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 3141
Topic: 6. Spine
A 65-year-old female presents with neurogenic claudication. Radiographs demonstrate degenerative spondylolisthesis.
What is the most common level of involvement and the corresponding nerve root most likely compressed in the lateral recess?
Correct Answer & Explanation
. L4-L5 level; L5 nerve root
Explanation
Degenerative spondylolisthesis most commonly occurs at the L4-L5 level. It is characterized by an intact pars interarticularis, facet hypertrophy, and ligamentum flavum buckling, leading to central and lateral recess stenosis. The L5 nerve root (traversing root) is most commonly compressed in the lateral recess at the L4-L5 level.
Question 3142
Topic: 6. Spine
A 25-year-old restrained driver involved in a high-speed motor vehicle collision sustains a flexion-distraction injury of the lumbar spine.
Which of the following associated injuries has the highest incidence in this patient profile?
Correct Answer & Explanation
. Hollow viscus injury (e.g., bowel perforation)
Explanation
Flexion-distraction injuries of the spine (Chance fractures) often occur from lap-belt injuries in motor vehicle accidents. The fulcrum of flexion is anterior to the spine (at the abdominal wall), causing tension failure of the posterior and middle columns. This mechanism is highly associated with intra-abdominal injuries, particularly hollow viscus injuries (e.g., small bowel perforations), which occur in up to 40-50% of cases.
Question 3143
Topic: 6. Spine
A 62-year-old male with severe cervical spondylotic myelopathy undergoes an MRI of the cervical spine.
Which specific MRI signal characteristic in the spinal cord is most strongly correlated with irreversible neurological deficit and poor postoperative functional recovery following decompression?
Correct Answer & Explanation
. Hypointensity on T1-weighted images accompanied by T2 hyperintensity
Explanation
In the setting of cervical spondylotic myelopathy, intrinsic spinal cord signal changes carry significant prognostic value. T2 hyperintensity is a common finding and often represents reversible edema or gliosis. However, the presence of hypointensity on T1-weighted images (which is typically accompanied by focal T2 hyperintensity) indicates cystic necrosis, cavitation, or permanent myelomalacia of the spinal cord. This specific finding is an independent predictor of poor neurological recovery following decompressive surgery.
Question 3144
Topic: Thoracolumbar Spine & Deformity
A 14-year-old female gymnast presents with chronic, progressive low back pain exacerbated by extension. Lateral radiographs demonstrate an isthmic spondylolisthesis at L5-S1.
In assessing her risk for continued slip progression, which spinopelvic parameter is considered the most predictive intrinsic biomechanical risk factor?
Correct Answer & Explanation
. A high Pelvic Incidence (PI)
Explanation
Pelvic incidence (PI) is a fixed morphological parameter unique to each individual (PI = Sacral Slope + Pelvic Tilt). A high pelvic incidence correlates with a more vertical orientation of the sacrum relative to the pelvis, which inherently increases the shear forces at the lumbosacral junction. Consequently, a high pelvic incidence is the most significant spinopelvic parameter predicting the risk of progression in pediatric and adolescent isthmic spondylolisthesis.
Question 3145
Topic: Cervical Spine
An 82-year-old frail female with osteopenia sustains a fall and presents with neck pain. CT scan reveals a displaced Type II odontoid fracture.
Conservative management with a hard cervical collar is considered but has a known high nonunion rate. If surgical intervention is elected, what is the preferred technique given her age and bone quality?
Correct Answer & Explanation
. Posterior C1-C2 instrumented fusion
Explanation
Type II odontoid fractures in the elderly (>70-80 years) present a significant challenge. While a rigid collar is often used, nonunion rates are very high. Halo vest immobilization is contraindicated in this demographic due to unacceptably high morbidity and mortality (e.g., respiratory complications, falls). If surgery is indicated, anterior odontoid screw fixation relies on good bone quality (which is lacking in osteopenia) and an intact transverse ligament. Therefore, posterior C1-C2 instrumented fusion (e.g., Harms technique) provides the highest union rates and biomechanical stability for elderly osteopenic patients with displaced Type II fractures.
Question 3146
Topic: 6. Spine
A 79-year-old male presents to the emergency department after a ground-level fall. He complains of upper neck pain. He has a history of severe COPD, congestive heart failure, and osteoporosis. CT imaging of the cervical spine shows a Type II odontoid fracture with 2mm of posterior displacement. What is the most appropriate management for this patient?
Correct Answer & Explanation
. Rigid cervical collar
Explanation
In elderly patients with significant comorbidities (e.g., severe COPD, osteoporosis), non-operative management with a rigid cervical collar is favored for Type II odontoid fractures. While the nonunion rate is high with collar therapy, fibrous nonunion is often well-tolerated, and the morbidity and mortality associated with surgery or a halo vest in frail elderly populations are prohibitively high.
Question 3147
Topic: 6. Spine
A 68-year-old male presents with bilateral leg heaviness and pain that worsens with standing and walking but improves when leaning forward on a shopping cart. MRI shows severe central canal stenosis at L4-L5. Which of the following anatomical structures bounds the central spinal canal posteriorly and contributes significantly to the stenosis when hypertrophied?
