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6. Spine MCQs

Practice Set 147 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 2921

Topic: 6. Spine

A 6-year-old girl has never been able to crawl or walk and can sit only when propped. History reveals no complications during pregnancy or delivery. Examination reveals a 30-degree scoliosis from T4 to L3. Deep tendon reflexes are absent, but fasciculations are present. The most likely genetic defect is the result of an abnormality in

Pediatrics Board Review 2004: High-Yield MCQs (Set 2) - Figure 20

. peripheral myelin protein 22.
. connexin 32.
. survival motor neuron.
. neurofibromin.
. frataxin.

Correct Answer & Explanation

. survival motor neuron.

Explanation

The patient's findings are consistent with an intermediate form of spinal muscular atrophy. Children with this condition appear normal at birth but are not able to walk. The disorder affects anterior horn cells. Fasciculations may be present, but deep tendon reflexes are typically absent. The development of scoliosis is almost universal with this type of spinal muscular atrophy. More than 90% of patients with spinal muscular atrophy have deletions in the telomeric survival motor neuron gene. Peripheral myelin protein 22 is abnormal in Charcot-Marie-Tooth type IA. Connexin 32 is abnormal in the X-linked type of Charcot-Marie-Tooth disease. Neurofibromin is affected in neurofibromatosis type 1. Friedreich's ataxia is secondary to a disorder of frataxin. Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 111-131.

Question 2922

Topic: 6. Spine

A 6-year-old girl has a painless spinal deformity. Examination reveals 2+ and equal knee jerks and ankle jerks, negative clonus, and a negative Babinski. The straight leg raising test is negative. Abdominal reflexes are asymmetrical. PA and lateral radiographs are shown in Figures 15a and 15b. What is the next most appropriate step in management?

. MRI of the spinal axis
. Physical therapy
. A brace for scoliosis
. Observation, with reevaluation in 6 to 12 months
. Posterior spinal fusion from T6 to T12

Correct Answer & Explanation

. MRI of the spinal axis

Explanation

The patient has an abnormal neurologic exam as shown by the abnormal abdominal reflexes. Furthermore, she has a significant curve and is younger than age 10 years. These findings are not consistent with idiopathic scoliosis. MRI will best rule out syringomyelia or an intraspinal tumor. Bracing and surgery are not indicated for this small curvature prior to obtaining an MRI scan. Ginsburg GM, Bassett GS: Back pain in children and adolescents: Evaluation and differential diagnosis. J Am Acad Orthop Surg 1997;5:67-78.

Question 2923

Topic: 6. Spine

Figures 3a and 3b show the MRI scans of a patient with neck pain. What is the most likely diagnosis?

. Neurofibromatosis
. Multiple sclerosis
. Cervical spondylotic myelopathy
. Acute poliomyelitis
. Gaucher's disease

Correct Answer & Explanation

. Neurofibromatosis

Explanation

Muliple neurofibromas result in marked foraminal enlargement as seen on the sagittal MRI scan. Collagen disorders leading to dural ectasia may show similar enlargement, but none of these is listed as a possible answer. Kim HW, Weinstein SL: Spine update: The management of scoliosis in neurofibromatosis. Spine 1997;22:2770-2776.

Question 2924

Topic: 6. Spine

An 18-year-old collegiate basketball player has had a 3-month history of activity-related back pain. She describes isolated low back pain without radiation that increases with training and playing basketball. Her pain resolves with rest. Physical therapy for 6 weeks has failed to provide relief. An axial CT scan is shown in Figure 17a, and Figures 17b and 17c show sagittal CT reconstructions through the right and left lumbar facets, respectively. Further management should consist of which of the following?

. CT-guided needle biopsy followed by radiation therapy
. L5-S1 fusion with instrumentation
. L5-S1 hemilaminotomy and partial diskectomy
. Activity restriction and bracing
. L5-S1 total disk arthroplasty

Correct Answer & Explanation

. Activity restriction and bracing

Explanation

The sagittal and axial CT scans show a bilateral spondylolysis at L5. The defect is in the pars interarticularis on the right side but at the base of the pedicle on the left. Having failed a trial of physical therapy with only a 3-month history of pain, the next most appropriate step in management should consist of activity modification and bracing in an antilordotic lumbosacral orthosis. Surgical intervention is reserved for patients who have failed to respond to a trial of bracing and activity restriction. Debnath UK, Freeman BJ, Grevitt MP, et al: Clinical outcome of symptomatic unilateral stress injuries of the lumbar pars interarticularis. Spine 2007;32:995-1000.

