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6. Spine MCQs

Practice Set 137 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 2721

Topic: 6. Spine

A 70-year-old man presents with profound back stiffness. Radiographs show confluent, flowing ossification along the anterolateral aspect of the thoracic and lumbar spine. To radiographically differentiate diffuse idiopathic skeletal hyperostosis (DISH) from ankylosing spondylitis, the clinician should look for which of the following characteristic features of DISH?

. Marginal syndesmophytes bridging the vertebrae
. Erosive changes and early fusion of the sacroiliac joints
. Relative preservation of the intervertebral disc spaces
. Bamboo spine appearance with uniform bilateral ossification
. Presence of classic Romanus lesions (squaring of vertebrae)

Correct Answer & Explanation

. Relative preservation of the intervertebral disc spaces

Explanation

DISH is characterized by flowing anterolateral ossification across at least four contiguous vertebrae with relative preservation of the intervertebral disc heights. Unlike ankylosing spondylitis, DISH lacks severe sacroiliac joint erosions and marginal syndesmophytes.

Question 2722

Topic: 6. Spine

A 45-year-old woman presents with severe right-sided neck pain radiating down her arm. Physical examination reveals weakness in wrist flexion and finger extension, a diminished triceps reflex, and decreased sensation over the dorsal aspect of the middle finger. Which cervical nerve root is most likely compressed?

. C5
. C6
. C7
. C8
. T1

Correct Answer & Explanation

. C7

Explanation

A C7 radiculopathy is characterized by weakness in the triceps (elbow extension), wrist flexors, and finger extensors. It presents with a diminished triceps reflex and sensory deficits over the middle finger.

Question 2723

Topic: 6. Spine

A 55-year-old diabetic patient presents with severe back pain, fevers, progressive bilateral lower extremity weakness, and urinary retention. MRI reveals a large ventral fluid collection with peripheral enhancement in the lumbar epidural space. What is the most likely causative organism and the optimal immediate management?

. Mycobacterium tuberculosis; immediate commencement of RIPE therapy
. Staphylococcus aureus; emergent surgical decompression and culture
. Streptococcus pneumoniae; IV ceftriaxone and dexamethasone
. Pseudomonas aeruginosa; CT-guided aspiration and targeted antibiotics
. Staphylococcus epidermidis; trial of IV vancomycin with serial exams

Correct Answer & Explanation

. Staphylococcus aureus; emergent surgical decompression and culture

Explanation

Staphylococcus aureus is the most common causative organism of spinal epidural abscesses. The presence of progressive neurologic deficits, including cauda equina syndrome, mandates emergent surgical decompression.

Question 2724

Topic: 6. Spine

In the evaluation of a patient with a neurologically intact L1 burst fracture, which of the following MRI findings most strongly dictates the need for surgical stabilization over nonoperative management?

. Loss of vertebral body height greater than 30%
. Retropulsion of bone occupying 40% of the spinal canal
. Edema and disruption of the interspinous ligaments and ligamentum flavum
. Kyphotic angulation of 15 degrees
. Bilateral laminar fractures

Correct Answer & Explanation

. Edema and disruption of the interspinous ligaments and ligamentum flavum

Explanation

Disruption of the posterior ligamentous complex (PLC) renders the spine mechanically unstable and is the strongest indication for surgical stabilization. Under the Thoracolumbar Injury Classification and Severity (TLICS) score, PLC disruption alone scores 3 points, tipping a burst fracture into a surgical recommendation.

Question 2725

Topic: 6. Spine

A 72-year-old man with a known history of diffuse idiopathic skeletal hyperostosis (DISH) presents after a minor mechanical fall with moderate mid-back pain. His neurologic examination is normal, and initial plain radiographs of the thoracic spine are interpreted as negative. What is the most appropriate next step?