Correct Answer & Explanation
. The ligamentum flavum and laminae
Explanation
The central spinal canal is bordered anteriorly by the posterior vertebral body and the intervertebral disc (covered by the PLL), laterally by the pedicles, and posteriorly by the laminae and the ligamentum flavum. Hypertrophy and buckling of the ligamentum flavum, along with facet arthropathy, are primary drivers of acquired central lumbar spinal stenosis.
Question 3148
Topic: 6. Spine
A 65-year-old male presents with classic symptoms of neurogenic claudication. He reports bilateral leg pain and fatigue that worsens with walking but is reliably relieved by leaning forward onto a shopping cart. In the pathogenesis of degenerative lumbar spinal stenosis, which structure is primarily responsible for dynamic central canal compression during spinal extension?
Correct Answer & Explanation
. Ligamentum flavum
Explanation
In degenerative lumbar spinal stenosis, extension of the spine decreases the sagittal diameter of the canal because the ligamentum flavum buckles inward (shingling), dynamically compressing the thecal sac. Flexion of the spine pulls the ligamentum flavum taut, increasing the available canal space and alleviating neurogenic claudication symptoms. Hypertrophic ligamentum flavum is a major structural contributor to central stenosis.
Question 3149
Topic: 6. Spine
A 45-year-old male presents with severe right arm pain radiating down to his middle finger. Neurologic examination reveals prominent triceps weakness and an absent triceps deep tendon reflex. His biceps and brachioradialis reflexes are intact. MRI reveals a posterolateral cervical disc herniation. At which cervical spinal level is the pathology most likely located?
Correct Answer & Explanation
. C6-C7
Explanation
The clinical presentation (triceps weakness, absent triceps reflex, and sensory symptoms radiating to the middle finger) is the classic triad of a C7 radiculopathy. The C7 nerve root exits the cervical spine through the C6-C7 neural foramen, making a C6-C7 posterolateral disc herniation the most likely structural cause.
Question 3150
Topic: 6. Spine
A 65-year-old man presents with progressive clumsiness in his hands, difficulty buttoning his shirt, and a broad-based gait.
Examination reveals a positive Hoffman's sign and inverted brachioradialis reflex. Which of the following physical exam findings is most highly specific for diagnosing cervical myelopathy?
Correct Answer & Explanation
. Finger escape sign (Wartenberg's sign of the hand)
Explanation
The finger escape sign (inability to hold the ulnar digits in adduction and extension due to intrinsic weakness and altered tone) is highly specific for cervical myelopathy. While hyperreflexia, Babinski sign, and clonus are classic upper motor neuron signs associated with myelopathy, they are less specific than the finger escape sign in localizing cervical cord compression. The Spurling test evaluates for cervical radiculopathy, not myelopathy.
Question 3151
Topic: 6. Spine
A 45-year-old male is involved in a high-speed motor vehicle collision and presents with the cervical spine radiograph findings typical of traumatic spondylolisthesis of the axis.
Which of the following describes the primary mechanism of injury for this specific fracture pattern (Hangman's fracture)?
Correct Answer & Explanation
. Hyperextension and axial loading
Explanation
A 'Hangman's fracture' is a traumatic spondylolisthesis of the axis (C2) involving fractures through the pars interarticularis. The classical mechanism of injury in modern trauma (e.g., unrestrained passenger hitting the windshield) is hyperextension and axial loading. Flexion-distraction typically causes Chance fractures, while flexion-compression typically causes anterior wedge or teardrop fractures.
Question 3152
Topic: 6. Spine
A 65-year-old male presents with deteriorating handwriting, dropping objects, and an unsteady, broad-based gait. On physical examination, flicking the volar nail of the middle finger results in an involuntary flexion reflex of the thumb and index finger. What is the name of this sign and its corresponding pathology?
Correct Answer & Explanation
. Hoffman's reflex - Cervical myelopathy
Explanation
The Hoffman's reflex is elicited by flicking the nail of the middle finger; a positive response is flexion of the IP joint of the thumb and index finger. It indicates an upper motor neuron lesion, classically cervical spondylotic myelopathy. Wartenberg's sign is the abducted posture of the small finger due to ulnar neuropathy. Lhermitte's sign is shock-like sensations down the spine with neck flexion. Froment's sign tests for ulnar nerve palsy (adductor pollicis weakness).
Question 3153
Topic: 6. Spine
A 28-year-old male presents after a diving accident. He is awake and alert, complaining of severe neck pain. Neurological exam reveals 4/5 strength in right elbow flexion and wrist extension, with numbness extending into the thumb. Radiographs are obtained showing a unilateral facet dislocation.
If an awake closed reduction is attempted but fails, what is the most appropriate next step in management?
Correct Answer & Explanation
. Obtain an MRI of the cervical spine
Explanation
In an awake, cooperative patient with a cervical facet dislocation, closed reduction via cranial traction may be attempted prior to MRI. However, if closed reduction fails, an MRI MUST be obtained prior to any open reduction to evaluate for a herniated nucleus pulposus. If a herniated disc is present, an anterior approach is necessary to decompress the spinal cord before the facet joint is reduced, mitigating the risk of devastating iatrogenic spinal cord injury.
