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6. Spine MCQs

Practice Set 157 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 3121

Topic: 6. Spine

Figure 16 shows the MRI scan of a 43-year-old man who has had worsening low back pain for the past 4 months. What is the most likely diagnosis?

Spine Surgery Board Review 2009: High-Yield MCQs (Set 2) - Figure 25

. Osteochondroma
. Posttraumatic kyphosis
. Staphylococcus aureus osteomyelitis
. Ankylosing spondylitis
. Tuberculosis

Correct Answer & Explanation

. Tuberculosis

Explanation

Tuberculosis of the spine is seen in 50% to 60% of skeletal disease and is most commonly found in the lower thoracic or upper lumbar spine. Typically two or more adjacent bodies are involved as seen in this MRI scan. The disk space is narrowed but still relatively preserved as opposed to pyogenic infections (black arrow). Epidural extensions often spread from vertebrae to vertebrae (white arrow); however, the posterior elements are not frequently involved (arrowhead). Tumors rarely spread to adjacent vertebrae. The anterior and posterior spread of the infectious process rules out trauma. Boachie-Adjei O, Squillante RG: Tuberculosis of the spine. Orthop Clin North Am 1996;27:95-103.

Question 3122

Topic: 6. Spine

A 36-year-old woman has neck pain in the upper cervical region and occipital discomfort after being involved in a motor vehicle accident. Examination reveals no forehead or scalp lacerations. The neurologic examination is normal. A CT scan shows no evidence of bony injury. Figures 39a and 39b show a lateral radiograph and an MRI scan. Management should consist of

. a hard cervical collar for 6 weeks.
. skeletal traction for 6 weeks, followed by halo vest immobilization for 6 weeks.
. halo vest immobilization for 3 months.
. posterior cervical C1-2 wiring with arthrodesis.
. anterior C2-3 diskectomy, fusion, and plating.

Correct Answer & Explanation

. posterior cervical C1-2 wiring with arthrodesis.

Explanation

The lateral radiograph shows 8 mm of atlantoaxial translation. In the absence of a bony injury, this represents rupture of the transverse atlantal ligament. The MRI scan reveals soft-tissue swelling posterior to the odontoid and a high intensity zone in the atlanto-dens interval consistent with acute injury. These injuries require arthrodesis because nonsurgical measures will not provide stability. Techniques for C1-2 fusion include Gallie, Brooks, or triple wiring. Transarticular screw fixation across the C1-2 articulation provides the most rigid means of fixation and the highest arthrodesis rates but is technically demanding. Anterior C2-3 arthrodesis will not address the level of instability. The normal atlanto-dens interval is 3 mm in an adult and 4 mm in a child. Kurz LT: Transverse atlantal ligament insufficiency, in Clark CR (ed): The Cervical Spine. Philadelphia, PA, Lippincott-Raven, 1998, pp 401-407.

Question 3123

Topic: 6. Spine

A patient who has had neck pain radiating down the arm for the past 4 weeks reports that the pain was excruciating during the first week. Management consisting of anti-inflammatory drugs and physical therapy has decreased the neck and arm symptoms from 10/10 to 3/10. He remains neurologically intact. MRI and CT scans are shown in Figures 5a and 5b. The best course of action should be

. immediate hospital admission and surgery because of the risk of paralysis.
. surgery within 24 hours.
. surgery within the next several days.
. elective surgery at the next available surgical date.
. additional nonsurgical management.

Correct Answer & Explanation

. additional nonsurgical management.

Explanation

Although the patient has a large herniated nucleus pulposus, the pain has decreased from 10/10 to 3/10 over a 4-week period and the patient is now free of any neurologic symptoms. It is quite likely that further nonsurgical management will continue to resolve his symptoms. In the absence of any neurologic deficits, there is no evidence that the patient is at significant risk for paralysis. Saal JS, Saal JA, Yurth EF: Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Spine 1996;21:1877-1883.

Question 3124

Topic: 6. Spine

A 42-year-old man with a history of renal cell carcinoma has progressive weakness in the lower extremities for the past 3 weeks. The patient desires intervention. A sagittal T2-weighted MRI scan is shown in Figure 9a, and a sagittal contrast enhanced T1-weighted MRI scan is shown in Figure 9b. He currently ambulates minimal distances with a walker. His life expectancy is 8 months. Treatment of the spine lesion should consist of

. radiation therapy.
. posterior laminectomy.
. anterior corpectomy and reconstruction.
. posterior laminectomy and fusion.
. kyphoplasty.

