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6. Spine MCQs

Practice Set 144 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 2861

Topic: Thoracolumbar Spine & Deformity
A 35-year-old male sustains an L1 burst fracture. He is neurologically intact. MRI demonstrates an intact posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity Score (TLICS), what is his total score and the generally recommended management?
. Score 2: Nonoperative management
. Score 3: Surgeon's discretion
. Score 4: Operative management
. Score 5: Operative management
. Score 7: Operative management

Correct Answer & Explanation

. Score 2: Nonoperative management

Explanation

The TLICS system scores injuries based on morphology, neurologic status, and posterior ligamentous complex (PLC) integrity. A burst fracture morphology scores 2 points. Intact neurology scores 0 points. An intact PLC scores 0 points. The total score is 2. A TLICS score of ≤ 3 indicates nonoperative management, a score of 4 is surgeon discretion, and a score ≥ 5 indicates operative management.

Question 2862

Topic: 6. Spine
Sorensen's criteria for the formal radiographic diagnosis of classic Scheuermann's kyphosis requires the presence of which of the following findings on a lateral spine radiograph?
. Anterior wedging of at least 5 degrees in 3 or more consecutive vertebrae
. Anterior wedging of at least 10 degrees in 2 consecutive vertebrae
. Schmorl's nodes in at least 3 consecutive vertebrae
. Endplate irregularities and disc space narrowing at a single level with local kyphosis
. Apophyseal ring fractures in the lumbar spine

Correct Answer & Explanation

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

Explanation

Classic Scheuermann's disease is characterized by rigid thoracic kyphosis. Sorensen's strict radiographic criteria for diagnosis require anterior wedging of ≥ 5 degrees in at least three consecutive vertebrae. Associated findings often include Schmorl's nodes and endplate irregularities, but the wedging parameter is the defining diagnostic criterion.

Question 2863

Topic: Thoracolumbar Spine & Deformity
According to the Wiltse classification of spondylolisthesis, a Type II (isthmic) slip is further subdivided based on the mechanism of pars interarticularis failure. Which of the following describes the pathophysiology defining a Type IIA slip?
. Congenital dysplasia of the L5-S1 facet joints
. Fatigue (stress) fracture of the pars interarticularis
. Elongation of an intact pars interarticularis due to repeated microfracture healing
. Acute traumatic fracture of the pars interarticularis
. Degenerative instability secondary to facet arthritis without a pars defect

Correct Answer & Explanation

. Fatigue (stress) fracture of the pars interarticularis

Explanation

The Wiltse classification defines Type II as Isthmic spondylolisthesis. It is subdivided into Type IIA (fatigue/stress fracture of the pars), Type IIB (elongated but intact pars, resulting from repeated microfracture and healing), and Type IIC (acute traumatic fracture of the pars). Type I is dysplastic, and Type III is degenerative.

Question 2864

Topic: 6. Spine

A 52-year-old male presents with severe right-sided neck pain radiating down his arm. Physical examination reveals notable weakness in right elbow extension, an absent triceps reflex, and sensory loss over the volar aspect of his right middle finger. A paracentral cervical disc herniation is most likely impinging which cervical nerve root?

. C5
. C6
. C7
. C8
. T1

Correct Answer & Explanation

. C7

Explanation

The clinical presentation is classic for a C7 radiculopathy. The C7 nerve root supplies motor innervation to the triceps (elbow extension) and wrist flexors. It mediates the triceps reflex. Sensory distribution involves the middle finger. A C6 radiculopathy would affect the brachioradialis/biceps reflex, wrist extension, and sensation over the thumb and index finger.

Question 2865

Topic: 6. Spine
A patient sustains a severe cervical spine injury resulting in tetraparesis. Neurological examination confirms that motor function is preserved below the neurological level of injury. Furthermore, out of the key muscle functions below the neurological level, 60% have a muscle grade of 3 or greater out of 5. Sacral sensation is intact. According to the ASIA Impairment Scale (AIS), how is this injury classified?
. ASIA A
. ASIA B
. ASIA C
. ASIA D
. ASIA E

Correct Answer & Explanation

. ASIA D

Explanation

The American Spinal Injury Association (ASIA) Impairment Scale classifies spinal cord injuries. ASIA D is defined as incomplete motor function preserved below the neurological level, with at least half (≥ 50%) of key muscle functions below the NLI having a muscle grade of 3 or greater. ASIA C requires more than half of key muscles below the NLI to have a grade of less than 3.

