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6. Spine MCQs

Practice Set 17 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 321

Topic: 6. Spine

A patient with a spinal cord injury has preserved motor function below the neurological level, and more than half of the key muscles below the neurological level have a muscle grade of 3 or greater. What is this patient's ASIA impairment scale grade?

. ASIA A
. ASIA B
. ASIA C
. ASIA D
. ASIA E

Correct Answer & Explanation

. ASIA D

Explanation

ASIA D is defined by motor function being preserved below the neurological level, with at least half of the key muscles having a muscle grade of 3 or more. ASIA C requires more than half the muscles to have a grade less than 3.

Question 322

Topic: 6. Spine

Which of the following clinical findings best distinguishes neurogenic shock from spinal shock?

. Absence of the bulbocavernosus reflex
. Flaccid paralysis below the level of injury
. Hypotension accompanied by bradycardia
. Loss of deep tendon reflexes
. Preservation of perianal sensation

Correct Answer & Explanation

. Hypotension accompanied by bradycardia

Explanation

Neurogenic shock is a hemodynamic phenomenon caused by a loss of sympathetic tone, classically characterized by hypotension and bradycardia. Spinal shock is a transient neurological phenomenon defined by the loss of all reflexes and motor function below the injury.

Question 323

Topic: 6. Spine

According to the Denis three-column model of the spine, the middle column comprises which of the following structures?

. Anterior half of the vertebral body and ALL
. Posterior half of the vertebral body and PLL
. Pedicles and facet joints
. Spinous process and supraspinous ligament
. Ligamentum flavum and neural arch

Correct Answer & Explanation

. Posterior half of the vertebral body and PLL

Explanation

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

Question 324

Topic: 6. Spine

A 68-year-old man presents with bilateral leg pain that worsens with walking and improves when leaning forward on a shopping cart. MRI shows severe L4-L5 central canal stenosis. Which of the following ligaments is most likely hypertrophied and contributing significantly to the dorsal compression?

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

Correct Answer & Explanation

. Ligamentum flavum

Explanation

Lumbar spinal stenosis is typically caused by anterior disc bulging, lateral facet joint hypertrophy, and dorsal ligamentum flavum hypertrophy. The ligamentum flavum buckles and infolds during extension, exacerbating canal compression.

Question 325

Topic: 6. Spine

The Torg-Pavlov ratio is used to assess cervical spinal stenosis on lateral plain radiographs. A ratio of less than what value is generally considered indicative of developmental cervical stenosis?

. 0.5
. 0.8
. 1.0
. 1.2
. 1.5

Correct Answer & Explanation

. 0.8

Explanation

The Torg-Pavlov ratio compares the sagittal diameter of the spinal canal to the sagittal diameter of the corresponding vertebral body. A ratio of less than 0.8 is a sensitive indicator of developmental cervical spinal stenosis.

Question 326

Topic: Thoracolumbar Spine & Deformity
A 14-year-old gymnast presents with lower back pain. Radiographs reveal a pars interarticularis defect at L5 with 35% forward translation of L5 on S1. According to the Meyerding classification, what grade is this spondylolisthesis?
. Grade I
. Grade II
. Grade III
. Grade IV
. Grade V

Correct Answer & Explanation

. Grade II

Explanation

The Meyerding classification grades spondylolisthesis based on the percentage of forward slip: Grade I (0-25%), Grade II (26-50%), Grade III (51-75%), and Grade IV (76-100%). A 35% slip falls into the Grade II category.

Question 327

Topic: 6. Spine

A 45-year-old intravenous drug user presents with severe, localized back pain, fever, and progressive lower extremity weakness. MRI with contrast demonstrates an epidural abscess at T8. What is the most common causative organism?

. Pseudomonas aeruginosa
. Escherichia coli
. Staphylococcus aureus
. Mycobacterium tuberculosis
. Streptococcus pneumoniae

Correct Answer & Explanation

. Staphylococcus aureus

Explanation

Staphylococcus aureus is the most common causative organism for spinal epidural abscesses and vertebral osteomyelitis across all patient populations, including intravenous drug users.

Question 328

Topic: 6. Spine

A patient presents with neck pain radiating down the arm, weakness in wrist flexion and finger extension, and a diminished triceps reflex. Sensation is decreased over the middle finger. Which cervical nerve root is most likely affected?

