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6. Spine MCQs

Practice Set 160 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 3181

Topic: Thoracolumbar Spine & Deformity

A 14-year-old female gymnast complains of chronic, activity-related low back pain. Radiographs reveal a Grade II spondylolisthesis at L5-S1. If this is an isthmic spondylolisthesis, what is the primary anatomic etiology of the slippage?

. Congenital dysplasia of the L5-S1 facet joints
. A bilateral defect or stress fracture in the pars interarticularis
. Degenerative hypertrophy of the ligamentum flavum
. A previous iatrogenic destabilization from laminectomy
. Microinstability related to a generalized connective tissue disorder

Correct Answer & Explanation

. A bilateral defect or stress fracture in the pars interarticularis

Explanation

Isthmic spondylolisthesis (Wiltse Type II) is caused by a defect (spondylolysis), elongation, or acute fracture in the pars interarticularis. This is common in adolescent athletes involved in repetitive lumbar hyperextension (e.g., gymnasts, fast bowlers). Dysplastic spondylolisthesis (Wiltse Type I) is due to congenital anomalies of the upper sacrum or the arch of L5 (facet joint dysplasia).

Question 3182

Topic: 6. Spine

A 55-year-old man of East Asian descent presents with progressive clumsiness in his hands, difficulty with fine motor tasks, and a wide-based gait. Imaging of his cervical spine is shown.

What is the underlying pathophysiology most likely responsible for his myelopathic symptoms?

. Hypertrophy of the ligamentum flavum
. Ectopic bone formation within the posterior longitudinal ligament
. Disc herniation leading to cord contusion
. Congenital fusion of the cervical vertebrae
. Destructive granulomatous infection of the vertebral body

Correct Answer & Explanation

. Ectopic bone formation within the posterior longitudinal ligament

Explanation

The scenario describes cervical myelopathy secondary to Ossification of the Posterior Longitudinal Ligament (OPLL). This condition is characterized by ectopic bone formation within the posterior longitudinal ligament and is particularly prevalent in East Asian populations. It causes progressive anterior compression of the spinal cord, leading to myelopathic symptoms such as clumsiness in the hands (loss of fine motor skills) and a spastic, wide-based gait.

Question 3183

Topic: 6. Spine

A 72-year-old male complains of bilateral calf, thigh, and buttock pain that worsens with walking. He is being evaluated to differentiate between neurogenic claudication (lumbar spinal stenosis) and vascular claudication. Which of the following findings is most specific for neurogenic claudication?

. Pain relief occurs promptly with standing still.
. Pain is brought on by riding a stationary bicycle.
. Diminished posterior tibial pulses.
. Pain relief when walking uphill or leaning over a shopping cart.
. Skin changes including loss of hair on the lower extremities.

Correct Answer & Explanation

. Pain relief when walking uphill or leaning over a shopping cart.

Explanation

Pain relief with lumbar flexion (e.g., walking uphill, pushing a shopping cart, or sitting) is a hallmark of neurogenic claudication due to lumbar spinal stenosis. Flexion of the lumbar spine increases the cross-sectional area of the spinal canal and neural foramina, relieving compression on the nerve roots. Vascular claudication typically worsens with walking uphill due to increased metabolic demand, and relieves simply by standing still.

Question 3184

Topic: 6. Spine

A 65-year-old male of Asian descent presents with progressive clumsiness in his hands, difficulty buttoning his shirts, and a broad-based, spastic gait. Lateral cervical radiograph demonstrates a continuous, dense strip of ossification along the posterior aspect of the vertebral bodies from C3 to C6. Which of the following best describes the primary pathophysiology of this condition?

. Ectopic ossification of the ligamentum flavum
. Ossification of the posterior longitudinal ligament (OPLL)
. Hypertrophy of the uncinate processes and facet joints
. Degenerative disc disease leading to massive anterior osteophyte formation
. Autoimmune fusion of the anterior longitudinal ligament

Correct Answer & Explanation

. Ossification of the posterior longitudinal ligament (OPLL)

Explanation

The clinical presentation (cervical myelopathy) and radiographic findings (dense ossification posterior to the vertebral bodies) are classic for Ossification of the Posterior Longitudinal Ligament (OPLL). This condition most commonly occurs in the cervical spine of patients of Asian descent. The ossification mass encroaches on the spinal canal, leading to compression of the spinal cord.

