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6. Spine MCQs

Practice Set 172 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 3421

Topic: 6. Spine

A 55-year-old man presents with bilateral hand clumsiness and a broad-based gait. On physical examination, tapping the distal brachioradialis tendon produces a diminished brachioradialis reflex but a brisk reflexive flexion of the fingers. This specific clinical sign indicates spinal cord and nerve root compression most likely at which of the following levels?

. C3-C4
. C4-C5
. C5-C6
. C6-C7
. C7-T1

Correct Answer & Explanation

. C5-C6

Explanation

The finding described is the 'inverted supinator reflex'. It is a localizing sign of cervical myelopathy indicating compression at the C5-C6 level. The lesion causes a lower motor neuron deficit at C5/C6 (absent brachioradialis reflex) and an upper motor neuron deficit below this level, leading to hyperreflexia of the C8-innervated finger flexors.

Question 3422

Topic: 6. Spine

A 40-year-old man presents to the emergency department with severe low back pain and bilateral radiculopathy following a heavy lifting injury. You suspect acute cauda equina syndrome. Based on recent literature, which of the following is considered the most sensitive and specific early clinical indicator of this condition?

. Bilateral absent Achilles reflexes
. Saddle anesthesia
. Lower extremity motor weakness in multiple myotomes
. Urinary retention with a post-void residual > 200 mL
. Loss of anal sphincter tone

Correct Answer & Explanation

. Urinary retention with a post-void residual > 200 mL

Explanation

While saddle anesthesia and loss of rectal tone are classic, they are often late signs. The earliest and most consistent symptom of cauda equina syndrome is urinary retention, often leading to overflow incontinence. A bladder scan showing a post-void residual (PVR) volume > 100-200 mL is highly sensitive for suspected cauda equina syndrome.

Question 3423

Topic: 6. Spine

In a patient presenting with cervical spondylotic myelopathy (CSM), which of the following preoperative magnetic resonance imaging (MRI) findings is most strongly correlated with a poor postoperative clinical outcome?

. T2-weighted hyperintensity confined to a single cervical level
. Focal T1-weighted hypointensity within the spinal cord
. Loss of cervical lordosis without kyphosis
. Anterior-posterior cord compression ratio of 0.6
. Presence of an ossified posterior longitudinal ligament (OPLL)

Correct Answer & Explanation

. Focal T1-weighted hypointensity within the spinal cord

Explanation

In the context of cervical spondylotic myelopathy, MRI signal changes provide prognostic information. While a faint T2-weighted hyperintensity may indicate reversible edema or gliosis and has a variable prognosis, a focal T1-weighted hypointensity indicates permanent cystic necrosis or myelomalacia of the spinal cord. Studies have consistently shown that T1 hypointensity is a strong independent predictor of poor neurologic recovery postoperatively.

Question 3424

Topic: Thoracolumbar Spine & Deformity

According to the Thoracolumbar Injury Classification and Severity Score (TLICS), a patient presents with an L1 burst fracture, intact neurology, and an MRI indicating a confirmed disruption of the posterior ligamentous complex (PLC). What is the patient's total TLICS score and the recommended management?

. Score 3; non-operative management
. Score 4; surgeon preference (operative or non-operative)
. Score 5; operative management
. Score 6; operative management
. Score 7; operative management

Correct Answer & Explanation

. Score 5; operative management

Explanation

The TLICS system scores three categories: Morphology, Neurologic Status, and PLC Integrity. A burst fracture = 2 points. Intact neurologic status = 0 points. Confirmed disruption of the PLC = 3 points. Total score = 2 + 0 + 3 = 5 points. A TLICS score of > 4 represents an indication for operative management. A score of < 4 indicates non-operative management, and a score of exactly 4 is indeterminate (surgeon preference).

Question 3425

Topic: 6. Spine

A 55-year-old man with advanced ankylosing spondylitis presents with a severe, rigid cervicothoracic kyphosis ('chin-on-chest' deformity) causing difficulty with forward gaze and swallowing. An extension osteotomy is planned. Which anatomical level is generally preferred for this corrective osteotomy to maximize safety and correction?

. C1-C2
. C3-C4
. C5-C6
. C7-T1
. T3-T4

Correct Answer & Explanation

. C7-T1

Explanation

The C7-T1 level is preferred for an extension osteotomy in ankylosing spondylitis because the spinal canal is relatively wide at this level, reducing the risk of spinal cord compression. Additionally, the vertebral artery usually enters the transverse foramen at C6, so operating below this level (C7-T1) helps avoid vertebral artery injury.