Correct Answer & Explanation

. anterior corpectomy and reconstruction.

Explanation

The MRI scans show a metastatic lesion in two contiguous vertebral bodies in the lower thoracic spine. Posterior laminectomy is not indicated because this does not adequately decompress the neural elements and will lead to progressive kyphosis. A posterior fusion may prevent progressive kyphosis but will not decompress the spinal cord. Renal cell carcinoma is not radiosensitive; therefore, radiation therapy would not be helpful in relieving neurologic compression. The lesion should be treated by an anterior corpectomy and reconstruction. This will allow for complete decompression as well as reconstruction of the anterior column. Kyphoplasty is not indicated in a lesion with disruption of the posterior cortex and neurologic impairment. Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 351-366.

Question 3125

Topic: 6. Spine

A 19-year-old man who sustained a spinal cord injury in a motor vehicle accident 3 days ago has 5/5 full strength in the deltoids and biceps bilaterally, 4/5 strength in wrist extension bilaterally, 1/5 triceps function on the right side, and 2/5 triceps function on the left side. The patient has no detectable lower extremity motor function. Based on the American Spinal Injury Association's classification, what is the patient's functional level?

. C4
. C5
. C6
. C7
. C8

Correct Answer & Explanation

. C6

Explanation

By convention when determining the motor level, the key muscle must be at least 3/5. The next most rostral level must be 4/5. Therefore, this patient's functional level is C6.

Question 3126

Topic: 6. Spine

A 24-year-old professional football player underwent surgery for a symptomatic cervical disk herniation with radiculopathy 9 months ago. A current radiograph is shown in Figure 17. He has normal neurologic findings, no pain, and full range of motion. A CT scan shows a solid fusion. When can he expect to return to play?

Spine Surgery 2006 Practice Questions: Set 3 (Solved) - Figure 2

. Immediately
. In three games
. After anterior plate removal
. Next season
. Cannot return

Correct Answer & Explanation

. Immediately

Explanation

The radiograph shows that the two-level anterior cervical diskectomy and fusion has healed. In addition, the patient has good range of motion and the neurologic examination is normal. Based on these findings, the patient can return to play immediately. Patients with one- or two-level anterior cervical diskectomies and fusions that have healed fully can return to play. Any loss of motion, persistent neurologic deficit, or significant adjacent segment degeneration may preclude a player from returning. Thomas B, McCullen GM, Yuan HA: Cervical spine injuries in football players. J Am Acad Orthop Surg 1999;7:338-347.

Question 3127

Topic: 6. Spine

A 35-year-old woman reports an 8-week history of neck pain radiating to her right upper extremity. She denies any history of trauma or provocative event. Examination reveals decreased pinprick sensation in her right middle finger, otherwise sensation is intact bilaterally. Finger flexors and interossei demonstrate 5/5 motor strength bilaterally. Finger extensors are 4/5 on the right and 5/5 on the left. The triceps reflex is 1+ on the right and 2+ on the left. The most likely diagnosis is a herniated nucleus pulposus at what level?

. C3-4
. C4-5
. C5-6
. C6-7
. C7-T1

Correct Answer & Explanation

. C6-7

Explanation

The patient's neurologic examination is consistent with a C7 radiculopathy on the right side. In a patient with this symptom complex in the absence of trauma, a cervical disk herniation is the most common etiology for a C7 radiculopathy. There are eight cervical nerve roots and the C7 nerve exits at the C6-7 disk space and is most frequently impinged by a disk herniation at this level. Houten JK, Errico TJ: Cervical spondylotic myelopathy and radiculopathy: Natural history and clinical presentation, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005, pp 985-990.

Question 3128

Topic: 6. Spine
A 21-year-old woman with scoliosis reports no pain, and her examination is unremarkable except for the scoliosis. Preoperative radiographs, including bending views, are shown in Figures 14a through 14e. The thoracic curve measures 62 degrees. Treatment should consist of
. posterior fusion from T2 to L3.
. posterior fusion from T4 to L1.
. posterior fusion from T4 to L4.
. anterior fusion from T6 to L1.
. anterior fusion from T9 to T11.

Correct Answer & Explanation

. posterior fusion from T4 to L1.

