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6. Spine MCQs

Practice Set 168 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 3341

Topic: Thoracolumbar Spine & Deformity

A 40-year-old male falls from a ladder and sustains an L1 burst fracture. Neurological examination is completely normal. MRI reveals a completely intact posterior ligamentous complex (PLC). Using the Thoracolumbar Injury Classification and Severity Score (TLICS), what is the total score and the most appropriate recommendation for treatment?

. Score 2; non-operative management
. Score 4; surgeon's choice (operative or non-operative)
. Score 5; operative management
. Score 7; operative management
. Score 3; non-operative management

Correct Answer & Explanation

. Score 2; non-operative management

Explanation

The TLICS system assigns points based on morphology, neurologic status, and integrity of the PLC. A burst fracture gets 2 points. A normal neurologic exam gets 0 points. An intact PLC gets 0 points. Total score = 2. A score of 3 or less indicates non-operative management is recommended. A score of 4 is indeterminate, and 5 or more suggests operative intervention.

Question 3342

Topic: Thoracolumbar Spine & Deformity

A patient sustains a traumatic spondylolisthesis of the axis (Hangman fracture) classified as Levine-Edwards Type IIA. What is the classic mechanism of injury, and what is the appropriate initial closed management?

. Hyperextension and axial loading; traction
. Flexion-distraction; application of halo vest in slight extension and compression
. Flexion-distraction; application of heavy cervical traction
. Hyperextension and distraction; C1-C2 transarticular screws
. Axial loading; rigid cervical collar

Correct Answer & Explanation

. Flexion-distraction; application of halo vest in slight extension and compression

Explanation

Type IIA Hangman fractures exhibit minimal translation but severe angulation and are caused by a flexion-distraction mechanism. Crucially, they worsen with traction (unlike standard Type II fractures). The correct initial management is gentle reduction via extension, followed by placement in a halo vest under slight compression.

Question 3343

Topic: 6. Spine

A 55-year-old Asian man presents with progressive clumsiness in his hands and difficulty walking. Lateral cervical radiographs reveal continuous ossification along the posterior aspect of the vertebral bodies from C3 to C6. What is the most common systemic condition or radiographic finding associated with this pathology?

. Rheumatoid arthritis
. Ankylosing spondylitis
. Diffuse idiopathic skeletal hyperostosis (DISH)
. Marfan syndrome
. Neurofibromatosis type 1

Correct Answer & Explanation

. Diffuse idiopathic skeletal hyperostosis (DISH)

Explanation

The clinical picture describes Ossification of the Posterior Longitudinal Ligament (OPLL), which causes cervical myelopathy. OPLL is strongly associated with Diffuse Idiopathic Skeletal Hyperostosis (DISH), with up to 50% of patients with OPLL demonstrating radiographic evidence of DISH.

Question 3344

Topic: 6. Spine

A 24-year-old female sustains a flexion-distraction injury (Chance fracture) of the L2 vertebra after a motor vehicle collision in which she was wearing a lap-belt only. Which of the following associated injuries must be most aggressively ruled out?

. Aortic dissection
. Splenic rupture
. Hollow viscus injury
. Renal artery thrombosis
. Diaphragmatic rupture

Correct Answer & Explanation

. Hollow viscus injury

Explanation

Chance fractures (flexion-distraction injuries) of the thoracolumbar spine are classically associated with lap-belt use. They carry a very high association (up to 40-50%) with intra-abdominal injuries, particularly hollow viscus injuries (e.g., small bowel perforations), which must be carefully ruled out.

Question 3345

Topic: 6. Spine

In the Levine and Edwards classification of traumatic spondylolisthesis of the axis (Hangman's fracture), a Type IIA fracture is characterized by severe angulation with minimal translation. What is the pathomechanical mechanism of this injury and the appropriate non-operative treatment?

. Hyperextension and axial loading; rigid cervical collar
. Flexion and distraction; application of Gardner-Wells tongs with heavy axial traction
. Flexion and distraction; application of a halo vest in slight extension with mild compression
. Hyperextension and distraction; immediate anterior cervical discectomy and fusion
. Flexion and compression; soft cervical collar

Correct Answer & Explanation

. Flexion and distraction; application of a halo vest in slight extension with mild compression

Explanation

A Type IIA Hangman's fracture results from a flexion-distraction injury, causing severe angulation but minimal translation. Because the primary injury involves disruption of the posterior longitudinal ligament and disc space in distraction, longitudinal traction is strictly contraindicated as it can cause over-distraction and catastrophic spinal cord injury. The treatment is closed reduction with mild compression and extension using a halo vest.

