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6. Spine MCQs

Practice Set 173 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 3441

Topic: 6. Spine

A 15-year-old boy presents with progressive thoracic kyphosis. Lateral spine radiographs are obtained. According to Sorensen's criteria, which of the following is required for the definitive radiographic diagnosis of Scheuermann's disease?

. Anterior wedging of at least 5 degrees in one vertebra
. Anterior wedging of at least 5 degrees in three adjacent vertebrae
. Schmorl's nodes in at least two adjacent vertebrae
. A Cobb angle greater than 40 degrees with rigid apex
. Endplate irregularities in the lumbar spine only

Correct Answer & Explanation

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

Explanation

Sorensen's criteria for the diagnosis of Scheuermann's kyphosis require the presence of anterior wedging of >5 degrees in at least three consecutive (adjacent) vertebrae. Schmorl's nodes and endplate irregularities are commonly seen but are not the primary defining criteria.

Question 3442

Topic: Thoracolumbar Spine & Deformity

A 16-year-old gymnast with an L5-S1 isthmic spondylolisthesis develops progressively worsening radicular leg pain. Imaging reveals an L5 pars defect with a Grade II slip and significant foraminal stenosis. Which nerve root is most likely compressed, and where does the compression occur?

. L4 root, in the lateral recess
. L5 root, in the neural foramen
. S1 root, in the lateral recess
. S1 root, in the neural foramen
. S2 root, centrally

Correct Answer & Explanation

. L5 root, in the neural foramen

Explanation

In L5-S1 isthmic spondylolisthesis, the exiting L5 nerve root is most commonly compressed within the neural foramen. The compression is typically caused by the hypertrophic fibrocartilaginous mass at the pars interarticularis defect (the 'Gill lesion').

Question 3443

Topic: 6. Spine
A 68-year-old male presents with deteriorating gait, hand clumsiness, and hyperreflexia. He is diagnosed with cervical spondylotic myelopathy. He reports that his balance is so poor he now requires the use of a cane to walk, but he is not restricted to a wheelchair. According to the Nurick classification for cervical myelopathy, what is his grade?
. Grade I
. Grade II
. Grade III
. Grade IV
. Grade V

Correct Answer & Explanation

. Grade IV

Explanation

The Nurick classification grades the severity of cervical myelopathy primarily based on ambulatory status: Grade 0 (root signs only), Grade I (signs of spinal cord involvement but normal gait), Grade II (mild gait involvement, able to be employed), Grade III (gait abnormality prevents employment, but walks unassisted), Grade IV (able to ambulate only with assistance/walker/cane), and Grade V (chairbound or bedridden). Requiring a cane corresponds to Grade IV.

Question 3444

Topic: Thoracolumbar Spine & Deformity
A 15-year-old gymnast complains of chronic low back pain that worsens with hyperextension. Radiographs confirm a grade I L5-S1 spondylolisthesis secondary to bilateral pars interarticularis defects. According to the Wiltse classification of spondylolisthesis, which type does this represent?
. 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 five major types of spondylolisthesis: Type I is Dysplastic (congenital abnormality of the upper sacrum/arch of L5); Type II is Isthmic (defect in the pars interarticularis, typical in young athletes like gymnasts); Type III is Degenerative (due to chronic instability without a pars defect); Type IV is Traumatic (fracture of the neural arch other than the pars); Type V is Pathologic.

Question 3445

Topic: 6. Spine

A 35-year-old female falls from a height and sustains a T12 burst fracture. On examination, she has 4/5 weakness in her right ankle dorsiflexors. MRI reveals disruption of the posterior ligamentous complex (PLC). What is her Thoracolumbar Injury Classification and Severity (TLICS) score?

. Score 4
. Score 5
. Score 7
. Score 8
. Score 10

Correct Answer & Explanation

. Score 8

Explanation

TLICS score calculation: Morphology = Burst fracture (2 points). Neurological status = Incomplete spinal cord / cauda equina injury (3 points). PLC status = Disrupted (3 points). Total = 2 + 3 + 3 = 8 points. A score > 4 is considered a strong indication for operative stabilization.

Question 3446

Topic: 6. Spine

A 60-year-old male presents with gait instability, hand clumsiness, and hyperreflexia in both the upper and lower extremities. Which of the following physical examination findings, if present, most specifically localizes his upper motor neuron lesion to a level cephalad to the foramen magnum?

