Menu

6. Spine MCQs

Practice Set 174 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 3461

Topic: 6. Spine

A 22-year-old male is involved in a high-speed motor vehicle collision while wearing a lap belt. Radiographs reveal a flexion-distraction injury of the L2 vertebra extending through the pedicles and posterior elements. Which concomitant injury is most likely to be found in this patient?

. Aortic dissection
. Renal artery thrombosis
. Intra-abdominal hollow viscus injury
. Diaphragmatic rupture
. Pelvic ring disruption

Correct Answer & Explanation

. Intra-abdominal hollow viscus injury

Explanation

Chance fractures (flexion-distraction injuries) sustained with seatbelts have a high association (up to 50%) with intra-abdominal injuries. Specifically, hollow viscus injuries (e.g., small bowel laceration or mesenteric avulsion) are extremely common due to the lap belt compressing the abdomen against the spine during deceleration. Immediate general surgery consultation and abdominal imaging are warranted.

Question 3462

Topic: 6. Spine

Which of the following clinical features most reliably differentiates neurogenic claudication from vascular claudication in an elderly patient with leg pain?

. Pain exacerbated by walking up an incline
. Pain radiating to the bilateral calves
. Improvement of symptoms when walking while leaning over a shopping cart
. Diminished posterior tibial pulses on examination
. Symptoms reliably occurring after walking a fixed, predictable distance

Correct Answer & Explanation

. Improvement of symptoms when walking while leaning over a shopping cart

Explanation

The 'shopping cart sign' indicates relief of claudication symptoms with lumbar flexion, which is a hallmark of neurogenic claudication from lumbar spinal stenosis. Lumbar flexion increases the cross-sectional area of the spinal canal. Vascular claudication is worsened by walking uphill (increased metabolic demand) and typically occurs at a predictable, fixed distance.

Question 3463

Topic: 6. Spine
A 40-year-old man sustains a traumatic spondylolisthesis of C2 (Hangman's fracture) following a motor vehicle accident. Radiographs reveal severe angulation (>15 degrees) with minimal translation (Levine-Edwards Type IIA). What is the primary mechanism of injury for this specific fracture subtype, and what is the absolute contraindication in its management?
. Flexion and distraction; cervical traction is contraindicated
. Hyperextension and axial loading; strict bed rest is contraindicated
. Hyperflexion and compression; halo vest is contraindicated
. Lateral bending; surgical fusion is contraindicated
. Axial loading; hard cervical collar is contraindicated

Correct Answer & Explanation

. Flexion and distraction; cervical traction is contraindicated

Explanation

A Levine-Edwards Type IIA Hangman's fracture is characterized by severe angulation and minimal translation, occurring via a flexion-distraction mechanism. Because the posterior longitudinal ligament and disc space are severely disrupted, applying cervical traction will over-distract the injury and is strictly contraindicated. Treatment typically involves a halo vest applied with gentle compression and slight extension.

Question 3464

Topic: 6. Spine

When evaluating a patient with suspected cervical spondylotic myelopathy, which of the following physical examination findings represents an upper motor neuron (UMN) sign?

. Absent brachioradialis reflex
. Positive Hoffmann sign
. Atrophy of the intrinsic hand muscles
. Fasciculations in the deltoid
. Decreased grip strength

Correct Answer & Explanation

. Positive Hoffmann sign

Explanation

Cervical myelopathy presents with upper motor neuron signs below the level of the lesion and potentially lower motor neuron signs at the level of the lesion. A positive Hoffmann sign, hyperreflexia, inverted radial reflex, clonus, and Babinski sign are UMN signs. Atrophy, absent reflexes, and fasciculations are lower motor neuron signs.

Question 3465

Topic: Thoracolumbar Spine & Deformity

A 35-year-old female falls from a height and sustains an L1 burst fracture. She is neurologically intact. MRI demonstrates an intact posterior ligamentous complex (PLC). Radiographs show 25% loss of anterior vertebral body height and CT shows 30% canal compromise. Based on the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the score and the recommended management?

