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6. Spine MCQs

Practice Set 175 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 3481

Topic: 6. Spine

A 65-year-old female presents with neurogenic claudication and L4-L5 degenerative spondylolisthesis. She is scheduled for surgery. According to the SPORT trial data, comparing surgical versus non-operative treatment for degenerative spondylolisthesis, which of the following statements is true regarding long-term (4-year) outcomes?

. Non-operative treatment has equivalent functional outcomes to surgery
. Patients treated surgically showed significantly greater improvement in pain and function compared to non-operative treatment
. Decompression alone showed superior outcomes to decompression with instrumented fusion
. The incidence of adjacent segment disease was 50% at 4 years
. Epidural steroid injections provided longer-lasting relief than surgery

Correct Answer & Explanation

. Patients treated surgically showed significantly greater improvement in pain and function compared to non-operative treatment

Explanation

The Spine Patient Outcomes Research Trial (SPORT) demonstrated that patients with symptomatic degenerative spondylolisthesis treated surgically (decompression and fusion) had significantly greater improvement in pain and function compared to those treated non-operatively, and this treatment effect was maintained at 4-year and 8-year follow-ups.

Question 3482

Topic: 6. Spine

A 35-year-old unrestrained driver is involved in a high-speed motor vehicle collision. Cervical spine imaging reveals a Levine-Edwards Type IIA traumatic spondylolisthesis of the axis (Hangman's fracture). The fracture shows severe angulation with minimal translation. Which of the following treatments is absolutely contraindicated in the management of this specific fracture pattern?

. Halo vest immobilization in extension
. Rigid cervical collar
. Axial cervical traction
. Posterior C2-C3 pedicle screw fixation
. Anterior cervical discectomy and fusion

Correct Answer & Explanation

. Halo vest immobilization in extension

Explanation

A Levine-Edwards Type IIA Hangman's fracture is caused by flexion-distraction forces, resulting in an oblique fracture through the pars interarticularis with severe angulation and minimal translation. Because the anterior longitudinal ligament and disc are disrupted, axial cervical traction is contraindicated as it will cause over-distraction and potential neurological injury. Reduction is achieved with gentle extension and compression, followed by Halo vest immobilization.

Question 3483

Topic: 6. Spine

During the neurological examination of a 60-year-old patient with suspected cervical spondylotic myelopathy, the examiner supports the patient's hand and forcefully flicks the distal phalanx of the middle finger into flexion. The patient exhibits a sudden reflexive flexion of the thumb and index finger. What is the name of this clinical sign?

. Babinski sign
. Hoffmann's sign
. Lhermitte's sign
. Wartenberg's sign
. Spurling's sign

Correct Answer & Explanation

. Hoffmann's sign

Explanation

Hoffmann's sign is an indicator of upper motor neuron (UMN) dysfunction, often seen in cervical myelopathy. It is elicited by flicking the nail of the middle finger downward; a positive response is the reflexive flexion of the thumb and/or index finger. Lhermitte's sign is electrical shock-like sensations down the spine with neck flexion. Wartenberg's sign is the involuntary abduction of the small finger.

Question 3484

Topic: 6. Spine

A 40-year-old male sustains a traumatic spondylolisthesis of the axis (Hangman's fracture) following a motor vehicle collision. Radiographs show severe angulation with minimal translation. Flexion imaging demonstrates an increase in angulation, while extension reduces it. According to the Levine and Edwards classification, what is the most appropriate management?

. Rigid cervical collar for 6 weeks
. Halo vest immobilization in traction and extension
. Reduction under fluoroscopy with gentle compression and extension followed by a halo vest
. Anterior C2-C3 fusion
. Posterior C1-C3 fusion

Correct Answer & Explanation

. Reduction under fluoroscopy with gentle compression and extension followed by a halo vest

Explanation

This is a Levine-Edwards Type IIa fracture (severe angulation, minimal translation, hinges into worse deformity with flexion). It occurs via a flexion-distraction mechanism. Traction is strongly contraindicated as it exacerbates the distraction and deformity. Treatment consists of gentle reduction using compression and slight extension, followed by halo vest immobilization.

Question 3485

Topic: Cervical Spine

Which of the following factors is the strongest independent predictor of non-union in the conservative management of a Type II odontoid fracture?

. Age less than 40 years
. Anterior displacement of 3 mm
. Posterior displacement of 2 mm
. Fracture gap greater than 1 mm
. Fracture displacement greater than 5 mm

Correct Answer & Explanation

. Fracture displacement greater than 5 mm

Explanation

Risk factors for non-union in Type II odontoid fractures include initial displacement > 5 mm, posterior displacement, age > 50 years, and a fracture gap > 1 mm. A displacement greater than 5 mm is one of the strongest independent predictors of failure with conservative care, often prompting early surgical intervention.

