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 2881
Topic: Cervical Spine
A 25-year-old male sustains a C1 burst (Jefferson) fracture after an axial loading injury. An AP open-mouth odontoid radiograph demonstrates lateral mass displacement. The transverse alar ligament is considered ruptured if the combined lateral mass overhang exceeds what specific measurement?
Correct Answer & Explanation
. 6.9 mm
Explanation
The Rule of Spence dictates that a combined lateral mass displacement of C1 on C2 greater than 6.9 mm on an AP open-mouth radiograph implies rupture of the transverse ligament. This indicates an unstable C1 ring injury requiring rigid immobilization or surgical stabilization.
Question 2882
Topic: Thoracolumbar Spine & Deformity
In preoperative planning for adult spinal deformity surgery, the surgeon calculates the patient's pelvic incidence (PI). Which of the following statements best describes this vital radiographic parameter?
Correct Answer & Explanation
. It is a fixed morphological parameter mathematically equal to pelvic tilt plus sacral slope
Explanation
Pelvic incidence (PI) is a fixed anatomical parameter unique to each individual's pelvis and does not change with posture or age. It is defined mathematically as the sum of Pelvic Tilt (PT) and Sacral Slope (SS) (i.e., PI = PT + SS).
Question 2883
Topic: 6. Spine
A 50-year-old intravenous drug user presents with acute back pain, fever, and progressive lower extremity weakness. MRI confirms a large lumbar spinal epidural abscess. Which location within the spinal canal is most commonly affected in this condition?
Correct Answer & Explanation
. Posterior epidural space
Explanation
Spinal epidural abscesses are most frequently located in the posterior epidural space. This posterior compartment is larger, contains epidural fat, and houses a rich venous plexus (Batson's plexus) that is highly susceptible to hematogenous bacterial seeding.
Question 2884
Topic: 6. Spine
A 65-year-old man undergoes total shoulder arthroplasty. Examination in the recovery room reveals the absence of voluntary deltoid and biceps contraction, weakness of wrist extension, and absence of sensation over the lateral arm and radial forearm. Management should now consist of
Correct Answer & Explanation
. Immobilization in a sling and early passive range of motion exercises
Explanation
One and two are incorrect because they would show artifact, which would interfere with evaluation of a brachial plexus lesion unless a hematoma is suspected. Number 3 is incorrect as timing of the EMG is important because electrophysiologic signs of denervation do not become apparent for more than two weeks after the injury and therefore should be performed four to six weeks after surgery if no clinical recovery is occurring. However, an electromyogram obtained early in the course of a neurologic injury may demonstrate a preexisting degenerative lesion. Answer number five is incorrect because in the literature it has been suggested that injuries to the brachial plexus showing no spontaneous improvement within three months should undergo surgical exploration. The answer number four is correct because after the neurological deficit is identified, efforts should be directed at maintaining passive motion of affected joint through the recovery phase. Temporary static splinting can be beneficial as well.
Question 2885
Topic: 6. Spine
A 66-year-old woman reports chronic mild low back pain. Over the last 3 years, she has noticed worsening buttock and posterior leg pain with standing and walking. Sitting seems to improve the pain. She also reports numbness in both legs with walking. An MRI scan and standing radiographs of the lumbar spine are shown in Figures 53a through 53c. She has undergone two epidural injections with good, but short-term relief. Further treatment to alleviate this patient's symptoms should consist of which of the following? Review Topic
Correct Answer & Explanation
. Laminectomy and fusion
Explanation
The patient reports symptoms that are classic for neurogenic claudication secondary to lumbar spinal stenosis. Nonsurgical management has failed to provide relief, thus a surgical approach is a reasonable treatment option at this point. Studies have shown significant benefit in patients with lumbar stenosis who choose to undergo surgical treatment. Manual or manipulative therapy is unlikely to provide relief. Facet injections are not effective for neurologic symptoms. An L4-5 laminotomy will not adequately address the patient's pathology. In the absence of instability on imaging studies, arthrodesis is not indicated.
