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6. Spine MCQs

Practice Set 136 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 2701

Topic: 6. Spine
A 39-year-old man reports low back pain, lower extremity numbness, and urinary retention after being injured in a motor vehicle accident 1 day ago. He is able to walk but is in pain. A straight leg raise results in increased back pain, and examination reveals that perianal sensation is decreased. Placement of a urinary catheter results in 500 mL of urine. What is the next most appropriate step in management?
. Emergent MRI
. Urology consultation
. Pain control with narcotics
. Pain control with a lumbar epidural steroid injection
. Physical therapy

Correct Answer & Explanation

. Emergent MRI

Explanation

Acute cauda equina syndrome, including saddle hypesthesia and bowel/bladder incontinence, is a red flag that demands emergent evaluation with MRI and urgent surgery if compression is confirmed. Results appear to be improved if surgery is performed within 48 hours. The other treatment approaches listed are not indicated if a cauda equina syndrome is present.

Question 2702

Topic: 6. Spine

What gene is implicated in spinal muscular atrophy? Review Topic

. Survival motor neuron I (SMN-I)
. Peripheral myelin protein 22 (PMP22)
. Dystrophin
. Androgen receptor

Correct Answer & Explanation

. Survival motor neuron I (SMN-I)

Explanation

Deletions in the SMN-I gene are found in 95% to 98% of patients with spinal muscular atrophy. Genetic testing is typically part of the diagnostic workup for spinal muscular atrophy. A positive test result is diagnostic, and, in most cases, eliminates the need for muscle biopsy. The other choices are not associated with spinal muscular atrophy. Defects in PMP22 are the cause of 70% to 80% of cases of Charcot-Marie-Tooth disease. Mutations in the dystrophin gene cause Duchenne muscular dystrophy, and mutations in the androgen receptor cause spinobulbar muscular atrophy (Kennedy's disease).

Question 2703

Topic: 6. Spine
When 6 weeks of noninvasive nonsurgical management fails to provide relief for a lumbar disk herniation, a trial of epidural steroid injections is likely to yield which of the following results?
. Eighty percent to ninety percent of patients report rapid and long-lasting relief of symptoms.
. Patients with extruded disk herniations report greater relief of symptoms than patients with contained herniations.
. Patients with less hydrated disk herniations report the most rapid relief of symptoms.
. Patients may experience temporary relief that lasts a maximum of 6 months.
. The percentage of patients who report significant improvement is similar to that of patients undergoing diskectomy.

Correct Answer & Explanation

. Patients with extruded disk herniations report greater relief of symptoms than patients with contained herniations.

Explanation

Lumbar epidural steroid injections appear to play a role in management of a lumbar disk herniation that has failed to respond to at least 6 weeks of nonsurgical treatment. Approximately 42% to 56% of patients report significant pain relief compared with 92% to 98% of those patients treated with diskectomy. Patients with extruded or sequestered herniations report the greatest and most rapid relief. Similarly, those with well-hydrated disk fragments report rapid relief of symptoms. A smaller percentage of patients report symptom relief compared with those having surgery, but the degree of improvement is similar for both groups and the improvement lasts up to 3 years.

Question 2704

Topic: 6. Spine
Examination of a supine patient in which the hip is abducted, externally rotated, and flexed is referred to as
. Beevor’s sign
. Lasegue’s sign
. Kernig’s sign
. Femoral stretch test
. Patrick’s test

Correct Answer & Explanation

. Patrick’s test

Explanation

During Patrick’s test, also known as the FABER test, the flexed, abducted, and externally rotated hip is positioned to isolate sacroiliac pathology. Back pain with this test is not considered diagnostic. With Kernig’s sign, the spinal cord is placed on stretch, eliciting root or meningeal irritation by forcibly flexing the patient’s head and neck with his or her hands clasped behind the head. For Lasegue’s sign, the patient performs a straight leg raise with the immobile hip already held in flexion. The femoral stretch test can be performed in the prone position or side lying, but the hip is held in extension while the knee is flexed, testing for femoral neuritis.

Question 2705

Topic: 6. Spine

A patient undergoes anterior spinal decompression through a left retroperitoneal approach as treatment of an L2 burst fracture. Following surgery, examination reveals the temperature of the right foot is cool when compared with the left foot. Which of the following neurologic structures has most likely been disrupted?

