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6. Spine MCQs

Practice Set 134 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 2661

Topic: 6. Spine

A 45-year-old male presents with severe right anterior thigh pain and weakness in knee extension. An MRI of the lumbar spine reveals a far-lateral (extraforaminal) disc herniation at the L3-L4 level. Which nerve root is most likely compressed by this specific pathology?

. L2
. L3
. L4
. L5
. S1

Correct Answer & Explanation

. L2

Explanation

In the lumbar spine, a far-lateral (extraforaminal) disc herniation compresses the exiting nerve root at the same level. Because the exiting nerve root leaves the neural foramen below the correspondingly numbered pedicle, an L3-L4 far-lateral disc herniation will compress the exiting L3 nerve root, causing anterior thigh pain and quadriceps weakness. A paracentral disc herniation at the same level would compress the traversing L4 root.

Question 2662

Topic: 6. Spine

A 68-year-old male presents with bilateral hand clumsiness, difficulty walking, and intermittent neurogenic claudication of the lower extremities. Physical exam shows hyperreflexia in the lower extremities, a positive Hoffman sign, and diminished reflexes in the upper extremities. An MRI demonstrates severe cervical stenosis at C4-C6 with cord signal change, as well as severe lumbar stenosis at L3-L5. When planning surgical intervention, what is the generally recommended approach?

. Simultaneous cervical and lumbar decompression in the same stage
. Staged procedures, addressing the cervical spine first
. Staged procedures, addressing the lumbar spine first
. Lumbar decompression alone to address the claudication
. Nonoperative management due to the high complication rate of dual pathology

Correct Answer & Explanation

. Simultaneous cervical and lumbar decompression in the same stage

Explanation

This patient has symptomatic tandem spinal stenosis (concurrent cervical myelopathy and lumbar stenosis). The generally accepted management algorithm is to address the cervical spine first. Decompressing the cervical spine initially halts the progression of myelopathy and prevents potentially catastrophic worsening of cervical cord compromise that could occur during patient positioning and intubation for the lumbar surgery.

Question 2663

Topic: Cervical Spine

A 30-year-old male sustains a C1 burst (Jefferson) fracture. An open-mouth odontoid radiograph demonstrates lateral displacement of the C1 lateral masses. According to the Rule of Spence, what total combined overhang of the C1 lateral masses on the C2 articular facets suggests a rupture of the transverse atlantal ligament (TAL)?

. > 3.0 mm
. > 5.0 mm
. > 6.9 mm
. > 9.0 mm
. > 11.5 mm

Correct Answer & Explanation

. > 3.0 mm

Explanation

The Rule of Spence dictates that on an open-mouth odontoid view, if the total combined lateral overhang of the C1 lateral masses on the C2 superior articular facets is greater than 6.9 mm, it strongly suggests incompetence or rupture of the transverse atlantal ligament (TAL), indicating instability. In the MRI era, TAL integrity is usually confirmed directly with high-resolution MRI.

Question 2664

Topic: 6. Spine

A 14-year-old gymnast presents with chronic low back pain. Radiographs (representative example shown below) demonstrate a Grade II isthmic spondylolisthesis at L5-S1.

Despite 6 months of nonoperative management, her pain persists and she has developed bilateral L5 radiculopathy. What is the most appropriate surgical treatment?

. L5-S1 anterior lumbar interbody fusion (ALIF) alone
. L5 laminectomy and pars repair (Buck's procedure)
. L5-S1 posterior decompression and instrumented posterolateral fusion
. L4-S1 posterior decompression and instrumented posterolateral fusion
. Sacroiliac fusion

Correct Answer & Explanation

. L5-S1 anterior lumbar interbody fusion (ALIF) alone

Explanation

For a symptomatic Grade II isthmic spondylolisthesis that has failed nonoperative management and is presenting with radiculopathy, the gold standard treatment is posterior decompression (e.g., Gill laminectomy to relieve the L5 nerve roots) and L5-S1 instrumented posterolateral fusion. Pars repair is generally reserved for Grade I slips or spondylolysis without a slip in young athletes.