Question 2925

Topic: 6. Spine

A 65-year-old man with ankylosing spondylitis sustains an extension injury to his cervical spine. Two days later, a progressive neurologic deficit develops at the C6 level. An MRI scan is shown in Figure 1. What is the most likely diagnosis?

Anatomy 2005 Practice Questions: Set 1 (Solved) - Figure 1

. Epidural hematoma
. Herniated disk
. Tumor
. Extruded epidural bony fragment
. Abscess

Correct Answer & Explanation

. Epidural hematoma

Explanation

It is common for patients with ankylosing spondylitis to sustain extension-type fractures, typically near the cervicothoracic junction. These fractures can be minimally displaced, making them difficult to diagnose. In addition, the vertebral bodies are vascular and their canals are relatively enclosed, making them vulnerable to epidural bleeding. The MRI scan shows an epidural hematoma posteriorly compressing the cord. Bohlman HH: Acute fractures and dislocations of the cervical spine. J Bone Joint Surg Am 1979;61:1119-1142. Weinstein PR, Karpman RR, Gall EP, et al: Spinal cord injury, spine fracture and spinal stenosis in ankylosing spondylitis. J Neurosurg 1982;57:609-616.

Question 2926

Topic: 6. Spine

Figures 23a and 23b show the MRI scans of a 50-year-old woman who has increasing gait disturbance. She reports three falls in the past week. Examination reveals hyperreflexia, motor weakness in the biceps and triceps, and a positive Hoffman's sign. What is the most appropriate treatment plan?

. Observation
. Physical therapy
. Epidural steroid injections
. Cervical laminectomy
. Anterior cervical diskectomy and fusion

Correct Answer & Explanation

. Anterior cervical diskectomy and fusion

Explanation

The patient has obvious signs of progressive myelopathy. Based on her significant physical examination findings, nonsurgical management will not significantly impact her outcome. Cervical decompression alone is contraindicated in patients with cervical kyphosis such as seen here. Anterior cervical fusion is the best option. Emery SE, Bohlman HH, Bolesta MJ, et al: Anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy: Two to seventeen-year follow-up. J Bone Joint Surg Am 1998;80:941-951. Ferguson RJ, Caplan LR: Cervical spondylotic myelopathy. Neurol Clin 1985;3:373-382.

Question 2927

Topic: 6. Spine

A 20-year-old man sustained an isolated displaced type II odontoid fracture in a motor vehicle accident. He is neurologically intact. Treatment consists of placement in halo traction, and the fracture is reduced. What is the next most appropriate step in treatment?

. Conversion to a halo vest
. Closed reduction and conversion to a halo vest
. Posterior atlantoaxial arthrodesis
. Odontoid screw fixation
. Continued halo immobilization

Correct Answer & Explanation

. Continued halo immobilization

Explanation

The traditional treatment of a reduced type II fracture is a halo vest. A 20-year-old man will tolerate a halo vest better than the elderly or women. Anterior screw fixation has gained increasing support; however, it too has risks and requires a significant learning curve. More recently, C1 lateral mass screws have become more popular. The long-term results and benefits have not yet been determined. Spivak JM, Connolly PF (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 193. Kiovikko MP, Kiuru MJ, Koskinen SK, et al: Factors associated with nonunion in conservatively-treated type-II fractures of the odontoid process. J Bone Joint Surg Br 2004;86:1146-1151. Herkowitz HN, Garfin SR, Eismont FJ: Rothman-Simone The Spine, ed 5. Philadelphia, PA, Saunders Elsevier, 2006, p 1091.

Question 2928

Topic: 6. Spine

Which of the following findings is the best radiographic indicator of segmental instability at L4-L5?

Spine Surgery Board Review 2006: High-Yield MCQs (Set 2) - Figure 5

. Anterior marginal osteophytes
. Modic end plate changes on MRI
. Disk space narrowing
. More than 3.5 mm of translation or 11 degrees of angulation compared with adjacent levels on flexion/extension radiographs
. More than 4 mm of translation or 10 degrees of angulation compared with adjacent levels on flexion/extension radiographs

Correct Answer & Explanation

. More than 4 mm of translation or 10 degrees of angulation compared with adjacent levels on flexion/extension radiographs

Explanation

Motion segments that demonstrate more than 4 mm of translation or 10 degrees of angulation compared with adjacent motion segments on flexion-extension radiographs have excessive motion and instability. Anterior marginal osteophytes form at the insertion of the annulus from increased forces but do not indicate increased motion. A spondylolisthesis or lateral listhesis is often static without increased motion. More than 3.5 mm of translation or 11 degrees of angulation is considered instability criteria for the cervical spine. Internal disk disruption does not denote instability. Boden SD, Wiesel SW: Lumbosacral segmental motion in normal individuals. Have we been measuring instability properly? Spine 1990;15:571-576.

