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6. Spine MCQs

Practice Set 155 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 3081

Topic: 6. Spine

A 46-year-old woman who was involved in a motor vehicle accident reports a 4-month history of right-sided lower back pain and pain radiating into the right thigh. The patient underwent an extensive 3-month course of physical therapy and now is dependent on narcotic medication for pain control. Epidural injection therapy has failed to improve her symptoms. Examination is significant for weakness of hip flexion in the seated position and for decreased sensation to light touch in the medial anterior thigh region. Straight leg raise is negative, but the femoral stretch test reproduces anterior thigh pain. A CT myelogram image, at L3-L4, is shown in Figure 3. What is the most appropriate management at this time?

Spine Surgery 2009 Practice Questions: Set 1 (Solved) - Figure 14

. Repeat epidural steroid injections
. Wide lumbar laminectomy
. Microdiskectomy from either a midline approach or far lateral approach
. Referral to pain management
. Minimally invasive posterior lumbar interbody fusion

Correct Answer & Explanation

. Microdiskectomy from either a midline approach or far lateral approach

Explanation

The CT scan reveals a right-sided lateral disk protrusion at L3-4 that has been symptomatic for more than 4 months despite appropriate nonsurgical management. Relative surgical indications include persistent radiculopathy despite an adequate trial of nonsurgical management, recurrent episodes of sciatica, persistent motor deficit with tension signs and pain, and pseudoclaudication caused by underlying stenosis. Whereas studies have shown improvement in patients with sciatica from a lumbar disk herniation treated either nonsurgically or surgically, those undergoing surgical treatment had an overall greater improvement of symptoms. Weinstein JN, Lurie JD, Tosteson TD, et al: Surgical vs nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006;296:2451-2459.

Question 3082

Topic: 6. Spine

A high school athlete reports the sudden onset of low back pain while performing a dead lift. Examination reveals a lumbar paraspinal spasm and a positive straight leg raising test. The deep tendon reflexes, motor strength, and sensation in the lower extremeties are normal. The radiographs are normal. If symptoms persist for more than a few weeks, management should consist of

. an electromyogram and nerve conduction velocity studies.
. an MRI scan.
. a bone scan.
. physical therapy.
. bed rest.

Correct Answer & Explanation

. an MRI scan.

Explanation

In adolescents, a lumbar herniated disk is characterized by a paucity of clinical findings; a positive straight leg raising test may be the only consistent positive finding. This may result in a long period of nonsurgical management that fails to provide relief. Activities that place a significant shear load on the lumbar spine, such as the dead lift, are associated with an increased risk of central disk herniation. When an adolescent who lifts weights has a history of low back pain that fails to respond to a short period of active rest, an MRI scan is the study of choice to evaluate for a lumbar herniated disk. Epstein JA, Epstein NE, Marc J, Rosenthal AD, Lavine LS: Lumbar intervertebral disk herniation in teenage children: Recognition and management of associated anomalies. Spine 1984;9:427-432.

Question 3083

Topic: 6. Spine

A previously healthy 30-year-old woman has neck pain and bilateral hand and lower extremity tingling with weakness after falling down stairs. She is alert and oriented. Examination reveals incomplete quadriplegia at the C6 level that remains unchanged throughout her evaluation and initial treatment. Radiographs show a bilateral facet dislocation of C6 on C7 without fracture. Attempts at reduction with halo cervical traction up to her body weight are unsuccessful. What is the next most appropriate step?

Spine Surgery Board Review 2006: High-Yield MCQs (Set 2) - Figure 4

. Posterior open reduction and fusion with fixation
. Anterior open reduction and fusion with fixation
. Technetium Tc 99m bone scan
. Closed manipulation
. MRI

Correct Answer & Explanation

. MRI

Explanation

A facet dislocation that cannot be reduced in an alert, awake patient with some preservation of cord function requires MRI to evaluate the disk prior to a reduction under anesthesia. The presence or absence of a disk herniation must be assessed, as this factor may influence the method of reduction. Vaccaro AR, Falatyn SP, Flanders AE, et al: Magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine dislocations. Spine 1999;24:1210-1217. Fardon DF, Garfin SR, Abitbol J (eds): Orthopaedic Knowledge Update: Spine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 247-262. Eismont FJ, Arena MJ, Green BA: Extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets. J Bone Joint Surg Am 1991;73:1555-1560.

Question 3084

Topic: 6. Spine
A collegiate football player who sustained an injury to his neck has significant neck pain and weakness in his extremities. Following immobilization, which of the following steps should be taken prior to transport?
. His helmet should be removed.
. His helmet and shoulder pads should be removed.
. His face mask should be removed.
. All equipment should be removed.
. No equipment should be removed.