. C5
. C6
. C7
. C8
. T1

Correct Answer & Explanation

. C7

Explanation

A C7 radiculopathy classically presents with weakness in the triceps, wrist flexors, and finger extensors. Sensory loss typically involves the long (middle) finger, and the triceps reflex is characteristically diminished.

Question 329

Topic: Thoracolumbar Spine & Deformity

A 15-year-old male athlete presents with axial lower back pain. Imaging confirms an acute, bilateral L5 pars interarticularis defect (spondylolysis) without spondylolisthesis. What is the initial recommended treatment?

. Immediate L5-S1 in situ posterolateral fusion
. Pars interarticularis repair (Buck's procedure)
. Restriction from sports and use of an antilordotic brace
. Epidural steroid injections
. Total disc replacement

Correct Answer & Explanation

. Restriction from sports and use of an antilordotic brace

Explanation

Acute, symptomatic spondylolysis in an adolescent athlete is initially managed non-operatively. Treatment consists of rest, restriction from athletic activities, and typically an antilordotic (TLSO) brace until the patient is pain-free.

Question 330

Topic: Thoracolumbar Spine & Deformity

A 25-year-old man sustains a flexion-distraction injury (Chance fracture) of L1 during a motor vehicle collision. What is the most common associated non-orthopedic injury in this setting?

. Aortic tear
. Small bowel or hollow viscus injury
. Splenic rupture
. Renal contusion
. Diaphragmatic hernia

Correct Answer & Explanation

. Small bowel or hollow viscus injury

Explanation

Chance fractures, or flexion-distraction injuries, are frequently caused by lap seatbelts and are highly associated with intra-abdominal injuries, particularly hollow viscus and small bowel ruptures. A high index of suspicion and general surgery consultation are essential.

Question 331

Topic: Thoracolumbar Spine & Deformity

A 34-year-old patient has a T12 burst fracture. On evaluation, the patient is neurologically intact, and MRI confirms an intact posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity Score (TLICS), what is the total score and recommended management?

. TLICS score 2; Nonoperative management with a brace
. TLICS score 4; Posterior spinal fusion
. TLICS score 5; Anterior corpectomy
. TLICS score 6; Short segment percutaneous fixation
. TLICS score 3; Laminectomy

Correct Answer & Explanation

. TLICS score 2; Nonoperative management with a brace

Explanation

The patient scores 2 points for a burst fracture, 0 points for being neurologically intact, and 0 points for an intact PLC, yielding a TLICS score of 2. A score of 3 or less is an indication for nonoperative management, typically with an orthosis.

Question 332

Topic: 6. Spine

Which of the following clinical features most reliably differentiates neurogenic claudication from vascular claudication in a patient evaluating for lower extremity pain during ambulation?

. Pain is rapidly relieved by standing still
. Pain worsens when walking uphill
. Pain is relieved by sitting or leaning forward
. Absent distal pulses
. Pain is strictly unilateral

Correct Answer & Explanation

. Pain is relieved by sitting or leaning forward

Explanation

Neurogenic claudication is characteristically relieved by lumbar flexion (such as sitting or leaning on a shopping cart), which increases the spinal canal volume. Vascular claudication is typically relieved simply by resting or standing still, and worsens with increased metabolic demand like walking uphill.

Question 333

Topic: 6. Spine

In a patient presenting with severe back pain and a large central L4-L5 disc herniation, which of the following findings is the most absolute indication for emergent surgical decompression?

. Unilateral foot drop
. Bilateral absent Achilles reflexes
. Urinary retention with overflow incontinence
. Severe intractable radicular leg pain
. Absent Babinski reflex

Correct Answer & Explanation

. Urinary retention with overflow incontinence

Explanation

Urinary retention with overflow incontinence is a hallmark sign of cauda equina syndrome. This represents an absolute surgical emergency requiring immediate decompression to preserve bowel and bladder function.

Question 334

Topic: 6. Spine

A 60-year-old diabetic male presents with progressive bilateral leg weakness, fever, and exquisite midline back pain. MRI confirms a spinal epidural abscess. What is the most common causative organism?