Question 2866

Topic: 6. Spine

A 30-year-old male presents after a motor vehicle accident with bilateral jumped facets at C5-C6. He has an incomplete spinal cord injury. MRI reveals a large, extruded disc herniation posterior to the C5-C6 disc space compressing the spinal cord. What is the most appropriate next step in management?

. Immediate closed reduction with cranial traction
. Anterior cervical discectomy and fusion (ACDF)
. Posterior cervical laminectomy and fusion without reduction
. Posterior cervical facet reduction and fusion
. Methylprednisolone protocol followed by bracing

Correct Answer & Explanation

. Anterior cervical discectomy and fusion (ACDF)

Explanation

In the presence of an extruded disc herniation with an incomplete neurologic deficit, closed reduction is contraindicated due to the high risk of retropulsing the disc further into the canal and worsening the neurologic deficit. The appropriate management is anterior decompression (ACDF) prior to or concurrent with reduction.

Question 2867

Topic: 6. Spine

A 65-year-old female presents with neurogenic claudication and an L4-L5 degenerative spondylolisthesis. She has failed conservative management. Which preoperative MRI finding is the strongest predictor of progressive postoperative instability if a decompression-only procedure (laminectomy without fusion) is performed?

. Bilateral facet fluid on T2-weighted imaging
. Disk height > 10 mm
. Facet angle > 50 degrees on axial MRI
. Disc bulge > 5 mm
. Ligamentum flavum hypertrophy > 3 mm

Correct Answer & Explanation

. Bilateral facet fluid on T2-weighted imaging

Explanation

Bilateral facet fluid > 1.5 mm on T2 MRI is a strong indicator of micro-instability at that spinal segment. Performing a laminectomy alone in these patients carries a high risk of progressive slip (instability) and the subsequent need for revision fusion surgery.

Question 2868

Topic: Cervical Spine

A 78-year-old male sustains a Type II odontoid fracture after a ground-level fall. The fracture is displaced posteriorly by 4 mm. He is neurologically intact, but his medical history is significant for severe COPD and osteoporosis. Which of the following is the most appropriate initial management?

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

Correct Answer & Explanation

. Hard cervical collar immobilization

Explanation

In elderly patients with a Type II odontoid fracture, halo vest immobilization is poorly tolerated and associated with high morbidity and mortality (especially with pulmonary issues like COPD). Anterior odontoid screw fixation has high failure rates in osteoporotic bone. A rigid cervical collar is the preferred initial treatment for many elderly patients, prioritizing life and minimizing morbidity, even if it progresses to an asymptomatic fibrous nonunion.

Question 2869

Topic: 6. Spine

A 42-year-old male presents to the ED with severe low back pain, bilateral lower extremity radicular pain, saddle anesthesia, and urinary retention with overflow incontinence. He undergoes an emergent lumbar MRI confirming a massive central disc herniation. According to the literature, emergent surgical decompression within what timeframe from the onset of symptoms is associated with the best chances of full functional recovery?

. 6 hours
. 12 hours
. 24 to 48 hours
. 72 hours
. 7 days

Correct Answer & Explanation

. 24 to 48 hours

Explanation

Cauda equina syndrome is a surgical emergency. The classic literature (including Ahn et al. and subsequent meta-analyses) suggests that surgical decompression performed within 48 hours of symptom onset provides a significant advantage in recovering both motor/sensory function and bowel/bladder control compared to delayed decompression.

Question 2870

Topic: 6. Spine

A 60-year-old male with a long-standing history of ankylosing spondylitis presents to the emergency department after a low-speed motor vehicle collision. He complains of neck pain but has a normal neurological examination. Plain radiographs of the cervical spine show a 'bamboo spine' but no obvious fracture. What is the mandatory next step in the workup?

