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 3061
Topic: 6. Spine
A skeletally mature 15-year-old girl who was thrown from the car in a rollover accident sustained the injuries shown in Figures 23a through 23d. Examination reveals no neurologic deficit, but the patient has moderate posterior spinal tenderness at the level of the injury. What is the most appropriate treatment?
Correct Answer & Explanation
. Thoracolumbosacral orthosis (TLSO) molded in extension
Explanation
The majority of patients with thoracolumbar burst fractures without neurologic deficit can be effectively treated with a TLSO or a hyperextension body cast. Indications for surgery are neurologic deficit and/or significant deformity (greater than 50% loss of anterior vertebral body height or marked kyphosis). Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 197-217.
Question 3062
Topic: 6. Spine
Figure 23 shows the radiograph of a 7 year-old girl with a low thoracic-level myelomeningocele. She has a history of skin ulcers over the apex of the deformity, but her current skin condition is good. Management of the spinal deformity should consist of
Correct Answer & Explanation
. kyphectomy and posterior fusion with instrumentation.
Explanation
This form of severe kyphosis results in intractable difficulties with sitting position, compression of internal organs, and chronic skin breakdown. Kyphectomy and posterior fusion with instrumentation, while associated with a high rate of complications, provides one of the best solutions to this clinical dilemma. The other choices are either completely ineffective or inadequate in managing this degree of deformity. Lindseth RE: Spine deformity in myelomeningocele. Instr Course Lect 1991;40:273-279.
Question 3063
Topic: 6. Spine
A 25-year-old man has chronic back pain that has been slowly worsening. He has no constitutional symptoms, and he denies any previous medical problems. Examination shows a tall lean build with no objective neurologic findings or skin lesions. Figure 32 shows a T2-weighted sagittal MRI scan. What is the most likely diagnosis?
Correct Answer & Explanation
. Marfan syndrome
Explanation
The MRI scan shows significant dural ectasia, which is seen in more than 60% of patients with Marfan syndrome. It is also relatively common in patients with neurofibromatosis, but this patient has no skin lesions. It has also been described in Ehlers-Danlos syndrome but is less common. Ahn NU, Sponseller PD, Ahn UM, Nallamshetty L, Kuszyk BS, Zinreich SJ: Dural ectasia is associated with back pain in Marfan' syndrome. Spine 2000;25:1562-1568.
Question 3064
Topic: 6. Spine
A 45-year-old woman has idiopathic scoliosis. Surgery is to include an anterior thoracic release through an open left thoracotomy. The thoracotomy will have what effect on the patient's pulmonary function postoperatively?
Correct Answer & Explanation
. Reduced postoperatively and often remains reduced long term
Explanation
A thoracotomy in an adult with idiopathic scoliosis causes a reduction in pulmonary function that often does not return to preoperative levels. What pulmonary function that does recover, recovers over many months. Long-term improvement in pulmonary function, compared to preoperative function, is rarely seen. This should be considered in planning surgical intervention in adults with scoliosis. Graham EJ, Lenke LG, Lowe TG, et al: Prospective pulmonary function evaluation following open thoracotomy for anterior spinal fusion in adolescent idiopathic scoliosis. Spine 2000;25:2319-2325.
Question 3065
Topic: 6. Spine
A patient who underwent an L5-S1 diskectomy 18 months ago has persistent pain in the left leg. Figures 9a and 9b show postoperative axial T1-weighted MRI scans at the L5-S1 level without and with gadolinium. What is the most likely diagnosis?
Correct Answer & Explanation
. Left S1 perineural fibrosis
Explanation
Persistent or recurrent symptoms after lumbar diskectomy are troublesome and can be difficult to assess. Gadolinium-enhanced MRI scans may be helpful. The images show enhancement about the left S1 root, a finding that is most consistent with perineural (epidural) fibrosis. The root itself does not enhance. Root enhancement has been associated with compressive radicular symptoms. A disk herniation does not enhance with gadolinium. A neurilemmoma enhances with gadolinium, but the involved root would be enlarged. There is no evidence of a fluid collection which would be consistent with an epidural abscess. Babar S, Saifuddin A: MRI of the post-discectomy lumbar spine. Clin Radiol 2002;57:969-981. Kikkawa I, Sugimoto H, Saita K, et al: The role of Gd-enhanced three-dimensional MRI fast low-angle shot (FLASH) in the evaluation of symptomatic lumbosacral nerve roots. J Orthop Sci 2001;6:101-109.
Question 3066
Topic: 6. Spine
Figures 29a and 29b show the AP and lateral radiographs of a 30-year-old man who has increasingly worse back pain and stiffness. Examination shows painful, limited spinal range of motion. There is no neurologic deficit. What laboratory study would be most helpful in confirming the diagnosis?