. Discharge with NSAIDs and outpatient physical therapy
. Fit the patient with a Jewett brace and arrange follow-up in 2 weeks
. Perform a bone scan to identify occult inflammatory lesions
. Obtain a CT scan of the entire spine to rule out an occult fracture
. Administer a tapering dose of oral corticosteroids

Correct Answer & Explanation

. Obtain a CT scan of the entire spine to rule out an occult fracture

Explanation

Patients with ankylosing spinal conditions like DISH are highly susceptible to unstable extension-type fractures from even minor trauma. Because plain radiographs frequently miss these fractures, a CT scan of the entire spine is mandatory.

Question 2726

Topic: 6. Spine

An 80-year-old man who was involved in a fall from ground height is evaluated in the emergency department for head lacerations and mild neck pain. Examination reveals only mild tenderness of the posterior neck region with some limitation of motion. Neurologic examination is normal. Radiographs of the cervical spine are shown in Figures 58a and 58b. What is the next most appropriate step in management for this patient? Review Topic

. Admission for 24-hour observation for possible intracranial hematoma
. Discharge with a soft collar and follow-up in 24 hours
. CT of the cervical spine
. Repeat radiographs of the cervical spine, including flexion and extension views
. Hard cervical collar for 6 weeks

Correct Answer & Explanation

. CT of the cervical spine

Explanation

The patient has radiographic findings compatible with diffuse idiopathic skeletal hyperostosis (DISH) of the cervical spine. Characteristics of DISH include flowing, non-marginal osteophytes at four or more levels. Patients with DISH develop a significant loss of flexibility of the spine. The spine acts more as a long bone with minimal force needed to create unstable fractures. Any minor trauma in patients with DISH should be worked up aggressively to rule out occult fracture. In this patient, radiographs fail to clearly rule out a fracture; therefore, CT of the cervical spine is indicated. Without a suspicion of history of a head injury, admission specifically for a possible intracranial hematoma is not warranted. The more concerning injury in a patient with DISH is occult neck fracture. Treatment with a soft or hard collar is not advised until a fracture is ruled out. Repeat radiographs are unlikely to show any occult fractures, and flexion and extension views would not be advised in a patient with a suspected vertebral fracture.

Question 2727

Topic: 6. Spine

A 60-year-old diabetic male presents with severe back pain, fever, and progressive lower extremity weakness over 48 hours. MRI reveals a spinal epidural abscess. What is the most common route of bacterial entry and the most common causative organism?

. Direct contiguous spread ; Staphylococcus epidermidis
. Hematogenous dissemination ; Staphylococcus aureus
. Direct contiguous spread ; Pseudomonas aeruginosa
. Hematogenous dissemination ; Streptococcus pneumoniae
. Iatrogenic inoculation ; Cutibacterium acnes

Correct Answer & Explanation

. Hematogenous dissemination ; Staphylococcus aureus

Explanation

The most common route of infection for a spinal epidural abscess is hematogenous dissemination from a distant primary source (such as skin, soft tissue, or the urinary tract). The most commonly isolated organism is Staphylococcus aureus, accounting for over 60% of these infections.

Question 2728

Topic: 6. Spine

A 58-year-old man presents to the clinic with 9 months of progressive right lower extremity pain. Over the past 4 months, he also notes a decreased ability to walk long distances due to pain, which is relieved by sitting down. Figure A and B

. Surgical management will lead to more improvement in pain but not function
. Surgical management will have higher 4-year mortality
. Surgical management will lead to more improvement in pain, function, and satisfaction
. Nonsurgical management will lead to more improvement in pain but not function
. Surgical management will lead more improvement in function, but less improvement in pain

Correct Answer & Explanation

. Surgical management will lead to more improvement in pain, function, and satisfaction

Explanation

The clinical presentation is consistent with lumbar stenosis. At 4 years, surgical management is expected to result in more improvement in pain, function, satisfaction than nonoperative management.Surgical management of lumbar stenosis typically consists of wide pedicle to pedicle decompression at the affected levels. Instrumention and fusion may be indicated if there is evidence of instability. Nonsurgical management typically involves oral medications, physical therapy, and corticosteroid injectionsWeinstein et al. (2010, 2008), as part of the SPORT trial, found that surgical management of symptomatic lumbar stenosis with decompressive laminectomy resulted in greater improvement in pain, function, and satisfaction as compared to nonsurgical management. These advantages were maintained at both two and four years of follow up.Figure A is a T2 sagittal MRI showing lumbar spinal stenosis from L1-L5, most prominent from L3-L5. Figure B is a T2 axial MRI showing severe stenosis at L4-L5 secondary to ligamentum flavum hypertrophy and facet arthropathy. Illustration A is an example of a one-level decompressive laminectomy.Incorrect Answers:mortality.