. Score 2, non-operative management
. Score 4, operative management
. Score 5, operative management
. Score 2, operative management
. Score 4, non-operative management

Correct Answer & Explanation

. Score 2, non-operative management

Explanation

The TLICS score is calculated as follows: Morphology (Burst = 2 points), Neurologic status (Intact = 0 points), PLC status (Intact = 0 points). The total score is 2. A score of 3 or less is an indication for non-operative management (e.g., orthosis/bracing). A score of 4 is indeterminate, and 5 or more indicates surgery.

Question 3466

Topic: 6. Spine

According to the Levine-Edwards classification of traumatic spondylolisthesis of the axis (Hangman's fracture), which of the following uniquely describes the mechanism and appropriate management of a Type IIA fracture?

. Hyperextension with minimal displacement; treated with a hard cervical collar.
. Flexion-distraction injury with significant angulation and minimal translation; skeletal traction is contraindicated.
. Hyperextension-axial loading with severe translation; requires immediate open reduction.
. Involvement of the odontoid process; treated with halo vest immobilization.
. Fracture through the pars interarticularis with an intact anterior longitudinal ligament; treated with anterior cervical plating.

Correct Answer & Explanation

. Flexion-distraction injury with significant angulation and minimal translation; skeletal traction is contraindicated.

Explanation

Levine-Edwards Type IIA fractures are caused by flexion-distraction forces. They present with minimal anterior translation but severe anterior angulation of C2 on C3. Because the posterior longitudinal ligament and disc are disrupted, applying skeletal traction is strictly contraindicated as it will exacerbate the distraction and deformity. Management typically involves gentle extension and compression, followed by halo vest immobilization.

Question 3467

Topic: 6. Spine

A patient presents with a suspected spinal epidural abscess. While the 'classic triad' of symptoms is well described, it is present in only a minority of cases. What is the most consistent, and typically the earliest, clinical symptom of a spinal epidural abscess?

. Radicular pain radiating to the extremities
. Progressive motor weakness
. Bowel or bladder dysfunction
. Localized, severe back pain
. High-grade, spiking fever

Correct Answer & Explanation

. Localized, severe back pain

Explanation

Localized back pain is the earliest and most consistent symptom of a spinal epidural abscess, occurring in up to 75-90% of patients. The natural history typically progresses in four stages: localized spinal pain, radicular pain, muscular weakness/sensory deficit, and finally paralysis. The classic triad of back pain, fever, and neurologic deficit is found in only about 10-15% of patients at initial presentation.

Question 3468

Topic: Cervical Spine

A 75-year-old male presents with neck pain following a ground-level fall. CT imaging reveals a Type II odontoid fracture according to the Anderson and D'Alonzo classification. Which of the following anatomical factors is the primary reason for the high rate of nonunion associated with this specific fracture pattern?

. Disruption of the apical ligament
. The presence of a vascular watershed area at the base of the dens
. Interposition of the transverse ligament in the fracture site
. Distraction forces from the alar ligaments
. Excessive motion at the atlanto-occipital joint

Correct Answer & Explanation

. The presence of a vascular watershed area at the base of the dens

Explanation

Type II odontoid fractures occur at the base of the dens. This region represents a vascular watershed area. The blood supply to the odontoid comes primarily from the anterior and posterior ascending arteries (branches of the vertebral arteries), which course cephalad. A fracture at the base disrupts this precarious blood supply, leading to a high rate of nonunion, particularly in the elderly population.

Question 3469

Topic: 6. Spine

A 65-year-old female presents with severe neurogenic claudication and an L4-L5 degenerative spondylolisthesis. She fails 6 months of conservative management. If she undergoes a lumbar decompression (laminectomy) alone without a concomitant fusion, what is the most common reason for early reoperation in this patient?