Question 2886
Topic: 6. Spine
A 43-year-old man is currently taking medication for the disease condition shown in Figure A. His wife is taking the same medication. Her radiograph is shown in Figure B. What is the medication?
Correct Answer & Explanation
. Adalimumab
Explanation
The male patient has ankylosing spondylitis (AS), and is taking the same medication as his wife, who has rheumatoid arthritis (RA). Adalimumab is approved for both conditions. TNF-alpha inhibitors are biological agents approved for 2nd-line treatment of AS. These include etanercept, infliximab, adalimumab, golimumab, and certolizumab pegol, which are all approved for treatment of RA and psoriatic arthritis as well. Figure A shows bilateral sacroiliitis and bilateral hip arthritis, which in a young male patient, is highly suggestive of AS. Figure B shows ulnar drift of the digits and MCPJ subluxation characteristic of RA.
Question 2887
Topic: 6. Spine
A 53-year-old man reports a 5-week history of worsening low back pain accompanied by bilateral knee and ankle pain and swelling. He also reports a lesser degree of neck and left elbow pain. He denies any history of trauma or provocative episodes. His medical history is significant for Reiter’s syndrome more than 25 years ago, with no subsequent exacerbations. Furthermore, he has recently returned from a vacation in Costa Rica and noted the development of infectious gastroenteritis with diarrhea within 1 week of his return. This was treated with a 10-day course of oral antibiotics and has since resolved. He denies any significant bowel or urinary symptoms at this time. His neurologic examination is essentially within normal limits, but is somewhat limited by his low back and leg pain. What further investigation is most appropriate at this time?
Correct Answer & Explanation
. Laboratory tests including a CBC count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP)
Explanation
The patient has polyarticular arthritis. Because of the patient’s recent trip to Costa Rica and the subsequent gastroenteritis, a CBC count, ESR, and CRP should be ordered to rule out infectious and inflammatory versus noninflammatory conditions.
Question 2888
Topic: Cervical Spine
A 60-year-old Asian male presents with progressive hand clumsiness and gait imbalance. CT of the cervical spine demonstrates continuous ossification of the posterior longitudinal ligament (OPLL) from C3 to C6 with a canal occupying ratio of 65%. The cervical spine is neutrally aligned. Which of the following is the most appropriate surgical approach with the lowest risk of direct dural injury?
Correct Answer & Explanation
. Posterior cervical laminectomy and fusion C3-C6
Explanation
In patients with severe OPLL (occupying ratio >50-60%) and neutral or lordotic alignment, a posterior approach (laminectomy and fusion or laminoplasty) is generally preferred over an anterior approach. Anterior resection of continuous OPLL carries a very high risk of dural tear and cerebrospinal fluid leak because the ossified mass is often densely adherent to or incorporated into the dura.
Question 2889
Topic: 6. Spine
A 65-year-old female presents with severe neurogenic claudication. Upright radiographs demonstrate a Grade I degenerative spondylolisthesis at L4-L5 with 4 mm of dynamic translation on flexion-extension views. According to the Spine Patient Outcomes Research Trial (SPORT) data, which of the following outcomes is most expected if she undergoes surgical decompression and fusion compared to nonoperative management at 4-year follow-up?
Correct Answer & Explanation
. Significantly better pain and physical function outcomes in the surgical group
Explanation
The SPORT trial for degenerative spondylolisthesis demonstrated that patients who underwent surgery (decompression and fusion) had significantly greater improvement in pain and function compared to those treated nonoperatively, and this treatment effect was maintained at 4-year and 8-year follow-ups.
Question 2890
Topic: 6. Spine
A 35-year-old male sustains an L1 burst fracture. He has bilateral weakness in ankle dorsiflexion (3/5) and bowel/bladder incontinence. MRI shows retropulsion of bone and complete disruption of the posterior ligamentous complex (PLC). What is his Thoracolumbar Injury Classification and Severity (TLICS) score, and what management is recommended?
Correct Answer & Explanation
. Score 8; surgical management
Explanation
The TLICS system scores morphology, neurologic status, and PLC integrity. Burst fracture = 2 points. Neurologic status (cauda equina injury due to bowel/bladder dysfunction and lower extremity weakness) = 3 points. PLC disruption = 3 points. Total = 8 points. A score ≥ 5 recommends surgical management.