Question 2729

Topic: 6. Spine
A 45-year-old man seen in the emergency department reports a 1-week history of worsening low back pain and a progressive neurologic deficit in the S1 distribution. Examination reveals 2/5 strength in the gastrocnemius. Laboratory studies show a WBC count of 13,500/mm³ and an erythrocyte sedimentation rate of 74 mm/h. Radiographs of the lumbosacral spine show narrowing of the L5-S1 disk space, with irregularity of the end plates. A sagittal T2-weighted MRI scan is shown in Figure 8. Definitive management should consist of:
. physical therapy that includes a program of centralization of his leg pain.
. a thoracolumbosacral brace to include one thigh.
. L5-S1 laminectomy.
. interbody cage fusion with allograft bone.
. anterior debridement and decompression with posterior stabilization.

Correct Answer & Explanation

. anterior debridement and decompression with posterior stabilization.

Explanation

DISCUSSION: The history, physical examination, laboratory, and radiographic findings are most consistent with an infectious process. When there are signs of neurologic compromise, surgery is generally recommended. This is an anterior process, and anterior column debridement is necessary, followed by stabilization. Anterior or posterior stabilization is a reasonable option, but posterior decompression alone is unlikely to adequately reverse the process and may lead to segmental kyphosis.

Question 2730

Topic: 6. Spine
A 65-year-old male presents with profound upper extremity weakness and mild lower extremity weakness after a hyperextension injury to his cervical spine. He has no cortical sensory loss but complains of burning pain in his hands. According to recent literature evaluating acute central cord syndrome without frank mechanical instability, what is the optimal timing and role of surgical decompression?
. Emergent surgery within 4 hours is mandatory to prevent permanent quadriplegia
. Early surgery within 24 hours is associated with improved motor recovery compared to delayed surgery
. Conservative management only, as surgery has not shown any long-term clinical benefit
. Surgery should be routinely delayed for 4 weeks to allow acute spinal cord edema to resolve
. High-dose methylprednisolone followed by surgical decompression at 7 days

Correct Answer & Explanation

. Early surgery within 24 hours is associated with improved motor recovery compared to delayed surgery

Explanation

Historically, acute central cord syndrome was managed non-operatively or with delayed surgery to allow cord edema to subside. However, recent studies and subset analyses of trials (such as STASCIS) have shown that early surgical decompression (within 24 hours) in patients with acute central cord syndrome and focal compression is safe and yields significantly improved ASIA motor scores and functional outcomes compared to delayed surgery or conservative care.

Question 2731

Topic: Cervical Spine

A 25-year-old male sustains a Type IIA odontoid fracture (transverse fracture comminuted at the base) following a high-speed collision. Which of the following conditions represents an absolute contraindication to anterior odontoid screw fixation?

. Concomitant anterior arch fracture of C1
. Displacement of the odontoid greater than 2 mm
. Associated rupture of the transverse atlantal ligament
. Concomitant fracture of the C2 spinous process
. Fracture gap less than 1 mm

Correct Answer & Explanation

. Associated rupture of the transverse atlantal ligament

Explanation

Anterior odontoid screw fixation requires an intact transverse atlantal ligament to maintain C1-C2 stability after the dens is fixed. If the transverse ligament is ruptured, the C1 ring can still translate anteriorly on C2 even if the odontoid fracture heals, leading to persistent atlantoaxial instability. Therefore, an associated transverse ligament rupture is an absolute contraindication to anterior screw fixation; a posterior C1-C2 instrumented fusion is required.