Question 3346

Topic: 6. Spine

A 45-year-old patient involved in a motor vehicle accident sustains a traumatic spondylolisthesis of the axis (Hangman's fracture). Radiographs reveal severe angulation of C2 on C3 with minimal translation (Levine-Edwards Type IIA). What is the mechanism of this specific injury pattern, and what is the appropriate initial management?

. Hyperextension and axial loading; application of rigid cervical collar
. Flexion-distraction; application of heavy skeletal traction
. Flexion-distraction; halo vest applied in slight compression and extension
. Hyperextension and axial loading; halo vest applied with heavy traction
. Axial loading; immediate occipitocervical fusion

Correct Answer & Explanation

. Flexion-distraction; halo vest applied in slight compression and extension

Explanation

Levine and Edwards Type IIA Hangman's fractures result from a flexion-distraction mechanism. Radiographically, they are characterized by severe angulation with minimal translation. Traction is strictly contraindicated in Type IIA fractures because it worsens the distraction and deformity. The correct treatment is closed reduction with gentle compression and slight extension, typically followed by immobilization in a halo vest.

Question 3347

Topic: 6. Spine

A 22-year-old male is brought to the trauma bay after a high-speed motor vehicle accident where he was wearing a lap belt only. Radiographs demonstrate a flexion-distraction injury (Chance fracture) extending through the pedicles and vertebral body of L2. Based on this mechanism, the patient is at highest risk for which of the following concomitant injuries?

. Diaphragmatic rupture
. Aortic transection
. Hollow viscus injury
. Renal artery avulsion
. Cardiac contusion

Correct Answer & Explanation

. Hollow viscus injury

Explanation

Chance fractures (flexion-distraction injuries of the spine) are classic 'seatbelt injuries' caused by hyperflexion over a lap belt functioning as a fulcrum. This violent mechanism places intense compressive forces on the anterior abdominal contents, leading to a high rate (up to 40-50%) of concomitant intra-abdominal injuries, most notably hollow viscus rupture (small bowel, colon) and mesenteric tears.

Question 3348

Topic: 6. Spine

In the pathophysiology of cervical spondylotic myelopathy, which of the following spinal cord tracts is typically affected first, leading to the earliest clinical symptoms of gait instability and loss of hand dexterity?

. Lateral spinothalamic tract
. Anterior spinothalamic tract
. Corticospinal tract
. Fasciculus cuneatus
. Spinocerebellar tract

Correct Answer & Explanation

. Corticospinal tract

Explanation

The lateral corticospinal tract is typically affected early in cervical spondylotic myelopathy due to compression and ischemia. This leads to upper motor neuron signs, gait instability, and loss of fine motor control (dexterity) in the hands.

Question 3349

Topic: Thoracolumbar Spine & Deformity

In evaluating a patient with adult spinal deformity, which of the following spino-pelvic parameters is a fixed morphologic parameter that does not change with patient position?

. Pelvic tilt (PT)
. Sacral slope (SS)
. Pelvic incidence (PI)
. Lumbar lordosis (LL)
. Sagittal vertical axis (SVA)

Correct Answer & Explanation

. Pelvic incidence (PI)

Explanation

Pelvic incidence (PI) is an anatomic parameter that is fixed after skeletal maturity. It is defined as the angle between a line perpendicular to the sacral endplate at its midpoint and a line connecting this point to the center of the bicoxofemoral axis. PI = PT + SS. PT and SS change with pelvic retroversion/anteversion.

Question 3350

Topic: 6. Spine
A 28-year-old male is involved in a high-speed motor vehicle collision. Radiographs reveal a Levine-Edwards Type II Hangman's fracture (traumatic spondylolisthesis of the axis). Which of the following best describes the pathomechanics of this specific fracture pattern?
. Hyperextension and axial loading
. Hyperflexion and axial compression
. Distraction and severe hyperflexion
. Lateral bending and rotation
. Hyperextension and axial loading followed by severe flexion

Correct Answer & Explanation

. Hyperextension and axial loading followed by severe flexion

Explanation

A Levine-Edwards Type II Hangman's fracture is characterized by an initial hyperextension and axial loading injury, followed by a severe flexion rebound mechanism. This results in an anterior translation of C2 on C3 with an angulated disc space. Type I is hyperextension/axial load alone. Type III involves severe flexion/compression.

Question 3351

Topic: 6. Spine

A 68-year-old male presents with bilateral leg pain when walking. You are attempting to differentiate between neurogenic claudication and vascular claudication. Which of the following findings is most consistent with neurogenic claudication?