Correct Answer & Explanation
. HLA-B27
Explanation
The radiographs show ankylosing spondylitis with sclerosis of the sacroiliac joints and a "bamboo spine" in the lumbar region. HLA-B27 is positive in 80% to 90% of patients with ankylosing spondylitis and in about 8% of the general population. The findings do not represent diffuse idiopathic skeletal hyperostosis (DISH), which is a radiographic diagnosis in which there are three consecutive levels of nonmarginated osteophytes without disk degeneration. Calin A: Ankylosing spondylitis. Clin Rheum Dis 1985;11:41-60. Booth R, Simpson J, Herkowitz H: Arthritis of the spine, in Herkowitz HH (ed): The Spine, ed 4. Philadelphia, PA, WB Saunders, 1992, p 431.
Question 3067
Topic: 6. Spine
Figure 7 shows the radiograph of a 64-year-old man who has neck pain and weakness of the upper and lower extremities following a motor vehicle accident. Examination reveals 3/5 quadriceps and 4/5 hip flexors but no ankle dorsiflexion or plantar flexion. His intrinsics are 1/5, with finger flexors of 3/5. He is awake, alert, and cooperative. Management should consist of
Correct Answer & Explanation
. MRI.
Explanation
In patients with facet dislocations and an incomplete neurologic deficit, early decompression of the canal via reduction of the dislocation generally is considered safe if the patient is alert and can cooperate. However, patients who cannot cooperate with serial neurologic examinations during the reduction are at risk for increased deficit secondary to herniated nucleus pulposus, and MRI should be performed prior to either closed or open reduction. Star AM, Jones AA, Cotler JM, et al: Immediate closed reduction of cervical spine dislocations using traction. Spine 1990;15:1068-1072.
Question 3068
Topic: Thoracolumbar Spine & Deformity
A 16-year-old boy has abdominal and back pain after being involved in a high-velocity head-on motor vehicle accident. He was restrained in the rear of the automobile by a lap belt only. A radiograph and CT scan are shown in Figure 47. The patient has no other injuries. Optimal management should include
Correct Answer & Explanation
. cast immobilization in hyperextension for 6 weeks, followed by a thoracolumbosacral orthosis.
Explanation
Pediatric bony Chance fractures occur following severe flexion injuries as seen after motor vehicle accidents with lap belt restraints. There is a high rate of associated intra-abdominal injuries. In the absence of associated injuries, these fractures are best treated with immobilization. Bed rest is not necessary. Surgical fixation usually is not needed. Surgical stabilization and two-level fusion may be indicated in select individuals with progressive kyphosis of more than 25 degrees or other conditions that preclude cast or brace immobilization. Greenwald TA, Mann DC: Pediatric seatbelt injuries: Diagnosis and treatment of lumbar flexion-distraction injuries. Paraplegia 1994;32:743-751. Glassman SD, Johnson JR, Holt RT: Seatbelt injuries in children. J Trauma 1992;33:882-886.
Question 3069
Topic: 6. Spine
During anterior surgery on the cervical spine, at what level would the lateral dissection of the longus coli muscle most likely cause Horner's syndrome?
Correct Answer & Explanation
. C6
Explanation
The sympathetic chain approaches the lateral border of the longus coli muscle at C6 and is more vulnerable to injury at this level. Injury to the chain will cause Horner's syndrome, usually seen as unilateral ptosis.
Question 3070
Topic: 6. Spine
Subluxation caused by rheumatoid arthritis is most commonly seen at what level of the cervical spine?
Correct Answer & Explanation
. C1-C2
Explanation
Approximately 65% of cervical subluxations occur at C1-C2. Of these, 50% are anterior, with the remainder being lateral and posterior. The second most common type is basilar invagination, occurring in 40% of patients. The third most common type is subaxial, occurring in 20% of patients with rheumatoid arthritis. Subluxation at more than one level is common. Boden S, Clark CR: Rheumatoid arthritis of the cervical spine, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, p 693. Boden SD, Dodge LD, Bohlman HH, Rechtine GR: Rheumatoid arthritis of the cervical spine: A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am 1993;75:1282-1297.
Question 3071
Topic: 6. Spine
A 40-year-old carpenter has a 3-month history of right arm pain and neck pain that now leaves him unable to work. Examination reveals a positive Spurling test, weakness of the biceps, and a mildly positive Hoffman's sign on the right side. Electromyography and nerve conduction velocity studies show a right C6 deficit. Figures 27a through 27c show MRI scans that reveal two-level spondylotic disease at C5-6 and C6-7, a large herniated nucleus pulposus at C5-6, and a prominent ridge and hard disk at C6-7. Nonsurgical management fails to provide relief, so the patient elects surgical intervention. Which of the following surgical options would give the best long-term results?