. Unrecognized dural tear causing a pseudomeningocele
. Progression of the spondylolisthesis leading to recurrent stenosis/instability
. Adjacent segment disease at L3-L4
. Deep surgical site infection
. Postoperative epidural hematoma

Correct Answer & Explanation

. Progression of the spondylolisthesis leading to recurrent stenosis/instability

Explanation

Degenerative spondylolisthesis indicates underlying segmental instability. The SPORT trial and other classic spine literature (e.g., Herkowitz and Kurz) demonstrated that performing a laminectomy/decompression alone in the setting of degenerative spondylolisthesis carries a high risk of accelerating the instability, leading to progressive slip, recurrent symptoms, and a higher rate of reoperation compared to decompression with fusion.

Question 3470

Topic: 6. Spine
A 25-year-old male sustains a Hangman's fracture (traumatic spondylolisthesis of C2). Radiographs reveal severe angulation of C2 on C3 with minimal translation. During closed reduction attempts in the ER, applying longitudinal traction causes the C2-C3 disc space to widen significantly and pathologically. Based on the Levine-Edwards classification, what is the injury type and correct management approach?
. Type I; Treated with an Aspen collar
. Type II; Treated with immediate longitudinal traction
. Type IIA; Traction is strictly contraindicated, treat with gentle compression/extension in a halo
. Type III; Treated with surgical stabilization
. Type I; Treated with a Halo vest in neutral

Correct Answer & Explanation

. Type IIA; Traction is strictly contraindicated, treat with gentle compression/extension in a halo

Explanation

Levine-Edwards Type IIA Hangman's fractures feature severe angulation with minimal translation. The injury involves disruption of the C2-C3 intervertebral disc and the posterior longitudinal ligament. Because the C2-C3 space is completely unstable in distraction, longitudinal traction is strictly contraindicated as it causes severe pathologic widening and potential neurologic injury. Management consists of reduction under fluoroscopy with gentle extension and compression, followed by a halo vest.

Question 3471

Topic: 6. Spine

A 25-year-old male sustains a traumatic spondylolisthesis of the axis (Hangman's fracture) following an MVA. Radiographs and CT demonstrate severe angulation of C2 on C3 with minimal translation. Flexion-extension views (done previously at an outside facility) show widening of the C2-C3 posterior disc space with flexion. According to the Levine and Edwards classification, what is the most appropriate management?

. Halo vest placement with longitudinal cervical traction
. Rigid cervical collar for 6 weeks
. Halo vest application in slight extension and compression
. Anterior C2-C3 cervical discectomy and fusion (ACDF)
. Posterior C1-C2 transarticular screw fixation

Correct Answer & Explanation

. Halo vest application in slight extension and compression

Explanation

This describes a Type IIA Hangman's fracture (severe angulation, minimal translation, disruption of the posterior C2-C3 disc space). Traction is strictly contraindicated as it will further widen the disc space and distract the fracture, leading to neurologic compromise. The treatment is closed reduction with slight extension and compression under fluoroscopy, followed by immobilization in a Halo vest.

Question 3472

Topic: 6. Spine

A 68-year-old male complains of bilateral posterior leg pain that worsens with walking and is relieved by sitting. Which of the following historical or physical examination findings is most specific for differentiating neurogenic claudication (lumbar spinal stenosis) from vascular claudication?

. Pain starts proximally and radiates distally
. Pain is reliably reproduced after walking a fixed distance
. Leg pain is relieved when riding a stationary bicycle
. Diminished pedal pulses
. Relief of pain with standing still

Correct Answer & Explanation

. Leg pain is relieved when riding a stationary bicycle

Explanation

The bicycle test of van Gelderen classically differentiates neurogenic from vascular claudication. Patients with neurogenic claudication lean forward while cycling, which flexes the spine, increases the spinal canal cross-sectional area, and prevents symptoms. Vascular claudication is worsened by the metabolic demand of cycling regardless of posture, and is classically relieved by simply standing still.

