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6. Spine MCQs

Practice Set 159 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 3161

Topic: 6. Spine

A 65-year-old man presents with progressive hand clumsiness and gait imbalance. MRI is shown.

Examination reveals a positive Hoffman's sign. Which physical exam finding would most specifically suggest concomitant lumbar spinal stenosis (tandem stenosis)?

. Hyperreflexia in the lower extremities
. Absent ankle reflexes with an upgoing Babinski sign
. Sustained clonus at the ankle
. Positive Lhermitte's sign
. Preservation of lower extremity proprioception

Correct Answer & Explanation

. Absent ankle reflexes with an upgoing Babinski sign

Explanation

The presence of cervical myelopathy typically causes upper motor neuron (UMN) signs in the lower extremities (hyperreflexia, clonus, positive Babinski). However, in 'tandem stenosis' (concurrent cervical myelopathy and lumbar stenosis), the lower motor neuron (LMN) signs from the lumbar compression can mask the UMN signs in the legs. Thus, absent ankle reflexes (LMN sign) coupled with an upgoing Babinski (UMN sign) is a classic presentation of tandem stenosis.

Question 3162

Topic: Thoracolumbar Spine & Deformity
In the Meyerding classification of spondylolisthesis, a Grade III slip corresponds to a vertebral body displacement of:
. Less than 25%
. 25% to 50%
. 51% to 75%
. 76% to 100%
. Spondyloptosis (>100%)

Correct Answer & Explanation

. 25% to 50%

Explanation

The Meyerding classification grades the severity of spondylolisthesis based on the percentage of forward translation of the superior vertebral body over the inferior one. Grade I is 1-25%; Grade II is 26-50%; Grade III is 51-75%; Grade IV is 76-100%; Grade V (spondyloptosis) is >100%.

Question 3163

Topic: 6. Spine
A 40-year-old male is involved in a motor vehicle collision. A lateral cervical radiograph is obtained. Imaging reveals a traumatic spondylolisthesis of the axis (Hangman's fracture) with 15 degrees of angulation but minimal (< 1 mm) translation. According to the Levine and Edwards classification, which of the following is strictly contraindicated in the initial management of this specific fracture pattern?
. Rigid cervical collar
. Cervical traction
. Halo vest immobilization
. Immediate anterior cervical discectomy and fusion
. Posterior C1-C2 transarticular screw fixation

Correct Answer & Explanation

. Halo vest immobilization

Explanation

This describes a Type IIA Hangman's fracture (severe angulation with minimal translation). The proposed mechanism is flexion-distraction. Because of the distraction component and severe instability of the C2-C3 disc space, cervical traction is strictly contraindicated as it can cause catastrophic over-distraction and neurologic injury. The recommended treatment for Type IIA fractures is gentle compression and extension in a halo vest.

Question 3164

Topic: 6. Spine

A 70-year-old male complains of bilateral leg and buttock pain that worsens after walking two blocks. He notes significant relief when he pushes a shopping cart. Physical examination reveals normal lower extremity pulses. Which of the following historical or physical examination findings is most specific for differentiating neurogenic claudication from vascular claudication?

. Pain relief upon standing still
. Exacerbation of pain while walking downhill
. Presence of 'stocking-glove' sensory deficit
. Diminished ankle reflexes
. Cramping pain strictly localized to the calf

Correct Answer & Explanation

. Exacerbation of pain while walking downhill

Explanation

Differentiating neurogenic claudication (lumbar spinal stenosis) from vascular claudication relies on postural changes. Neurogenic claudication is exacerbated by lumbar extension, which decreases the cross-sectional area of the spinal canal and neural foramina. Walking downhill requires lumbar extension, thus exacerbating neurogenic claudication. Conversely, walking uphill or leaning forward (shopping cart sign) induces lumbar flexion, opening the canal and providing relief. Vascular claudication is typically relieved simply by standing still, regardless of spine posture, and is reliably reproduced by a specific distance of walking.

Question 3165

Topic: Cervical Spine

An 82-year-old male sustains a fall from standing and presents with neck pain. Computed tomography reveals a Type II odontoid fracture with 2 mm of posterior displacement.

He is neurologically intact. What is the most appropriate management, considering his age and fracture pattern?

. Halo vest immobilization
. Anterior odontoid screw fixation
. Posterior C1-C2 fusion
. Rigid cervical collar
. Soft cervical collar

Correct Answer & Explanation

. Rigid cervical collar

Explanation

Management of Type II odontoid fractures in the elderly is controversial. However, recent evidence suggests that rigid cervical collar immobilization is the preferred initial treatment for stable or minimally displaced Type II odontoid fractures in patients over 80 years old, as it provides a lower complication rate and lower 1-year mortality compared to surgical intervention or halo vest immobilization. Halo immobilization in the elderly is associated with high morbidity and mortality (up to 40%).