Question 2732

Topic: Thoracolumbar Spine & Deformity

A 40-year-old male falls from a height of 10 feet, sustaining an L1 burst fracture. He is neurologically intact on presentation. A subsequent MRI demonstrates an intact posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his total score and the generally recommended management?

. Score 2, non-operative management
. Score 3, non-operative management
. Score 4, operative or non-operative management
. Score 5, operative management
. Score 6, operative management

Correct Answer & Explanation

. Score 2, non-operative management

Explanation

The TLICS system assigns points based on three categories: injury morphology, neurologic status, and integrity of the posterior ligamentous complex (PLC). Burst fracture morphology = 2 points. Neurologically intact = 0 points. Intact PLC = 0 points. Total score = 2. A score of 3 or less is an indication for non-operative management, a score of 4 is equivocal, and 5 or more indicates operative intervention.

Question 2733

Topic: 6. Spine

A 30-year-old female is brought to the emergency department after a motor vehicle collision. She is awake, fully alert, and cooperative. Examination reveals an isolated C6 motor weakness. Radiographs demonstrate a unilateral C5-C6 facet dislocation. What is the most appropriate next step in her management?

. Immediate MRI of the cervical spine before any reduction attempt
. Immediate closed reduction using cervical traction under vigilant neurologic monitoring
. Emergent anterior cervical discectomy and fusion without attempted closed reduction
. Emergent posterior cervical fusion without attempted closed reduction
. Application of a halo vest in situ

Correct Answer & Explanation

. Immediate closed reduction using cervical traction under vigilant neurologic monitoring

Explanation

In an awake, alert, and cooperative patient with a cervical facet dislocation, rapid closed reduction with cranial traction is indicated and considered safe. Continuous clinical neurologic monitoring is essential. MRI is not required prior to closed reduction in this specific clinical scenario, as delayed reduction increases the risk of permanent neurologic deficit. MRI prior to reduction is required if the patient is obtunded or fails closed reduction.

Question 2734

Topic: 6. Spine

A 12-year-old boy, who was wearing only a lap-belt in the back seat of a car during a high-speed collision, presents with severe mid-back pain. Radiographs demonstrate a flexion-distraction injury (Chance fracture) at the L2 level. Which of the following concomitant injuries is classically associated with this mechanism and must be rigorously ruled out?

. Traumatic aortic transection
. Renal artery thrombosis
. Intra-abdominal hollow viscus injury
. Massive pulmonary contusion
. Traumatic diaphragmatic rupture

Correct Answer & Explanation

. Intra-abdominal hollow viscus injury

Explanation

A Chance fracture is a flexion-distraction injury of the spine, classically seen in patients restrained by a lap-belt during a sudden deceleration. The fulcrum of flexion is anterior to the spine (at the abdominal wall), causing severe distraction forces across the posterior and middle columns. This specific mechanism is highly associated with concomitant intra-abdominal injuries, most notably bowel rupture or other hollow viscus injuries (seen in up to 40-50% of cases).

Question 2735

Topic: 6. Spine

An 82-year-old male sustains a hyperextension injury to his cervical spine after a fall. Examination reveals 2/5 motor strength in his bilateral upper extremities and 4/5 motor strength in his lower extremities. Proprioception and pain sensation are intact but diminished. What is the most likely prognosis for his motor recovery?

. Hand dexterity will recover fully in over 90% of cases
. Lower extremities will recover first, followed by bowel/bladder function
. Ambulatory recovery is rare and requires early surgical decompression
. Upper extremities will recover before lower extremities
. Bowel and bladder function is permanently lost in the majority of patients

Correct Answer & Explanation

. Lower extremities will recover first, followed by bowel/bladder function

Explanation

This patient has Central Cord Syndrome, characterized by upper extremity weakness that is disproportionately greater than lower extremity weakness. The typical sequence of neurological recovery is lower extremity function first (most regain ambulation), followed by bowel and bladder control, then proximal upper extremity function, and lastly (often incompletely) fine intrinsic hand dexterity.

Question 2736

Topic: Cervical Spine

An 85-year-old female presents with a Type II odontoid fracture displaced 3 mm posteriorly after a ground-level fall. She has significant medical comorbidities. She is neurologically intact. What is the most appropriate initial management?

