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6. Spine MCQs

Practice Set 16 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 301

Topic: 6. Spine

In evaluating a patient with a suspected L4-L5 posterolateral disc herniation, which of the following physical examination findings is most anticipated?

. Weakness in ankle plantar flexion
. Diminished patellar reflex
. Weakness in great toe extension
. Diminished Achilles reflex
. Numbness over the medial malleolus

Correct Answer & Explanation

. Weakness in great toe extension

Explanation

A posterolateral disc herniation at L4-L5 typically compresses the traversing L5 nerve root. L5 radiculopathy is characterized by weakness in extensor hallucis longus (great toe extension) and sensory changes over the dorsum of the foot.

Question 302

Topic: 6. Spine

A 72-year-old man with long-standing ankylosing spondylitis presents with severe neck pain after a minor fall. Initial plain radiographs of the cervical spine are read as normal. What is the most appropriate next step in management?

. Discharge with NSAIDs and muscle relaxants
. Obtain flexion-extension radiographs
. CT scan of the cervical spine
. Prescribe a soft collar and physical therapy
. MRI of the brain

Correct Answer & Explanation

. CT scan of the cervical spine

Explanation

Patients with ankylosing spondylitis are at an extremely high risk for unstable spinal fractures even after minor trauma. Because osteopenia and altered anatomy can obscure fractures on plain films, a CT scan is mandatory if clinical suspicion exists.

Question 303

Topic: 6. Spine

Which of the following defines the "middle column" in the Denis three-column classification of the thoracolumbar spine?

. Anterior half of the vertebral body and ALL
. Posterior half of the vertebral body, posterior annulus, and PLL
. Pedicles and facet joints
. Spinous processes and supraspinous ligament
. Laminae and ligamentum flavum

Correct Answer & Explanation

. Posterior half of the vertebral body, posterior annulus, and PLL

Explanation

The Denis middle column consists of the posterior half of the vertebral body, the posterior annulus fibrosus, and the posterior longitudinal ligament (PLL). Disruption of the middle column is the defining feature of a burst fracture.

Question 304

Topic: 6. Spine

A 40-year-old presents with acute cauda equina syndrome secondary to a massive L5-S1 disc herniation. To maximize the chance of complete neurologic recovery, including bowel and bladder function, surgical decompression should ideally be performed within what timeframe?

. 12 hours
. 24 hours
. 48 hours
. 72 hours
. 1 week

Correct Answer & Explanation

. 48 hours

Explanation

Surgical decompression for acute cauda equina syndrome should be performed urgently. Evidence suggests that decompression within 48 hours maximizes the potential for neurologic recovery, particularly sphincter function.

Question 305

Topic: 6. Spine

A 60-year-old man presents with bilateral hand clumsiness, difficulty buttoning his shirts, and a broad-based, unsteady gait. Examination reveals a positive Hoffmann reflex and hyperreflexia in the lower extremities. Which of the following is the most likely diagnosis?

. Peripheral neuropathy
. Amyotrophic lateral sclerosis
. Cervical spondylotic myelopathy
. Syringomyelia
. Lumbar spinal stenosis

Correct Answer & Explanation

. Peripheral neuropathy

Explanation

The patient exhibits classic upper motor neuron signs (Hoffmann reflex, hyperreflexia, broad-based gait) combined with upper extremity dexterity issues. This constellation of symptoms strongly indicates cervical spondylotic myelopathy.

Question 306

Topic: 6. Spine

In a patient with traumatic central cord syndrome following a hyperextension injury, which of the following patterns of neurologic deficit is most characteristic?

. Upper extremity motor deficit greater than lower extremity
. Complete loss of motor function with preserved dorsal columns
. Ipsilateral motor loss and contralateral pain/temperature loss
. Lower extremity motor deficit greater than upper extremity
. Complete loss of bowel and bladder function only

Correct Answer & Explanation

. Upper extremity motor deficit greater than lower extremity

Explanation

Central cord syndrome typically affects the medially located tracts of the cervical spinal cord. Because the cervical motor tracts serving the upper extremities are located more medially than those serving the lower extremities, patients experience disproportionately greater upper extremity weakness.

Question 307

Topic: 6. Spine

What is the primary vascular supply to the anterior spinal artery in the lower thoracic and upper lumbar region, which is at particular risk during anterior thoracolumbar surgical approaches?

. Artery of Adamkiewicz
. Great radicular vein
. Segmental medullary arteries
. Vertebral artery
. Posterior spinal artery

Correct Answer & Explanation

. Artery of Adamkiewicz

Explanation

The artery of Adamkiewicz (great anterior radiculomedullary artery) is the major blood supply to the lower two-thirds of the spinal cord. It typically arises on the left side between T8 and L1, and its injury can result in anterior cord syndrome.