Question 3166

Topic: Cervical Spine

During an ulnar collateral ligament (UCL) reconstruction in a professional baseball pitcher, the surgeon aims to reconstruct the primary restraint to valgus stress at the elbow. Which specific band or bundle is the most critical to reconstruct?

. Posterior bundle
. Transverse ligament
. Anterior band of the anterior bundle
. Posterior band of the anterior bundle
. Radial collateral ligament

Correct Answer & Explanation

. Anterior band of the anterior bundle

Explanation

The ulnar collateral ligament (UCL) complex consists of the anterior bundle, posterior bundle, and transverse ligament. The anterior bundle is the primary restraint to valgus stress at the elbow from 30 to 120 degrees of flexion. The anterior bundle is further divided into an anterior band (tight in extension to 60 degrees of flexion) and a posterior band (tight in flexion >60 degrees). The anterior band is the most isometric and critical component reconstructed during surgery.

Question 3167

Topic: 6. Spine

A 70-year-old female presents with bilateral leg pain and cramping that worsens with walking and is relieved by sitting or leaning forward over a shopping cart. Magnetic resonance imaging (MRI) reveals severe central canal stenosis at L4-L5. Hypertrophy of which of the following structures is a primary contributor to her central stenosis?

. Posterior longitudinal ligament
. Anterior longitudinal ligament
. Ligamentum flavum
. Interspinous ligament
. Iliolumbar ligament

Correct Answer & Explanation

. Ligamentum flavum

Explanation

The patient has neurogenic claudication secondary to lumbar spinal stenosis. The classic shopping cart sign indicates relief with lumbar flexion, which increases the cross-sectional area of the spinal canal. The primary degenerative contributors to central canal stenosis are intervertebral disc bulging/herniation, facet joint hypertrophy, and hypertrophy/buckling of the ligamentum flavum.

Question 3168

Topic: 6. Spine
A 25-year-old male is involved in a high-speed motor vehicle collision. Radiographs demonstrate a traumatic spondylolisthesis of the axis (Hangman's fracture) with an oblique fracture line through the pars interarticularis, minimal translation, but extreme angulation (>11 degrees). The C2-C3 disc space appears disrupted posteriorly. According to the Levine-Edwards classification, what is the most appropriate initial management for this specific injury pattern (Type IIa)?
. Immediate application of heavy axial traction followed by a halo vest
. Halo vest applied with gentle compression and extension
. Halo vest applied in slight flexion
. Anterior cervical discectomy and fusion at C2-C3
. Posterior C1-C2 transarticular screw fixation

Correct Answer & Explanation

. Halo vest applied with gentle compression and extension

Explanation

The scenario describes a Levine-Edwards Type IIa Hangman's fracture. This injury is caused by a flexion-distraction mechanism, leading to severe angulation with minimal initial translation. A critical point in management is that axial traction is STRICTLY CONTRAINDICATED, as it will exacerbate the distraction and worsen the deformity. The appropriate non-operative management involves the application of a halo vest under gentle compression and extension to reduce the angulation and stabilize the fracture.

Question 3169

Topic: 6. Spine

A 65-year-old male with a history of neurogenic claudication undergoes a posterior lumbar decompressive laminectomy. Hypertrophy of which of the following anatomical structures is most directly responsible for the dorsal compression of the thecal sac in central lumbar spinal stenosis?

. Posterior longitudinal ligament
. Anterior longitudinal ligament
. Ligamentum flavum
. Interspinous ligament
. Supraspinous ligament

Correct Answer & Explanation

. Ligamentum flavum

Explanation

Central lumbar spinal stenosis is typically caused by a combination of disc bulging anteriorly, facet joint hypertrophy laterally, and hypertrophy/buckling of the ligamentum flavum posteriorly. The ligamentum flavum forms the dorsal margin of the spinal canal and its hypertrophy is the primary dorsal contributor to canal narrowing. The posterior longitudinal ligament is ventral to the thecal sac.

Question 3170

Topic: 6. Spine

A 65-year-old man presents with progressive clumsiness in his hands, difficulty buttoning his shirt, and a broad-based gait. A T2-weighted MRI shows spinal cord compression with intrinsic cord signal change at C4-C5.

Which of the following MRI findings is associated with the poorest prognosis for neurological recovery after surgical decompression in cervical spondylotic myelopathy?

. T2 hyperintensity that is single-level
. T1 hypointensity corresponding to the T2 hyperintensity
. T2 hyperintensity involving less than 50% of the cord cross-sectional area
. Presence of osteophytes at the level of compression
. Decreased CSF space without cord signal change

Correct Answer & Explanation

. T1 hypointensity corresponding to the T2 hyperintensity

Explanation

In cervical spondylotic myelopathy, the presence of T1 hypointensity corresponding to a T2 hyperintense lesion indicates myelomalacia or cystic necrosis of the spinal cord. This finding is a strong predictor of poor functional recovery following surgical decompression.