Question 3473

Topic: 6. Spine

A 35-year-old male is brought to the emergency department after falling from a 15-foot scaffold. He complains of severe back pain. Neurological examination reveals 4/5 weakness in the extensor hallucis longus bilaterally, with intact bowel and bladder function. CT of the lumbar spine shows an L1 burst fracture with 40% loss of anterior vertebral body height and retropulsion of a bone fragment into the spinal canal. MRI confirms high T2 signal indicating complete disruption of the posterior ligamentous complex. According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is this patient's total score?

. 4
. 5
. 6
. 7
. 8

Correct Answer & Explanation

. 8

Explanation

The TLICS system scores injuries based on three categories: 1) Morphology: Burst fracture = 2 points. 2) Neurologic status: Incomplete spinal cord or nerve root injury = 3 points. 3) Posterior Ligamentous Complex (PLC) integrity: Disrupted = 3 points. The patient has a burst morphology (2), an incomplete neurological deficit (3), and a disrupted PLC (3). Total score = 2 + 3 + 3 = 8. A score > 4 is considered a strong indication for surgical intervention.

Question 3474

Topic: 6. Spine

A 42-year-old male presents to the emergency department with acute lower back pain radiating down both legs after lifting a heavy box. Which of the following is considered the most consistent and earliest clinical sign of cauda equina syndrome?

. Saddle anesthesia
. Urinary retention
. Bowel incontinence
. Bilateral foot drop
. Loss of the Achilles reflex

Correct Answer & Explanation

. Urinary retention

Explanation

Urinary retention is the most sensitive and often the earliest clinical symptom of cauda equina syndrome (CES). The post-void residual (PVR) volume will be abnormally high (typically >100-200 mL). Bowel incontinence and frank saddle anesthesia may develop slightly later as the sacral roots are further compressed. The absence of urinary retention makes CES highly unlikely.

Question 3475

Topic: Thoracolumbar Spine & Deformity
A 16-year-old elite female gymnast presents with insidious onset lower back pain that worsens with extension activities. Oblique radiographs of the lumbar spine demonstrate a 'collar on the Scotty dog'. According to the Wiltse classification of spondylolisthesis, what type of defect does this patient have?
. Type I (Dysplastic)
. Type II (Isthmic)
. Type III (Degenerative)
. Type IV (Traumatic)
. Type V (Pathologic)

Correct Answer & Explanation

. Type II (Isthmic)

Explanation

The patient has a pars interarticularis defect (spondylolysis), classically seen as a 'collar on the Scotty dog' on oblique radiographs. In the Wiltse classification of spondylolisthesis, a pars defect (often a stress/fatigue fracture common in gymnasts) is classified as Type II (Isthmic). Type I is Dysplastic (congenital abnormality of the upper sacrum or L5 arch), Type III is Degenerative, Type IV is Traumatic (fractures of the posterior arch other than the pars), and Type V is Pathologic.

Question 3476

Topic: 6. Spine
A 65-year-old Asian male presents with progressive clumsiness in his hands, difficulty fastening buttons, and an unsteady gait. Radiographs and MRI demonstrate continuous ossification of the posterior longitudinal ligament (OPLL) from C3 to C6, causing >60% canal stenosis. His cervical spine alignment demonstrates rigid kyphosis (K-line negative). Which of the following surgical strategies is the most appropriate?
. Anterior cervical corpectomy and fusion (ACCF) alone
. Posterior cervical laminectomy alone
. Posterior cervical laminoplasty alone
. Anterior decompression and fusion followed by posterior instrumented fusion
. Cervical disc arthroplasty at all affected levels

Correct Answer & Explanation

. Anterior decompression and fusion followed by posterior instrumented fusion

Explanation

In patients with severe OPLL and a kyphotic cervical alignment (K-line negative), posterior decompression alone (laminectomy or laminoplasty) is inadequate because the spinal cord will remain draped over the anterior pathology and will not drift backward. Anterior decompression alone for massive, multi-level OPLL carries a high risk of dural tears, construct failure, and graft dislodgment. Therefore, a combined anterior-posterior approach (or an anterior approach with posterior instrumentation for stability) is the most reliable strategy to adequately decompress the cord and stabilize the spine in a K-line negative patient.