. Cauda equina
. Conus medullaris
. Genitofemoral nerve
. Lumbar sympathetic plexus
. Lumbar parasympathetic plexus

Correct Answer & Explanation

. Lumbar sympathetic plexus

Explanation

Chapter 6, p. 240: “The sympathetic chain lies in the lateral aspect of the vertebral body and on the most medial aspect of the psoas muscle. It is easy to identify as the tissue is cleared from the front of the vertebrae.”Chapter 60, p. 777: “[After sympathetic denervation], at first the blood flow rises markedly because of lost vascular tone, but over a period of says to weeks the blood flow returns to almost normal because of progressive increase tone of the vascular musculature itself, thus compensating for the loss of sympathetic tone.”

Question 2706

Topic: 6. Spine
The use of nasotracheal intubation for airway management is contraindicated in the acute multiply injured patient when the patient has
. suspected cervical spine trauma.
. head injuries and spontaneous respirations.
. respiratory arrest.
. a need for prolonged ventilatory support.
. a hemopneumothorax.

Correct Answer & Explanation

. respiratory arrest.

Explanation

The use of nasotracheal intubation is less desirable in patients with respiratory arrest because placement of the tube is most reliable when the patient is breathing. Nasotracheal intubation is advantageous in patients with suspected cervical spine trauma because it does not require hyperextension of the neck. A nasotracheal tube may be more comfortable than an orally placed tube because it is fixed at several points and moves less freely within the larynx, subglottic area, and trachea. The presence of a hemothorax or pneumothorax does not affect the choice of airway control but does require placement of a chest tube.

Question 2707

Topic: 6. Spine
If additional posterior spinal surgery is performed to allow the patient to stand erect, the surgeon will need to advise the family about the risks of the procedure. In addition to risk for neurologic injury, what is the most likely complication?
. Substantial blood loss
. Cerebral vascular accident
. Degeneration of sacroiliac joints
. Cervical spine stenosis

Correct Answer & Explanation

. Substantial blood loss

Explanation

This case starts as standard degenerative spondylolisthesis but develops into a sagittal imbalance problem necessitating a major spinal procedure including a pedicle subtraction osteotomy and extended posterior spinal instrumentation. Three-column osteotomies are associated with increased risk for neurologic injury and substantial blood loss.

Question 2708

Topic: Cervical Spine

Biomechanical studies evaluating the distal tibiofibular syndesmosis have determined the relative contributions of its ligamentous components. Which of the following anatomical structures provides the greatest resistance to lateral displacement of the fibula?

. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Interosseous ligament
. Inferior transverse ligament
. Deltoid ligament

Correct Answer & Explanation

. Posterior inferior tibiofibular ligament (PITFL)

Explanation

The posterior inferior tibiofibular ligament (PITFL) is the strongest component of the syndesmotic complex and provides the greatest resistance (approximately 42%) to lateral displacement of the fibula. This is followed by the AITFL (35%) and the interosseous ligament (22%).

Question 2709

Topic: 6. Spine
A 23-year-old man is involved in a motor vehicle accident. An AP radiograph is shown in Figure 29a, and axial and sagittal CT scans are shown in Figures 29b and 29c. Neurologic examination shows 1/5 strength of his quadriceps and iliopsoas on the right, with 1/5 quadriceps function on the left. Definitive treatment of his injury should consist of
. anterior corpectomy with interbody strut.
. posterior fusion with instrumentation and posterolateral decompression.
. closed reduction and a thoracolumbosacral orthosis (TLSO).
. anterior reduction and instrumentation.
. supine bed rest for 6 weeks, followed by immobilization in a TLSO.

Correct Answer & Explanation

. posterior fusion with instrumentation and posterolateral decompression.

Explanation

The imaging studies show a fracture-dislocation. Surgical treatment of this injury consists of a decompression reduction, stabilization, and fusion. A posterolateral decompression can also be performed as necessary. An isolated anterior procedure in this type of injury is contraindicated. The anterior longitudinal ligament is most likely intact; therefore, an anterior procedure further destabilizes the spine. Reduction by an anterior approach would also be difficult. Nonsurgical management of the neurologic injury in this patient is not indicated.

Question 2710

Topic: 6. Spine
In the Levine-Edwards classification of traumatic spondylolisthesis of the axis (Hangman's fracture), which fracture type is strictly contraindicated for the use of cervical traction?
. Type I
. Type II
. Type IIA
. Type III
. Type IV

Correct Answer & Explanation

. Type IIA

Explanation

Type IIA fractures are characterized by severe angulation with minimal translation and are caused by flexion-distraction injuries. Application of cervical traction can exacerbate the injury by over-distracting the fracture site, risking iatrogenic spinal cord injury.