. Discharge with NSAIDs and physical therapy
. Flexion-extension radiographs of the cervical spine
. CT scan of the entire cervical spine
. MRI of the lumbar spine
. Reassurance and a soft cervical collar for comfort only

Correct Answer & Explanation

. CT scan of the entire cervical spine

Explanation

Patients with ankylosing spondylitis have highly rigid, osteopenic spines that fracture easily, often through the disc spaces or vertebral bodies (acting biomechanically like long-bone fractures). Because plain radiographs are extremely insensitive for detecting these fractures due to altered and overlapping anatomy, a CT scan of the entire cervical spine is mandatory in evaluating AS patients with neck pain following even minor trauma.

Question 2871

Topic: Thoracolumbar Spine & Deformity

A 35-year-old female falls from a height. Imaging reveals an L1 burst fracture. She is neurologically intact. MRI demonstrates an intact posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity Score (TLICS), what is her total score, and what is the recommended management?

. Score 2, Nonoperative management
. Score 4, Operative management
. Score 4, Surgeon's choice
. Score 5, Operative management
. Score 2, Operative management

Correct Answer & Explanation

. Score 2, Nonoperative management

Explanation

The TLICS system assigns points for morphology, neurologic status, and PLC integrity. Burst fracture = 2 points. Neurologically intact = 0 points. PLC intact = 0 points. Total score = 2. A score of <= 3 recommends nonoperative management. A score of 4 is surgeon's choice. A score >= 5 strongly recommends operative management.

Question 2872

Topic: 6. Spine

A 65-year-old male with progressive gait imbalance and fine motor clumsiness of the hands is found to have a positive Hoffmann sign on physical examination. This reflex finding is an indicator of compression or dysfunction affecting which specific neural pathway?

. Corticospinal tract
. Spinothalamic tract
. Dorsal column medial lemniscus
. Vestibulospinal tract
. Rubrospinal tract

Correct Answer & Explanation

. Corticospinal tract

Explanation

The Hoffmann sign indicates an upper motor neuron lesion, specifically resulting from dysfunction of the corticospinal tract. It is a key examination finding in cervical spondylotic myelopathy.

Question 2873

Topic: 6. Spine

Which of the following historical findings most reliably differentiates neurogenic claudication from vascular claudication in a patient presenting with bilateral leg pain during ambulation?

. Relief of pain with standing completely stationary
. Decreased ankle-brachial index after exercise
. Exacerbation of symptoms when riding a stationary bicycle
. Relief of symptoms when walking uphill
. Proximal-to-distal radiation of cramping pain

Correct Answer & Explanation

. Relief of symptoms when walking uphill

Explanation

Walking uphill places the lumbar spine in relative flexion, increasing the cross-sectional area of the spinal canal and relieving symptoms of neurogenic claudication. Vascular claudication is exacerbated by exertion regardless of spinal posture and is relieved by standing stationary.

Question 2874

Topic: 6. Spine

A 45-year-old presents with severe acute low back pain and bilateral sciatica. Which of the following objective findings is the most sensitive early indicator for evaluating suspected cauda equina syndrome?

. Decreased resting anal sphincter tone
. Post-void residual bladder volume greater than 100-200 mL
. Bilateral absent Achilles reflexes
. Saddle anesthesia to pinprick testing
. Loss of the bulbocavernosus reflex

Correct Answer & Explanation

. Post-void residual bladder volume greater than 100-200 mL

Explanation

Urinary retention is the most consistent and sensitive early finding in cauda equina syndrome. A post-void residual (PVR) volume of less than 100 mL reliably rules out urinary retention in the context of this syndrome.

Question 2875

Topic: 6. Spine

A 32-year-old male dives into shallow water and presents with quadriplegia. Lateral cervical radiographs reveal greater than 50% anterior subluxation of C5 on C6. What is the primary mechanism of this injury, and what is the associated soft tissue risk prior to reduction?