. Symptoms are relieved by standing still upright.
. Symptoms are relieved by sitting or leaning forward over a shopping cart.
. Pain is exacerbated when riding a stationary bicycle.
. Walking uphill is generally more painful than walking downhill.
. Diminished posterior tibial pulses are a hallmark finding.

Correct Answer & Explanation

. Symptoms are relieved by sitting or leaning forward over a shopping cart.

Explanation

Neurogenic claudication (seen in lumbar spinal stenosis) is characteristically relieved by sitting or lumbar flexion (e.g., leaning over a shopping cart or walking uphill), which flexes the spine and increases the cross-sectional area of the spinal canal. Vascular claudication is worsened by any increased metabolic demand and is relieved by standing still.

Question 3352

Topic: 6. Spine

A 62-year-old male with cervical myelopathy undergoes a C3-C6 posterior laminectomy and fusion. Postoperative day 2, he develops profound weakness of the deltoid and biceps unilaterally, without sensory changes. What is the most widely accepted pathophysiologic mechanism for this complication?

. Ischemic injury to the anterior spinal artery
. Posterior cord syndrome
. Intraoperative traction injury to the brachial plexus
. Posterior shift of the spinal cord causing tethering of the C5 nerve root
. Unrecognized epidural hematoma

Correct Answer & Explanation

. Posterior shift of the spinal cord causing tethering of the C5 nerve root

Explanation

Postoperative C5 palsy is a known complication following cervical decompression. The most widely accepted mechanism is the 'tethering effect' where the posterior shift of the spinal cord after decompression causes increased tension on the relatively short and horizontally oriented C5 nerve roots.

Question 3353

Topic: Thoracolumbar Spine & Deformity
A 45-year-old female presents with neurogenic claudication. Standing lateral radiographs reveal a Grade I L4-L5 spondylolisthesis without pars interarticularis defects. The facet joints appear sagittally oriented. Based on the Wiltse classification, what type of spondylolisthesis does this patient have?
. Type I (Dysplastic)
. Type II (Isthmic)
. Type III (Degenerative)
. Type IV (Traumatic)
. Type V (Pathologic)

Correct Answer & Explanation

. Type III (Degenerative)

Explanation

The Wiltse classification defines Type III as degenerative spondylolisthesis. It occurs secondary to intersegmental instability and facet arthropathy without a pars defect, and is most common at L4-L5 in middle-aged females with sagittally oriented facets.

Question 3354

Topic: 6. Spine

A 65-year-old man presents with progressive clumsiness of his hands, difficulty buttoning his shirt, and a broad-based, unsteady gait. Physical exam demonstrates a positive Hoffmann sign and hyperreflexia in the lower extremities. What is the most sensitive imaging study to evaluate the cause of this condition?

. CT scan of the cervical spine without contrast
. Flexion-extension radiographs of the cervical spine
. MRI of the cervical spine
. EMG and nerve conduction studies of the upper extremities
. Myelography of the lumbar spine

Correct Answer & Explanation

. MRI of the cervical spine

Explanation

The patient's symptoms (clumsy hands, gait instability) and signs (Hoffmann sign, hyperreflexia) are classic for cervical spondylotic myelopathy (an upper motor neuron lesion). MRI of the cervical spine is the imaging modality of choice to evaluate spinal cord compression, signal changes in the cord (myelomalacia), and the exact level(s) of stenosis.

Question 3355

Topic: 6. Spine

A 68-year-old woman complains of bilateral leg and buttock pain that worsens when walking and improves when sitting or leaning forward over a shopping cart. The 'bicycle test of van Gelderen' is performed to differentiate neurogenic claudication from vascular claudication. In this test, neurogenic claudication is supported if the patient:

. Experiences pain equally while cycling with the spine flexed or extended
. Has onset of calf pain at exactly the same distance repeatedly
. Can pedal longer with the spine flexed compared to standing erect
. Develops diminished pedal pulses after 5 minutes of cycling
. Experiences relief of symptoms only after 10 minutes of complete rest

Correct Answer & Explanation

. Can pedal longer with the spine flexed compared to standing erect

Explanation

In the bicycle test of van Gelderen, the patient pedals a stationary bike. If the pain is vascular, it is related to muscle work and will occur regardless of spine posture. If it is neurogenic claudication (lumbar spinal stenosis), leaning forward (flexing the spine) increases the cross-sectional area of the spinal canal and neural foramina, alleviating compression and allowing the patient to cycle longer without symptoms compared to when the spine is extended.