Question 2665

Topic: 6. Spine

A 55-year-old male presents with worsening gait instability and fine motor dysfunction in his hands. MRI of the cervical spine demonstrates severe central canal stenosis at C4-C5 with T2-weighted hyperintensity in the spinal cord. Which of the following MRI findings is associated with the poorest prognosis for neurologic recovery after decompressive surgery?

. T2 hyperintensity that resolves on T1-weighted images
. Multilevel diffuse T2 hyperintensity
. Focal T2 hyperintensity with corresponding T1 hypointensity
. Loss of cervical lordosis without kyphosis
. Mild central canal stenosis at adjacent levels

Correct Answer & Explanation

. T2 hyperintensity that resolves on T1-weighted images

Explanation

In the setting of cervical spondylotic myelopathy (CSM), T2 hyperintensity within the spinal cord indicates edema, ischemia, or myelomalacia. The presence of a corresponding T1 hypointensity signifies cystic necrosis or permanent myelomalacia and is a strong negative prognostic indicator for neurologic recovery following surgical decompression.

Question 2666

Topic: Cervical Spine

An 82-year-old male presents to the emergency department after a ground-level fall. Imaging reveals a displaced Anderson D'Alonzo Type II odontoid fracture. His medical history is significant for severe COPD on home oxygen and congestive heart failure. He is neurologically intact. Which of the following is the most appropriate management strategy?

. Rigid cervical collar immobilization
. Halo vest immobilization
. Anterior odontoid screw fixation
. Posterior C1-C2 transarticular screw fixation
. Posterior C1-C2 fusion using the Harms technique

Correct Answer & Explanation

. Rigid cervical collar immobilization

Explanation

In the elderly population with severe medical comorbidities, the treatment of Type II odontoid fractures is challenging. Halo vest immobilization is generally contraindicated in this demographic due to unacceptably high rates of morbidity and mortality (e.g., pneumonia, pin site infections). While surgical fixation provides higher union rates, patients with severe cardiorespiratory disease are often poor surgical candidates. Immobilization in a rigid cervical collar is the treatment of choice in such cases; although the nonunion rate is high, the nonunions are typically stable and asymptomatic fibrous unions.

Question 2667

Topic: Thoracolumbar Spine & Deformity

A 14-year-old female competitive gymnast presents with progressive low back pain and hamstring tightness. Radiographs demonstrate a grade II L5-S1 isthmic spondylolisthesis. She has failed 6 months of comprehensive nonoperative management including physical therapy and bracing. What is the most appropriate surgical intervention?

. L5-S1 anterior lumbar interbody fusion (ALIF) alone
. L5 laminectomy without fusion
. L5-S1 posterior instrumented fusion
. L4-S1 posterior instrumented fusion
. L5-S1 artificial disc replacement

Correct Answer & Explanation

. L5-S1 anterior lumbar interbody fusion (ALIF) alone

Explanation

For a pediatric or adolescent patient with a symptomatic low-grade (Grade I or II) isthmic spondylolisthesis that has failed conservative treatment, an L5-S1 posterolateral fusion (with or without instrumentation) is the gold standard surgical treatment. Laminectomy alone is contraindicated in the pediatric population as it increases instability and the risk of further slip progression. ALIF alone or disc replacement is not indicated for this pathology in adolescents.

Question 2668

Topic: Thoracolumbar Spine & Deformity

A 45-year-old male sustains an L1 burst fracture after falling from a height. Neurological examination reveals normal motor and sensory function in the bilateral lower extremities, and normal rectal tone. CT imaging demonstrates a 40% loss of anterior vertebral body height, 15 degrees of local kyphosis, and 25% spinal canal compromise. MRI confirms that the posterior ligamentous complex (PLC) is completely intact. According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his total score and the generally recommended management?

