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 2741
Topic: 6. Spine
A 55-year-old male with a known history of ankylosing spondylitis presents to the emergency department after a low-energy ground-level fall. He complains of moderate neck pain but is neurologically intact. Initial cross-table lateral cervical spine radiographs reveal an ossified anterior longitudinal ligament with a widened C5-C6 disc space. What is the most appropriate next step in management?
Correct Answer & Explanation
. Computed tomography (CT) of the entire spine
Explanation
Patients with ankylosing spondylitis are highly susceptible to unstable spinal fractures even from minor trauma, and these injuries are often highly unstable. Due to the altered biomechanics of the ankylosed spine, there is a high incidence of non-contiguous secondary fractures (up to 20%). Therefore, the standard of care is to obtain a CT scan of the entire spine (cervical, thoracic, and lumbar) to rule out additional fractures.
Question 2742
Topic: 6. Spine
A 12-year-old male sustains a Chance fracture of L2 while wearing a lap belt during a high-speed motor vehicle collision. Which of the following concomitant injuries is most statistically likely to be found in this patient?
Correct Answer & Explanation
. Small bowel perforation
Explanation
Chance fractures are flexion-distraction injuries commonly associated with lap belt use in motor vehicle accidents, particularly in the pediatric population. They carry a very high association (up to 40-50%) with intra-abdominal hollow viscus injuries, most notably small bowel perforations or mesenteric avulsions, due to the corresponding severe localized compression of the abdominal contents against the spine.
Question 2743
Topic: Thoracolumbar Spine & Deformity
A 30-year-old male sustains a fall from a height. Radiographs and CT show an L1 burst fracture. His neurologic examination is completely normal. MRI reveals a complete disruption of the posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his total score and the recommended treatment?
Correct Answer & Explanation
. Score 5; operative treatment
Explanation
The TLICS score is calculated based on three categories: 1) Morphology: Burst fracture = 2 points. 2) Neurologic status: Intact = 0 points. 3) Posterior ligamentous complex (PLC) integrity: Disrupted = 3 points. Total score = 2 + 0 + 3 = 5. A TLICS score of > 4 indicates instability, and operative intervention is strictly recommended.
Question 2744
Topic: 6. Spine
A 42-year-old female presents to the emergency department after a motor vehicle collision. She is awake, alert, and fully cooperative. She has a right-sided C6 radiculopathy but no long tract signs (no myelopathy). Lateral cervical radiographs reveal a unilateral jumped facet at C5-C6 with 25% anterior translation. What is the most appropriate next step in management?
Correct Answer & Explanation
. Urgent closed reduction using cranial tongs and progressive traction under continuous neurologic monitoring
Explanation
According to current spinal trauma guidelines, an awake, alert, and cooperative patient with a cervical facet dislocation can safely undergo immediate closed reduction via skeletal traction with serial neurologic examinations. MRI prior to reduction is not required and may unnecessarily delay spinal cord/nerve root decompression. MRI is mandated prior to reduction ONLY if the patient is unexaminable (e.g., comatose) or fails closed reduction.
Question 2745
Topic: Cervical Spine
An 82-year-old female with multiple medical comorbidities including severe COPD and ischemic heart disease sustains a Type II odontoid fracture with 2 mm of posterior displacement after a mechanical fall. She is neurologically intact. Which of the following is the most appropriate initial management strategy?
Correct Answer & Explanation
. Immobilization in a rigid cervical collar
Explanation
In elderly patients (>80 years) with significant medical comorbidities, the treatment of Type II odontoid fractures must balance fracture healing with the severe morbidity and mortality of interventions. Halo immobilization in the elderly carries a mortality rate approaching 20-30% due to respiratory complications and falls. Operative fixation also carries high perioperative risks. Current evidence strongly supports that immobilization in a rigid cervical collar is the most appropriate initial treatment. Although the nonunion rate is higher, the majority are stable fibrous nonunions that remain clinically asymptomatic.
Question 2746
Topic: Thoracolumbar Spine & Deformity
A 24-year-old female presents after a high-speed motor vehicle collision. She was wearing a lap-only seatbelt. Imaging reveals a flexion-distraction injury (Chance fracture) at L2. She is neurologically intact. Which of the following is the most commonly associated concomitant injury in this patient population?
Correct Answer & Explanation
. Hollow viscus injury
Explanation
Chance fractures are flexion-distraction injuries commonly associated with lap seatbelts. Up to 50% of these patients have concomitant intra-abdominal injuries, with hollow viscus (especially small bowel) perforations being the most common.
Question 2747
Topic: 6. Spine
A 68-year-old male with long-standing ankylosing spondylitis presents to the emergency department complaining of new-onset lower cervical pain after a minor bump in his car. Initial standard radiographs of the cervical spine show classic bridging syndesmophytes but no obvious fracture. Neurological exam is intact. What is the most appropriate next step in management?