. Streptococcus pneumoniae
. Escherichia coli
. Staphylococcus aureus
. Pseudomonas aeruginosa
. Mycobacterium tuberculosis

Correct Answer & Explanation

. Staphylococcus aureus

Explanation

Staphylococcus aureus is by far the most common organism responsible for spinal epidural abscesses and vertebral osteomyelitis. Prompt recognition, blood cultures, and targeted antibiotic therapy, often combined with surgical decompression, are required.

Question 335

Topic: Thoracolumbar Spine & Deformity

In a pediatric patient with an L5-S1 isthmic spondylolisthesis, which of the following radiographic parameters is considered the strongest predictor of slip progression?

. Pelvic incidence
. High slip angle
. Sacral slope
. Decreased lumbar lordosis
. Grade of the initial slip alone

Correct Answer & Explanation

. High slip angle

Explanation

A high slip angle (kyphosis at the lumbosacral junction) is the strongest predictor of progression in isthmic spondylolisthesis. It reflects the local destabilizing shear forces acting on the L5-S1 motion segment.

Question 336

Topic: 6. Spine

The resolution of spinal shock in a patient with a complete cervical spinal cord injury is clinically marked by the return of which of the following?

. Voluntary toe movement
. Deep tendon reflexes in the lower extremities
. Bulbocavernosus reflex
. Normal resting bladder tone
. Sensation in the perianal area

Correct Answer & Explanation

. Bulbocavernosus reflex

Explanation

Spinal shock is a temporary physiologic state of areflexia and flaccidity below the level of injury. The return of the bulbocavernosus reflex signals the end of spinal shock, allowing for the accurate determination of a complete versus incomplete injury.

Question 337

Topic: 6. Spine

A Levine-Edwards Type II traumatic spondylolisthesis of the axis (Hangman's fracture) is characterized by a fracture of the pars interarticularis combined with which of the following?

. Less than 3 mm of displacement and no angulation
. Significant translation and severe kyphotic angulation
. Bilateral facet dislocation
. Unilateral facet dislocation
. A concurrent type II odontoid fracture

Correct Answer & Explanation

. Significant translation and severe kyphotic angulation

Explanation

A Levine-Edwards Type II Hangman's fracture involves the pars interarticularis with significant translation and kyphotic angulation. It involves disruption of the C2-C3 disc and posterior longitudinal ligament, representing an unstable flexion-rebound extension injury.

Question 338

Topic: 6. Spine

A 55-year-old male with severe ankylosing spondylitis complains of new-onset back pain after a minor slip. Radiographs suggest a fracture through the T12-L1 disc space. What is the most appropriate next step in management?

. Prescribe NSAIDs and a soft corset brace
. Strict bed rest for 6 weeks
. CT and MRI of the entire spinal axis
. Immediate anterior corpectomy
. Physical therapy for extension strengthening

Correct Answer & Explanation

. CT and MRI of the entire spinal axis

Explanation

Patients with ankylosing spondylitis have highly rigid spines that are prone to highly unstable, shear-type fractures even with minimal trauma. Advanced imaging (CT/MRI) of the entire spine is critical to evaluate the fracture extent, rule out non-contiguous fractures, and assess for epidural hematomas.

Question 339

Topic: Cervical Spine

An 84-year-old female sustains a Type II odontoid fracture with 2 mm of posterior displacement following a ground-level fall. She has no neurological deficits. Which of the following is the most appropriate management?

. Halo vest immobilization for 12 weeks
. Rigid cervical collar for 6-12 weeks
. Anterior odontoid screw fixation
. Posterior C1-C2 transarticular screw fusion
. Non-rigid soft cervical collar for comfort

Correct Answer & Explanation

. Rigid cervical collar for 6-12 weeks

Explanation

In elderly patients with Type II odontoid fractures, rigid cervical collar immobilization is the treatment of choice. Operative intervention and halo vests carry unacceptably high morbidity and mortality rates in this age group.

Question 340

Topic: 6. Spine

A 45-year-old man presents with sharp pain radiating down his right arm, weakness in triceps extension, and numbness isolated to his middle finger. Which cervical nerve root is most likely compressed?

. C5
. C6
. C7
. C8
. T1

Correct Answer & Explanation

. C7

Explanation

The C7 nerve root supplies the triceps muscle (extension of the elbow), wrist flexors, and provides sensation to the middle finger. A C6-C7 disc herniation typically impinges the C7 root.

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