Question 3185

Topic: 6. Spine

In the Thoracolumbar Injury Classification and Severity (TLICS) score, three main categories are evaluated. Which of the following singular findings contributes the highest point value (3 points) to the total score, strongly favoring surgical stabilization?

. A burst fracture morphology
. A complete spinal cord injury (ASIA A)
. Disruption of the posterior ligamentous complex (PLC)
. A compression fracture morphology
. Nerve root injury

Correct Answer & Explanation

. Disruption of the posterior ligamentous complex (PLC)

Explanation

The TLICS system evaluates Morphology, Neurologic Status, and Posterior Ligamentous Complex (PLC) integrity. Complete disruption of the PLC yields 3 points (Suspected/Indeterminate is 2). In Neurologic status, an incomplete cord injury or cauda equina syndrome yields 3 points, while a complete cord injury only yields 2 points. Therefore, PLC disruption (3 points) is a massive driver for surgical intervention (Total score >4 favors surgery).

Question 3186

Topic: 6. Spine

A 65-year-old male presents with bilateral leg pain that worsens with walking. The pain is relieved by sitting or leaning over a shopping cart.

Which of the following clinical findings is most useful for confirming that his symptoms are neurogenic rather than vascular in origin?

. Pain onset occurring consistently after a fixed walking distance
. Decreased ankle-brachial index (< 0.8)
. Pain relief strictly isolated to standing stationary
. Presence of normal pedal pulses and an ankle-brachial index > 0.9
. Loss of hair over the anterior tibia and shiny skin

Correct Answer & Explanation

. Presence of normal pedal pulses and an ankle-brachial index > 0.9

Explanation

The patient's presentation of relief with sitting or spinal flexion (shopping cart sign) is classic for neurogenic claudication due to lumbar spinal stenosis. Vascular claudication is typically relieved simply by resting/standing stationary and occurs at a set distance. The presence of normal pedal pulses and a normal ankle-brachial index (>0.9) objectively rules out vascular claudication, making it the best finding to differentiate the two.

Question 3187

Topic: 6. Spine

A 19-year-old Asian male presents with painless, unilateral, progressive weakness and atrophy of his right hand intrinsic muscles. Sensory exam is normal, and his lower extremities are unaffected. A dynamic flexion MRI of the cervical spine reveals anterior displacement of the posterior dural sac, compressing the lower cervical cord.

What is the most likely diagnosis?

. Amyotrophic lateral sclerosis
. Cervical spondylotic myelopathy
. Syringomyelia
. Hirayama disease
. Parsonage-Turner syndrome

Correct Answer & Explanation

. Hirayama disease

Explanation

The clinical picture of progressive unilateral distal upper extremity atrophy in a young male, coupled with dynamic flexion MRI showing forward displacement of the posterior dural sac causing cord compression, is pathognomonic for Hirayama disease (juvenile muscular atrophy of the distal upper extremity). The repeated dynamic compression leads to ischemia of the anterior horn cells in the lower cervical cord.

Question 3188

Topic: 6. Spine

A 50-year-old man presents with chronic neck pain radiating down his right arm. Neurological examination reveals marked weakness in elbow extension, wrist flexion, and finger extension. He also has decreased sensation over the dorsal aspect of the long finger. The triceps reflex is 1+. Which cervical nerve root is most likely compressed?

. C5
. C6
. C7
. C8
. T1

Correct Answer & Explanation

. C7

Explanation

A C7 radiculopathy classically presents with motor weakness in the triceps (elbow extension), wrist flexors (flexor carpi radialis), and finger extensors. Patients often have a diminished triceps reflex and sensory changes over the long (middle) finger. C6 radiculopathy would affect wrist extensors and the brachioradialis reflex, with sensory changes in the thumb and index finger.