Question 308

Topic: Thoracolumbar Spine & Deformity

A 14-year-old competitive gymnast complains of chronic, localized lower back pain that worsens with extension. Radiographs reveal a pars interarticularis defect at L5 without anterior slippage. What is the correct terminology for this condition?

. Spondylosis
. Spondylolysis
. Spondylolisthesis
. Spondyloptosis
. Spondyloarthropathy

Correct Answer & Explanation

. Spondylolysis

Explanation

Spondylolysis refers specifically to a defect or stress fracture in the pars interarticularis. If anterior translation (slippage) of the vertebral body occurs as a result, it becomes isthmic spondylolisthesis.

Question 309

Topic: 6. Spine

A patient arrives in the trauma bay with a severe cervical spine injury. Vital signs demonstrate bradycardia and hypotension. Physical examination shows warm, well-perfused extremities. Which of the following conditions is most likely driving these vital sign abnormalities?

. Spinal shock
. Hypovolemic shock
. Neurogenic shock
. Cardiogenic shock
. Septic shock

Correct Answer & Explanation

. Neurogenic shock

Explanation

Neurogenic shock is a dysautonomia that results from disruption of the descending sympathetic pathways in the cervical or high thoracic spine. It is characterized by loss of sympathetic tone, leading to vasodilation (warm extremities), hypotension, and unopposed vagal tone (bradycardia).

Question 310

Topic: 6. Spine

During a posterior approach to the lumbar spine, prolonged and aggressive retraction of the paraspinal muscles can lead to denervation and subsequent muscle atrophy. Which nerve is most directly responsible for innervating the multifidus muscle?

. Ventral ramus
. Sinuvertebral nerve
. Medial branch of the dorsal ramus
. Lateral branch of the dorsal ramus
. Recurrent meningeal nerve

Correct Answer & Explanation

. Medial branch of the dorsal ramus

Explanation

The medial branch of the dorsal primary ramus provides innervation to the facet joints and the deep paraspinal muscles, particularly the multifidus. Injury to this nerve during excessive retraction leads to multifidus atrophy.

Question 311

Topic: 6. Spine

An 80-year-old man with advanced cervical spondylosis falls forward, striking his chin. He develops profound weakness in both hands but can still walk, albeit with a spastic gait. MRI confirms a central cord injury without fracture. Which spinal cord tracts are primarily responsible for his upper extremity deficit?

. Dorsal columns
. Spinothalamic tracts
. Lateral corticospinal tracts
. Ventral spinocerebellar tracts
. Anterior horn cells

Correct Answer & Explanation

. Lateral corticospinal tracts

Explanation

The lateral corticospinal tracts carry descending motor fibers. In central cord syndrome, the more medially situated fibers within these tracts (which innervate the cervical/upper extremities) are disproportionately damaged compared to the lateral sacral/lumbar fibers.

Question 312

Topic: Thoracolumbar Spine & Deformity

Which of the following radiographic parameters is the most important biomechanical predictor of adjacent segment disease following a multi-level lumbar fusion?

. Failure to restore sagittal lumbar lordosis
. Use of pedicle screws larger than 6.5mm in diameter
. The specific choice of interbody graft material
. Preoperative disc space height at the adjacent level
. Presence of lumbar scoliosis less than 10 degrees

Correct Answer & Explanation

. Failure to restore sagittal lumbar lordosis

Explanation

Sagittal imbalance, specifically the failure to restore physiological lumbar lordosis matching the patient's pelvic incidence, significantly increases mechanical stress on adjacent segments. This is a primary driver of adjacent segment degeneration.

Question 313

Topic: 6. Spine

A 22-year-old man is evaluated after a motor vehicle rollover. Radiographs show a fracture through the pars interarticularis of C2 bilaterally with anterior translation of C2 on C3. This "Hangman's fracture" typically results from which mechanism of injury?

. Axial loading
. Hyperflexion and rotation
. Hyperextension and axial loading
. Hyperextension and distraction
. Lateral bending

Correct Answer & Explanation

. Hyperextension and distraction

Explanation

Traumatic spondylolisthesis of the axis, commonly referred to as a Hangman's fracture, is classically caused by a forceful hyperextension and distraction mechanism. This pattern was historically seen in judicial hangings and is now common in high-speed MVAs.

