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6. Spine MCQs

Practice Set 167 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 3321

Topic: 6. Spine

A 68-year-old female presents with severe neurogenic claudication secondary to L4-L5 central spinal stenosis. She has no significant mechanical back pain, and dynamic flexion-extension radiographs show no measurable spondylolisthesis or instability. After failing 6 months of conservative management, what is the most appropriate surgical intervention?

. L4-L5 laminectomy with instrumented posterolateral fusion
. L4-L5 anterior lumbar interbody fusion (ALIF)
. L4-L5 laminectomy alone
. Interspinous process spacer placement
. L4-L5 posterior lumbar interbody fusion (PLIF)

Correct Answer & Explanation

. L4-L5 laminectomy alone

Explanation

In patients with symptomatic lumbar spinal stenosis who fail conservative treatment, and who lack clinical or radiographic evidence of instability (no spondylolisthesis, no significant dynamic translation), surgical decompression alone (laminectomy) is the gold standard. High-level evidence (such as the SPORT trial) demonstrates that the addition of a fusion procedure in the absence of instability increases operative time, blood loss, and costs without improving clinical outcomes.

Question 3322

Topic: 6. Spine

A 55-year-old diabetic male presents with progressive back pain, fever, and bilateral leg weakness. MRI shows an epidural abscess from L2 to L4 with severe thecal sac compression. What is the most appropriate initial management?

. Intravenous antibiotics alone
. CT-guided aspiration
. Urgent surgical decompression and debridement
. Corticosteroids followed by oral antibiotics
. Observation with serial MRI

Correct Answer & Explanation

. Urgent surgical decompression and debridement

Explanation

Progressive neurologic deficit (leg weakness) in the presence of an epidural abscess is an absolute indication for urgent surgical decompression and debridement. Antibiotics alone are only indicated for patients without neurologic deficits, those who are completely paralyzed for more than 48-72 hours, or those medically unfit for surgery.

Question 3323

Topic: Cervical Spine

An 82-year-old male sustains a Type II odontoid fracture with 2 mm of displacement after a low-energy fall. A decision is made regarding non-operative treatment. Compared to a rigid cervical collar, the use of a halo vest in this specific age group is most strongly associated with:

. Higher rates of fracture union
. Significantly increased mortality and morbidity
. Decreased risk of pin-site infection
. Improved patient compliance
. Lower rates of dysphagia

Correct Answer & Explanation

. Significantly increased mortality and morbidity

Explanation

Halo vest immobilization in the elderly (generally >65 years) is poorly tolerated and associated with high rates of morbidity and mortality (up to 20-30%), primarily due to respiratory complications (pneumonia) and falls. Studies have shown no significant improvement in union rates compared to rigid cervical collars in elderly patients; thus, a rigid collar is often the preferred non-operative treatment.

Question 3324

Topic: 6. Spine

A 65-year-old male complains of bilateral leg pain, heaviness, and fatigue when walking. The symptoms are consistently relieved when leaning forward on a shopping cart or riding a stationary bicycle. On physical examination, which of the following findings is most likely to be present?

. Absent pedal pulses
. Positive straight leg raise test
. Decreased pain with lumbar extension
. Normal ankle-brachial index
. Hyperreflexia and clonus

Correct Answer & Explanation

. Normal ankle-brachial index

Explanation

The patient's history is classic for neurogenic claudication secondary to lumbar spinal stenosis. Symptoms improve with lumbar flexion (shopping cart sign, cycling) because it increases the cross-sectional area of the spinal canal. Unlike vascular claudication, patients with neurogenic claudication typically have normal distal perfusion, characterized by normal pedal pulses and a normal ankle-brachial index (ABI > 0.9).

Question 3325

Topic: Thoracolumbar Spine & Deformity

A 40-year-old man falls from a height of 10 feet and sustains an L1 burst fracture. He is neurologically intact (ASIA E). MRI confirms that the posterior ligamentous complex (PLC) is intact. According to the Thoracolumbar Injury Classification and Severity Score (TLICS), what is his score and the recommended management?

. Score 2, suggesting non-operative management
. Score 4, suggesting operative management
. Score 5, suggesting operative management
. Score 6, suggesting operative management
. Score 7, suggesting operative management

Correct Answer & Explanation

. Score 2, suggesting non-operative management

Explanation

The TLICS system assigns points based on morphology, neurologic status, and PLC integrity. A burst fracture (morphology) gets 2 points. Intact neurologic status gets 0 points. Intact PLC gets 0 points. Total score = 2. A score of 3 or less suggests non-operative management. A score of 4 is indeterminate, and 5 or more suggests surgery.