Explanation

The patient has a King type III curve with a very flexible lumbar spine that derotates and levels well on side bending. The fractional upper thoracic curve is also quite flexible and will not need to be addressed; therefore, treatment should consist of posterior spinal fusion from T4 to L1. An anterior spinal fusion at the very apex of the curve will not address the curve satisfactorily, and an approach across the diaphragm provides little benefit in this patient.

Question 3129

Topic: 6. Spine

Examination of a 9-year-old boy reveals a right thoracic prominence on forward flexion. Neurologic examination is normal, and no other abnormalities are noted. AP radiographs reveal a 30-degree right thoracic curve. Initial management should consist of

. anteroposterior fusion.
. observation.
. MRI of the spine.
. an orthosis.
. instrumentation without fusion.

Correct Answer & Explanation

. MRI of the spine.

Explanation

The patient has juvenile scoliosis. MRI has shown an association between juvenile scoliosis and intraspinal abnormalities, most often syringomyelia and Arnold-Chiari malformations. All juvenile curves greater than 20 degrees should be evaluated with MRI despite the absence of neurologic findings. Weinstein SL (ed): The Pediatric Spine: Principles and Practice, ed 1. New York, NY, Raven Press, 1994, pp 685-705 Nohria V, Oakes WJ: Chiari I malformation: A review of 43 patients. Pediatr Neurosurg 1990-91;16:222-227.

Question 3130

Topic: 6. Spine

A 60-year-old woman with rheumatoid arthritis has atlanto-axial instability and basilar invagination. What MRI findings would suggest the need for cervical fusion?

. Cervical medullary angle of 125 degrees
. Space available for the cord of 15 mm
. Cord diameter in flexion of 10 mm
. C3-4 subluxation of 2 mm
. Erosion of the tip of the odontoid

Correct Answer & Explanation

. Cervical medullary angle of 125 degrees

Explanation

The cervical medullary junction should be 135 degrees or greater. An angle of 125 degrees suggests compression of the cervical medullary junction. Other findings supporting surgical intervention include a cord diameter in flexion of less than 6 mm or less than 13 mm of space available for the cord. Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 1998, pp 700-701. Monsey RB: Rheumatoid arthritis of the cervical spine. J Am Acad Orthop Surg 1997;5:240-248.

Question 3131

Topic: 6. Spine

A 25-year-old man sustained an L1 compression fracture in a fall from his roof. He is neurologically intact and has no other injuries. Radiographs reveal a 25% loss of height anteriorly and 5 degrees of kyphosis at the fracture site. A CT scan reveals no compromise of the posterior column. Management should consist of

. bed rest only for 6 weeks.
. mobilization in a kinetic therapy bed for 6 weeks, followed by a hyperextension brace.
. a total contact thoracolumbosacral orthosis and rapid mobilization.
. anterior decompression, vertebral reconstruction, and stabilization.
. posterior reduction, stabilization, and grafting.

Correct Answer & Explanation

. a total contact thoracolumbosacral orthosis and rapid mobilization.

Explanation

The patient has a stable fracture that can be initially treated with bed rest, followed by bracing and quick mobilization. The outcome is good and surgery is not required. These fractures can be treated nonsurgically if there is less than 50% compression, 15 degrees of angulation, and intact posterior structures. Cantor JB, Lebwohl NH, Garvey T, Eismont FJ: Nonoperative management of stable thoracolumbar burst fractures with early ambulation and bracing. Spine 1993;18:971-976.

Question 3132

Topic: 6. Spine

A 36-year-old woman is brought to the emergency department intubated and sedated following a motor vehicle accident. She is moving her upper and lower extremities spontaneously. She cannot follow commands. CT scans are shown in Figures 7a through 7c. The initial survey does not reveal any other injuries. Initial management of the cervical injury should consist of immediate

. immobilization with a halo ring and vest with reduction when medically stable.
. closed traction reduction using Gardner-Wells tongs.
. posterior open reduction, stabilization, and fusion.
. cervical MRI followed by reduction.
. anterior open reduction, stabilization, and fusion.

Correct Answer & Explanation

. cervical MRI followed by reduction.

Explanation

The patient has a bilateral facet dislocation of C6-C7 with preservation of at least some neurologic function. Urgent reduction is necessary. However, because she is sedated and unable to follow commands, an MRI scan is necessary before any closed or open posterior reduction to look for an associated disk herniation. If a disk herniation is present, it must be removed prior to any reduction maneuver to prevent iatrogenic neurologic injury. It is very unlikely that this injury can be reduced with an open anterior procedure alone. Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 189-199.