. Score 2, nonoperative management
. Score 4, operative management
. Score 5, operative management
. Score 2, operative management
. Score 4, nonoperative management

Correct Answer & Explanation

. Score 2, nonoperative management

Explanation

The Thoracolumbar Injury Classification and Severity (TLICS) system is based on three categories: injury morphology, neurological status, and integrity of the posterior ligamentous complex (PLC). For this patient: Morphology is a burst fracture (2 points). Neurological status is intact (0 points). PLC is intact (0 points). The total score is 2. A TLICS score of 3 or less indicates nonoperative management (e.g., bracing or observation), a score of 4 is indeterminate (surgeon preference), and a score of 5 or more indicates operative intervention.

Question 2669

Topic: 6. Spine

A 52-year-old male presents with severe radicular pain radiating down his right arm to his middle finger. Neurological examination reveals weakness in elbow extension and wrist flexion. His triceps reflex is 1+ on the right and 2+ on the left. Biceps and brachioradialis reflexes are symmetric and 2+. He has decreased pinprick sensation over the volar aspect of his middle finger. Compression of which cervical nerve root is most likely responsible for these findings?

. C5
. C6
. C7
. C8
. T1

Correct Answer & Explanation

. C5

Explanation

The clinical presentation is classic for a C7 radiculopathy, typically caused by a C6-C7 disc herniation. The C7 nerve root supplies the triceps muscle (elbow extension) and contributes to wrist flexion and extension. The hallmark reflex change is a diminished triceps reflex. Sensory changes are characteristically found in the middle finger.

Question 2670

Topic: 6. Spine

A 40-year-old male presents with bilateral leg sciatica, perineal numbness, and new-onset urinary incontinence. An ultrasound bladder scan reveals a post-void residual of 400 mL. MRI confirms a massive L4-L5 central disc herniation severely compressing the thecal sac.

According to current literature, what is the generally accepted critical time threshold for emergent surgical decompression to optimize the chances of full neurologic recovery?

. Within 12 hours of symptom onset
. Within 48 hours of symptom onset
. Within 72 hours of symptom onset
. Within 1 week of symptom onset
. The timing of surgery has no documented correlation with neurologic outcome

Correct Answer & Explanation

. Within 12 hours of symptom onset

Explanation

Cauda equina syndrome is an orthopedic emergency. Meta-analyses and extensive clinical literature, most notably by Ahn et al., have demonstrated that surgical decompression performed within 48 hours of the onset of symptoms significantly improves the chances of recovering motor, sensory, and sphincter (bladder/bowel) function compared to decompression performed after 48 hours. While some advocate for even earlier intervention (e.g., <24 hours), 48 hours is the widely tested and accepted critical threshold in board examinations.

Question 2671

Topic: 6. Spine

A 55-year-old diabetic male with a history of intravenous drug use presents with severe, localized back pain, low-grade fever, and progressive bilateral lower extremity weakness. MRI reveals a dorsal fluid collection in the epidural space from T8 to T10, causing significant spinal cord compression. What is the most common causative organism for this pathology?

. Pseudomonas aeruginosa
. Streptococcus pneumoniae
. Staphylococcus aureus
. Mycobacterium tuberculosis
. Escherichia coli

Correct Answer & Explanation

. Pseudomonas aeruginosa

Explanation

The patient's presentation and imaging are classic for a spinal epidural abscess. Staphylococcus aureus is by far the most common causative organism, accounting for approximately two-thirds of all cases. Other less common pathogens include gram-negative bacilli (e.g., in IV drug users), coagulase-negative staphylococci, and mycobacteria, but S. aureus remains the predominant pathogen.

Question 2672

Topic: 6. Spine

A 70-year-old male presents with deteriorating handwriting, difficulty buttoning his shirts, and a progressive, unsteady, broad-based gait. On physical examination, the examiner supports the patient's hand and sharply flicks the volar aspect of the distal phalanx of the patient's middle finger. This maneuver immediately produces rapid, involuntary flexion of the thumb and index finger. What is the name of this clinical sign, and what neurologic localization does it indicate?