Question 3189

Topic: 6. Spine

A 25-year-old male sustains a severe flexion-distraction injury resulting in a burst fracture of T4 with complete paralysis and loss of sensation below the nipples. He presents to the trauma bay with a blood pressure of 80/40 mmHg and a heart rate of 50 beats per minute. His extremities are warm and flushed. This specific clinical presentation is most consistent with:

. Hemorrhagic shock
. Spinal shock
. Neurogenic shock
. Cardiogenic shock
. Septic shock

Correct Answer & Explanation

. Neurogenic shock

Explanation

Neurogenic shock is a distributive shock caused by a loss of sympathetic tone following a high thoracic (T6 and above) or cervical spinal cord injury. It presents with the classic triad of hypotension, bradycardia, and warm, flushed extremities (peripheral vasodilation). Spinal shock, distinct from neurogenic shock, refers to the temporary loss of all spinal reflexes below the level of injury (e.g., absent bulbocavernosus reflex) immediately following spinal cord injury.

Question 3190

Topic: 6. Spine

In patients with cervical spondylotic myelopathy undergoing non-operative management, which of the following MRI findings is considered a poor prognostic indicator for neurological recovery?

. Duration of symptoms less than 6 months
. Cross-sectional area of the spinal cord < 40 mm2
. Presence of unilateral upper extremity radiculopathy
. Patient age under 50 years
. Maintenance of lordotic sagittal alignment

Correct Answer & Explanation

. Cross-sectional area of the spinal cord < 40 mm2

Explanation

A spinal cord cross-sectional area of < 40 mm2 (transverse area), presence of myelomalacia (T2 hyperintensity/T1 hypointensity in the cord), duration of symptoms > 6 months, and severe clinical deficit (Nurick > 3) are established poor prognostic indicators for conservative management of cervical myelopathy.

Question 3191

Topic: Cervical Spine

An 82-year-old male with a history of severe osteoporosis presents after a ground-level fall. Imaging reveals a displaced Type II odontoid fracture. He has significant neck pain but is neurologically intact. To optimize union rates and minimize morbidity and mortality, which of the following is the most appropriate surgical management?

. Anterior odontoid screw fixation
. Application of a halo vest
. Cervical collar application and strict bed rest
. Posterior C1-C2 instrumented fusion
. Occipitocervical fusion

Correct Answer & Explanation

. Posterior C1-C2 instrumented fusion

Explanation

In an elderly patient (e.g., >80 years old) with a displaced Type II odontoid fracture, posterior C1-C2 instrumented fusion provides the highest rate of fracture union and has lower morbidity compared to alternative surgical methods like an anterior odontoid screw (which relies on good bone quality, often poor in this demographic, and poses a higher risk of hardware failure or dysphagia). Halo vest immobilization in the elderly is associated with high nonunion rates and severe morbidity/mortality (pin site infection, pneumonia, cardiac arrest) and is generally avoided.

Question 3192

Topic: 6. Spine

A 70-year-old male presents with bilateral leg pain and fatigue when walking short distances. Which of the following features most strongly suggests a diagnosis of neurogenic claudication secondary to lumbar spinal stenosis rather than vascular claudication?

. Pain is rapidly relieved simply by standing completely still
. Symptoms are exacerbated by pushing a shopping cart
. Symptoms are reliably reproduced after walking a precise distance each time
. Pain is improved when walking uphill and exacerbated walking downhill
. The presence of diminished pedal pulses and distal hair loss

Correct Answer & Explanation

. Pain is improved when walking uphill and exacerbated walking downhill

Explanation

Neurogenic claudication is hallmarked by exacerbation of symptoms with lumbar extension and relief with lumbar flexion. Walking uphill flexes the lumbar spine, enlarging the spinal canal and foramina, thereby relieving symptoms. Walking downhill forces the spine into extension, exacerbating symptoms. In contrast, vascular claudication is distance-dependent, relieved merely by resting (standing still), and presents with signs of poor perfusion (diminished pulses).

Question 3193

Topic: 6. Spine

A 65-year-old female presents with progressive neurogenic claudication and lower back pain. Imaging shows an L4-L5 grade I degenerative spondylolisthesis with severe central canal stenosis. After failing 6 months of comprehensive conservative treatment, she considers operative intervention. According to the Spine Patient Outcomes Research Trial (SPORT), which of the following statements regarding surgical versus nonoperative treatment at 4-year follow-up is correct?