Question 3133

Topic: 6. Spine

Immediately after undergoing lumbar instrumentation, a patient reports severe right leg pain and has 4+/5 weakness. Figure 24 shows an axial CT scan of L5. Exploratory surgery will most likely reveal

Spine Surgery 2006 Practice Questions: Set 3 (Solved) - Figure 14

. transection of the L5 root.
. displacement of the L5 root.
. partial laceration of the L5 root.
. segmental artery injury.
. spinal fluid leakage.

Correct Answer & Explanation

. displacement of the L5 root.

Explanation

The most common finding at exploration of an inappropriately placed pedicle screw is displacement of the nerve. Pedicle breach is common, ranging from 2% to 20%, but most are asymptomatic. All of the choices are possible, but in a large series conducted by Lonstein and associates, the authors reported that displacement of the root, most often medial, was the most common finding. Laceration, contusion, or transfixion usually was not seen. Spinal fluid leakage occurs less frequently and is not expected in the minimal broach illustrated. Esses SI, Sachs BL, Dreyzin V: Complications associated with the technique of pedicle screw fixation: A selected survey of ABS members. Spine 1993;18:2231-2238. Laine T, Lund T, Ylikoski M, et al: Accuracy of pedicle screw insertion with and without computer assistance: A randomised controlled clinical study in 100 consecutive patients. Eur Spine J 2000;9:235-240.

Question 3134

Topic: 6. Spine

A 68-year-old male presents with deteriorating handwriting, frequent falls, and numbness in his hands. A sagittal T2 MRI is shown:

He demonstrates a positive Hoffman sign. Which physical examination finding corresponds to the loss of proprioception in the dorsal columns commonly seen in this condition?

. Lhermitte's sign
. Positive Romberg test
. Sustained clonus
. Inverted radial reflex
. Babinski sign

Correct Answer & Explanation

. Positive Romberg test

Explanation

Cervical spondylotic myelopathy affects various spinal tracts. Involvement of the dorsal columns leads to loss of proprioception, resulting in a wide-based gait and a positive Romberg test. Corticospinal tract involvement leads to upper motor neuron signs like hyperreflexia, clonus, Babinski sign, and Hoffman sign.

Question 3135

Topic: Thoracolumbar Spine & Deformity
A 14-year-old gymnast presents with chronic, mechanically reproducible low back pain. Radiographs reveal a pars interarticularis defect at L5 with a 30% anterior translation of L5 on S1. According to the Meyerding classification, what grade is this spondylolisthesis, and what is the primary initial management?
. Grade I; physical therapy and core strengthening
. Grade II; physical therapy and core strengthening
. Grade II; immediate posterior spinal fusion
. Grade III; TLSO brace for 6 months
. Grade III; primary pars repair

Correct Answer & Explanation

. Grade II; physical therapy and core strengthening

Explanation

The Meyerding classification grades the magnitude of slip based on the superior endplate of the vertebra below. Grade I: 0-25%, Grade II: 26-50%, Grade III: 51-75%, Grade IV: 76-100%, Grade V: >100% (spondyloptosis). A 30% slip is Grade II. The initial management for low-grade (I and II) isthmic spondylolisthesis without progressive neurologic deficit is non-operative, emphasizing activity modification, hamstring stretching, and core stabilization.

Question 3136

Topic: 6. Spine

A 65-year-old man presents with progressive hand clumsiness and broad-based gait over 6 months. Physical exam reveals bilateral Hoffmann signs and 3+ patellar reflexes. An MRI of the cervical spine is obtained. Which of the following specific MRI findings is most strongly predictive of a poor postoperative neurologic prognosis following surgical decompression for cervical spondylotic myelopathy?

. High signal intensity on T2-weighted images alone
. Low signal intensity on T1-weighted images
. Loss of native cervical lordosis
. Multi-level vs single-level cord compression
. High signal intensity on STIR sequences

Correct Answer & Explanation

. Low signal intensity on T1-weighted images

Explanation

In cervical spondylotic myelopathy, a high signal on T2-weighted images often represents edema or gliosis and has a mixed predictive value. However, the presence of a corresponding low signal intensity on T1-weighted imaging indicates permanent cystic necrosis of the spinal cord (myelomalacia) and strongly correlates with a poor prognosis for neurologic recovery after decompression.

Question 3137

Topic: 6. Spine

A 54-year-old male with a history of intravenous drug use presents with severe back pain, fever, and progressively worsening bilateral lower extremity weakness over the last 48 hours. A representative MRI is shown below.