Correct Answer & Explanation
. Obtain a non-contrast CT scan of the cervical spine
Explanation
Patients with ankylosing spondylitis are highly susceptible to highly unstable, transdiscal or chalk-stick fractures of the spine even from minor trauma. Standard radiographs are notoriously inadequate for ruling out fractures in this population; a CT scan is mandatory.
Question 2748
Topic: 6. Spine
A 45-year-old male sustains an L1 thoracolumbar burst fracture. He is neurologically intact. When calculating the Thoracolumbar Injury Classification and Severity (TLICS) score to determine operative vs nonoperative management, which of the following MRI findings would add the most points and independently push the total score towards surgical intervention?
Correct Answer & Explanation
. Disruption of the posterior ligamentous complex (PLC)
Explanation
In the TLICS system, disruption of the posterior ligamentous complex (PLC) is assigned 3 points. When combined with a burst morphology (2 points), the score becomes 5, which strongly favors surgical intervention (score > 4). Canal stenosis without neurologic deficit does not independently add points in TLICS.
Question 2749
Topic: 6. Spine
A 13-year-old girl who is 2 years postmenarche has been referred for management of scoliosis. She denies any history of back pain. Radiographs show a right thoracic curve of 35°. She has a Risser sign of 4 and a bone age of 15.5 years. Management should consist of
Correct Answer & Explanation
. observation and follow-up radiographs in 6 months.
Explanation
Discussion: Because the patient is skeletally mature with a curve of less than 40°, there is no benefit to bracing and surgery is not indicated. Management should consist of observation and follow-up radiographs in 6 months.
Question 2750
Topic: 6. Spine
When the iliac apophysis starts ossifying in the normal adolescent, growth of the sitting height or trunk height is characterized by
Correct Answer & Explanation
. an increase of 3 to 5 cm in girls and an increase of 5 to 8 cm in boys.
Explanation
Discussion: Studies by Anderson and associates have resulted in a growth-remaining chart for sitting height that shows an increase of 3 to 5 cm in girls and an increase of 5 to 8 cm in boys. Future growth of the spine may impact brace longevity and fit.
Question 2751
Topic: 6. Spine
A 20-year-old professional female jockey who is wearing a helmet is thrown from her horse. What is the most likely location of her injury?
Correct Answer & Explanation
. Head
Explanation
Discussion: The incidence of injury associated with horseback riding is estimated to be one per 350 riding hours to one per 1,000 riding hours. Of these injuries, approximately 15% to 27% are severe enough to warrant hospital admission. Significant and serious injuries in equestrian activities are associated with recreational riders and those not wearing a helmet. Head and spine injuries are more common in recreational and nonhelmeted riders. Extremity injuries are more common in professional and helmeted riders. Professional riders are less likely to be admitted to the hospital than recreational riders, and are about half as likely to be disabled at 6 months after injury as recreational riders.
Question 2752
Topic: 6. Spine
Which of the following palpable bony landmarks is correctly matched with its corresponding vertebral level?
Correct Answer & Explanation
. Carotid tubercle and C6
Explanation
The carotid tubercle is usually located at the level of C6. The angle of the mandible is at C1-C2; the hyoid is at C4; the superior portion of the thyroid cartilage is C4-C5; and the cricoid cartilage is at C6.
Question 2753
Topic: Thoracolumbar Spine & Deformity
A 22-year-old male presents after a high-speed motor vehicle collision where he was wearing a lap belt. Radiographs and CT demonstrate a flexion-distraction injury (Chance fracture) extending through the L2 vertebral body. Which associated injury must be ruled out due to its high incidence in this scenario?
Correct Answer & Explanation
. Intra-abdominal hollow viscus injury
Explanation
Chance fractures (flexion-distraction injuries) commonly occur in lap-belt restrained passengers during severe decelerations. They are highly associated with intra-abdominal injuries (up to 50% incidence), particularly hollow viscus injuries like bowel perforations, necessitating urgent general surgery evaluation.
Question 2754
Topic: 6. Spine
A 62-year-old male requires a THA for end-stage osteoarthritis. He has a history of an instrumented lumbar fusion from L2 to the sacrum. Given the stiffness in his lumbopelvic segment, how does his pelvic dynamics alter his risk profile, and how should the acetabular component positioning be adjusted?
Correct Answer & Explanation
. He will lack normal posterior pelvic tilt when transitioning from standing to sitting; the cup should be placed in less anteversion to prevent anterior impingement and posterior dislocation.
Explanation
In a patient with a stiff lumbopelvic junction (e.g., L-spine fusion to the sacrum), the pelvis cannot dynamically adjust to position changes. Normally, when moving from a standing to a sitting position, the lumbar spine flexes and the pelvis tilts posteriorly, which functionally increases acetabular anteversion and clears the anterior acetabular rim from the proximal femur. A stiff spine prevents this posterior tilt, leaving the acetabulum functionally retroverted relative to the flexed femur. This leads to anterior impingement and an increased risk of posterior dislocation. To compensate, the surgeon should aim for increased operative anteversion and inclination.