. Jaw jerk reflex
. Hoffmann sign
. Inverted supinator reflex
. Babinski sign
. Sustained ankle clonus

Correct Answer & Explanation

. Jaw jerk reflex

Explanation

Hyperreflexia in the limbs indicates an upper motor neuron (UMN) lesion, which could be in the cervical spine or higher. The jaw jerk reflex assesses the trigeminal nerve (Cranial Nerve V). An exaggerated jaw jerk reflex localizes the UMN lesion to above the mid-pons (cephalad to the foramen magnum), helping differentiate cranial/brain pathology from cervical spondylotic myelopathy.

Question 3447

Topic: Thoracolumbar Spine & Deformity

A 35-year-old male sustains a T12 burst fracture after a fall. Neurological examination is completely intact. Radiographs and an MRI demonstrate splaying of the spinous processes and complete disruption of the posterior ligamentous complex (PLC). Based on the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his total score and the recommended treatment strategy?

. Score 3; non-operative treatment with a TLSO brace
. Score 4; surgeon's choice between operative and non-operative management
. Score 5; surgical stabilization is indicated
. Score 7; surgical stabilization is indicated
. Score 2; non-operative treatment with early mobilization

Correct Answer & Explanation

. Score 5; surgical stabilization is indicated

Explanation

The TLICS score assigns points based on morphology, neurologic status, and PLC integrity. Burst morphology = 2 points. Intact neurologic status = 0 points. Disrupted PLC = 3 points. Total score = 5 points. A TLICS score of 3 or less is typically treated non-operatively, 4 is indeterminate (surgeon's choice), and 5 or more indicates surgical stabilization.

Question 3448

Topic: 6. Spine

A 35-year-old male arrives in the emergency department intubated, sedated, and unexaminable following a high-speed motor vehicle collision. Radiographs reveal a C5-C6 bilateral facet dislocation. Which of the following is the most appropriate next step in management?

. Immediate closed reduction with cranial traction in the emergency department.
. MRI of the cervical spine.
. Anterior cervical discectomy and fusion without imaging.
. Posterior cervical fusion without reduction.
. Application of a halo vest.

Correct Answer & Explanation

. MRI of the cervical spine.

Explanation

In an obtunded or unexaminable patient with a cervical facet dislocation, an MRI is mandatory prior to closed or open reduction to rule out a herniated disc. If a disc herniation is present, a closed reduction could cause the disc material to be pushed into the spinal cord, leading to catastrophic neurologic injury. An anterior approach is generally required first in these cases.

Question 3449

Topic: Thoracolumbar Spine & Deformity

In adult spinal deformity surgery, achieving optimal sagittal balance is critical. The goal for restoring lumbar lordosis (LL) is typically based on the patient's pelvic incidence (PI). What is the generally accepted target relationship between PI and LL?

. LL should equal PI plus 20 degrees
. LL should be within 10 degrees of PI
. PI should be half of the LL
. LL should be twice the pelvic tilt (PT)
. LL should be independent of PI but exactly match thoracic kyphosis

Correct Answer & Explanation

. LL should be within 10 degrees of PI

Explanation

In sagittal plane deformity correction, the target is a PI-LL mismatch of less than 10 degrees (ideally LL = PI +/- 9 degrees). This helps ensure that the patient can maintain an upright posture with minimal energy expenditure and reduces the risk of adjacent segment disease and mechanical failure.

Question 3450

Topic: 6. Spine

According to the Denis classification of sacral fractures, a Zone 3 fracture is anatomically located central to the neural foramina. This fracture pattern carries the highest risk of injury to which of the following neural structures?

. L4 nerve root
. L5 nerve root
. Cauda equina
. Sciatic nerve
. Pudendal nerve

Correct Answer & Explanation

. Cauda equina

Explanation

Denis classified sacral fractures into three zones based on their relationship to the neural foramina. Zone 1 (alar) fractures are lateral to the foramina. Zone 2 (foraminal) fractures involve the foramina and have the highest risk of radiculopathy, typically L5 or S1. Zone 3 (central) fractures involve the spinal canal medial to the foramina and carry the highest risk (over 50%) of cauda equina syndrome, resulting in bowel, bladder, and sexual dysfunction.

Question 3451

Topic: 6. Spine

A 55-year-old male with cervical myelopathy secondary to ossification of the posterior longitudinal ligament (OPLL) is evaluated for surgery. Imaging shows a 'K-line negative' cervical spine. What is the most appropriate surgical approach?