Question 3326

Topic: 6. Spine

A 68-year-old man presents with a 6-month history of deteriorating handwriting, difficulty buttoning his shirt, and an unsteady gait. On physical examination, he demonstrates hyperreflexia in the lower extremities, a positive Hoffmann's sign bilaterally, and an inverted brachioradialis reflex. What is the most definitive imaging study to confirm the suspected diagnosis?

. Electromyography (EMG) and Nerve Conduction Studies
. Dynamic flexion-extension radiographs of the cervical spine
. Magnetic Resonance Imaging (MRI) of the cervical spine
. Somatosensory Evoked Potentials (SSEPs)
. Computed Tomography (CT) scan of the brain

Correct Answer & Explanation

. Magnetic Resonance Imaging (MRI) of the cervical spine

Explanation

The patient's presentation of clumsiness in the hands (myelopathy hand), gait instability, upper motor neuron signs (hyperreflexia, Hoffmann's), and lower motor neuron signs at a specific level (inverted brachioradialis reflex indicates a C5/C6 level lesion) is classic for cervical spondylotic myelopathy. MRI of the cervical spine is the gold standard imaging modality to visualize spinal cord compression, signal changes (myelomalacia), and the exact level of stenosis.

Question 3327

Topic: 6. Spine

A 14-year-old girl presents with back pain and hamstring tightness. Radiographs show a Meyerding Grade IV L5-S1 isthmic spondylolisthesis. What is the most common neurological deficit observed if slip progression continues or during surgical reduction?

. L4 nerve root
. L5 nerve root
. S1 nerve root
. S2 nerve root
. Cauda equina syndrome

Correct Answer & Explanation

. L5 nerve root

Explanation

In L5-S1 isthmic spondylolisthesis, the L5 nerve root is at greatest risk. As L5 slips anteriorly on S1, the L5 nerve root gets stretched over the posterior aspect of the sacral dome. It is also the most commonly injured root during surgical reduction of a high-grade slip.

Question 3328

Topic: 6. Spine

A 50-year-old male presents with neck pain radiating down his right arm. Examination reveals weakness in elbow extension, diminished triceps reflex, and numbness over the dorsum of the middle finger. Which cervical nerve root is most likely compressed?

. C5
. C6
. C7
. C8
. T1

Correct Answer & Explanation

. C7

Explanation

The C7 nerve root is the most commonly involved root in cervical radiculopathy. It manifests with weakness in elbow extension (triceps), wrist flexion, and finger extension; an abnormal triceps reflex; and sensory changes over the middle finger.

Question 3329

Topic: 6. Spine

A 19-year-old male presents with slowly progressive, unilateral weakness and atrophy of his right hand and forearm over the past 2 years. He denies sensory loss or lower extremity weakness. Cervical spine MRI in a neutral position is unremarkable, but a dynamic flexion MRI reveals anterior displacement of the posterior dura with flattening of the lower cervical cord. What is the most likely diagnosis?

. Amyotrophic lateral sclerosis
. Syringomyelia
. Hirayama disease
. Klippel-Feil syndrome
. Cervical spondylotic myelopathy

Correct Answer & Explanation

. Hirayama disease

Explanation

Hirayama disease (juvenile muscular atrophy of the distal upper extremity) is a cervical myelopathy predominantly affecting young males. It is caused by anterior displacement of the posterior dural sac during neck flexion, leading to cord compression and anterior horn cell ischemia, resulting in isolated distal upper extremity atrophy.

Question 3330

Topic: Thoracolumbar Spine & Deformity
A 14-year-old female gymnast presents with an insidious onset of lower back pain. Radiographs demonstrate a grade II L5-S1 spondylolisthesis, and oblique views reveal an obvious defect in the pars interarticularis. According to the Wiltse classification of spondylolisthesis, into which category does this patient fall?
. Type I (Dysplastic)
. Type II (Isthmic)
. Type III (Degenerative)
. Type IV (Traumatic)
. Type V (Pathologic)

Correct Answer & Explanation

. Type II (Isthmic)

Explanation

The Wiltse classification defines Type II as Isthmic, which involves a defect or lesion in the pars interarticularis. Subtype IIA is a stress fracture of the pars (most common in young athletes like gymnasts). Type I is dysplastic (congenital abnormalities of the upper sacrum or L5 arch). Type III is degenerative. Type IV is traumatic (fracture in areas other than the pars). Type V is pathologic.