Question 3356

Topic: 6. Spine

A 68-year-old male presents with deteriorating hand dexterity, a broad-based gait, and urinary urgency. Physical examination reveals hyperreflexia and a positive Hoffmann's sign. The examiner percusses the distal brachioradialis tendon, which elicits spontaneous flexion of the patient's fingers without wrist extension. What is the name of this clinical sign?

. Spurling's sign
. Lhermitte's sign
. Inverted supinator reflex
. Wartenberg's sign
. Tinel's sign

Correct Answer & Explanation

. Inverted supinator reflex

Explanation

The inverted supinator reflex is highly specific for cervical spondylotic myelopathy. It occurs when tapping the brachioradialis tendon (innervated by C6) elicits no wrist extension/supination, but rather spontaneous finger flexion (innervated by C8). This indicates a lower motor neuron lesion at the C5-C6 level combined with an upper motor neuron lesion affecting the uninhibited segments below (C8).

Question 3357

Topic: 6. Spine

A 65-year-old male presents with classic neurogenic claudication secondary to severe lumbar spinal stenosis at L4-L5. His symptoms are entirely activity-dependent, resolving completely when he sits or bends forward. He has no resting pain and his neurologic exam is normal. During counseling regarding non-operative management, what should the patient be told about the expected natural history of his condition over the next 5 years?

. He is at high risk for rapid progression to cauda equina syndrome
. He will experience predictable, steady neurological decline
. Symptomatic improvement is expected in the majority of patients
. His symptoms will likely remain stable with mild fluctuations, without severe deterioration
. The anatomical stenosis will spontaneously resolve due to disk resorption

Correct Answer & Explanation

. His symptoms will likely remain stable with mild fluctuations, without severe deterioration

Explanation

The natural history of mildly-to-moderately symptomatic lumbar spinal stenosis is generally benign and stable. Longitudinal studies indicate that up to 70-80% of patients managed conservatively will remain stable or experience only minor fluctuations in their symptoms over several years. Rapid deterioration or progression to cauda equina syndrome is exceedingly rare.

Question 3358

Topic: 6. Spine

During a neurologic exam of a 65-year-old male with neck pain and clumsy hands, the examiner aggressively flicks the distal phalanx of the middle finger, resulting in involuntary flexion of the interphalangeal joint of the thumb and index finger. This clinical sign indicates compression of which neurological structure or tract?

. Spinothalamic tract
. Dorsal columns
. Corticospinal tract
. Brachial plexus (lower trunk)
. Anterior horn cells of the cervical spine

Correct Answer & Explanation

. Corticospinal tract

Explanation

The maneuver described is Hoffman's sign, which is an upper motor neuron (UMN) sign indicating cervical spinal cord compression (cervical myelopathy). The corticospinal tract is the descending motor pathway; its compression leads to hyperreflexia and pathologic reflexes like Hoffman's and Babinski signs.

Question 3359

Topic: 6. Spine

Which of the following patient history or physical examination findings is most specific for neurogenic claudication (lumbar spinal stenosis) as opposed to vascular claudication?

. Pain in the calves that is promptly relieved by standing completely still
. Cramping, reproducible pain in the calves occurring after walking a specific distance
. Diminished dorsalis pedis and posterior tibial pulses
. Leg pain that is significantly relieved by leaning forward onto a shopping cart
. Symptoms that are severely exacerbated by riding a stationary bicycle

Correct Answer & Explanation

. Leg pain that is significantly relieved by leaning forward onto a shopping cart

Explanation

The 'shopping cart sign' is highly specific for neurogenic claudication. Leaning forward (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 is exacerbated by muscle exertion (like stationary biking) regardless of posture and is relieved quickly by simply resting (standing still).

Question 3360

Topic: 6. Spine

A 65-year-old male presents with progressive clumsiness in his hands and broad-based gait instability. MRI confirms severe cervical spondylotic myelopathy. When classifying the severity of his myelopathy using the Nurick grading system, which of the following clinical factors is the primary determinant of his grade?

. Upper extremity dexterity
. Bowel and bladder function
. Gait abnormality and ambulatory status
. Sensory deficits in the hands
. Degree of spinal canal narrowing on MRI

Correct Answer & Explanation

. Gait abnormality and ambulatory status

Explanation

The Nurick classification for cervical spondylotic myelopathy is based exclusively on the patient's gait dysfunction and ambulatory status (e.g., Grade 1: signs of cord involvement but normal gait; Grade 5: wheelchair-bound or bedridden).

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