Question 3486

Topic: 6. Spine

A 72-year-old male with a history of cervical spondylosis presents after a hyperextension injury to his neck from a low-level fall. He exhibits pronounced weakness in his upper extremities (deltoid and biceps 3/5, hand intrinsic 2/5) but retains 4/5 strength in his lower extremities. He has patchy sensory loss in his arms and hyperreflexia in his legs. MRI confirms spinal cord signal change at C4-C5 with severe preexisting stenosis. What is the most accurate statement regarding his condition?

. The lower extremity motor tracts are affected more severely because they are located medially in the corticospinal tract
. Early surgical decompression (within 24 hours) has been definitively shown to improve final motor outcomes compared to delayed surgery
. The pattern of injury describes an anterior cord syndrome
. The upper extremity motor tracts are affected more severely because they are located medially in the corticospinal tract
. The prognosis for regaining fine motor hand dexterity is excellent

Correct Answer & Explanation

. The upper extremity motor tracts are affected more severely because they are located medially in the corticospinal tract

Explanation

The patient has Central Cord Syndrome, which classically presents with disproportionate upper extremity weakness compared to the lower extremities. The classic anatomical explanation is the somatotopic organization of the lateral corticospinal tract, where the cervical (upper extremity) motor tracts are located more medially, closer to the central gray matter, making them more susceptible to central cord injury. The prognosis for full recovery of hand dexterity is generally poor.

Question 3487

Topic: 6. Spine

A 65-year-old female presents with neurogenic claudication and lower back pain. Imaging shows an L4-L5 grade I degenerative spondylolisthesis. Flexion-extension radiographs reveal 4 mm of dynamic translation. She fails 6 months of conservative management. According to the SPORT trial and current guidelines, what is the recommended surgical management?

. L4-L5 laminectomy alone without fusion
. L4-L5 laminectomy with posterior instrumented fusion
. Stand-alone anterior lumbar interbody fusion (ALIF)
. Epidural steroid injections followed by physical therapy
. Interspinous process spacer placement

Correct Answer & Explanation

. L4-L5 laminectomy with posterior instrumented fusion

Explanation

For patients with degenerative spondylolisthesis and spinal stenosis who fail conservative management, decompression (laminectomy) combined with instrumented posterolateral fusion has historically shown better long-term clinical outcomes than decompression alone, particularly when dynamic instability (>3 mm translation on flex/ext views) is present.

Question 3488

Topic: 6. Spine

A 55-year-old man of Asian descent presents with progressive clumsiness in his hands and a positive Hoffman's sign. A CT scan of the cervical spine confirms ossification of the posterior longitudinal ligament (OPLL). Which of the following conditions is most strongly associated with this pathology?

. HLA-B27 positivity
. Diffuse idiopathic skeletal hyperostosis (DISH)
. Neurofibromatosis type 1
. Ankylosing Spondylitis
. Rheumatoid Arthritis

Correct Answer & Explanation

. Diffuse idiopathic skeletal hyperostosis (DISH)

Explanation

OPLL has a strong association with Diffuse Idiopathic Skeletal Hyperostosis (DISH). Up to 50% of patients with OPLL also demonstrate radiographic evidence of DISH, and both conditions share similar metabolic and genetic predisposing factors, including associations with type 2 diabetes and obesity.

Question 3489

Topic: 6. Spine

A 68-year-old male presents with bilateral lower extremity pain with walking. You are attempting to distinguish between neurogenic claudication (due to lumbar spinal stenosis) and vascular claudication. Which of the following clinical findings strongly favors neurogenic claudication?

. Pain starts in the calves and radiates proximally
. Symptoms are reliably reproducible after walking a specific, fixed distance
. Walking uphill is more painful than walking downhill
. Relief of symptoms occurs immediately upon standing stationary
. Relief of symptoms occurs when leaning forward (shopping cart posture)

Correct Answer & Explanation

. Relief of symptoms occurs when leaning forward (shopping cart posture)

Explanation

Neurogenic claudication is classically relieved by lumbar flexion (e.g., leaning over a shopping cart, sitting, walking uphill), which opens the spinal canal and neural foramina. Vascular claudication is relieved simply by stopping the metabolic demand (standing stationary) and typically worsens with uphill walking due to increased muscle exertion.

Question 3490

Topic: Thoracolumbar Spine & Deformity

A 12-year-old female presents with back pain and a slip angle of 55 degrees on standing lateral radiographs, consistent with high-grade dysplastic spondylolisthesis. Which of the following is the most characteristic physical exam finding associated with this condition?