Question 3331

Topic: 6. Spine

A 65-year-old male presents with deteriorating hand dexterity, a broad-based gait, and hyperreflexia. MRI shows multilevel cervical spondylosis with cord compression from C3 to C6, but with well-preserved cervical lordosis. He denies any significant axial neck pain. Which of the following surgical approaches is most appropriate?

. Anterior cervical discectomy and fusion (ACDF) C3-C6
. Cervical laminectomy and fusion C3-C6
. Cervical laminoplasty C3-C6
. Anterior cervical corpectomy C3-C6
. Posterior cervical foraminotomies

Correct Answer & Explanation

. Cervical laminoplasty C3-C6

Explanation

The patient has cervical spondylotic myelopathy involving more than 3 levels (C3-C6). In a patient with well-maintained cervical lordosis and minimal axial neck pain, a posterior motion-preserving decompression such as cervical laminoplasty is ideal. It avoids the morbidity of multilevel anterior fusion (dysphagia, pseudoarthrosis) and prevents post-laminectomy kyphosis by preserving the posterior tension band.

Question 3332

Topic: Thoracolumbar Spine & Deformity

A 14-year-old female gymnast presents with persistent lower back pain exacerbated by extension. Lateral radiographs reveal a grade I isthmic spondylolisthesis at L5-S1. She has failed 6 months of conservative management including physical therapy, rest, and bracing. What is the most appropriate surgical treatment?

. L5-S1 posterolateral instrumented fusion
. L5 laminectomy without fusion
. L4-S1 anterior lumbar interbody fusion (ALIF)
. Translaminar screw fixation
. Sacroiliac joint fusion

Correct Answer & Explanation

. L5-S1 posterolateral instrumented fusion

Explanation

For pediatric or adolescent patients with symptomatic isthmic spondylolisthesis who fail comprehensive nonoperative management, an in situ posterolateral instrumented fusion of the affected segment (L5-S1) is the gold standard surgical treatment. Laminectomy without fusion in a pediatric patient is contraindicated as it exacerbates instability. Interbody fusion is generally not required for low-grade slips in this age group.

Question 3333

Topic: Thoracolumbar Spine & Deformity

What is the most significant radiographic risk factor for the progression of a dysplastic (isthmic) spondylolisthesis in a skeletally immature patient?

. High pelvic incidence
. Slip angle greater than 45 degrees
. Sacral slope less than 30 degrees
. Meyerding Grade I slip at presentation
. Presence of spina bifida occulta

Correct Answer & Explanation

. Slip angle greater than 45 degrees

Explanation

In skeletally immature patients with isthmic spondylolisthesis, a high slip angle (greater than 45-50 degrees) is the most significant radiographic risk factor for the progression of the slip. A high slip angle indicates a more vertical orientation of the L5-S1 disc space, placing higher shear forces across the lumbosacral junction. While high pelvic incidence is associated with the development of spondylolisthesis, the slip angle is the most predictive of progression.

Question 3334

Topic: 6. Spine

A 45-year-old male presents with severe neck pain radiating down his right arm. Physical examination reveals weakness in wrist flexion and finger extension, and an absent triceps reflex. Sensation is diminished over the volar aspect of the middle finger. Which cervical nerve root is most likely compressed?

. C5
. C6
. C7
. C8
. T1

Correct Answer & Explanation

. C7

Explanation

The clinical findings are classic for a C7 radiculopathy. The C7 nerve root supplies the triceps (elbow extension), wrist flexors (flexor carpi radialis), and finger extensors (extensor digitorum communis). The primary reflex tested is the triceps reflex, and the dermatomal sensory distribution is the middle finger. C6 radiculopathy would affect wrist extension and the brachioradialis reflex with numbness in the thumb/index finger.

Question 3335

Topic: Thoracolumbar Spine & Deformity
According to the Wiltse classification of spondylolisthesis, which subtype is characterized by an elongated, but intact, pars interarticularis resulting from repeated micro-fractures and subsequent healing?
. Type I (Dysplastic)
. Type IIA (Lytic/Stress fracture)
. Type IIB (Elongated pars)
. Type IIC (Acute pars fracture)
. Type III (Degenerative)

Correct Answer & Explanation

. Type IIB (Elongated pars)

Explanation

The Wiltse classification categorizes spondylolisthesis. Type II is isthmic (pars defect). Type IIA is a stress fracture (lytic). Type IIB represents an elongated pars interarticularis secondary to repetitive micro-fracture and healing without complete separation. Type IIC is an acute fracture.