Question 314

Topic: 6. Spine

When examining a patient with suspected degenerative lumbar spinal stenosis, which diagnostic imaging modality is considered the gold standard for defining the cross-sectional area of the dural sac and the degree of soft-tissue neural compression?

. Anteroposterior and lateral plain radiographs
. Non-contrast Computed Tomography (CT)
. Magnetic Resonance Imaging (MRI)
. CT myelography
. Technetium-99 bone scan

Correct Answer & Explanation

. Magnetic Resonance Imaging (MRI)

Explanation

MRI is the gold standard imaging modality for evaluating lumbar spinal stenosis. It provides superior soft-tissue contrast to visualize thecal sac compression, nerve root impingement, disc herniations, and ligamentum flavum hypertrophy.

Question 315

Topic: 6. Spine

A 22-year-old male sustains a severe flexion-distraction injury to the thoracolumbar spine (Chance fracture) during a motor vehicle collision. Which of the following is the most commonly associated concomitant injury?

. Thoracic aortic rupture
. Hollow viscus injury
. Renal contusion
. Diaphragmatic rupture
. Pelvic ring disruption

Correct Answer & Explanation

. Hollow viscus injury

Explanation

Chance fractures are flexion-distraction injuries heavily associated with lap seatbelt wear. They have a high incidence (up to 50%) of concomitant intra-abdominal injuries, particularly hollow viscus injuries like bowel perforations.

Question 316

Topic: 6. Spine

A 45-year-old man presents with severe right leg pain. Examination reveals weakness in big toe extension and decreased sensation over the dorsal first web space. The Achilles and patellar reflexes are normal. Which nerve root is most likely compressed?

. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L5

Explanation

A posterolateral disc herniation at the L4-L5 level typically compresses the traversing L5 nerve root. This results in weakness in the extensor hallucis longus (big toe extension) and altered sensation in the first dorsal web space.

Question 317

Topic: 6. Spine

When calculating the Thoracolumbar Injury Classification and Severity (TLICS) score, an incomplete spinal cord injury assigns how many points to the total score?

. 1 point
. 2 points
. 3 points
. 4 points
. 5 points

Correct Answer & Explanation

. 3 points

Explanation

In the TLICS system, neurological status is scored as follows: intact (0), nerve root (2), complete cord (2), incomplete cord (3), and cauda equina (3). An incomplete cord injury assigns 3 points, reflecting its urgency for decompression.

Question 318

Topic: 6. Spine

A 55-year-old man with longstanding Ankylosing Spondylitis presents with neck pain after a minor fall. Initial plain radiographs are read as normal, but he develops progressive upper extremity weakness. What is the most appropriate next step in management?

. Reassurance and soft collar
. Flexion-extension cervical radiographs
. MRI of the cervical spine
. Electromyography (EMG)
. Cervical epidural steroid injection

Correct Answer & Explanation

. MRI of the cervical spine

Explanation

Patients with ankylosing spondylitis are at high risk for highly unstable, occult cervical spine fractures even after minor trauma. MRI or fine-cut CT is mandatory to rule out a fracture and assess for epidural hematoma.

Question 319

Topic: 6. Spine

According to the Levine and Edwards classification of traumatic spondylolisthesis of the axis (Hangman's fracture), a Type IIA injury is classically associated with which mechanism and imaging finding?

. Hyperextension with minimal displacement
. Hyperextension with bilateral facet dislocation
. Flexion-distraction with severe angulation and minimal translation
. Flexion-compression with severe translation
. Axial loading with comminution of the C2 body

Correct Answer & Explanation

. Flexion-distraction with severe angulation and minimal translation

Explanation

A Type IIA Hangman's fracture is caused by a flexion-distraction injury, resulting in severe angulation but minimal translation. Traction is strictly contraindicated in Type IIA injuries as it will worsen the fracture gap and displacement.

Question 320

Topic: 6. Spine

Which of the following is an absolute indication for surgical decompression and bullet retrieval in a patient who sustains a gunshot wound to the spine?

. Bullet lodged entirely within the vertebral body
. Complete neurological deficit lasting greater than 48 hours
. Bullet fragment within the spinal canal with a complete, non-progressive deficit
. Bullet fragment in the paravertebral soft tissue with no deficit
. Bullet causing a progressive neurological deficit or cauda equina syndrome

Correct Answer & Explanation

. Bullet causing a progressive neurological deficit or cauda equina syndrome

Explanation

Most gunshot wounds to the spine are managed non-operatively regardless of the presence of fragments in the canal. Absolute indications for surgery include progressive neurological decline, cauda equina syndrome, or a bullet lodged in the disc space (due to toxicity and migration risk).

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