. Posterior cervical laminectomy alone
. Posterior cervical laminoplasty
. Anterior cervical corpectomy and fusion (ACCF)
. Cervical epidural steroid injection
. Posterior cervical foraminotomy

Correct Answer & Explanation

. Anterior cervical corpectomy and fusion (ACCF)

Explanation

The K-line is a straight line connecting the midpoints of the spinal canal at C2 and C7 on a lateral radiograph. If the OPLL mass crosses this line anteriorly, the patient is 'K-line negative'. In K-line negative patients, a posterior-only decompression (laminectomy or laminoplasty) is ineffective because the spinal cord will not sufficiently drift dorsally away from the anterior compressive mass. An anterior approach (like ACCF) or a combined anterior-posterior approach is required for adequate decompression.

Question 3452

Topic: 6. Spine

A 40-year-old female sustains a Levine-Edwards Type IIa Hangman's fracture (traumatic spondylolisthesis of the axis) following a motor vehicle collision. Radiographs demonstrate severe angulation with minimal translation. What is the effect of applying acute cervical traction in the management of this specific fracture subtype?

. It safely and anatomically corrects the angulation
. It overdistracts the fracture, risking severe neurologic injury
. It dynamically compresses the fracture fragments
. It is the definitive standard of care for union
. It prevents dynamic translation without affecting alignment

Correct Answer & Explanation

. It overdistracts the fracture, risking severe neurologic injury

Explanation

The Levine-Edwards Type IIa Hangman's fracture is caused by a flexion-distraction mechanism, resulting in severe angulation but minimal translation. Because the primary injury involves significant posterior soft tissue and intervertebral disc disruption with an element of distraction, the application of cervical traction is strictly contraindicated. Traction can lead to extreme overdistraction of the fracture site and catastrophic neurologic deficit. Management involves closed reduction with slight extension and compression, followed by halo vest immobilization.

Question 3453

Topic: 6. Spine
A 14-year-old female gymnast presents with chronic lower back pain. Radiographs reveal a Grade II isthmic spondylolisthesis at L5-S1. What is the pathognomonic finding associated with this condition on oblique lumbar radiographs?
. Bamboo spine
. Bamboo sign
. Scotty dog with a collar
. Inverted Napoleon hat sign
. Vacuum phenomenon

Correct Answer & Explanation

. Scotty dog with a collar

Explanation

The 'Scotty dog with a collar' (or decapitated Scotty dog) on an oblique lumbar radiograph represents a defect in the pars interarticularis (spondylolysis), which is the underlying cause of an isthmic spondylolisthesis. The 'inverted Napoleon hat sign' is seen on AP radiographs in severe (Grade III/IV) spondylolisthesis.

Question 3454

Topic: 6. Spine
A 45-year-old male is involved in a motor vehicle accident. Cervical spine CT reveals a traumatic spondylolisthesis of the axis (Hangman's fracture) with severe angular deformity but minimal translation. The fracture line is oblique. The application of cervical traction is strictly contraindicated. Which Levine-Edwards classification type does this represent?
. Type I
. Type II
. Type IIA
. Type III
. Type IV

Correct Answer & Explanation

. Type IIA

Explanation

A Levine-Edwards Type IIA Hangman's fracture is characterized by severe angulation and minimal translation, with an oblique fracture line running from anterior-inferior to posterior-superior. The mechanism is flexion-distraction. Application of cervical traction is contraindicated because it will exacerbate the deformity and potentially cause neurologic injury by widening the posterior disk space. Treatment typically involves a halo vest placed in slight extension and compression.

Question 3455

Topic: 6. Spine

A 60-year-old male presents with progressive clumsiness in his hands and gait instability. Imaging confirms Ossification of the Posterior Longitudinal Ligament (OPLL) from C3 to C6. The sagittal MRI and CT show a kyphotic cervical alignment, making the K-line negative. Which of the following is the most appropriate surgical intervention?

. Anterior cervical corpectomy and fusion (ACCF)
. Cervical laminoplasty
. Cervical laminectomy without fusion
. Posterior cervical fusion alone
. Minimally invasive posterior cervical foraminotomies

Correct Answer & Explanation

. Anterior cervical corpectomy and fusion (ACCF)

Explanation

The K-line is a line connecting the midpoints of the spinal canal at C2 and C7. A negative K-line means the OPLL mass extends posterior to this line, usually due to kyphosis or a massive ossification. In K-line negative OPLL, the spinal cord will not sufficiently shift backward after a posterior-only decompression (like laminoplasty), resulting in poor neurological recovery. An anterior approach (corpectomy) or a combined anterior-posterior approach is indicated.

Question 3456

Topic: Thoracolumbar Spine & Deformity

A 32-year-old male falls from a height and presents neurologically intact. CT imaging shows an L1 burst fracture with 30% canal compromise. An MRI clearly demonstrates a wide disruption of the interspinous ligaments and facet capsules with significant edema (definite Posterior Ligamentous Complex disruption). Based on the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the score and corresponding recommendation?