Question 3336

Topic: 6. Spine

Cervical spondylotic myelopathy (CSM) classically presents with a combination of upper motor neuron signs in the lower extremities and lower motor neuron signs in the upper extremities. Which of the following spinal cord tracts is compressed anteriorly, resulting in the upper motor neuron signs seen in the legs?

. Fasciculus gracilis
. Fasciculus cuneatus
. Lateral corticospinal tract
. Spinothalamic tract
. Dorsal spinocerebellar tract

Correct Answer & Explanation

. Lateral corticospinal tract

Explanation

The upper motor neuron signs in the lower extremities (hyperreflexia, spasticity, positive Babinski) in CSM are caused by compression of the lateral corticospinal tracts, which are located in the lateral and anterior aspects of the spinal cord.

Question 3337

Topic: Cervical Spine

A 75-year-old male presents to the emergency department after a mechanical fall from standing height, complaining of neck pain. CT scan of the cervical spine reveals a Type II odontoid fracture with 2 mm of posterior displacement. He is neurologically intact. What is the most appropriate initial management for this patient?

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

Correct Answer & Explanation

. Rigid cervical collar

Explanation

In elderly patients (generally defined as >65 or >70 years) with a Type II odontoid fracture, treatment is debated, but a rigid cervical collar is often preferred as initial management. This is because halo vest immobilization and operative interventions carry disproportionately high morbidity and mortality in this population. Although nonunion rates are higher with a collar, the nonunions are frequently stable and asymptomatic (fibrous nonunion).

Question 3338

Topic: Thoracolumbar Spine & Deformity

Which of the following is an essential radiographic criterion for the definitive diagnosis of typical Scheuermann's kyphosis (Sorensen criteria)?

. Anterior wedging of at least 5 degrees in three consecutive vertebrae
. Anterior wedging of at least 10 degrees in two consecutive vertebrae
. Schmorl's nodes in at least three non-consecutive vertebrae
. A regional thoracic kyphosis angle greater than 50 degrees without structural wedging
. Endplate irregularity isolated to the thoracolumbar junction

Correct Answer & Explanation

. Anterior wedging of at least 5 degrees in three consecutive vertebrae

Explanation

The classic Sorensen criteria for the diagnosis of Scheuermann's kyphosis require the presence of thoracic kyphosis greater than 40 degrees and at least three consecutive vertebrae demonstrating a minimum of 5 degrees of anterior wedging each.

Question 3339

Topic: Thoracolumbar Spine & Deformity

According to the Thoracolumbar Injury Classification and Severity Score (TLICS), which is used to guide treatment for thoracolumbar trauma, a total score of 5 points generally indicates which of the following management strategies?

. Non-operative management is strictly indicated
. Operative management is indicated
. The choice between operative and non-operative management is equivocal (surgeon's choice)
. A definite fracture-dislocation pattern is present
. A purely ligamentous injury without fracture is present

Correct Answer & Explanation

. Operative management is indicated

Explanation

The TLICS system guides treatment based on three categories: injury morphology, neurological status, and integrity of the posterior ligamentous complex (PLC). A total score of 3 or less suggests non-operative management; a score of 4 is indeterminate (surgeon's choice); and a score of 5 or greater indicates that operative management is generally recommended due to instability or neurological compromise.

Question 3340

Topic: Cervical Spine

A 60-year-old Asian male presents with progressive clumsiness in his hands and difficulty walking. Radiographs and CT of the cervical spine reveal a continuous band of ossification along the posterior aspect of the C3-C6 vertebral bodies. MRI shows spinal cord compression with T2 signal change. Which of the following is the most appropriate surgical approach, assuming neutral cervical sagittal alignment?

. Anterior cervical discectomy and fusion (ACDF)
. Anterior cervical corpectomy and fusion (ACCF)
. Posterior cervical laminectomy without fusion
. Posterior cervical laminoplasty
. Combined anterior-posterior decompression and fusion

Correct Answer & Explanation

. Posterior cervical laminoplasty

Explanation

The diagnosis is Ossification of the Posterior Longitudinal Ligament (OPLL). For multi-level (>3 levels) OPLL with neutral or lordotic cervical alignment, a posterior approach such as laminoplasty (or laminectomy with fusion) is preferred to avoid the high complication rates (e.g., dural tears, CSF leak) associated with anterior resection of the ossified mass.

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