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6. Spine MCQs

Practice Set 177 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 3521

Topic: 6. Spine

A 19-year-old male is ejected during a motor vehicle rollover. On presentation, his right upper extremity is flail, massively swollen, and pulseless. Chest radiograph shows significant lateral displacement of the right scapula relative to the thoracic spine compared to the uninjured side. The mortality associated with this specific syndrome is most closely tied to which complication?

. Fulminant sepsis from closed dead muscle space
. Massive hemorrhage from disruption of the subclavian or axillary vessels
. Associated traumatic brain injury
. Delayed tension pneumothorax
. Pulmonary embolism from upper extremity deep vein thrombosis

Correct Answer & Explanation

. Massive hemorrhage from disruption of the subclavian or axillary vessels

Explanation

This patient has scapulothoracic dissociation, essentially a closed forequarter amputation. It is characterized by lateral displacement of the scapula, massive tearing of the shoulder girdle musculature, and severe stretch or complete avulsion of the brachial plexus and subclavian/axillary vessels. Mortality is significant (approx. 10-20%) and is predominantly a consequence of acute exsanguinating hemorrhage from the disrupted large vessels.

Question 3522

Topic: Cervical Spine

An 82-year-old woman with severe osteoporosis falls and sustains a Type II odontoid fracture. She is neurologically intact. Which of the following treatment modalities is associated with the highest rate of morbidity and mortality in this specific patient population, and is therefore generally contraindicated?

. Rigid cervical collar immobilization
. Soft cervical collar immobilization
. Anterior odontoid screw fixation
. Posterior C1-C2 arthrodesis
. Halo vest immobilization

Correct Answer & Explanation

. Halo vest immobilization

Explanation

In the elderly population (typically >65 or >80 years of age), halo vest immobilization for cervical spine fractures is associated with a significantly increased risk of major complications, including aspiration pneumonia, cardiac arrest, respiratory failure, and death. Mortality rates in the elderly treated with a halo vest have been reported as high as 40%. Therefore, halo vest immobilization is generally contraindicated in this age group.

Question 3523

Topic: 6. Spine

A 35-year-old man falls from a height of 30 feet, sustaining a spinopelvic dissociation characterized by a U-shaped sacral fracture on imaging. Upon physical examination, he has decreased perianal sensation, loss of voluntary anal sphincter tone, and urinary retention. This clinical presentation is primarily due to injury at which of the following neurologic levels?

. Unilateral L5 nerve root
. Cauda equina
. Isolated S1 nerve root
. Femoral nerve
. Pudendal nerve

Correct Answer & Explanation

. Cauda equina

Explanation

A U-shaped sacral fracture involves bilateral longitudinal sacral fractures connected by a transverse fracture line, most commonly occurring at the S1 or S2 level. Because the transverse component crosses the central sacral spinal canal, it highly compromises the sacral nerve roots of the cauda equina. This results in cauda equina syndrome, characterized by saddle anesthesia, loss of sphincter tone, and bowel/bladder dysfunction.

Question 3524

Topic: 6. Spine

A 32-year-old man is brought to the emergency department after a high-speed motor vehicle collision. Imaging reveals a traumatic spondylolisthesis of the axis (Hangman's fracture) with bilateral pars interarticularis fractures. Which of the following is the classic mechanism of injury for this fracture pattern?

. Axial loading and hyperextension
. Hyperflexion and distraction
. Lateral bending and rotation
. Pure axial loading
. Pure rotation

Correct Answer & Explanation

. Axial loading and hyperextension

Explanation

A Hangman's fracture (traumatic spondylolisthesis of C2) is classically caused by a combination of hyperextension and axial loading forces, leading to fractures through the bilateral pars interarticularis.

Question 3525

Topic: 6. Spine

A 56-year-old mechanic has had pain in the hypothenar region of his dominant right hand for the past 6 months. He reports weakness in his grip and pain is worse with activity. Which of the following examination findings is most suggestive of a cervical etiology?