Question 2891
Topic: 6. Spine
A 70-year-old male presents with cervical spondylotic myelopathy. He reports bilateral hand clumsiness and significant difficulty walking, which forced him to retire from his job as a mechanic. However, he remains able to ambulate around his home and in the community without the use of a cane or walker. According to the Nurick classification system, what grade best describes this patient's condition?
Correct Answer & Explanation
. Grade 3
Explanation
The Nurick classification for cervical myelopathy is based on gait abnormality. Grade 0 = root signs only. Grade 1 = signs of cord involvement but normal gait. Grade 2 = mild gait involvement, able to be employed. Grade 3 = gait abnormality prevents employment, but can walk unassisted. Grade 4 = requires assistance (cane/walker) to ambulate. Grade 5 = wheelchair-bound or bedridden. Because he is unemployed due to his gait but walks unassisted, he is Grade 3.
Question 2892
Topic: 6. Spine
A 65-year-old male complains of bilateral posterior calf pain that consistently occurs after walking two blocks. The pain is rapidly relieved by sitting or leaning forward over a shopping cart. The patient notes no pain when riding a stationary bicycle. Which of the following is the most reliable clinical or historical finding to differentiate his condition from vascular claudication?
Correct Answer & Explanation
. Pain relief with lumbar flexion (e.g., stationary bicycling)
Explanation
The patient's symptoms are classic for neurogenic claudication secondary to lumbar spinal stenosis. The most reliable differentiator from vascular claudication is that neurogenic claudication is position-dependent; it is relieved by lumbar flexion (which increases the cross-sectional area of the spinal canal) and exacerbated by extension. Therefore, riding a stationary bicycle (which involves lumbar flexion) is well-tolerated in neurogenic claudication, whereas it provokes pain in vascular claudication due to increased muscle oxygen demand.
Question 2893
Topic: 6. Spine
During preoperative planning for a posterior spinal fusion in a 14-year-old girl with an adolescent idiopathic scoliosis (Lenke 1A curve), the surgeon aims to identify the Stable Vertebra to help determine the distal extent of the fusion. How is the Stable Vertebra defined on standard standing AP radiographs?
Correct Answer & Explanation
. The most cephalad vertebra below the curve that is bisected by the center sacral vertical line (CSVL).
Explanation
In the evaluation of scoliosis, the Stable Vertebra is defined as the most proximal (cephalad) vertebra below the curve that is bisected by the Center Sacral Vertical Line (CSVL). The Neutral Vertebra is the most cephalad vertebra without axial rotation. The End Vertebra is the most tilted vertebra at the cephalad or caudal end of the curve. The Apical Vertebra is the most laterally deviated.
Question 2894
Topic: Cervical Spine
An 80-year-old man falls from a standing height and sustains an Anderson and D'Alonzo Type II odontoid fracture with 3 mm of posterior displacement. He is neurologically intact. DEXA scan reveals severe osteoporosis (T-score -3.1). He is a community ambulator and has no other major medical comorbidities. What is the most appropriate definitive management?
Correct Answer & Explanation
. Posterior C1-C2 instrumental fusion
Explanation
In an elderly patient with a Type II odontoid fracture, conservative management (halo or collar) is associated with unacceptably high rates of nonunion, morbidity, and mortality (especially halo vests, which are poorly tolerated in the elderly). Anterior odontoid screw fixation is contraindicated in the setting of severe osteoporosis due to poor screw purchase, and is less successful with posterior displacement. Posterior C1-C2 instrumental fusion provides rigid fixation with high fusion rates and is the gold standard for definitive surgical management in this population.
Question 2895
Topic: 6. Spine
A 50-year-old male with a history of intravenous drug use presents with severe, unrelenting mid-back pain, a low-grade fever, and progressive paraparesis. Blood cultures are drawn. An emergent MRI of the thoracic spine with and without gadolinium contrast is obtained to evaluate for a spinal epidural abscess. Which of the following MRI findings is most characteristic of this diagnosis?
