. Rigid cervical collar and upright mobilization

Explanation

The patient has an atlanto-occipital dissociation (AOD), indicated by a BDI and BAI both >12 mm (normal is <12 mm). AOD is a highly unstable injury characterized by disruption of the tectorial membrane and alar ligaments. The standard of care is rigid stabilization via an occipitocervical fusion. Halo immobilization is contraindicated as it can cause overdistraction of the unstable occipitocervical junction.

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