Question 3426

Topic: 6. Spine
A 40-year-old male is involved in a severe motor vehicle collision. Cervical spine CT demonstrates a traumatic spondylolisthesis of the axis (Hangman's fracture) with severe anterior angulation and 6 mm of translation of C2 on C3. There is an associated unilateral C2-C3 facet dislocation. According to the Levine-Edwards classification, what is the most appropriate management?
. Rigid cervical collar immobilization for 6 weeks
. Halo vest immobilization in extension
. Halo vest immobilization following prolonged axial traction
. Closed reduction under conscious sedation
. Open reduction and internal fixation

Correct Answer & Explanation

. Open reduction and internal fixation

Explanation

This describes a Levine-Edwards Type III Hangman's fracture, characterized by bilateral pars fractures combined with a unilateral or bilateral C2-C3 facet dislocation. Axial traction is strictly contraindicated as it can cause over-distraction and severe neurologic injury. The definitive treatment of choice is open reduction and internal fixation.

Question 3427

Topic: 6. Spine

A 45-year-old male presents to the ED with severe radicular lower back pain, bilateral lower extremity paresthesias, and saddle anesthesia. An urgent MRI confirms a massive L4-L5 central disc extrusion. A bladder scan is performed to assess for neurogenic urinary retention. What is the widely accepted minimum post-void residual (PVR) volume that is highly suggestive of Cauda Equina Syndrome in this clinical context?

. 50 mL
. 100 mL
. 200 mL
. 500 mL
. 1000 mL

Correct Answer & Explanation

. 500 mL

Explanation

In the evaluation of suspected Cauda Equina Syndrome, urinary retention is a hallmark sign. A post-void residual (PVR) volume greater than 100-200 mL is abnormal; however, > 200 mL is the universally recognized threshold that is highly suggestive of neurogenic bladder dysfunction necessitating emergent surgical decompression.

Question 3428

Topic: 6. Spine

A 20-year-old female presents to the trauma bay after a high-speed motor vehicle collision where she was wearing only a lap belt. Radiographs and CT of the lumbar spine reveal a flexion-distraction injury (Chance fracture) through the L2 vertebral body. She is neurologically intact. Which of the following associated injuries has the highest incidence with this specific fracture pattern?

. Intra-abdominal hollow viscus injury
. Bladder rupture
. Diaphragmatic hernia
. Thoracic aortic tear
. Renal pedicle avulsion

Correct Answer & Explanation

. Intra-abdominal hollow viscus injury

Explanation

A Chance fracture is a flexion-distraction injury of the spine, historically associated with lap-belt use in motor vehicle accidents. The fulcrum of flexion is shifted anteriorly to the abdominal wall, leading to distraction forces through the posterior and middle columns, and sometimes the anterior column. This mechanism frequently causes concurrent severe compressive or sheer injuries to intra-abdominal organs. Hollow viscus (bowel) injuries occur in up to 40-50% of patients with Chance fractures.

Question 3429

Topic: 6. Spine

A 65-year-old male complains of bilateral leg pain, heaviness, and cramping that worsens with walking. The symptoms are relieved by sitting or leaning forward over a shopping cart. Which of the following clinical features is most characteristic of his likely diagnosis when differentiating it from vascular claudication?

. Pain relief when standing completely stationary
. Exacerbation of symptoms when riding a stationary bicycle
. Absent dorsalis pedis and posterior tibial pulses
. Proximal to distal progression of symptoms during ambulation
. Pallor of the lower extremities upon leg elevation

Correct Answer & Explanation

. Proximal to distal progression of symptoms during ambulation

Explanation

The patient's presentation is classic for neurogenic claudication secondary to lumbar spinal stenosis (relief with lumbar flexion). Neurogenic claudication typically radiates in a proximal-to-distal direction (buttocks/thighs to calves), whereas vascular claudication typically begins distally in the calf and progresses proximally. Additionally, vascular claudication is relieved by merely standing stationary, whereas neurogenic requires sitting or lumbar flexion. Riding a stationary bike flexes the spine and preserves exercise tolerance in neurogenic claudication, but exacerbates vascular claudication due to increased metabolic demand.

Question 3430

Topic: 6. Spine
A 24-year-old man is involved in an MVA. Imaging shows a traumatic spondylolisthesis of the axis (Hangman's fracture) with severe angulation and >5 mm of translation of C2 on C3. The C2-C3 facet joints are dislocated bilaterally. According to the Levine and Edwards classification, what is the injury type and its recommended primary treatment?
. Type I; rigid cervical collar
. Type II; halo vest immobilization
. Type IIA; axial traction followed by halo
. Type III; open reduction and internal fixation
. Type III; halo vest immobilization in extension

Correct Answer & Explanation

. Type III; open reduction and internal fixation

Explanation

This is a Type III Hangman fracture (pars interarticularis fractures with bilateral C2-C3 facet dislocations). Traction is contraindicated as it may exacerbate the dislocation or cause neurologic injury. The recommended treatment for Type III is open reduction and internal fixation.