Question 2929

Topic: 6. Spine
A 42-year-old woman is brought to the emergency department following a motor vehicle accident. She has sustained multiple injuries, and she is intubated and pharmacologically paralyzed. Sagittal cervical CT scans through the right cervical facets, the left cervical facets, and the midline are shown in Figures 12a through 12c, respectively. Definitive management of her cervical injury should consist of
. anterior diskectomy and fusion at C4-C5.
. immobilization in a Philadelphia collar and voluntary flexion and extension radiographs when awake.
. occipital-cervical fusion with instrumentation.
. halo immobilization for 12 weeks.
. left C6 superior facetectomy and posterior fusion at C6-C7 with instrumentation.

Correct Answer & Explanation

. occipital-cervical fusion with instrumentation.

Explanation

The CT scans reveal an occipital-cervical dissociation with subluxation of the occipitocervical joints bilaterally. Definitive management should consist of an occipital-cervical fusion with instrumentation. Immobilization in a Philadelphia collar is inadequate for this highly unstable injury, and halo immobilization, while affording adequate temporary immobilization, is not appropriate definitive management for this ligamentous injury. The patient does not have an injury at C4-C5 or C6-C7. Jackson RS, Banit DM, Rhyne AL III, et al: Upper cervical spine injuries. J Am Acad Orthop Surg 2002;10:271-280.

Question 2930

Topic: 6. Spine

An otherwise healthy 45-year-old woman reports the onset of severe right leg pain. Figure 20a shows an axial MRI scan of the L4-5 level, and Figure 20b shows a sagittal view with the arrow at the L4-5 level. What nerve root is the most likely source of her pain?

. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L4

Explanation

The scans show a disk herniation in the far lateral region of the disk. In particular, the sagittal view shows the herniation adjacent to the exiting L4 nerve root. Disk herniations in this area that cause symptoms are more likely to compress the nerve exiting at the same level rather than the next most caudal level. McCulloch JA: Microdiscectomy, in Frymoyer JW (ed): The Adult Spine: Principles and Practice. New York, NY, Raven Press, 1991, vol 2, pp 1765-1783.

Question 2931

Topic: 6. Spine

A 42-year-old man has had left lower extremity pain in an L5 radicular pattern for the past 6 weeks. He denies significant axial low back pain. History reveals that he underwent an L4-5 diskectomy with successful relief of similar pain 5 years ago. Which of the following imaging studies would offer the greatest amount of information?

. Lumbar MRI with gadolinium
. CT
. CT with contrast myelography
. Lumbar lateral flexion-extension radiographs
. Bone scan with CT correlation

Correct Answer & Explanation

. Lumbar MRI with gadolinium

Explanation

MRI with gadolinium will best identify recurrent herniated nucleus pulposus or other root compression and distinguish scar from recurrent disk. CT is unable to distinguish scar from recurrent disk density, and the addition of myelogram dye can reveal compromise of the thecal sac but cannot distinguish the scar from recurrent disk as the source of compression. Although lateral flexion-extension radiographs may be important to rule out any instability, much of that information can be inferred from the associated disk and adjacent bony changes on MRI. Bone scan techniques may identify subtle stress fractures resulting from previous aggressive facet resection, but low back pain also would be expected. Mirowitz SA, Shady KL: Gadopentetate dimeglumine-enhanced MR imaging of the postoperative lumbar spine: Comparison of fat-suppressed and conventional T1-weighted images. Am J Roentgenol 1992;159:385-389.

Question 2932

Topic: 6. Spine
An 8-year-old boy reports progressive difficulty with walking. Examination reveals muscle weakness, with proximal groups more affected than distal muscles. Deep tendon reflexes are within normal limits. Laboratory studies show a creatine kinase level of 7,200 IU. Based on these findings, what is the most likely diagnosis?
. Becker muscular dystrophy
. Spinal muscular atrophy, type III
. Emery-Dreifuss dystrophy
. Limb girdle dystrophy
. Guillain-Barre syndrome