Question 2711

Topic: 6. Spine

A 65-year-old male with long-standing ankylosing spondylitis presents to the emergency department after a low-energy ground-level fall. He complains of severe lower neck pain but has no focal neurological deficits. Initial plain radiographs of the cervical spine are unremarkable. What is the most appropriate next step in management?

. Discharge with a soft cervical collar and outpatient follow-up
. CT scan or MRI of the entire cervical and upper thoracic spine
. Flexion-extension cervical radiographs to assess stability
. Electromyography to rule out subclinical radiculopathy
. Reassurance, NSAIDs, and physical therapy

Correct Answer & Explanation

. CT scan or MRI of the entire cervical and upper thoracic spine

Explanation

Patients with ankylosing spondylitis are at high risk for highly unstable, transcortical or transdiscal spinal fractures even after minor trauma. Because these fractures are easily obscured by abnormal anatomy on plain radiographs, advanced imaging (CT or MRI) is mandatory.

Question 2712

Topic: Cervical Spine

An 82-year-old male presents with severe neck pain following a fall. CT demonstrates a Type II odontoid fracture with 4 mm of posterior displacement. He is neurologically intact and lives independently. What is the most significant advantage of posterior C1-C2 segmental instrumentation compared to halo-vest immobilization in this patient?

. Lower initial perioperative morbidity
. Decreased risk of long-term dysphagia
. Higher rate of fracture union and lower long-term mortality
. Preservation of normal atlantoaxial rotation
. Shorter overall hospital length of stay

Correct Answer & Explanation

. Higher rate of fracture union and lower long-term mortality

Explanation

In elderly patients with Type II odontoid fractures, halo-vest immobilization is associated with high respiratory morbidity and high mortality. Surgical stabilization (e.g., C1-C2 posterior fusion) significantly improves union rates and decreases long-term mortality despite higher initial surgical risks.

Question 2713

Topic: Cervical Spine

A 25-year-old man sustains a C1 ring fracture after diving into a shallow pool. An open-mouth odontoid radiograph is obtained. According to the Rule of Spence, a sum of lateral mass displacement greater than 6.9 mm strongly implies an incompetent or ruptured injury to which of the following structures?

. Alar ligament
. Transverse ligament
. Apical ligament
. Tectorial membrane
. Posterior atlantooccipital membrane

Correct Answer & Explanation

. Transverse ligament

Explanation

A combined lateral mass overhang of more than 6.9 mm on an open-mouth view implies a rupture of the transverse ligament. This marks the fracture as an unstable injury pattern often requiring halo immobilization or surgical fusion.

Question 2714

Topic: 6. Spine

A 55-year-old intravenous drug user presents with fever, severe thoracic back pain, and progressive paraparesis over 48 hours. MRI reveals extensive discitis/osteomyelitis at T7-T8 with a large ventral epidural abscess causing severe spinal cord compression and localized kyphosis. What is the most likely causative organism and the optimal initial surgical approach?

. Staphylococcus aureus / Posterior laminectomy
. Staphylococcus aureus / Anterior corpectomy and fusion
. Pseudomonas aeruginosa / Posterior laminectomy
. Escherichia coli / Anterior corpectomy and fusion
. Staphylococcus epidermidis / Posterior spinal fusion without decompression

Correct Answer & Explanation

. Staphylococcus aureus / Anterior corpectomy and fusion

Explanation

S. aureus is the most common cause of spinal epidural abscesses. When accompanied by ventral cord compression and kyphosis from osteomyelitis/discitis, an anterior approach (corpectomy and fusion) is preferred to adequately decompress the cord and provide structural support.

Question 2715

Topic: 6. Spine

A 19-year-old restrained passenger in a high-speed motor vehicle collision sustains a flexion-distraction injury (Chance fracture) of the L2 vertebra. Based on the mechanism of injury, this patient is at highest risk for which of the following associated conditions?

. Splenic rupture
. Hollow viscus injury
. Hepatic laceration
. Renal contusion
. Aortic transection

Correct Answer & Explanation

. Hollow viscus injury

Explanation

Chance fractures typically occur via a seatbelt mechanism, causing severe flexion and distraction. They are highly associated with intra-abdominal injuries, particularly hollow viscus injuries (bowel rupture) in up to 40-50% of cases.