. Lhermitte's sign; indicates multiple sclerosis or dorsal column pathology
. Hoffmann's sign; indicates an upper motor neuron lesion in the cervical spine
. Inverted supinator reflex; indicates a lower motor neuron lesion at C5
. Babinski sign; indicates an isolated peripheral neuropathy
. Wartenberg's sign; indicates an ulnar nerve entrapment at the elbow

Correct Answer & Explanation

. Lhermitte's sign; indicates multiple sclerosis or dorsal column pathology

Explanation

The clinical scenario and the physical exam maneuver describe Hoffmann's sign. Elicited by flicking the nail of the middle finger, a positive sign is the reflexive flexion of the thumb and/or index finger. It is indicative of an upper motor neuron (UMN) lesion above the level of C5, such as in cervical spondylotic myelopathy, which aligns with his symptoms of clumsiness (myelopathic hand) and gait dysfunction.

Question 2673

Topic: 6. Spine

A 68-year-old female presents with progressive clumsiness in her hands and difficulty walking. Radiographs and MRI demonstrate severe cervical spondylosis from C3 to C6 with a rigid 20-degree cervical kyphosis and cord signal changes. Which of the following is the most appropriate surgical approach?

. Posterior cervical laminectomy and fusion
. Anterior cervical decompression and fusion (ACDF) or corpectomy
. Cervical laminoplasty
. Posterior cervical foraminotomies
. Standalone posterior interlaminar stabilization

Correct Answer & Explanation

. Posterior cervical laminectomy and fusion

Explanation

In the setting of cervical myelopathy with a rigid kyphotic deformity, an anterior approach is necessary to adequately decompress the spinal cord and correct the sagittal alignment. A posterior-only approach (laminectomy or laminoplasty) is contraindicated as the cord will remain draped over the anterior osteophytes in a rigid kyphotic spine.

Question 2674

Topic: 6. Spine

According to the Spine Patient Outcomes Research Trial (SPORT) data regarding the treatment of degenerative spondylolisthesis with spinal stenosis, which of the following statements is most accurate at 4-year follow-up?

. Nonoperative treatment is superior to surgery for pain relief.
. Surgical treatment shows a significant advantage in pain and function compared to nonoperative treatment.
. There is no difference in functional outcomes between the surgical and nonoperative cohorts.
. Patients undergoing decompression alone had superior outcomes to those undergoing decompression and fusion.
. Epidural steroid injections provided equivalent long-term relief to surgical decompression.

Correct Answer & Explanation

. Nonoperative treatment is superior to surgery for pain relief.

Explanation

The SPORT trial demonstrated that patients who underwent surgery for degenerative spondylolisthesis with spinal stenosis maintained significantly improved pain and function at 4 years compared to those treated nonoperatively.

Question 2675

Topic: 6. Spine

A 72-year-old male falls forward striking his face, causing a hyperextension injury to his neck. On examination, he has motor strength of 2/5 in his bilateral upper extremities and 4/5 in his bilateral lower extremities. What is his most likely diagnosis and overall prognosis for ambulation?

. Anterior cord syndrome; poor prognosis for ambulation
. Central cord syndrome; good prognosis for ambulation
. Brown-Sequard syndrome; excellent prognosis for ambulation
. Posterior cord syndrome; poor prognosis for ambulation
. Spinal shock; unpredictable prognosis

Correct Answer & Explanation

. Anterior cord syndrome; poor prognosis for ambulation

Explanation

The patient has Central Cord Syndrome, typically caused by hyperextension in a stenotic cervical spine, resulting in upper extremity weakness out of proportion to lower extremity weakness. Most patients (especially those who are younger or have milder deficits) recover enough lower extremity function to ambulate.