Given the classic findings for this pathology, what is the most likely causative organism, and what is the standard definitive treatment?

. Staphylococcus aureus; urgent surgical decompression and targeted antibiotics
. Pseudomonas aeruginosa; CT-guided aspiration and targeted antibiotics
. Mycobacterium tuberculosis; anterior corpectomy and multi-drug chemotherapy
. Staphylococcus epidermidis; non-operative management with a rigid orthosis
. Streptococcus pneumoniae; high-dose intravenous corticosteroids alone

Correct Answer & Explanation

. Staphylococcus aureus; urgent surgical decompression and targeted antibiotics

Explanation

The clinical scenario and presumed MRI findings (epidural fluid collection causing cord compression) are classic for a spinal epidural abscess. The most common causative organism overall, and specifically in intravenous drug users, is Staphylococcus aureus. Because the patient is exhibiting progressive neurologic deficits (lower extremity weakness), urgent surgical decompression (usually a laminectomy) combined with targeted intravenous antibiotics is the standard definitive treatment to prevent permanent neurologic injury.

Question 3138

Topic: 6. Spine

A 62-year-old male presents with deteriorating manual dexterity, a feeling of imbalance, and progressive lower extremity spasticity. Physical examination reveals a positive Hoffmann's sign bilaterally and hyperreflexia in both knees and ankles. MRI of the cervical spine reveals severe central canal stenosis. Which of the following MRI findings is associated with the poorest postoperative prognosis for neurologic recovery in this patient?

. T2 hyperintensity isolated to the central gray matter
. T1 hypointensity in the spinal cord substance at the level of maximum compression
. A compression ratio (AP/transverse diameter) of 0.8
. Presence of a large, soft central disc herniation at C5-C6
. Modic Type I changes in the adjacent vertebral bodies

Correct Answer & Explanation

. T1 hypointensity in the spinal cord substance at the level of maximum compression

Explanation

The patient is presenting with classic signs of Cervical Spondylotic Myelopathy (CSM). MRI is critical for assessing the degree of cord compression and intrinsic cord damage. While T2 hyperintensity in the cord indicates edema or gliosis, focal T1 hypointensity indicates permanent structural damage (myelomalacia or cystic necrosis) and is widely recognized as the most reliable MRI indicator of a poor postoperative prognosis for neurologic recovery. A larger compression ratio (closer to 1.0) is normal; a severely flattened cord (<0.4) indicates worse stenosis.

Question 3139

Topic: 6. Spine

A 62-year-old male of East Asian descent presents with progressive myelopathy. His imaging is shown.

Which of the following specific CT findings is the strongest independent predictor of a dural tear during an anterior cervical corpectomy and decompression for this condition?

. C2-C7 sagittal vertical axis > 4 cm
. Continuous type ossification spanning > 3 levels
. The 'double-layer' sign
. K-line negativity
. Facet joint ankylosis

Correct Answer & Explanation

. The 'double-layer' sign

Explanation

The image indicates Ossification of the Posterior Longitudinal Ligament (OPLL). The 'double-layer' sign on a CT scan is highly specific for dural ossification and represents a significant risk for dural tears during anterior decompressive surgeries. It consists of anterior and posterior hyperdense ossified rims separated by a central hypodense non-ossified ligament.

Question 3140

Topic: 6. Spine
In preoperative planning for a long posterior spinal fusion to correct adult spinal deformity, achieving appropriate sagittal balance is critical. To minimize the risk of adjacent segment disease and mechanical failure, the postoperative lumbar lordosis (LL) should be matched to the patient's pelvic incidence (PI). What is the generally accepted target relationship between PI and LL?
. LL should be at least 20 degrees greater than PI
. PI minus LL should be ≤ 10 degrees
. LL should be exactly half of the PI
. PI minus LL should be ≥ 20 degrees
. LL should equal the sacral slope minus 10 degrees

Correct Answer & Explanation

. PI minus LL should be ≤ 10 degrees

Explanation

Pelvic incidence (PI) is a fixed morphological parameter. Lumbar lordosis (LL) must be tailored to the individual's PI to achieve a harmonious sagittal profile and minimize energy expenditure during standing. The SRS-Schwab adult spinal deformity classification sets a target of PI-LL mismatch of less than or equal to 10 degrees (PI - LL ≤ 10°) to achieve optimal clinical outcomes.

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