Question 3154
Topic: 6. Spine
A 65-year-old man presents with deteriorating handwriting, difficulty buttoning his shirt, and gait instability. Exam reveals hyperreflexia in the lower extremities and a positive "Finger Escape Sign." What does this specific physical examination finding indicate?
Correct Answer & Explanation
. Inability to maintain the ulnar digits in extension and adduction due to intrinsic weakness from cervical myelopathy
Explanation
The Finger Escape Sign is a clinical manifestation of cervical spondylotic myelopathy. When the patient is asked to hold their fingers in active extension and adduction, the little and ring fingers spontaneously drift into abduction and flexion within 30 to 60 seconds due to intrinsic muscle weakness and loss of upper motor neuron control.
Question 3155
Topic: 6. Spine
A 72-year-old female presents with bilateral leg and buttock pain that worsens predictably with walking and standing, but improves rapidly when she leans forward over a shopping cart. She has normal palpable peripheral pulses. On advanced imaging, an absolute measurement below what threshold for the anteroposterior (AP) dimension of the lumbar spinal canal is classically diagnostic of absolute spinal stenosis?
Correct Answer & Explanation
. 10 mm
Explanation
The patient's clinical history is classic for neurogenic claudication secondary to lumbar spinal stenosis. While relative stenosis is typically defined as an AP canal diameter of less than 12 mm, absolute spinal stenosis is defined as an AP canal diameter of less than 10 mm on a mid-sagittal MRI or CT scan.
Question 3156
Topic: 6. Spine
A 70-year-old man presents with deteriorating handwriting and difficulty buttoning his shirts. Physical examination demonstrates a positive inverted supinator reflex. What is the most likely level of spinal cord compression?
Correct Answer & Explanation
. C5-C6
Explanation
The inverted supinator reflex is elicited by tapping the brachioradialis tendon (innervated by C5-C6). A positive sign results in finger flexion (C8) rather than elbow flexion/supination, indicating a lower motor neuron lesion at C5-C6 and an upper motor neuron lesion below that level, thus localizing the compression to C5-C6.
Question 3157
Topic: 6. Spine
A 72-year-old woman complains of bilateral leg pain and cramping that worsens with walking and standing upright, but is rapidly relieved when she leans forward over a shopping cart. Which of the following physical examination findings is most consistent with her likely diagnosis?
Correct Answer & Explanation
. Normal lower extremity neurologic examination at rest
Explanation
The patient's presentation of neurogenic claudication (shopping cart sign) is classic for lumbar spinal stenosis. Unlike vascular claudication, patients with neurogenic claudication often have completely normal physical and neurological examinations while seated or at rest.
Question 3158
Topic: 6. Spine
A 25-year-old male presents after an MVA with neck pain and right C6 radiculopathy. Radiographs show a unilateral facet dislocation at C5-C6. MRI confirms no herniated disc. He is awake and cooperative but unable to undergo closed reduction. What is the next best step in management?
Correct Answer & Explanation
. Anterior cervical discectomy and fusion (ACDF)
Explanation
For a unilateral facet dislocation in an awake patient who fails closed reduction (or if closed reduction is not feasible), an anterior approach (ACDF) is generally preferred as it allows for direct visualization and removal of any disc material prior to reduction, minimizing the risk of neurologic deterioration, and provides excellent biomechanical stability.
Question 3159
Topic: Thoracolumbar Spine & Deformity
An 18-year-old gymnast complains of chronic lower back pain. Lateral radiographs demonstrate a pars interarticularis defect at L5 with an anterior translation of the L5 vertebral body over S1 by 60%. What is the appropriate Meyerding grade for this slip?
Correct Answer & Explanation
. Grade III
Explanation
The Meyerding classification system grades the severity of spondylolisthesis based on the percentage of forward translation: Grade I (0-25%), Grade II (26-50%), Grade III (51-75%), Grade IV (76-100%), and Grade V (>100%, Spondyloptosis). 60% falls into Grade III.
Question 3160
Topic: 6. Spine
A 28-year-old female presents to the emergency department after a motor vehicle collision. She is awake, alert, and cooperative. She complains of severe neck pain. Neurological examination is completely intact. Lateral cervical spine radiographs show an anterior translation of C5 on C6 of approximately 60% of the vertebral body width, with dislocated facets bilaterally. What is the most appropriate next step in management?
Correct Answer & Explanation
. Awake closed reduction using cranial tongs and progressive weight traction
Explanation
In an awake, alert, and cooperative patient with a bilateral facet dislocation and no (or stable) neurological deficits, the standard of care is to attempt a prompt awake closed reduction using progressive cranial tong traction. MRI prior to reduction is generally reserved for patients who have altered mental status, cannot cooperate with serial neurological exams during closed reduction, or have failed closed reduction. An awake reduction allows the physician to monitor the patient for neurologic deterioration (indicating a potential disc herniation being dragged into the canal), at which point traction would be reversed and an MRI obtained.
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