Correct Answer & Explanation

. His face mask should be removed.

Explanation

Prior to transport, the face mask should be removed so that the airway can be easily accessible. If serious injury is suspected, the helmet and shoulder pads should be left in place until he is assessed at the hospital and radiographs are obtained. Leaving the helmet and shoulder pads in place helps to keep the spine in the most neutral alignment. Removal of the helmet will result in extension of the neck, whereas removal of the shoulder pads will most likely result in flexion of the neck.

Question 3085

Topic: 6. Spine

A 40-year-old woman with no history of back problems has a symptomatic L4-5 disk herniation with an L5 radiculopathy that has failed to respond to 12 weeks of nonsurgical management. In the preoperative discussion, the surgeon advises the patient that the chance of recurrence of the herniation after successful diskectomy is what percent?

. 0%
. 1%
. 5% to 10%
. 30% to 40%
. 70% to 80%

Correct Answer & Explanation

. 5% to 10%

Explanation

The incidence of recurrent disk herniation after a successful diskectomy is approximately 5% to 10%. Indications for surgical diskectomy for a recurrence are the same as for a primary diskectomy. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 685-698.

Question 3086

Topic: 6. Spine
A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. What is the most common sentinel event related to spine surgery?
. Surgery on the wrong patient
. Surgery on the wrong side
. Incorrect procedure performed
. Intraoperative death
. Surgery on the wrong level

Correct Answer & Explanation

. Surgery on the wrong level

Explanation

Patient safety and prevention of medical errors is a major focus of recent national advocacy groups. Analysis has shown that the most common sentinel event in spine surgery is surgery on the wrong level. Therefore, it is recommended that every patient have the surgical site signed, the level of surgery marked intraoperatively, and a radiograph taken. Surgery on the wrong level is most likely to occur in single-level decompressive procedures.

Question 3087

Topic: 6. Spine

Vertebral fractures are common in the thoracolumbar spine. What is the most important factor that determines the strength of the cancellous bone in the vertebral body?

. Mineral content
. Rate of loading
. Anatomic level of the vertebra
. Apparent density
. Trabecular number

Correct Answer & Explanation

. Apparent density

Explanation

Cancellous bone strength and stiffness are determined primarily by the apparent density (the amount of bone per unit volume). Strength varies approximately as the square of the density, and stiffness as the cube of the density; therefore, these are very strong relationships. Cancellous bone strength also depends on the mineral content, the rate of loading (it is viscoelastic), the anatomic level, and the trabecular number (an histomorphometry term), but all to a markedly lesser extent than density. Carter DR, Hayes WC: The compressive behavior of bone as a two-phase porous structure. J Bone Joint Surg Am 1977;59:954-962.

Question 3088

Topic: 6. Spine

A 25-year-old man is unresponsive at the scene of a high-speed motor vehicle accident and remains obtunded. Initial evaluation in the emergency department reveals a left-sided femoral shaft fracture and a right-sided humeral shaft fracture. The cervical spine remains immobilized in a semi-rigid cervical collar, and the initial AP and lateral radiographs obtained in the emergency department are unremarkable. What is the most appropriate management at this time?

. Lateral radiographs with passive flexion/extension views
. Helical CT scan of the cervical-thoracic region
. Careful manual palpation of the cervical spine for subtle defects or step-offs
. MRI of the cervical spine
. Continued use of the cervical collar until the patient becomes responsive for examination

Correct Answer & Explanation

. Helical CT scan of the cervical-thoracic region

Explanation

Clearance of the cervical spine can be difficult in the obtunded or unresponsive patient. Various trauma series have been reported to detect up to 95% of cervical fractures but only when ideal imaging views have been obtained, which is not often possible in the unresponsive or uncooperative patient. Passively performed cervical flexion-extension under live fluoroscopy has been suggested but is not without inherent risk in the potentially unstable cervical spine. CT of the cervical spine has gained acceptance for the evaluation of these patients given the excellent evaluation of the osseous anatomy and for the common availability in most emergency departments. Sanchez and associates, using a protocol to evaluate for cervical spine injuries after blunt trauma, were able to detect 99% of cervical fractures with 100% specificity. Chiu WC, Haan JM, Cushing BM, et al: Ligamentous injuries of the cervical spine in unreliable blunt trauma patients: Incidence, evaluation, and outcome. J Trauma 2001;50:457-463. Sanchez B, Waxman K, Jones T, et al: Cervical spine clearance in blunt trauma: Evaluation of a computed tomography-based protocol. J Trauma 2005;59:179-183.