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

Correct Answer & Explanation

. Rigid cervical collar immobilization

Explanation

In elderly patients (especially those >80 years old) with Type II odontoid fractures, halo vest immobilization is associated with high morbidity and mortality (up to 40%). Surgical intervention carries significant perioperative risks. Current evidence supports rigid cervical collar immobilization as the initial treatment of choice; although the nonunion rate is high, fibrous nonunions are typically stable and asymptomatic in this demographic.

Question 2737

Topic: Thoracolumbar Spine & Deformity

A 30-year-old male falls from a roof and sustains a T12 burst fracture. He is neurologically intact with no focal deficits. An MRI is obtained, which demonstrates an intact posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his total score and recommended treatment?

. Score 4; surgical intervention recommended
. Score 2; non-operative treatment recommended
. Score 5; surgical intervention recommended
. Score 2; surgical intervention recommended
. Score 7; surgical intervention recommended

Correct Answer & Explanation

. Score 2; non-operative treatment recommended

Explanation

The TLICS score is calculated based on three categories: injury morphology, neurologic status, and posterior ligamentous complex (PLC) integrity. A burst fracture morphology receives 2 points. Intact neurologic status receives 0 points. An intact PLC receives 0 points. The total score is 2. A TLICS score of less than 4 implies non-operative management is recommended.

Question 2738

Topic: 6. Spine

A 42-year-old male arrives at the trauma bay intubated and sedated following a severe motor vehicle collision. A CT scan of the cervical spine reveals a bilateral C5-C6 facet dislocation. What is the most appropriate next step in management?

. Closed reduction using cranial tongs and sequential weight application
. Immediate anterior cervical discectomy and fusion (ACDF)
. Immediate posterior cervical instrumented fusion
. MRI of the cervical spine
. CT angiogram of the neck to rule out vertebral artery injury

Correct Answer & Explanation

. MRI of the cervical spine

Explanation

In an unexaminable patient (e.g., intubated, sedated, or altered mental status) with a cervical facet dislocation, an MRI of the cervical spine must be obtained prior to any reduction attempts. This is crucial to evaluate for an extruded cervical disc herniation. If a disc is present behind the vertebral body, an anterior approach to remove the disc must be performed before reduction to prevent iatrogenic spinal cord transection.

Question 2739

Topic: 6. Spine

A 33-year-old male sustains a C6 spinal cord injury. On examination, he has 0/5 motor function below the C6 myotome. However, he has preserved pinprick and light touch sensation in the S4-S5 dermatomes, and deep anal pressure is intact. Voluntary anal contraction is absent. How is this injury classified on the ASIA Impairment Scale?

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

Correct Answer & Explanation

. ASIA B

Explanation

The American Spinal Injury Association (ASIA) Impairment Scale evaluates the completeness of a spinal cord injury. ASIA B signifies a sensory incomplete but motor complete injury. The patient has sensory preservation below the neurological level of injury, importantly including the sacral segments S4-S5, but has no motor function preserved more than 3 levels below the motor level, and lacks voluntary anal contraction.

Question 2740

Topic: 6. Spine

A 25-year-old female is involved in a high-speed motor vehicle collision while wearing only a lap seatbelt. She sustains a severe flexion-distraction injury (Chance fracture) at the L2 vertebral level. This specific spinal fracture pattern is most frequently associated with concomitant injuries to which of the following organ systems?

. Genitourinary
. Cardiovascular
. Pulmonary
. Gastrointestinal
. Gynecological

Correct Answer & Explanation

. Gastrointestinal

Explanation

Chance fractures are flexion-distraction injuries of the spine classically caused by acute hyperflexion over a fulcrum, such as a lap-only seatbelt in a motor vehicle collision. The severe compressive and shearing forces transmitted through the abdomen place intra-abdominal contents at high risk. Gastrointestinal injuries, particularly hollow viscus perforations or mesenteric tears, occur in up to 40-50% of patients with a Chance fracture.

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