Correct Answer & Explanation
. Two-level diskectomy at C5-6 and C6-7, with fusion at C5-7
Explanation
The patient has a single-level deficit by clinical examination but an adjacent level that may be pathologic. Hilibrand and associates, in a review of 374 patients with myeloradiculopathy treated with single-level or multilevel anterior cervical diskectomy and fusion, showed that 25% of patients had an occurrence of new radiculopathy or myelopathy at an adjacent level within 10 years after surgery. Reoperation rates were highest in those patients where the adjacent nonfused segment was C5-6 or C6-7. Those patients who had multilevel fusions had a lower incidence of adjacent segment disease. The authors recommended incorporating an adjacent level in the initial procedure in patients with myelopathy or radiculopathy when significant disease was noted. Posterior keyhole foraminotomy is an excellent procedure for single-level radiculopathy but is not effective in relieving myelopathy. Anterior cervical diskectomy without fusion has an increased incidence of hypermobility and neck pain on long-term follow-up. In a later review, these authors reported improved fusion rates and better clinical outcomes with the use of strut fusions instead of multilevel interbody grafts. Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman HH: Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg Am 1999;81:519-528. Henderson CM, Hennessy RG, Shuey HM Jr, Shackelford EG: Posterior-lateral foraminotomy as an exclusive operative technique for cervical radiculopathy: A review of 846 consecutively operated cases. Neurosurgery 1983;13:504-512.
Question 3072
Topic: 6. Spine
A 65-year-old woman has significant neck pain after falling and striking her head. A radiograph and sagittal CT scan are shown in Figures 23a and 23b. What is the most likely diagnosis?
Correct Answer & Explanation
. Perched unilateral facet dislocation
Explanation
The radiograph shows a displacement of C5 on C6 of approximately 25%. The CT scan shows a perched facet at C5-6. There is no evidence of a facet fracture. A bilateral facet dislocation would show a displacement of more than 50%. Rothman RH, Simeone FA (eds): The Spine, ed 4. Philadelphia PA, WB Saunders, 1999, pp 927-937.
Question 3073
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 degrees. 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
Because the patient is skeletally mature with a curve of less than 40 degrees, there is no benefit to bracing and surgery is not indicated. Management should consist of observation and follow-up radiographs in 6 months. Lonstein JE, Carlson JM: The prediction of curve progression in untreated idiopathic scoliosis during growth. J Bone Joint Surg Am 1984;66:1061-1071.
Question 3074
Topic: Thoracolumbar Spine & Deformity
A 19-year-old woman reports lower back pain following a motor vehicle accident. Radiographs obtained immediately after the accident and a bone scan obtained 4 weeks later are shown in Figures 25a through 25c. The patient asks questions regarding the cause, genetics, and natural history of her condition. She should be informed that the condition was
Correct Answer & Explanation
. preexisting to her accident, exists in 5% of the population, has a familial predisposition, and is unlikely to progress.
Explanation
The radiographs show L5 spondylolysis without spondylolisthesis (slip). The bone scan is normal, indicating that the pars interarticularis fractures are not acute. The incidence of spondylolysis is approximately 5% in the general population. The lesion generally develops in children age 5 to 6 years, and there is a second peak in the adolescent population. There is a familial predisposition, with reported rates of 27% to 69% in close relatives. A recent long-term follow-up study found that 90% of the spondylolisthesis had occurred before the patient's first visit to the physician. Spondylolisthesis tends to progress during the initial growth spurt and is similar in some respects to idiopathic scoliosis. Progression of a lytic spondylolysis to spondylolisthesis in adulthood has been reported; however, this is exceedingly rare. Lauerman WC, Cain JE: Isthmic spondylolisthesis in the adult. J Am Acad Orthop Surg 1996;4:201-208. Hensinger RN: Spondylolysis and spondylolisthesis in children and adolescents. J Bone Joint Surg Am 1989;71:1098-1107. Seitsalo S, Osterman K, Hyvarinen H, Tallroth K, Schlenzka D, Poussa M: Progression of spondylolisthesis in children and adolescents: A long-term follow-up of 272 patients. Spine 1991;16:417-421.
Question 3075
Topic: 6. Spine
A 71-year-old woman undergoes a posterior lumbar decompression and fusion from L4-S1. Thirty-six hours after the procedure, she reports severe right-sided chest pain and shortness of breath. Doppler ultrasound reveals a clot proximal to the knee within the femoral vein. A large pulmonary embolus is confirmed by CT angiography. The next most appropriate step in management should consist of
Correct Answer & Explanation
. placement of a vena cava filter.