Question 3171

Topic: 6. Spine

A 14-year-old female gymnast presents with insidious onset of low back pain exacerbated by extension. Radiographs show a unilateral pars interarticularis defect at L5.

What is the classic radiographic appearance of this defect on an oblique lumbar radiograph?

. Bamboo spine
. Scottie dog with a collar
. Picture frame vertebra
. Rugger jersey spine
. Ivory vertebra

Correct Answer & Explanation

. Scottie dog with a collar

Explanation

Spondylolysis, a defect in the pars interarticularis, classically appears as a 'collar' or 'break' around the neck of the 'Scottie dog' on an oblique radiograph of the lumbar spine.

Question 3172

Topic: 6. Spine
A 45-year-old man is involved in a motor vehicle collision. Imaging demonstrates a traumatic spondylolisthesis of the axis (Hangman's fracture) with 15 degrees of angulation and 2 mm of translation (Levine and Edwards Type IIA). Which of the following treatments or maneuvers is strictly contraindicated in the initial nonoperative management of this specific fracture pattern?
. Cervical traction
. Halo vest immobilization in slight extension
. Rigid cervical collar
. Application of compression forces
. Supine positioning

Correct Answer & Explanation

. Halo vest immobilization in slight extension

Explanation

A Levine and Edwards Type IIA Hangman's fracture is characterized by severe angulation with minimal translation. This pattern indicates disruption of the posterior longitudinal ligament and the C2-C3 disc with an intact anterior longitudinal ligament acting as a hinge. Cervical traction is strictly contraindicated because it will distract the fracture site, exacerbate the angulation deformity, and cause neurologic injury. Treatment consists of closed reduction in slight extension and compression in a halo vest.

Question 3173

Topic: 6. Spine

A 68-year-old man presents with bilateral leg pain, heaviness, and cramping that worsens after walking two blocks. The orthopedic surgeon is attempting to distinguish between neurogenic claudication secondary to lumbar spinal stenosis and vascular claudication. Which of the following clinical findings most reliably points toward a diagnosis of neurogenic claudication?

. Pain is rapidly relieved by standing still
. Diminished distal pedal pulses on examination
. Pain is relieved or prevented by walking up an incline
. Pain is rapidly exacerbated by riding a stationary bicycle
. Presence of a stocking-glove sensory deficit

Correct Answer & Explanation

. Pain is relieved or prevented by walking up an incline

Explanation

Neurogenic claudication is exacerbated by lumbar extension (which decreases the cross-sectional area of the spinal canal) and relieved by lumbar flexion. Walking up an incline causes the patient to lean forward (flex the lumbar spine), thereby keeping the spinal canal open and preventing symptoms. Conversely, walking up an incline increases metabolic demand, which would worsen vascular claudication. Bicycling also involves flexion and is typically well-tolerated in neurogenic claudication.

Question 3174

Topic: Thoracolumbar Spine & Deformity
A 14-year-old gymnast presents with persistent lower back and radicular leg pain. Imaging reveals an L5-S1 isthmic spondylolisthesis with 60% anterior translation of L5 on S1 (Meyerding Grade III). She has failed non-operative management, and surgical reduction with instrumented fusion is planned. Which nerve root is at the highest risk of iatrogenic traction injury during the reduction maneuver?
. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L5

Explanation

During the surgical reduction of a high-grade L5-S1 spondylolisthesis, the L5 nerve root is at the highest risk for traction injury. As L5 is pulled posteriorly and superiorly to align with S1, the L5 nerve root becomes stretched over the sacral ala.

Question 3175

Topic: 6. Spine

A 30-year-old female is involved in a motor vehicle collision and sustains a traumatic spondylolisthesis of the axis (Hangman's fracture).

Radiographs show severe angulation of C2 on C3, widening of the posterior C2-C3 disk space, but minimal anterior translation. This pattern is consistent with a Levine and Edwards Type IIA fracture. What is the mechanism of injury for a Type IIA fracture, and what early management step is strictly contraindicated?

. Flexion-distraction; application of axial traction is contraindicated.
. Hyperextension-axial loading; use of a hard cervical collar is contraindicated.
. Flexion-compression; application of a halo vest is contraindicated.
. Hyperextension-distraction; surgical fusion is contraindicated.
. Axial compression; application of axial traction is contraindicated.

Correct Answer & Explanation

. Flexion-distraction; application of axial traction is contraindicated.