. Score 2; Non-operative management
. Score 4; Surgeon preference for operative vs non-operative
. Score 5; Surgical intervention indicated
. Score 7; Surgical intervention indicated
. Score 3; TLSO bracing

Correct Answer & Explanation

. Score 5; Surgical intervention indicated

Explanation

The TLICS score is calculated from three categories: Morphology (Burst = 2 points), Neurologic status (Intact = 0 points), and Posterior Ligamentous Complex (PLC) status (Definite disruption = 3 points). Total score = 2 + 0 + 3 = 5. A TLICS score >4 indicates surgical intervention is the recommended treatment.

Question 3457

Topic: Cervical Spine

A 78-year-old male falls from a standing height and sustains a Type II odontoid fracture. Computed tomography reveals an anteriorly displaced fracture with an oblique fracture line running from anterior-inferior to posterior-superior. Which of the following is the most appropriate surgical management?

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

Correct Answer & Explanation

. Posterior C1-C2 fusion

Explanation

In elderly patients with Type II odontoid fractures, conservative management (collar/halo) carries a high rate of nonunion and halo vests have significant morbidity/mortality. Surgical fixation is preferred. An anterior odontoid screw is contraindicated in this scenario because of the 'reverse obliquity' of the fracture line (anterior-inferior to posterior-superior), which would cause the fragment to shear anteriorly upon screw compression. Additionally, poor bone quality in an elderly patient is a relative contraindication for an anterior screw. Therefore, posterior C1-C2 fusion is the treatment of choice.

Question 3458

Topic: Thoracolumbar Spine & Deformity

A 32-year-old male sustains a T12 burst fracture after a fall. He is neurologically intact. MRI is obtained, and the status of the posterior ligamentous complex (PLC) is deemed 'indeterminate'. According to the Thoracolumbar Injury Classification and Severity (TLICS) score, how many points are assigned specifically to the PLC component in this scenario?

. 0
. 1
. 2
. 3
. 4

Correct Answer & Explanation

. 3

Explanation

In the TLICS scoring system, the integrity of the Posterior Ligamentous Complex (PLC) is scored as follows: Intact = 0 points; Indeterminate (or suspected injury) = 2 points; Disrupted (definite injury) = 3 points. Total score dictates management (<=3 non-operative, 4 is surgeon's choice, >=5 operative).

Question 3459

Topic: 6. Spine

A 65-year-old man undergoes a C3-C6 posterior cervical laminectomy and instrumented fusion for cervical spondylotic myelopathy. On postoperative day 2, he develops profound new-onset weakness in unilateral shoulder abduction and elbow flexion, but reports no pain and has normal lower extremity function. His preoperative MRI showed severe central canal stenosis but no significant foraminal stenosis. What is the most likely etiology of this complication?

. Epidural hematoma
. Iatrogenic spinal cord contusion
. C5 nerve root tethering
. Unrecognized preoperative C5 radiculopathy
. Postoperative C4-C5 pseudoarthrosis

Correct Answer & Explanation

. C5 nerve root tethering

Explanation

Postoperative C5 palsy is a well-documented complication of cervical decompression (laminectomy or laminoplasty), characterized by motor-dominant weakness in the deltoid and biceps. The most accepted mechanism is the posterior drift of the spinal cord following decompression, which stretches the relatively short C5 nerve roots (the 'tethering' effect). It typically presents within the first few days postoperatively and is treated conservatively.

Question 3460

Topic: 6. Spine

A 68-year-old woman complains of bilateral calf and buttock pain that worsens with walking and prolonged standing. The pain is relieved by sitting or leaning forward over a shopping cart. During a bicycle stress test, her symptoms do not reproduce while pedaling. Which of the following best explains why spinal extension exacerbates her symptoms?

. It stretches the inflamed exiting nerve roots in the intervertebral foramen
. It decreases the cross-sectional area of the spinal canal by buckling the ligamentum flavum
. It causes a dynamic anterior subluxation of the vertebral bodies
. It compresses the anterior spinal artery leading to cord ischemia
. It increases tension on the posterior longitudinal ligament

Correct Answer & Explanation

. It decreases the cross-sectional area of the spinal canal by buckling the ligamentum flavum

Explanation

The patient's presentation is classic for neurogenic claudication secondary to lumbar spinal stenosis. Extension of the lumbar spine exacerbates the stenosis by causing the hypertrophied ligamentum flavum to buckle into the spinal canal and by overriding the facet joints, thereby decreasing the cross-sectional area of the neural foramina and central canal. Flexion stretches the ligamentum flavum, increasing canal space and relieving symptoms.

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