Explanation
In a review of 13,000 spinal procedures, nine patients were treated with heparin following development of pulmonary emboli. Of these patients, six had serious complications ranging from wound drainage to paralysis. Heparin therapy instituted within 10 days of the surgical procedure resulted in a 100% complication rate. Vena cava filter placement has a complication rate of 0.12% to 10.1%. Removable filters are currently in clinical trials. Cain JE Jr, Major MR, Lauerman WC, et al: The morbidity of heparin therapy after development of pulmonary embolus in patients undergoing thoracolumbar or lumbar spinal fusion. Spine 1995;20:1600-1603. Roberts AC: Venous imaging and inferior vena cava filters. Curr Opin Radiol 1992;4:88-96.
Question 3076
Topic: 6. Spine
An 18-year-old man sustained a knife injury to his midback, with the entry wound 2 cm to the left of the midline. He has been diagnosed with a hemicord transection. Neurologic examination will most likely reveal left-sided loss of
Correct Answer & Explanation
. vibratory and light touch sensation and motor function, and right-sided loss of pain and temperature sensation.
Explanation
Brown-Sequard syndrome results from an injury to one half of the spinal cord and is characteristically seen in penetrating injuries. The spinothalamic fibers cross the midline below the level of the lesion, resulting in contralateral loss of pain and temperature sensation. The posterior columns and corticospinal tracts carry vibratory, position, and light touch sensation, as well as motor function from the ipsilateral side of the body. This results in the characteristic neurologic findings seen with Brown-Sequard syndrome. Northrup BE, Evaluation and early treatment of acute injuries to the spine and spinal cord, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 541-549.
Question 3077
Topic: 6. Spine
Figure 12 shows the lumbar CT scan of a 24-year-old man who was injured in a snowmobile accident. What is the mechanism of injury?
Correct Answer & Explanation
. Vertical compression
Explanation
A true compression fracture is a single-column injury that does not create canal compromise. A burst fracture is a two- or three-column injury that disrupts the middle column and thereby narrows the spinal canal. This patient has a burst fracture. The mechanism of injury is usually vertical compression or flexion compression. Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 197-217.
Question 3078
Topic: 6. Spine
A 62-year-old man with a long history of ankylosing spondylitis has neck pain after lightly bumping his head on the wall. Examination reveals neck pain with any attempted motion; the neurologic examination is normal. Plain radiographs show extensive ankylosis of the cervical spine and kyphosis but no fracture. What is the next most appropriate step in management?
Correct Answer & Explanation
. Immobilization of the neck, followed by CT with reconstruction
Explanation
A high level of suspicion must be given for a fracture in any patient with ankylosing spondylitis who reports neck pain, even with minimal or no trauma. The neck should be immobilized in its normal position, which is often kyphotic, and plain radiographs should be obtained. If no obvious fracture is seen, CT with reconstruction should be obtained. The placement of in-line traction can have catastrophic effects because it may malalign the spine. Brigham CD: Ankylosing spondylitis and seronegative spondyloarthropathies, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 724-727.
Question 3079
Topic: 6. Spine
Figure 6 shows the lateral radiograph of a 22-year-old woman who has painful Scheuermanns's kyphosis in the middle and lower thoracic spine. When planning surgical correction using instrumentation, the distal aspect of the instrumentation should ideally extend to the
Correct Answer & Explanation
. first lordotic segment of the lumbar spine.
Explanation
Posterior constructs for Scheuermann's kyphosis ideally should extend from the most superior to the most inferior aspect of the Cobb angulation. However, the most distal fusion level must be in a stable or lordotic position to avoid the development of junctional kyphosis. Lowe reported that failure to incorporate the first lordotic segment of the lumbar spine is associated with a higher risk of junctional kyphosis. The first lordotic segment of the lumbar spine is typically at least one level below the distal aspect of the curve as measured by the Cobb technique and most commonly is in the upper part of the lumbar spine. Lowe TG: Scheuermann's disease. Orthop Clin North Am 1999;30:475-487.
Question 3080
Topic: Cervical Spine
Figure 21 shows the tomogram of a 26-year-old woman who sustained an axial load injury to her neck in a fall off a horse. What ligament is injured?
Correct Answer & Explanation
. Transverse
Explanation
Levine and Edwards, in their description of the classic C1 burst (Jefferson) fracture, noted that spread of the lateral masses of more than 7 mm is indicative of a transverse ligament rupture. Long-term C1-C2 instability, however, has not been described with this fracture pattern. Although long-term traction followed by halo vest immobilization has been described as the best technique for achieving an ideal result, treatment of this injury remains somewhat controversial. Levine AM, Edwards CC: Fractures of the atlas. J Bone Joint Surg Am 1991;73:680-691.
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