Explanation

A Levine and Edwards Type IIA Hangman's fracture is characterized by severe angulation with minimal translation and an enlarged posterior disc space. The mechanism of injury is flexion-distraction. Application of axial traction is strictly contraindicated as it will further distract the already completely disrupted C2-C3 disc space and can cause catastrophic spinal cord injury.

Question 3176

Topic: 6. Spine

A 68-year-old man presents with bilateral leg pain and cramping that worsens with walking and prolonged standing, but improves when he leans forward over a shopping cart or sits down. What is the most likely pathophysiologic mechanism for his symptom relief with flexion?

. Decreased metabolic demand on the lower extremity musculature
. Unbuckling of the ligamentum flavum leading to increased canal volume
. Increased tension on the dural sac
. Spasm of the paraspinal musculature
. Relief of arterial claudication

Correct Answer & Explanation

. Unbuckling of the ligamentum flavum leading to increased canal volume

Explanation

The patient's symptoms are classic for neurogenic claudication secondary to lumbar spinal stenosis. Lumbar flexion relieves symptoms by unbuckling the ligamentum flavum, which increases the cross-sectional area of the spinal canal and neural foramina, thereby temporarily relieving compression on the neural elements.

Question 3177

Topic: 6. Spine

A 70-year-old man presents with progressive bilateral hand clumsiness, difficulty buttoning his shirt, and gait instability. Examination reveals a positive Hoffman's sign bilaterally, inverted radial reflex, and hyperreflexia in the lower extremities. An MRI of the cervical spine is ordered. What is the most likely diagnosis?

. Amyotrophic lateral sclerosis
. Cervical spondylotic myelopathy
. Syringomyelia
. Multiple sclerosis
. Guillain-Barre syndrome

Correct Answer & Explanation

. Cervical spondylotic myelopathy

Explanation

The patient exhibits classic signs of cervical spondylotic myelopathy (CSM), which is the most common cause of spinal cord dysfunction in adults over 55. Symptoms include loss of fine motor skills (hand clumsiness) and gait changes. Physical exam reveals upper motor neuron signs such as Hoffman's sign, hyperreflexia, Babinski sign, and the inverted radial reflex.

Question 3178

Topic: 6. Spine
A 35-year-old male is involved in a high-speed motor vehicle collision. Radiographs demonstrate a traumatic spondylolisthesis of the axis (Hangman's fracture) with severe angulation and >3 mm of translation. The C2-C3 disc space is disrupted, and the C2 articular facets are dislocated anteriorly. According to the Levine and Edwards classification (Type III), what is the most appropriate management?
. Rigid cervical orthosis for 6 weeks
. Halo vest immobilization after closed postural reduction
. Closed reduction with skeletal traction
. Posterior open reduction of the facets and C2-C3 fusion
. Anterior C2-C3 fusion alone

Correct Answer & Explanation

. Posterior open reduction of the facets and C2-C3 fusion

Explanation

Levine and Edwards Type III Hangman's fractures involve bilateral C2-C3 facet dislocations with severe angulation and translation. They are highly unstable and cannot be managed with closed reduction or traction due to the risk of further displacement and catastrophic neurologic injury. The recommended treatment is posterior open reduction of the dislocated facets followed by C2-C3 posterior spinal fusion.

Question 3179

Topic: Thoracolumbar Spine & Deformity
A 15-year-old female gymnast complains of chronic lower back pain. Lateral lumbar radiographs reveal an isthmic spondylolisthesis at L5-S1 with 65% anterior translation of L5 on S1. According to the Meyerding classification, what grade is this slip?
. Grade I
. Grade II
. Grade III
. Grade IV
. Grade V (Spondyloptosis)

Correct Answer & Explanation

. Grade III

Explanation

The Meyerding classification grades spondylolisthesis based on the percentage of anterior translation of the superior vertebral body over the inferior one. Grade I: 0-25%; Grade II: 26-50%; Grade III: 51-75%; Grade IV: 76-100%; Grade V: >100% (Spondyloptosis). A 65% slip falls into the Grade III category.

Question 3180

Topic: 6. Spine

A 45-year-old male presents to the emergency department with severe low back pain and bilateral radicular leg pain. Which of the following clinical findings is the most sensitive early indicator of Cauda Equina Syndrome?

. Saddle anesthesia (S4-S5 dermatomal sensory loss)
. Bilateral loss of Achilles reflexes
. Urinary retention with elevated post-void residual volume
. Loss of rectal sphincter tone on digital exam
. Profound bilateral foot drop

Correct Answer & Explanation

. Urinary retention with elevated post-void residual volume

Explanation

Urinary retention is the most sensitive symptom/finding in suspected Cauda Equina Syndrome (CES). A normal post-void residual volume (typically < 100-200 mL) makes CES highly unlikely. While saddle anesthesia and decreased rectal tone are classic, specific signs, they may present later or be absent in early incomplete CES.

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