Question 3089

Topic: 6. Spine

In the upright standing position, approximately what percent of the vertical load is borne by the lumbar spine facet joints?

Spine Surgery 2000 Practice Questions: Set 1 (Solved) - Figure 35

. 0%
. 20%
. 40%
. 60%
. 80%

Correct Answer & Explanation

. 20%

Explanation

Direct measurement and finite element modeling results show that approximately 20% of the vertical load is borne by the posterior structures of the lumbar spine in the upright position. Adams MA, Hutton WC: The effect of posture on the role of the apophyseal joints in resisting intervertebral compressive forces. J Bone Joint Surg Br 1980;62:358-362.

Question 3090

Topic: 6. Spine

Figures 25a and 25b show the radiograph and MRI scan of a 48-year-old man who reports increasing unsteadiness in his gait and hand clumsiness. Examination reveals a positive Hoffmann's reflex bilaterally, positive clonus, and a spastic gait. Management should consist of

. cervical laminoplasty at C3-C7.
. anterior corpectomy at C4, with a C3-C5 fibular strut.
. epidural steroids and physical therapy for cervical traction.
. multilevel cervical anterior diskectomy and fusion.
. observation for progression over the next few months.

Correct Answer & Explanation

. cervical laminoplasty at C3-C7.

Explanation

The patient has a congenitally small spinal canal with secondary multilevel degenerative changes causing stenosis and cord compression across multiple segments, including directly posterior to the vertebral bodies. A multilevel diskectomy may address the cord compression at the disk level, but not posterior to the bodies, and most likely would be inadequate. The patient has significant stenosis distal to C5, necessitating a more extensive surgical approach than simply C3-C5. Because the patient's cervical lordosis is preserved, a posterior procedure such as laminoplasty or laminectomy would allow the cord to fall away from the anterior pathology and afford decompression. Cervical myelopathy does not tend to resolve, and there is a significant risk for progression; therefore, surgical management usually is recommended. Edwards CC II, Riew KD, Anderson PA, et al: Cervical myelopathy: Current diagnostic and treatment strategies. Spine J 2003;3:68-81.

Question 3091

Topic: 6. Spine
Figure 16 shows the radiograph of a 56-year-old man who has neck pain after a rollover accident on his lawnmower. The injury appears to be isolated, and he is neurologically intact. Management of the fracture should consist of
. posterior C1-2 fusion.
. anterior C2-3 fusion.
. Gardner-Wells traction for 6 weeks, followed by 6 weeks of halo vest immobilization.
. halo vest immobilization.
. a hard collar.

Correct Answer & Explanation

. halo vest immobilization.

Explanation

The radiograph shows a type IIa Hangman's fracture, and the classic treatment is halo vest immobilization. Traction should be avoided in type IIa injuries because of the risk of overdistraction. A lesser form of immobilization such as a hard collar or a Minerva jacket can be used for nondisplaced (type I) fractures. Surgery generally is reserved for type III fractures (includes C2-3 facet dislocation), or extenuating circumstances such as multiple trauma or other fractures of the cervical spine that require surgical stabilization.

Question 3092

Topic: 6. Spine

A 44-year-old farmer involved in a rollover accident on his tractor sustained an L1 burst fracture with a 20% loss of anterior vertebral body height, 30% canal compromise, and 15 degrees of kyphosis. He remains neurologically intact. The preferred initial course of action should consist of

. posterior spinal fusion with instrumentation.
. a thoracolumbosacral orthosis (TLSO) extension brace and early mobilization.
. bed rest for 6 weeks followed by mobilization in a cast.
. anterior L1 corpectomy and fusion with instrumentation.
. anterior corpectomy followed by posterior fusion with instrumentation.

Correct Answer & Explanation

. a thoracolumbosacral orthosis (TLSO) extension brace and early mobilization.

Explanation

Surgical decompression is unnecessary in a patient with no neurologic deficit and canal compromise of less than 50%. A compression deformity of less than 50% and kyphosis of less than 30 degrees may be successfully treated with a TLSO extension brace. Deformity in this range will reliably heal with minimal risk for late deformity or residual pain. Although some studies suggest 6 weeks of bed rest as treatment, early mobilization and bracing is preferred. Hartman MB, Chrin AM, Rechtine GR: Nonoperative treatment of thoracolumbar fractures. Paraplegia 1995;33:73-76. Chow GH, Nelson BJ, Gebhard JS, Brugman JL, Brown CW, Donaldson DH: Functional outcome of thoracolumbar burst fractures managed with hyperextension casting or bracing and early mobilization. Spine 1996;21:2170-2175.