. Nonoperative treatment yields superior results in pain reduction compared to surgery.
. Surgical treatment provides significantly greater improvement in pain and function compared to nonoperative treatment.
. Both groups demonstrate equal long-term improvement in functional outcomes.
. Surgical treatment is associated with a significantly higher rate of long-term mortality.
. Epidural steroid injections provide equivalent long-term relief to surgical decompression.

Correct Answer & Explanation

. Surgical treatment provides significantly greater improvement in pain and function compared to nonoperative treatment.

Explanation

The Spine Patient Outcomes Research Trial (SPORT) demonstrated that for patients with degenerative spondylolisthesis and symptomatic spinal stenosis, surgical treatment (decompression with or without fusion) maintained significantly greater improvement in pain and function compared to nonoperative treatment at 4-year follow-up. This benefit persisted in long-term 8-year follow-up data.

Question 3194

Topic: 6. Spine

A 55-year-old male with a history of intravenous drug use presents with severe, progressive midthoracic back pain, a temperature of 39.0°C, and rapidly progressive bilateral lower extremity weakness over the past 24 hours. MRI with gadolinium reveals a large anterior epidural abscess causing severe spinal cord compression at T8. What is the most appropriate and definitive next step in management?

. Immediate administration of intravenous antibiotics and close neurological observation
. CT-guided needle aspiration for culture prior to definitive antibiotic therapy
. Anterior corpectomy, abscess evacuation, spinal cord decompression, and stabilization
. Posterior laminectomy alone for decompression
. Epidural steroid injection followed by bracing

Correct Answer & Explanation

. Anterior corpectomy, abscess evacuation, spinal cord decompression, and stabilization

Explanation

An anterior spinal epidural abscess causing acute, progressive neurological deficit requires urgent surgical decompression. In the thoracic spine, where the pathology is anterior to the spinal cord, an anterior approach (such as an anterior corpectomy and fusion) is preferred. A posterior laminectomy alone is relatively contraindicated as it fails to address the anterior pathology adequately, can further destabilize the spine, and risks causing or worsening kyphosis, which can stretch and damage the already compromised spinal cord.

Question 3195

Topic: 6. Spine



A 60-year-old male presents with progressively worsening manual dexterity and balance issues over the past 8 months. Examination reveals a positive Hoffmann's sign and hyperreflexia. MRI shows multi-level cervical stenosis with cord signal changes. Which of the following MRI findings most strongly predicts a poor neurologic recovery following surgical decompression?

. Presence of T2 hyperintensity confined to a single level
. Duration of symptoms strictly less than 6 months
. Transverse area of the spinal cord of 50 mm^2 at the level of maximum compression
. Multilevel spondylosis without foraminal stenosis
. Presence of T1 hypointensity within the spinal cord

Correct Answer & Explanation

. Presence of T1 hypointensity within the spinal cord

Explanation

In the setting of cervical spondylotic myelopathy, T1 hypointensity on MRI represents permanent structural damage to the spinal cord (myelomalacia, necrosis, or cavitation) and is a strong independent predictor of poor clinical outcomes and limited neurologic recovery following decompression. T2 hyperintensity alone can represent reversible edema.

Question 3196

Topic: 6. Spine



A 35-year-old male presents following a high-speed motor vehicle accident. CT scan shows a T12 burst fracture with 40% canal compromise. His neurologic exam reveals 3/5 strength in bilateral hip flexors and knee extensors, with preserved perineal sensation. According to the Thoracolumbar Injury Classification and Severity Score (TLICS), how many points are assigned specifically for his neurologic status, and what is the overall treatment implication?

. 2 points; favoring nonoperative treatment
. 3 points; favoring operative treatment
. 3 points; favoring nonoperative treatment
. 2 points; favoring operative treatment
. 4 points; favoring operative treatment

Correct Answer & Explanation

. 4 points; favoring operative treatment

Explanation

The TLICS system allocates points based on morphology, neurologic status, and posterior ligamentous complex (PLC) integrity. For neurologic status: intact = 0, nerve root = 2, complete cord injury = 2, incomplete cord injury/cauda equina = 3. This patient has an incomplete deficit (3 points). With morphology being a burst fracture (2 points), the score is at least 5, which strongly favors operative intervention.