Correct Answer & Explanation
. A T1 hypointense, T2 hyperintense lesion in the epidural space demonstrating peripheral rim enhancement with gadolinium.
Explanation
A spinal epidural abscess classically appears on MRI as an epidural mass that is isointense to hypointense on T1-weighted imaging and hyperintense on T2-weighted imaging. Following the administration of gadolinium contrast, the liquid purulent center does not enhance, but the highly vascularized inflammatory capsule surrounding the pus does, resulting in a characteristic peripheral or 'rim' enhancement pattern.
Question 2896
Topic: 6. Spine
A 65-year-old female presents with progressive hand clumsiness and gait imbalance. Lateral cervical radiographs reveal continuous ossification of the posterior longitudinal ligament (OPLL) from C3-C6 with a kyphotic alignment (K-line negative). Sagittal MRI confirms severe cord compression. Which of the following surgical approaches is most appropriate?
Correct Answer & Explanation
. Anterior cervical corpectomy and fusion
Explanation
In patients with OPLL and a kyphotic cervical spine (K-line negative), posterior decompression (laminoplasty or laminectomy alone) is generally insufficient because the spinal cord will not drift back posteriorly away from the anterior compressive pathology. An anterior approach (corpectomy and fusion) or a combined anterior-posterior approach is indicated to directly decompress the cord and correct the kyphosis.
Question 2897
Topic: 6. Spine
A 72-year-old male with a history of a multi-level lumbar fusion (L2-Pelvis) is planned for a total hip arthroplasty. Preoperative sitting and standing lateral spinopelvic radiographs show a change in pelvic tilt of 3 degrees. To minimize the risk of posterior dislocation during sitting, how should the acetabular component be positioned compared to a patient with normal spinopelvic mobility?
Correct Answer & Explanation
. Increased anteversion and increased inclination
Explanation
A patient with a prior lumbar fusion to the pelvis has a 'stiff' spinopelvic junction (less than 10 degrees of pelvic tilt change between standing and sitting). Normally, the pelvis retroverts during sitting, opening the acetabulum anteriorly to accommodate hip flexion. In a stiff spine, this retroversion does not occur, increasing the risk of anterior impingement and posterior dislocation during sitting. Therefore, the acetabular component should be placed in greater anteversion and inclination to compensate for the lack of dynamic pelvic retroversion.
Question 2898
Topic: Thoracolumbar Spine & Deformity
According to the Wiltse classification of spondylolisthesis, which type is characterized by congenital abnormalities of the upper sacrum or the neural arch of L5, leading to progressive slipping primarily seen in pediatric patients?
Correct Answer & Explanation
. Type I (Dysplastic)
Explanation
The Wiltse classification categorizes spondylolisthesis. Type I is Dysplastic, caused by congenital anomalies of the lumbosacral junction (e.g., attenuated pars, maloriented facets) and has a high rate of progression. Type II is Isthmic (pars defect). Type III is Degenerative. Type IV is Traumatic (fracture in areas other than the pars). Type V is Pathologic (generalized or localized bone disease).
Question 2899
Topic: Cervical Spine
A 78-year-old male sustains a Type II odontoid fracture after a low-energy fall. Which of the following factors is most strongly associated with a high risk of non-union if treated conservatively with a halo vest?
Correct Answer & Explanation
. Initial fracture displacement > 5 mm
Explanation
Risk factors for non-union of Type II odontoid fractures treated non-operatively include initial displacement > 5 mm, age > 65 years, angulation > 10 degrees, and delayed treatment. Posterior displacement versus anterior displacement is debated, but displacement > 5mm and advanced age are well-established primary risk factors for failure of conservative management.
Question 2900
Topic: Thoracolumbar Spine & Deformity
A 35-year-old male sustains an L1 burst fracture in a motor vehicle collision. 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 what is the recommended management?
Correct Answer & Explanation
. Score 2, non-operative management
Explanation
The TLICS system assigns points based on morphology, neurologic status, and posterior ligamentous complex (PLC) integrity. 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 indeterminate (surgeon's choice), and 5 or more warrants surgical intervention.
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