Question 3431

Topic: 6. Spine

A 65-year-old male complains of bilateral leg pain and cramping that worsens with walking. You are attempting to differentiate neurogenic claudication from vascular claudication. Which of the following historical features or physical exam findings is most specific for neurogenic claudication?

. Pain relief with standing still
. Pain exacerbation when walking uphill
. Pain relief when leaning forward on a shopping cart
. Decreased ankle-brachial index
. Absent distal pulses

Correct Answer & Explanation

. Pain relief when leaning forward on a shopping cart

Explanation

Neurogenic claudication (due to lumbar spinal stenosis) is classically relieved by spinal flexion (e.g., leaning forward on a shopping cart or sitting), as this posture increases the cross-sectional area of the spinal canal and neural foramina. Walking uphill is also better tolerated because it requires a flexed posture, unlike vascular claudication, which worsens with the increased metabolic demand of walking uphill.

Question 3432

Topic: 6. Spine
A 35-year-old man presents following a motor vehicle accident. Radiographs reveal a traumatic spondylolisthesis of the axis (Hangman's fracture) with severe angulation and >5 mm of translation of C2 on C3. The C2-C3 facet joints are dislocated. According to the Levine-Edwards classification, what is the grade and typical mechanism of this injury?
. Type I; hyperextension and axial loading
. Type II; hyperextension and axial loading followed by severe flexion
. Type IIa; flexion and distraction
. Type III; flexion and compression followed by hyperextension
. Type III; flexion and distraction with accompanying bilateral facet dislocation

Correct Answer & Explanation

. Type III; flexion and distraction with accompanying bilateral facet dislocation

Explanation

Levine-Edwards Type III Hangman's fracture involves a fracture of the pars interarticularis with accompanying bilateral C2-C3 facet dislocations. The mechanism is flexion and distraction. Severe angulation and translation with facet dislocation characterize a Type III injury, which is highly unstable and typically requires open reduction and internal fixation.

Question 3433

Topic: 6. Spine

A 65-year-old man presents with progressive clumsiness in his hands and a broad-based gait. Physical examination reveals a positive Hoffmann's sign and a positive inverted radial reflex. What does a positive inverted radial reflex indicate in the context of cervical spondylotic myelopathy?

. A lesion strictly localized to the C4 spinal nerve root
. A lower motor neuron lesion at the C5 level
. An upper motor neuron lesion above the C5 level
. A spinal cord lesion at the C5 or C6 level with hyperreflexia of the digits
. Loss of proprioception due to posterior column compression at C7

Correct Answer & Explanation

. A spinal cord lesion at the C5 or C6 level with hyperreflexia of the digits

Explanation

The inverted brachioradialis (radial) reflex is elicited by tapping the brachioradialis tendon at the distal radius. A normal response is elbow flexion. An abnormal, 'inverted' response consists of absent elbow flexion but brisk finger flexion. This indicates a lower motor neuron lesion at C5/C6 (absent brachioradialis reflex) combined with an upper motor neuron lesion below that level (hyperreflexia of the C8-innervated finger flexors), strongly suggesting a spinal cord lesion at C5-C6.

Question 3434

Topic: Cervical Spine

A 22-year-old male is evaluated for neck pain following an axial loading injury. Radiographs show a C1 burst fracture (Jefferson fracture). Which of the following findings on an open-mouth odontoid view is indicative of a complete rupture of the transverse atlantal ligament?

. Combined lateral mass displacement > 6.9 mm
. Combined lateral mass displacement > 3.0 mm
. Atlantodental interval (ADI) > 3 mm
. Atlantodental interval (ADI) > 5 mm
. Basion-dental interval > 12 mm

Correct Answer & Explanation

. Combined lateral mass displacement > 6.9 mm

Explanation

According to the rule of Spence, a combined lateral mass overhang (displacement) of C1 on C2 of greater than 6.9 mm on an open-mouth AP radiograph indicates a rupture of the transverse atlantal ligament, rendering the C1 ring fracture unstable.

Question 3435

Topic: Thoracolumbar Spine & Deformity
A 15-year-old female gymnast presents with chronic low back pain. Radiographs reveal a grade II L5-S1 spondylolisthesis. Oblique radiographs demonstrate bilateral defects in the pars interarticularis. According to the Wiltse classification of spondylolisthesis, which type does this patient have?
. Dysplastic (Type I)
. Isthmic (Type II)
. Degenerative (Type III)
. Traumatic (Type IV)
. Pathologic (Type V)

Correct Answer & Explanation

. Isthmic (Type II)

Explanation

The Wiltse classification categorizes spondylolisthesis into five types. Type II is Isthmic, which involves a defect, elongation, or acute fracture of the pars interarticularis. It is the most common type seen in young athletes (e.g., gymnasts). Type I is dysplastic, Type III is degenerative, Type IV is traumatic (fracture other than pars), and Type V is pathologic.