. Hyperextension; disc herniation posterior to C6
. Hyperflexion; high incidence of disc herniation posterior to C5
. Axial loading; burst fracture with retropulsed disc
. Lateral bending; unilateral disc avulsion
. Distraction; complete intervertebral disc resorption

Correct Answer & Explanation

. Hyperflexion; high incidence of disc herniation posterior to C5

Explanation

Bilateral facet dislocation results from severe hyperflexion and is characterized radiographically by >50% anterior translation of the vertebral body. An MRI is often required prior to closed or open reduction due to the high risk of a pre-existing cervical disc herniation that could cause further cord compression during reduction.

Question 2876

Topic: Thoracolumbar Spine & Deformity
According to the Wiltse classification of spondylolisthesis, a vertebral slip occurring secondary to a fatigue fracture of the pars interarticularis is classified as which type?
. Type I (Dysplastic)
. Type II (Isthmic)
. Type III (Degenerative)
. Type IV (Traumatic)
. Type V (Pathologic)

Correct Answer & Explanation

. Type II (Isthmic)

Explanation

Type II (Isthmic) spondylolisthesis is caused by a defect in the pars interarticularis, typically due to a stress/fatigue fracture. Type I is dysplastic, Type III is degenerative, Type IV is traumatic (fracture other than pars), and Type V is pathologic.

Question 2877

Topic: 6. Spine

A 48-year-old male presents with severe radicular pain radiating down the anterior aspect of his left thigh. Motor testing reveals profound weakness in knee extension, but ankle dorsiflexion is normal. An MRI shows a far lateral (extraforaminal) disc herniation at the L4-L5 level. Which nerve root is most likely compressed?

. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L4

Explanation

In the lumbar spine, a far lateral (extraforaminal) disc herniation typically compresses the exiting nerve root at the same level. Therefore, an L4-L5 far lateral herniation compresses the L4 nerve root, causing weakness in quadriceps (knee extension) and anterior thigh pain.

Question 2878

Topic: 6. Spine

A 65-year-old male presents with deteriorating hand dexterity and a broad-based gait. Tapping the volar surface of the distal phalanx of the middle finger elicits reflex flexion of the thumb and index finger. What spinal tract is primarily implicated in the disinhibition causing this clinical sign?

. Spinothalamic tract
. Corticospinal tract
. Dorsal columns
. Spinocerebellar tract
. Vestibulospinal tract

Correct Answer & Explanation

. Corticospinal tract

Explanation

The Hoffmann sign indicates upper motor neuron dysfunction, primarily implicating the descending corticospinal tract in cervical spondylotic myelopathy. It signifies reflex disinhibition due to spinal cord compression.

Question 2879

Topic: 6. Spine

A 14-year-old gymnast presents with persistent lower back pain. Radiographs reveal a Grade II isthmic spondylolisthesis at L5-S1. If radiculopathy is present, what is the most common neurological examination finding associated with this condition?

. Weakness in ankle dorsiflexion
. Decreased patellar reflex
. Pain and numbness in the L5 nerve root distribution
. Pain and numbness in the S1 nerve root distribution
. Loss of rectal sphincter tone

Correct Answer & Explanation

. Pain and numbness in the L5 nerve root distribution

Explanation

In pediatric isthmic spondylolisthesis at L5-S1, the fibrocartilaginous pars defect mass typically compresses the exiting L5 nerve root in the neural foramen. This contrasts with degenerative spondylolisthesis, where the traversing root is usually affected.

Question 2880

Topic: 6. Spine

A 70-year-old male presents with bilateral leg pain when walking. Which of the following history or physical examination findings most strongly differentiates neurogenic claudication from vascular claudication?

. Pain is relieved almost immediately by standing perfectly still
. Pain classically radiates from the distal extremity to the proximal thigh
. Pulses are absent in the dorsalis pedis and posterior tibial arteries
. Symptoms are relieved when walking while pushing a shopping cart
. Symptoms are severely exacerbated by riding a stationary bicycle

Correct Answer & Explanation

. Symptoms are relieved when walking while pushing a shopping cart

Explanation

Neurogenic claudication is typically relieved by lumbar flexion (e.g., pushing a shopping cart, riding a bike, sitting) because flexion increases the cross-sectional area of the stenotic spinal canal. Vascular claudication is strictly related to muscle exertion and is relieved simply by standing still.

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