Question 2676

Topic: Cervical Spine

An 84-year-old male with multiple medical comorbidities sustains a Type II odontoid fracture after a ground-level fall. He is neurologically intact. Which of the following represents the most appropriate initial management strategy with the lowest risk of severe complications or mortality?

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

Correct Answer & Explanation

. Halo vest immobilization

Explanation

In the elderly population, halo vest immobilization is associated with unacceptably high morbidity and mortality. A rigid cervical collar is the preferred nonoperative treatment, prioritizing survival over bony union, as nonunion is frequently asymptomatic or well-tolerated.

Question 2677

Topic: 6. Spine

When evaluating a patient with a spinal metastasis using the Spinal Instability Neoplastic Score (SINS), which of the following clinical or radiographic features contributes the highest point value to the total score?

. Osteoblastic nature of the lesion
. Junctional location (e.g., occipitocervical, cervicothoracic)
. Presence of mechanical pain with movement
. Spinal alignment abnormality (e.g., new kyphosis)
. Involvement of the posterior elements

Correct Answer & Explanation

. Osteoblastic nature of the lesion

Explanation

In the SINS criteria, a spinal alignment abnormality (such as a new deformity, kyphosis, or translation) contributes the maximum of 4 points. Mechanical pain contributes 3 points, and a junctional location contributes 3 points.

Question 2678

Topic: 6. Spine

A 50-year-old male with a history of intravenous drug use presents with severe lumbar back pain, fevers, and new-onset bilateral lower extremity weakness that has rapidly progressed over the last 6 hours. MRI reveals a ventral epidural abscess from L3 to L5 causing severe thecal sac compression. What is the most appropriate definitive management?

. CT-guided aspiration and targeted intravenous antibiotics for 6 weeks
. Immediate initiation of broad-spectrum IV antibiotics and observation
. Emergent surgical decompression and culture-specific IV antibiotics
. High-dose intravenous corticosteroids
. Placement of a lumbar drain

Correct Answer & Explanation

. CT-guided aspiration and targeted intravenous antibiotics for 6 weeks

Explanation

A spinal epidural abscess presenting with an acute, progressive neurologic deficit is a surgical emergency. Emergent surgical decompression is required to prevent irreversible neurologic injury, followed by long-term intravenous antibiotics.

Question 2679

Topic: 6. Spine

A 65-year-old male presents with severe cervical spondylotic myelopathy and a rigid cervical kyphosis. Surgical planning is undertaken for a posterior cervical fusion. To achieve optimal sagittal alignment and minimize adjacent segment disease, which of the following spinopelvic parameters is most critical to restore?

. T1 slope minus cervical lordosis (T1S - CL) < 15 degrees
. Cervical sagittal vertical axis (cSVA) < 4 cm
. Pelvic incidence minus lumbar lordosis (PI - LL) < 10 degrees
. Thoracic kyphosis (TK) < 40 degrees
. C2-C7 plumb line offset < 2 cm

Correct Answer & Explanation

. T1 slope minus cervical lordosis (T1S - CL) < 15 degrees

Explanation

In cervical deformity correction, achieving a T1 slope minus cervical lordosis (T1S - CL) mismatch of less than 15-20 degrees correlates with improved health-related quality of life. This parameter is analogous to the PI-LL mismatch in the lumbar spine.

Question 2680

Topic: 6. Spine

A 45-year-old male presents with acute onset weakness in ankle dorsiflexion and numbness over the dorsal web space of his first and second toes. MRI demonstrates a large, extruded disc herniation in the far-lateral (extraforaminal) zone at the L4-L5 level. Which nerve root is most likely compressed?

. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L3

Explanation

In the lumbar spine, far-lateral (extraforaminal) disc herniations compress the exiting nerve root at that level. An L4-L5 far-lateral disc herniation compresses the L4 nerve root, unlike paracentral herniations which compress the traversing L5 root.

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