Question 3093

Topic: Cervical Spine

What is the structure indicated by the letter "A" in Figure 21?

Anatomy Board Review 2008: High-Yield MCQs (Set 2) - Figure 13

. Annular ligament
. Lateral ulnar collateral ligament
. Accessory collateral ligament
. Radial collateral ligament
. Transverse ligament

Correct Answer & Explanation

. Radial collateral ligament

Explanation

The ligaments shown are the components of the lateral collateral ligament complex, and the structure indicated by the letter "A" is the radial collateral ligament. The lateral ulnar collateral ligament is the structure indicated by the letter "C" and the annular ligament is indicated by the letter "B." The transverse ligament is a component of the medial collateral ligament complex. Morrey BF: Anatomy of the elbow joint, in Morrey BF (ed): The Elbow and Its Disorders. Philadelphia, PA, WB Saunders, 1993, p 30.

Question 3094

Topic: 6. Spine

A 16-year-old boy with spastic quadriplegic cerebral palsy has been referred for evaluation and management of scoliosis. His parents report increasing problems with sitting balance, positioning, and hygiene because of the deformity. The radiograph shown in Figure 46 reveals a lordoscoliosis of 105 degrees with marked pelvic obliquity. Attempts at correcting the pelvic obliquity on supine bending radiographs show significant rigidity. Management should consist of

Pediatrics Board Review 2001: High-Yield MCQs (Set 4) - Figure 1

. a thoracolumbosacral orthosis.
. posterior spinal fusion.
. anterior and posterior spinal fusion.
. electrical stimulation.
. wheelchair modifications.

Correct Answer & Explanation

. anterior and posterior spinal fusion.

Explanation

Spinal stabilization is the treatment of choice in patients with severe scoliosis who have progressive positioning, sitting balance, and/or hygiene problems despite maximal nonsurgical management. Pelvic rigidity and marked frontal plane deformity necessitate anterior and posterior procedures so as to maximize correction and fusion. Weinstein SL (ed): The Pediatric Spine: Principles and Practice. New York, NY, Raven Press, 1994, pp 977-997.

Question 3095

Topic: 6. Spine

A 10-month-old girl has the spinal deformity shown in Figures 55a and 55b with no apparent neurologic finding. The next step in evaluation should be to obtain

. a genitourinary ultrasound.
. an MRI scan of the spine.
. an AP radiograph of the pelvis.
. an electromyogram and nerve conduction velocity studies.
. an echocardiogram.

Correct Answer & Explanation

. a genitourinary ultrasound.

Explanation

Approximately 60% of patients with a congenital spine abnormality have associated malformations outside the spinal column. Genitourinary abnormalities are probably the most common, occurring in up to 37% of patients. These are usually anatomic anomalies, such as renal agenesis, duplication, fusion, and ectopia. A genitourinary ultrasound is the least invasive screening tool. Other associated anomalies include cervical vertebral abnormalities, VATER syndrome, and intraspinal abnormalities such as diastematomyelia. An MRI scan is not recommended as part of the screening examination; however, if the patient had neurologic signs or symptoms, an MRI scan would be indicated. Beals RK, Robbins JR, Rolfe B: Anomalies associated with vertebral malformations. Spine 1993;18:1329-1332.

Question 3096

Topic: 6. Spine

A 14-year-old girl with polyarticular juvenile rheumatoid arthritis (JRA) has severe neck pain and reports the onset of urinary incontinence. A lateral radiograph and lateral tomogram of the cervical spine are shown in Figures 15a and 15b. An MRI scan of the upper cervical spine is shown in Figure 15c. Management should consist of

. a rigid cervical orthosis.
. a soft cervical collar.
. posterior C1-2 fusion with halo immobilization.
. administration of methotrexate.
. activity restrictions.

Correct Answer & Explanation

. posterior C1-2 fusion with halo immobilization.

Explanation

The plain radiograph and tomogram show an abnormality of the upper cervical spine, with erosion of the dens. The MRI scan shows evidence of cord impingement. The cervical spine is frequently involved in polyarticular JRA. Stiffness and autofusion are commonly seen, but C1-2 instability can also occur secondary to synovitis and bony erosion. Basilar invagination is rare in JRA. There is no consensus regarding fusion in the asymptomatic patient. In patients with symptoms and neurologic signs, C1-2 posterior fusion is indicated. Fried JA, Athreya B, Gregg JR, Das M, Doughty R: The cervical spine in juvenile rheumatoid arthritis. Clin Orthop 1983;179:102-106.