Question 2716

Topic: Thoracolumbar Spine & Deformity

A 14-year-old boy presents with progressive thoracic back pain and a visible rounding of his upper back. Standing lateral radiographs are obtained to evaluate for Scheuermann kyphosis. According to the classic Sorensen criteria, radiographic confirmation of this diagnosis requires anterior wedging of at least what magnitude, involving how many consecutive vertebrae?

. 5 degrees in at least 3 consecutive vertebrae
. 10 degrees in at least 2 consecutive vertebrae
. 10 degrees in at least 3 consecutive vertebrae
. 15 degrees in at least 2 consecutive vertebrae
. 5 degrees in at least 4 consecutive vertebrae

Correct Answer & Explanation

. 5 degrees in at least 3 consecutive vertebrae

Explanation

The Sorensen criteria for diagnosing Scheuermann kyphosis define the condition radiographically by the presence of anterior wedging of 5 degrees or more in at least 3 consecutive thoracic vertebrae.

Question 2717

Topic: 6. Spine

A 45-year-old man with a history of recurrent low back pain presents to the emergency department with acute worsening of his symptoms, radiating down both legs. Which of the following clinical findings is the most sensitive early clinical indicator of cauda equina syndrome?

. Bilateral lower extremity weakness
. Saddle anesthesia
. Urinary retention
. Fecal incontinence
. Loss of the Achilles reflex

Correct Answer & Explanation

. Urinary retention

Explanation

Urinary retention is the most sensitive symptom (approaching 90%) for true cauda equina syndrome. Postvoid residual volumes > 100-200 mL can help confirm this diagnosis prior to definitive MRI.

Question 2718

Topic: 6. Spine
A 38-year-old construction worker sustains a pelvic crush injury resulting in a sacral fracture. CT scan characterizes the fracture as Denis Zone III. This specific zone of injury is most strongly associated with which of the following complications?
. L5 nerve root traction injury
. High rate of hypertrophic nonunion
. Bowel and bladder dysfunction
. Isolated S1 radiculopathy
. Sciatic nerve transection

Correct Answer & Explanation

. Bowel and bladder dysfunction

Explanation

Denis Zone III sacral fractures involve the central sacral canal. Because they disrupt the sacral nerve roots bilaterally within the canal, they have the highest incidence of severe neurologic compromise, including bowel and bladder dysfunction (cauda equina injury).

Question 2719

Topic: 6. Spine

An 82-year-old man with a long-standing history of ankylosing spondylitis presents to the emergency department complaining of severe neck pain after tripping on a rug. Initial plain AP and lateral radiographs of the cervical spine demonstrate extensive syndesmophytes but no obvious fracture. Neurological exam is intact. What is the most appropriate next step in management?

. Discharge with a short course of NSAIDs
. Perform flexion-extension cervical radiographs
. Obtain a CT scan of the cervical spine
. Apply a soft cervical collar and arrange follow-up
. Refer for immediate outpatient physical therapy

Correct Answer & Explanation

. Obtain a CT scan of the cervical spine

Explanation

Patients with ankylosing spondylitis have rigidly fused, brittle spines highly susceptible to occult fractures even from low-energy trauma. A CT scan of the cervical spine is mandatory in these patients complaining of neck pain, as plain radiographs are notoriously difficult to interpret and often miss fractures.

Question 2720

Topic: 6. Spine

A 68-year-old woman presents with bilateral lower extremity pain and cramping that worsens with walking. You are attempting to differentiate between neurogenic and vascular claudication. Which of the following historical features is highly characteristic of neurogenic claudication?

. Pain is immediately relieved upon simply standing still
. Symptom onset is highly consistent at exact walking distances
. Pain is rapidly exacerbated when walking uphill
. Pain is significantly relieved by lumbar flexion, such as leaning on a shopping cart
. Associated symptoms include pale, cool extremities

Correct Answer & Explanation

. Pain is significantly relieved by lumbar flexion, such as leaning on a shopping cart

Explanation

Neurogenic claudication (due to lumbar spinal stenosis) is classically relieved by lumbar flexion (e.g., sitting, leaning forward on a shopping cart), which increases the cross-sectional area of the spinal canal. Relief with simply standing still or worsened symptoms walking uphill are typical of vascular claudication.

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