Question 3477

Topic: 6. Spine

A 65-year-old male presents with deteriorating handwriting, generalized clumsiness, and frequent tripping. Neurological examination reveals an inverted brachioradialis reflex. This clinical finding is most indicative of spinal cord compression at which of the following neurologic levels?

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

Correct Answer & Explanation

. C5-C6

Explanation

An inverted brachioradialis reflex is characterized by spontaneous flexion of the digits when the brachioradialis tendon is struck. It indicates a lower motor neuron lesion at C5-C6 (abolishing the normal brachioradialis reflex) combined with an upper motor neuron lesion affecting the reflex arc below this level (causing hyperreflexia of the C8-innervated finger flexors). It strongly correlates with cervical myelopathy at the C5-C6 level.

Question 3478

Topic: 6. Spine

A 55-year-old Asian male presents with progressive hand clumsiness and broad-based gait. Cervical spine CT demonstrates continuous ossification of the posterior longitudinal ligament (OPLL) from C3 to C6. The K-line, drawn from the mid-point of the spinal canal at C2 to C7 on a sagittal MR image, demonstrates that the OPLL mass lies posterior to the line (a 'K-line negative' cervical spine). Which surgical approach is most highly recommended?

. Posterior cervical laminectomy alone
. Posterior cervical laminoplasty
. Anterior cervical corpectomy and fusion
. Cervical disc arthroplasty
. Posterior cervical foraminotomy

Correct Answer & Explanation

. Anterior cervical corpectomy and fusion

Explanation

A 'K-line negative' cervical spine means the OPLL mass is large and local kyphosis is typically present, extending posterior to the line connecting the mid-canal of C2 and C7. In this scenario, posterior decompression procedures (laminectomy or laminoplasty) are insufficient because the spinal cord will not effectively 'drift back' away from the anterior compressive mass. Anterior decompression (corpectomy and fusion) is necessary to directly remove the pathology and restore canal diameter.

Question 3479

Topic: 6. Spine

A 68-year-old male presents with bilateral lower extremity pain and cramping that worsens with walking and improves when he pushes a shopping cart. He undergoes stationary bicycle testing. Which of the following findings would most specifically differentiate neurogenic claudication from vascular claudication during this test?

. Pain occurs immediately upon starting to pedal
. Pain is relieved when pedaling with the spine in an extended position
. Pain is relieved when pedaling with the spine in a flexed position
. Pedal pulses become non-palpable during exercise
. Calf pain increases regardless of spine posture

Correct Answer & Explanation

. Pain is relieved when pedaling with the spine in a flexed position

Explanation

In the stationary bicycle test (van Gelderen test), a patient with neurogenic claudication (due to lumbar spinal stenosis) can pedal for a prolonged period without pain if the spine is flexed, because flexion increases the cross-sectional area of the spinal canal and foramina. In contrast, a patient with vascular claudication will experience ischemic muscle pain regardless of the spine's position.

Question 3480

Topic: 6. Spine

A 62-year-old man with cervical myelopathy secondary to ossification of the posterior longitudinal ligament (OPLL) from C3-C6 is planned for surgery. Lateral radiographs demonstrate a C2-C7 lordosis of 5 degrees, and the OPLL mass exceeds the K-line (K-line negative). Which surgical option is strictly contraindicated?

. Anterior cervical corpectomy and fusion
. Cervical laminoplasty alone
. Anterior cervical discectomy and fusion
. Posterior laminectomy and instrumented fusion
. Combined anterior-posterior decompression and fusion

Correct Answer & Explanation

. Combined anterior-posterior decompression and fusion

Explanation

In K-line negative OPLL, the OPLL mass is large and kyphosis is often present or alignment is poor. Posterior decompression alone (laminoplasty) is contraindicated because it does not allow the spinal cord to drift backward sufficiently to clear the anterior compressive mass, leading to poor neurological recovery. An anterior decompression or a posterior decompression with instrumented fusion to correct alignment is required.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page