Question 3097

Topic: 6. Spine

What is the most common neurologic complication following an anterior cervical diskectomy and fusion?

. Spinal cord injury
. Nerve root injury
. Vagus nerve injury
. Recurrent laryngeal nerve injury
. Horner's syndrome

Correct Answer & Explanation

. Recurrent laryngeal nerve injury

Explanation

The recurrent laryngeal nerve provides innervation to the vocal cords and was the most common neurologic injury reported in a series of 36,000 patients. The nerve is felt to be more vulnerable during a right-sided approach because of its anatomic course. A recent study has also suggested a role for increased endotracheal cuff pressures in this nerve injury. Flynn TB: Neurologic complications of anterior cervical interbody fusion. Spine 1982;7:536-539.

Question 3098

Topic: 6. Spine

A 20-year-old college athlete is seen for follow-up after sustaining an injury at football practice 2 days ago. He reports that he tackled a player and felt neck pain and numbness in both arms. The numbness resolved within seconds, but his neck remains painful and stiff. He denies any history of neck pain or injury. Examination reveals limited neck motion. The neurologic examination and radiographs are normal. MRI scans of the cervical spine are shown in Figure 34. During counseling, the patient, his family, and his coach should be informed that he has an acute cervical disk herniation and cannot play

Spine Surgery Board Review 2000: High-Yield MCQs (Set 4) - Figure 8

. until his symptoms resolve and the MRI findings return to normal.
. until his symptoms resolve and his physical examination findings return to normal.
. until he undergoes surgical decompression.
. until he undergoes surgical decompression and fusion.
. again because it is considered a career-ending injury.

Correct Answer & Explanation

. until his symptoms resolve and his physical examination findings return to normal.

Explanation

A player who has an acute cervical disk herniation should not be allowed to return to play until the acute phase is over. Certain players with large herniations may require surgery before returning to play to eliminate the risk of disk-related stenosis and cord compression. Morganti C, Sweeney CA, Albanese SA, Burak C, Hosea T, Connolly PJ: Return to play after cervical spine injury. Spine 2001;26:1131-1136.

Question 3099

Topic: Thoracolumbar Spine & Deformity

Which of the following clinical scenarios represents an appropriate indication for convex hemiepiphysiodesis/hemiarthrodesis in the treatment of a child with a congenital spinal deformity?

. A 3-year-old child with a hemivertebra opposite a contralateral bar and thoracic scoliosis that measures 53 degrees
. A 4-year-old child with a fully segmented L1 hemivertebra and scoliosis that measures 80 degrees
. A 4-year-old child with a fully segmented T10 hemivertebra and scoliosis that measures 50 degrees
. A 4-year-old child with a posterolateral hemivertebra at the thoracolumbar junction and a kyphoscoliotic deformity that measures 45 degrees
. A 10-year-old child with a hemivertebra and scoliosis that measures 50 degrees

Correct Answer & Explanation

. A 4-year-old child with a fully segmented T10 hemivertebra and scoliosis that measures 50 degrees

Explanation

Convex hemiarthrodesis and hemiepiphysiodesis are procedures designed to gradually reduce curve magnitude in congenital scoliosis because of hemivertebrae. They are used to surgically create an anterior and posterior bar to arrest growth on the convexity of the existing deformity. Success of the technique is predicated on continued growth on the concave side of the deformity. Prerequisites for this procedure include curves of limited length (less than or equal to five vertebrae), curves of reasonable magnitude (less than 70 degrees), absence of kyphosis, concave growth potential, and appropriate age (younger than age 5 years).

Question 3100

Topic: 6. Spine
Which of the following findings is considered a poor prognostic factor for postoperative neurologic recovery in patients with rheumatoid arthritis?
. Anterior atlantoaxial interval of more than 5 mm
. Subaxial subluxation of more than 3.5 mm
. Subaxial subluxation and space available for the cord equal to 14 mm
. Cervicomedullary angle of 135 degrees
. Posterior atlantoaxial interval that is less than or equal to 10 mm

Correct Answer & Explanation

. Posterior atlantoaxial interval that is less than or equal to 10 mm

Explanation

When markedly diminished space available for the cord (demonstrated by a posterior atlantoaxial interval of less than 10 mm) is seen, there is a poor prognosis for recovery (25% of Ranawat class IIIb patients) following surgery. A posterior atlantoaxial interval of 14 mm or less is a predictor of increased risk of paralysis, but patients with an interval between 10 mm and 14 mm have a greater chance of recovery. Space available for the cord that is at least 14 mm is not associated with an increased risk of neurologic deficit. Boden SD, Dodge LD, Bohlman HH, et al: 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.

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