. Phalen's test positivity
. Iliopsoas contracture
. Hamstring tightness
. Quadriceps weakness
. Ankle clonus

Correct Answer & Explanation

. Hamstring tightness

Explanation

High-grade spondylolisthesis in children is classically accompanied by severe hamstring tightness. This leads to a typical waddling gait with knees bent and a retroverted pelvis, known as the Phalen-Dickson sign.

Question 3491

Topic: 6. Spine

A 50-year-old man presents with neck pain radiating down his right arm. Examination reveals weakness in wrist flexion and finger extension, with diminished triceps reflex and numbness in the middle finger. Which cervical nerve root is most likely compressed?

. C5
. C6
. C7
. C8
. T1

Correct Answer & Explanation

. C7

Explanation

A C7 radiculopathy is characterized by weakness in the triceps, wrist flexors, and finger extensors. The triceps reflex is often diminished, and sensory changes typically involve the middle finger.

Question 3492

Topic: Thoracolumbar Spine & Deformity

A 15-year-old male presents with increasing middle back pain and a visible rounding of his spine. Standing lateral radiographs reveal thoracic kyphosis of 60 degrees. According to the Sorensen criteria, which of the following radiographic findings must be present to establish a definitive diagnosis of Scheuermann's kyphosis?

. Decreased kyphosis on active extension
. Presence of Schmorl's nodes on MRI
. Anterior wedging of >5 degrees in 3 consecutive vertebrae
. Apophyseal ring fractures at multiple levels
. A defect in the pars interarticularis of the lower thoracic vertebrae

Correct Answer & Explanation

. Anterior wedging of >5 degrees in 3 consecutive vertebrae

Explanation

Scheuermann's disease is a rigid structural thoracic or thoracolumbar kyphosis. The Sorensen criteria mandate that there must be anterior wedging of greater than 5 degrees in at least three consecutive vertebrae. While Schmorl's nodes and apophyseal ring irregularities are commonly associated radiographic findings, they are not strictly required by the diagnostic criteria.

Question 3493

Topic: 6. Spine

A 25-year-old male is involved in a high-speed motor vehicle collision. CT of the cervical spine shows a traumatic spondylolisthesis of the axis (Hangman's fracture) with severe angulation but minimal translation of C2 on C3. MRI reveals a disrupted C2-3 disc space and an intact anterior longitudinal ligament. This is classified as a Levine-Edwards Type IIA fracture. What is the most appropriate initial management?

. Application of 15 lbs of longitudinal cervical traction
. Surgical stabilization using isolated C2 pars screws
. Halo vest immobilization in slight extension and compression
. Halo vest immobilization with continuous longitudinal traction
. Anterior cervical discectomy and fusion at C2-C3

Correct Answer & Explanation

. Halo vest immobilization in slight extension and compression

Explanation

A Levine-Edwards Type IIA Hangman's fracture involves severe angulation with minimal translation and is caused by a flexion-distraction injury mechanism. The C2-3 disc is torn, but the ALL is intact. Longitudinal traction is strictly contraindicated as it will distract the C2-3 space and exacerbate instability. Treatment involves gentle reduction with slight compression and extension, followed by Halo vest immobilization.

Question 3494

Topic: 6. Spine

A 65-year-old male presents with deteriorating handwriting, dropping objects, and a subjective feeling of lower extremity stiffness. Physical examination demonstrates hyperreflexia in the patellar and Achilles tendons. Striking the distal brachioradialis tendon elicits no reflex in the brachioradialis itself, but produces a brisk spontaneous flexion of the fingers. This specific finding (the inverted brachioradialis reflex) indicates spinal cord compression at which specific level?

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

Correct Answer & Explanation

. C5-C6

Explanation

The inverted brachioradialis reflex is highly localizing for cervical myelopathy at the C5-C6 disc space (affecting the C6 nerve root). The compressive lesion causes a lower motor neuron lesion at C6 (hence the absent brachioradialis reflex) while simultaneously causing an upper motor neuron lesion to the spinal tracts supplying lower levels, leading to hyperactive finger flexion (C8/T1).

Question 3495

Topic: Cervical Spine

An 82-year-old male sustains a Type II odontoid fracture with 4 mm of posterior displacement following a low-energy fall. He has no neurologic deficits but has severe neck pain. What is the most appropriate management?

. Rigid cervical collar for 12 weeks
. Halo vest immobilization
. Anterior odontoid screw fixation
. Posterior C1-C2 instrumented fusion
. Occipitocervical fusion

Correct Answer & Explanation

. Posterior C1-C2 instrumented fusion

Explanation

Type II odontoid fractures in the elderly (>70 years) have an unacceptably high nonunion rate with conservative management and poor tolerance/high mortality associated with halo vests. Anterior screw fixation has lower success rates due to osteopenia. Posterior C1-C2 fusion provides the highest union rates and best functional outcomes for displaced Type II fractures in this demographic.