Correct Answer & Explanation

. Becker muscular dystrophy

Explanation

Patients with Becker muscular dystrophy have an abnormality in dystrophin, but unlike patients with Duchenne muscular dystrophy, some dystrophin is present. As a result, the progression of muscle weakness is slower, with the diagnosis typically made after age 8 years. Similar to patients with Duchenne muscular dystrophy, patients with Becker muscular dystrophy have pseudohypertrophy of the calves, markedly increased creatine kinase levels, and X-linked transmission of the condition. In addition, these patients are more prone to cardiomyopathy; a condition that should be carefully evaluated if any surgery is required. Patients with spinal muscular atrophy also have proximal muscle weakness, but the onset of weakness occurs earlier in childhood. These patients also have absent deep tendon reflexes and fasciculations, but pseudohypertrophy is absent and creatine kinase levels are normal. Patients with Emery-Dreifuss dystrophy may have a similar clinical picture to Becker's muscular dystrophy, but pseudohypertrophy is absent and creatine kinase levels are only mildly elevated. In addition, neck extension, elbow flexion, and ankle equinus contractures develop at an early age. Limb girdle dystrophy is a group of progressive muscular dystrophies that is not associated with pseudohypertrophy or a significant elevation of creatine kinase levels. Guillain-Barre syndrome is a condition associated with results from postinfectious demyelination of the peripheral nerve. These patients have the acute onset of weakness, hypotonia, and areflexia; creatine kinase levels are normal. Sussman MD: Muscular dystrophy, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1573-1583.

Question 2933

Topic: 6. Spine

A 13-year-old boy is comatose and has irregular breathing after being struck by a car while riding his bicycle. Auscultation suggests a pneumothorax on the right side and swelling about the right arm and leg. Initial management should consist of

. careful neurologic evaluation because of suspected brain injury.
. CT of the brain because of suspected subdural hematoma.
. insertion of an internal jugular vein central line for vascular access.
. airway control, placement of vascular access lines, and cervical spine radiographs.
. a chest tube and chest radiograph.

Correct Answer & Explanation

. airway control, placement of vascular access lines, and cervical spine radiographs.

Explanation

The first priority is to gain control of the airway with intubation. Following intubation, management should consist of ventilation and placement of a chest tube if needed, vascular access and circulatory stabilization, radiographs of the cervical spine and chest, and CT of the brain. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support Course. Instructor's Manual. Chicago, IL, American College of Surgeons, 1984.

Question 2934

Topic: Thoracolumbar Spine & Deformity

A patient who is an observant Jehovah's Witness requires major surgery for scoliosis that will likely result in significant blood loss. Which of the following might the patient consider allowing the surgical team to use?

Spine Surgery 2009 Practice Questions: Set 1 (Solved) - Figure 2

. Transfusion of whole blood
. Transfusion of packed red blood cells
. A cell saver with continuity maintained in a "closed circuit"
. Transfusion of plasma
. Transfusion of platelets

Correct Answer & Explanation

. A cell saver with continuity maintained in a "closed circuit"

Explanation

Jehovah's Witnesses will not accept the transfusion of blood or blood products such as packed red or white cells, platelets, or plasma. However, many Jehovah's Witnesses will accept the use of a cell saver in a "closed circuit." Jimenez R, Lewis VO (eds): Culturally Competent Care Guidebook. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007.

Question 2935

Topic: Cervical Spine

Figure 25 shows the CT scan of an adult patient who has neck pain following a motor vehicle accident. What is the most likely diagnosis?

Anatomy Board Review 2005: High-Yield MCQs (Set 2) - Figure 25

. Jefferson's fracture
. C1-C2 rotational instability
. Transverse ligament rupture
. Normal finding
. Basilar invagination

Correct Answer & Explanation

. Transverse ligament rupture

Explanation

If the atlanto-dens interval is greater than 3 mm in an adult, a transverse ligament rupture usually is suspected. The atlanto-dens interval can be seen with CT or in lateral radiographs of the upper cervical spine. Transverse ligament rupture can occur as an isolated entity or in association with an odontoid or a Jefferson's fracture. Patients with this type of injury usually require fusion. Dickman CA, Greene KA, Sonntag VK: Injuries involving the transverse atlantal ligament: Classification and treatment guidelines based upon experience with 39 injuries. Neurosurgery 1996;38:44-50.

Question 2936

Topic: 6. Spine

Which of the following palpable bony landmarks is correctly matched with its corresponding vertebral level?

Spine Surgery Board Review 2009: High-Yield MCQs (Set 2) - Figure 6

. Angle of the mandible and the C2-C3 interspace
. Hyoid bone and C6
. Carotid tubercle and C6
. Superior portion of the thyroid cartilage and the C3 vertebral body
. Cricoid cartilage and C7-T1

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. Smith GW, Robinson RA: The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and interbody fusion. J Bone Joint Surg Am 1958;40:607.