Question 3436

Topic: Cervical Spine
An 82-year-old male presents with neck pain after a low-energy fall. Radiographs and CT show a displaced Type II odontoid fracture. He has multiple medical comorbidities (ASA III). What is the most appropriate management?
. Halo vest immobilization for 12 weeks
. Rigid cervical collar for 6-8 weeks
. Anterior odontoid screw fixation
. Posterior C1-C2 fusion
. Minerva cast application

Correct Answer & Explanation

. Rigid cervical collar for 6-8 weeks

Explanation

In elderly patients (especially >80 years) with significant comorbidities, the morbidity and mortality of halo vest immobilization or surgical intervention (like C1-C2 fusion) are prohibitively high. Evidence supports treating Type II odontoid fractures in this population with a rigid cervical collar, prioritizing life and comfort over fracture union, as nonunion is typically well-tolerated if fibrous stability is achieved.

Question 3437

Topic: 6. Spine

A 55-year-old diabetic male presents with severe back pain, fever, progressive bilateral lower extremity weakness, and urinary retention over the past 24 hours. MRI confirms a large dorsal epidural abscess at T8-T10. What is the most appropriate definitive management?

. Intravenous antibiotics alone for 6 weeks
. CT-guided percutaneous aspiration and intravenous antibiotics
. Emergent posterior laminectomy, debridement, and intravenous antibiotics
. Anterior corpectomy, strut grafting, and intravenous antibiotics
. High-dose corticosteroids and emergent radiation therapy

Correct Answer & Explanation

. Emergent posterior laminectomy, debridement, and intravenous antibiotics

Explanation

The patient has a spinal epidural abscess with progressive neurologic deficits (myelopathy). This is a surgical emergency. Emergent surgical decompression (posterior laminectomy for a dorsal abscess) and debridement is required to prevent irreversible neurologic damage. This is followed by culture-directed intravenous antibiotic therapy.

Question 3438

Topic: Thoracolumbar Spine & Deformity

A 40-year-old male sustains an isolated thoracolumbar fracture at T12 following a fall. Neurological examination is completely normal. CT imaging demonstrates a burst fracture of T12 with 30% loss of anterior vertebral body height and splaying of the pedicles. MRI reveals the posterior ligamentous complex (PLC) is intact. According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his total score and the generally recommended treatment pathway?

. Score 2; nonoperative management
. Score 3; surgical management
. Score 4; surgeon's choice
. Score 5; surgical management
. Score 7; surgical management

Correct Answer & Explanation

. Score 2; nonoperative management

Explanation

The TLICS scoring system considers three parameters: injury morphology, neurological status, and integrity of the posterior ligamentous complex (PLC). Morphology: burst fracture = 2 points. Neurological status: intact = 0 points. PLC: intact = 0 points. Total score = 2. A score of less than 4 implies nonoperative management is indicated.

Question 3439

Topic: 6. Spine

A 65-year-old female with adult degenerative scoliosis presents with intractable neurogenic claudication and low back pain. Corrective surgery is planned. Which of the following is the primary indication for extending a spinal fusion down to the pelvis rather than stopping at L5?

. Cobb angle greater than 30 degrees
. L5-S1 fractional curve greater than 15 degrees
. Previous microdiscectomy at L4-L5
. Flexible coronal curve on lateral bending films
. Normal sagittal balance

Correct Answer & Explanation

. L5-S1 fractional curve greater than 15 degrees

Explanation

Extending a long spinal fusion to the pelvis in adult spinal deformity is indicated when there is significant L5-S1 pathology, such as a fractional curve > 15 degrees, advanced L5-S1 disc degeneration, spondylolisthesis at L5-S1, or previous laminectomy at L5-S1. Stopping at L5 in the presence of these conditions often leads to rapid adjacent segment failure and pseudoarthrosis.

Question 3440

Topic: 6. Spine

During the physical examination of a patient with suspected cervical radiculopathy, the examiner applies downward axial compression to the patient's head while the neck is extended and laterally flexed to the symptomatic side. This provocative maneuver is known as:

. Hoffman's sign
. Lhermitte's sign
. Spurling's test
. Babinski reflex
. Adson's test

Correct Answer & Explanation

. Spurling's test

Explanation

Spurling's test (foraminal compression test) is performed by extending and laterally bending the neck to the symptomatic side while applying axial compression. A positive test is the reproduction of radicular arm pain, indicating cervical nerve root compression within the neural foramen.

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