Question 2755
Topic: Thoracolumbar Spine & Deformity
A 65-year-old woman is scheduled for a total hip arthroplasty. Standing and sitting lateral spinopelvic radiographs reveal a stiff lumbar spine with a pelvic tilt change of 5 degrees between standing and sitting, and a significantly decreased standing sacral slope. What is the most appropriate modification in acetabular cup positioning to minimize the risk of dislocation?
Correct Answer & Explanation
. Increase anteversion and increase abduction
Explanation
A stiff lumbar spine (change in pelvic tilt < 10 degrees) combined with a decreased standing sacral slope indicates a 'flatback' deformity where the pelvis is already retroverted and does not retrovert further normally upon sitting. This puts the patient at a high risk for anterior impingement and subsequent posterior dislocation during sitting. To compensate for the lack of dynamic functional pelvic retroversion in flexion, the cup should be placed in more anteversion and slightly more inclination (abduction).
Question 2756
Topic: 6. Spine
A 72-year-old male with a prior T10-to-pelvis fusion for degenerative scoliosis is undergoing a primary total hip arthroplasty. Standing lateral radiographs reveal a stiff spine with decreased lumbar lordosis and a fixed posterior pelvic tilt. To minimize dislocation risk, how should the acetabular component orientation be adjusted relative to the standard Lewinnek safe zone?
Correct Answer & Explanation
. Decrease anteversion and decrease abduction
Explanation
Patients with a stiff spine and a flatback deformity (fixed posterior pelvic tilt) fail to flex their pelvis when sitting, but face a high risk of anterior dislocation in extension. Therefore, the cup should be placed with decreased anteversion and decreased abduction.
Question 2757
Topic: 6. Spine
A 68-year-old male with a long-standing surgical fusion of his lumbar spine (L2-S1) is scheduled for a total hip arthroplasty. Flexion-extension spine radiographs confirm a completely stiff spinopelvic junction with lack of posterior pelvic tilt when sitting. To minimize the risk of dislocation, how should the acetabular cup be positioned relative to the standard safe zone?
Correct Answer & Explanation
. Placed with increased anteversion and increased inclination
Explanation
A stiff lumbar spine fails to posteriorly tilt during sitting, preventing the natural increase in functional acetabular anteversion. To prevent anterior impingement and posterior dislocation, the cup should be placed in greater anteversion and inclination.
Question 2758
Topic: 6. Spine
A 30-year-old female is involved in a high-speed motor vehicle collision and sustains a Denis Zone III sacral fracture. Which of the following clinical findings is most likely associated with this specific injury pattern compared to Zone I or Zone II fractures?
Correct Answer & Explanation
. Bowel and bladder dysfunction
Explanation
The Denis classification of sacral fractures divides them into Zone I (alar), Zone II (transforaminal), and Zone III (central sacral canal). Zone III injuries carry the highest risk of neurologic deficits (approaching 60%), typically manifesting as cauda equina syndrome, which includes saddle anesthesia, loss of sphincter tone, and bowel/bladder/sexual dysfunction.
Question 2759
Topic: 6. Spine
A 24-year-old motorcyclist sustains a severe closed traction injury to his right brachial plexus. Examination reveals a flail, insensate right upper extremity and a right-sided ptosis and miosis. An MRI of the cervical spine is performed. Which of the following MRI findings is most consistent with the clinical examination and indicates an irreparable lesion at the root level?
Correct Answer & Explanation
. Presence of a traumatic pseudomeningocele
Explanation
The patient has a pan-brachial plexus injury with a Horner syndrome (ptosis, miosis, anhidrosis), indicating involvement of the T1 sympathetic fibers. This suggests a pre-ganglionic root avulsion. The hallmark MRI finding of a pre-ganglionic nerve root avulsion is a traumatic pseudomeningocele, which represents a dural tear with cerebrospinal fluid leakage into the extra-spinal soft tissues. Pre-ganglionic lesions are not amenable to direct nerve repair or grafting and require nerve transfers.
Question 2760
Topic: 6. Spine
A 50-year-old patient presents with right-sided neck pain radiating down the arm, weakness in elbow extension and wrist flexion, and a diminished triceps reflex. Sensation is decreased over the palmar aspect of the middle finger. MRI demonstrates a paracentral disc herniation at the C6-C7 level. Which spinal nerve root is compressed, and where does it normally exit?
Correct Answer & Explanation
. C7 nerve root, exiting above the C7 pedicle
Explanation
The clinical presentation (weak triceps, weak wrist flexion, decreased middle finger sensation, diminished triceps reflex) is classic for a C7 radiculopathy. In the cervical spine, there are 8 cervical nerve roots but only 7 cervical vertebrae. Roots C1-C7 exit above their corresponding numbered pedicles. Therefore, the C7 nerve root exits through the C6-C7 neural foramen, which is located above the C7 pedicle.
Test Yourself
Switch to an interactive, timed exam simulation to truly master this topic.