Question 3197

Topic: 6. Spine

A 14-year-old gymnast presents with chronic low back pain exacerbated by extension. Radiographs show a grade II isthmic spondylolisthesis at L5-S1. What is the most common neurological finding associated with this condition if radiculopathy is present?

. Weakness in ankle dorsiflexion
. Decreased patellar reflex
. Weakness in ankle plantar flexion
. Numbness in the medial aspect of the lower leg
. Radicular pain in the L5 distribution

Correct Answer & Explanation

. Radicular pain in the L5 distribution

Explanation

In L5-S1 isthmic spondylolisthesis, the exiting L5 nerve root is most commonly compressed within the neural foramen by fibrocartilaginous tissue of the pars defect, resulting in L5 radiculopathy (pain, weakness in EHL, and sensory changes in the first dorsal web space).

Question 3198

Topic: 6. Spine

A 22-year-old restrained passenger is involved in a high-speed motor vehicle collision. CT of the lumbar spine reveals a flexion-distraction injury (Chance fracture) at L2. Which of the following associated injuries has the highest incidence in this patient population?

. Aortic transection
. Intra-abdominal visceral injury
. Spinal cord complete transection
. Renal artery thrombosis
. Pelvic ring disruption

Correct Answer & Explanation

. Intra-abdominal visceral injury

Explanation

Chance fractures (flexion-distraction injuries of the spine) are highly associated with lap-belt use in motor vehicle accidents. They carry a very high rate (up to 40-50%) of concomitant intra-abdominal visceral injuries, particularly to hollow viscous organs like the small bowel.

Question 3199

Topic: 6. Spine

A 32-year-old male is involved in a high-speed motor vehicle collision and arrives with a unilateral C6-C7 facet dislocation and a dense C6 radiculopathy.

Closed reduction with cranial tongs is attempted in the awake patient but is unsuccessful. What is the most appropriate next step in management?

. Perform immediate posterior open reduction without further imaging
. Discharge the patient with a halo-vest orthosis for non-operative management
. Obtain an urgent MRI of the cervical spine followed by surgical intervention
. Perform an immediate anterior cervical discectomy and fusion (ACDF)
. Re-attempt closed reduction under general anesthesia

Correct Answer & Explanation

. Obtain an urgent MRI of the cervical spine followed by surgical intervention

Explanation

In cases of cervical facet dislocation where awake closed reduction fails, or in a patient who cannot be examined (e.g., obtunded), an MRI of the cervical spine is the standard of care before proceeding to open reduction. The MRI is essential to identify the presence of a herniated intervertebral disc. If an anterior disc herniation is present, a posterior-only open reduction poses a significant risk of extruding the disc further into the spinal canal, potentially causing a catastrophic spinal cord injury. Therefore, MRI dictates whether an anterior approach (to remove the disc before reduction) is required.

Question 3200

Topic: 6. Spine

A 70-year-old male complains of bilateral lower extremity pain and cramping when walking a distance of two blocks. Which of the following clinical features most strongly distinguishes neurogenic claudication (due to lumbar spinal stenosis) from vascular claudication?

. Pain relief when standing completely stationary
. Palliative effect of walking uphill compared to walking downhill
. Diminished pedal pulses and shiny skin
. Exacerbation of pain with spinal flexion
. Distal to proximal progression of symptoms

Correct Answer & Explanation

. Palliative effect of walking uphill compared to walking downhill

Explanation

Neurogenic claudication, characteristic of lumbar spinal stenosis, is typically relieved by lumbar flexion (which increases the cross-sectional area of the spinal canal and neural foramina). Therefore, patients often experience relief when sitting, leaning on a shopping cart, or walking uphill (which necessitates a flexed posture). Conversely, vascular claudication is strictly tied to the metabolic demand of the muscles; patients have pain with walking any incline (uphill worsens vascular demand) and find relief simply by standing still. Neurogenic claudication is typically aggravated by standing still in extension.

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