Question 3496

Topic: 6. Spine

A 65-year-old woman presents with neurogenic claudication. Imaging reveals a Grade I degenerative spondylolisthesis at L4-L5. Which nerve root is most commonly compressed in this specific pathology, and where does the compression typically occur?

. L4 root in the neuroforamen
. L4 root in the lateral recess
. L5 root in the lateral recess
. L5 root in the neuroforamen
. S1 root in the central canal

Correct Answer & Explanation

. L5 root in the lateral recess

Explanation

In degenerative spondylolisthesis (most common at L4-L5), the pathology involves central canal or lateral recess stenosis due to facet hypertrophy and ligamentum flavum buckling. This primarily compresses the traversing nerve root (L5) in the lateral recess. This contrasts with isthmic spondylolisthesis, where the exiting root (L4 in L4-5, or L5 in L5-S1) is compressed in the foramen.

Question 3497

Topic: Cervical Spine

A 45-year-old man falls from a height and sustains a Type II odontoid fracture. Displacement is 6 mm posteriorly. Which of the following conditions is an absolute contraindication to anterior odontoid screw fixation?

. Age less than 50 years
. Anterior displacement of 4 mm
. Rupture of the transverse atlantal ligament
. Concomitant C1 anterior arch fracture
. Delay in surgery of 3 days

Correct Answer & Explanation

. Rupture of the transverse atlantal ligament

Explanation

Anterior odontoid screw fixation relies entirely on an intact transverse atlantal ligament (TAL) to maintain C1-C2 stability postoperatively. If the TAL is ruptured (evidenced by MRI or C1 lateral mass displacement >6.9 mm), anterior screw fixation is contraindicated, and posterior C1-C2 fusion is required.

Question 3498

Topic: 6. Spine

A 68-year-old man presents with progressive clumsiness in his hands, difficulty buttoning his shirt, and a broad-based shuffling gait. Physical examination reveals a positive Hoffmann's sign. Which of the following physical examination findings is highly specific for cervical spondylotic myelopathy localized to the C5-C6 level?

. Inverted brachioradialis reflex
. Lhermitte's sign
. Hyperactive knee jerk
. Clonus at the ankle
. Loss of vibration sense in the toes

Correct Answer & Explanation

. Inverted brachioradialis reflex

Explanation

An inverted brachioradialis reflex (finger flexion and absent radial deviation upon tapping the brachioradialis tendon) is a highly specific upper motor neuron sign for cervical myelopathy at the C5-C6 level. It indicates a lower motor neuron lesion at C5/C6 and an upper motor neuron lesion below that level.

Question 3499

Topic: 6. Spine

A 55-year-old male of East Asian descent presents with progressive clumsiness in his hands and broad-based gait. Lateral cervical spine radiographs show Ossification of the Posterior Longitudinal Ligament (OPLL). Which of the following defines a 'K-line negative' cervical spine, and what is its surgical implication?

. The OPLL mass does not cross a line from the anterior C2 to C7 bodies; posterior laminoplasty is indicated.
. The OPLL mass crosses a line connecting the midpoints of the spinal canal at C2 and C7; an anterior or combined approach is indicated.
. A line connecting the posterior elements of C2 to C7 is kyphotic; conservative management is indicated.
. The OPLL mass crosses a line from the tip of the dens to the C7 spinous process; anterior corpectomy is strictly contraindicated.
. The cervical spine lacks lordosis; posterior laminectomy alone without fusion is the treatment of choice.

Correct Answer & Explanation

. The OPLL mass crosses a line connecting the midpoints of the spinal canal at C2 and C7; an anterior or combined approach is indicated.

Explanation

The K-line is defined as 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 to posteriorly (K-line negative), the spine is typically kyphotic or has a massive OPLL, meaning a posterior decompression (laminoplasty) will not allow the cord to drift back sufficiently. Thus, an anterior decompression or a combined anterior-posterior approach is indicated.

Question 3500

Topic: Thoracolumbar Spine & Deformity
A 14-year-old gymnast presents with chronic low back pain that worsens with extension. Lateral lumbar radiographs reveal a grade I spondylolisthesis at L5-S1 with a visible pars interarticularis defect. According to the Wiltse classification, which 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 II (Isthmic)

Explanation

The Wiltse classification of spondylolisthesis is: Type I: Dysplastic (congenital abnormalities of the upper sacrum or L5 arch). Type II: Isthmic (lesion in the pars interarticularis, typical in young athletes like gymnasts). Type III: Degenerative (secondary to long-standing segmental instability). Type IV: Traumatic (fractures in areas other than the pars). Type V: Pathologic (generalized or localized bone disease). Type VI: Iatrogenic.

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