Question 2937

Topic: 6. Spine

A 21-year-old woman sustained a minimally displaced traumatic spondylolisthesis of C2 (Hangman's fracture) after striking the windshield with her forehead during a motor vehicle accident. Management should consist of

Trauma Board Review 2000: High-Yield MCQs (Set 2) - Figure 7

. skeletal tong traction for 6 weeks.
. anterior C2-3 diskectomy, grafting, and plate fixation.
. halo application for 8 weeks.
. a rigid collar for 4 to 6 weeks, followed by mobilization.
. posterior stabilization with C2 pedicle screws.

Correct Answer & Explanation

. a rigid collar for 4 to 6 weeks, followed by mobilization.

Explanation

According to the classification of Levine and Edwards, a type I Hangman's fracture is minimally displaced without angulation and represents a stable injury. Good clinical success has been achieved with nonsurgical management consisting of use of a rigid collar until the patient reports pain relief, followed by quick mobilization.

Question 2938

Topic: 6. Spine

Examination of a 25-year-old man who was injured in a motor vehicle accident reveals a fracture-dislocation of C5-6 with a Frankel B spinal cord injury. He also has a closed right femoral shaft fracture and a grade II open ipsilateral midshaft tibial fracture. Assessment of his vital signs reveals a pulse rate of 45/min, a blood pressure of 80/45 mm Hg, and respirations of 25/min. A general surgeon has assessed the abdomen, and a peritoneal lavage is negative. His clinical presentation is most consistent with what type of shock?

Trauma 2006 Practice Questions: Set 1 (Solved) - Figure 18

. Neurogenic
. Hemorrhagic
. Spinal
. Septic
. Hypovolemic

Correct Answer & Explanation

. Neurogenic

Explanation

Assessment of the acutely injured patient follows the Advanced Trauma Life Support protocol. Cervical cord injury is often associated with a disruption in sympathetic outflow. Absent sympathetic input to the lower extremities leads to vasodilatation, decreased venous return to the heart, and subsequent hypotension. With hypotension, the physiologic response of tachycardia is not possible because of the unopposed vagal tone. This results in bradycardia. Patient positioning, fluid support, pressor agents, and atropine are used to treat neurogenic shock.

Question 2939

Topic: 6. Spine

Figures 29a and 29b show the radiograph and CT scan of a 48-year-old man who has diffuse spinal pain. What is the most likely diagnosis?

. Rheumatoid arthritis
. Diffuse idiopathic skeletal hyperostosis (DISH)
. Normal findings
. Ankylosing spondylitis
. Osteopetrosis

Correct Answer & Explanation

. Ankylosing spondylitis

Explanation

The studies show marginal syndesmophyte formation characteristic of ankylosing spondylitis. These patients typically have diffuse ossification of the disk space without large osteophyte formation. DISH typically presents with large osteophytes, referred to as nonmarginal syndesmophytes. In this patient, the zygoapophyseal joints are fused rather than degenerative as would be seen in rheumatoid arthritis, and the costovertebral joints are also fused. Osteopetrosis does not normally ankylose the disk space. McCullough JA, Transfeldt EE: Macnab's Backache, ed 3. Baltimore, MD, Williams and Wilkins, 1997, pp 190-194.

Question 2940

Topic: 6. Spine

Following an episode of transient quadriplegia in contact sports, an athlete's return to play is absolutely contraindicated when

. the spinal canal to vertebral body ratio (Torg ratio) is less than or equal to 0.8.
. electromyelographic studies are abnormal.
. MRI scans or contrast-enhanced CT scans show severe spinal stenosis.
. unilateral burning pain persists.
. the episode of quadriplegia lasts 5 minutes.

Correct Answer & Explanation

. MRI scans or contrast-enhanced CT scans show severe spinal stenosis.

Explanation

Return to play decisions after traumatic spinal or spinal cord injury are not always clear-cut and often must be made on a patient-by-patient basis. The Torg ratio has been found to have low sensitivity in patients with large vertebral bodies. Abnormal electromyographic studies can persist in the face of normal function and do not define spinal injury. Duration of quadriplegia is not related to anatomic pathology. Findings on MRI scans or contrast-enhanced CT scans consistent with stenosis include lack of a significant cerebrospinal fluid signal around the cord, bony or ligament hypertrophy, or disk encroachment. Based on these findings, return to play should be avoided. Cantu RC, Bailes JE, Wilberger JE Jr: Guidelines for return to contact or collision sport after a cervical spine injury. Clin Sports Med 1998;17:137-146. Herzog RJ, Wiens JJ, Dillingham MF, Sontag MJ: Normal cervical spine morphometry and cervical stenosis in asymptomatic professional football players: Plain film radiography, multiplanar computer tomography, and magnetic resonance imaging. Spine 1991;16:178-186.

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