. Relief of symptoms with shoulder abduction (placing hand over the head)
. Hypothenar atrophy
. Reproduction of pain with hyperflexion and contralateral rotation of the head
. Positive Tinel's sign at the levator scapulae
. Subluxable ulnar nerve at the cubital tunnel

Correct Answer & Explanation

. Relief of symptoms with shoulder abduction (placing hand over the head)

Explanation

Hypothenar atrophy is a nonspecific sign that can be seen in ulnar neuropathy, C8 radiculopathy, or even cervical myelopathy; however, the atrophy usually is not unilateral and includes other muscle groups. The Spurling test is an excellent method of eliciting cervical radicular pain but involves hyperextension and ipsilateral rotation of the cervical spine, resulting in nerve root compression by reducing the cross-sectional area of the ipsilateral neuroforamen. Tinel's sign at the levator scapulae, if present, is indicative of an upper cervical (C3 or C4) radiculopathy. A subluxable ulnar nerve at the cubital tunnel, while often asymptomatic, points toward cubital tunnel syndrome as an etiology for this patient's pain. The shoulder abduction relief (SAR) sign (relief of upper extremity pain with shoulder abduction) is virtually pathognomic of cervical radiculopathy because this maneuver results in relaxation of a compressed and/or inflamed cervical nerve root. The SAR sign is the converse analog of the straight leg raising sign in the lumbar examination for lumbar radiculopathy, as it relieves tension in the nerve root, thereby relieving symptoms. Ducker TB, Zeidman SM: Neurologic and functional evaluation, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 143-161. An HS: Clinical presentation of discogenic neck pain, radiculopathy, and myelopathy, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 755-764.

Question 3526

Topic: 6. Spine

A 25-year-old obtunded male is brought to the trauma bay after a motor vehicle collision. CT shows a right-sided unilateral facet dislocation at C5-C6. What is the most appropriate next step in management?

. Awake closed reduction using Gardner-Wells tongs
. Immediate anterior cervical discectomy and fusion (ACDF) without further imaging
. Obtain a cervical MRI prior to surgical intervention
. Application of a halo vest and discharge
. Posterior open reduction without a pre-reduction MRI

Correct Answer & Explanation

. Obtain a cervical MRI prior to surgical intervention

Explanation

In an obtunded or unexaminable patient with a cervical facet dislocation, an MRI must be obtained prior to closed or open reduction to rule out a compressive disc herniation. This prevents potentially catastrophic iatrogenic spinal cord injury during reduction.

Question 3527

Topic: 6. Spine

In the evaluation of adult spinal deformity, achieving appropriate sagittal balance is critical. Which of the following formulas best describes the ideal relationship between pelvic incidence (PI) and lumbar lordosis (LL) to optimize outcomes?

. PI - LL < 10 degrees
. PI + LL = 10 degrees
. PI - LL > 20 degrees
. LL - PI < 20 degrees
. PI / LL = 1.5

Correct Answer & Explanation

. PI - LL < 10 degrees

Explanation

To achieve optimal sagittal balance in adult spinal deformity, the lumbar lordosis (LL) should match the pelvic incidence (PI) within 10 degrees. A mismatch of greater than 10 degrees strongly correlates with increased disability and adjacent segment disease.

Question 3528

Topic: 6. Spine

A 45-year-old man presents with acute right anterior thigh pain and weakness in knee extension. A representative MRI reveals a far lateral disc herniation at the L4-L5 level on the right.

Which nerve root is most likely compressed in this scenario?

. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L3

Explanation

Far lateral (extraforaminal) disc herniations compress the exiting nerve root at the same level, unlike central or paracentral herniations which affect the traversing root. Therefore, a far lateral disc at L4-L5 compresses the exiting L4 nerve root.

Question 3529

Topic: Thoracolumbar Spine & Deformity

Which of the following morphological fracture patterns is assigned the highest point value in the Thoracolumbar Injury Classification and Severity (TLICS) system?

. Compression fracture
. Burst fracture
. Translational/rotational injury
. Distraction injury
. Flexion-teardrop fracture

Correct Answer & Explanation

. Distraction injury

Explanation

In the TLICS system, morphology is scored as follows: compression (1), burst (2), translation/rotation (3), and distraction (4). Distraction morphology carries the highest point value as it implies severe instability.

Question 3530

Topic: Cervical Spine

A 65-year-old female with a 20-year history of rheumatoid arthritis presents with progressive hand clumsiness. Flexion-extension cervical radiographs show an anterior atlantodens interval (ADI) of 11 mm. What is the most reliable radiographic predictor of impending neurologic deficit in this patient?

. Anterior atlantodens interval (ADI) > 10 mm
. Posterior atlantodens interval (PADI) < 14 mm
. Cervical lordosis angle < 10 degrees
. Presence of subaxial subluxation
. Basilar invagination > 5 mm

Correct Answer & Explanation

. Posterior atlantodens interval (PADI) < 14 mm

Explanation

In rheumatoid arthritis, the posterior atlantodens interval (PADI), also known as the space available for the cord (SAC), is the most reliable predictor of neurologic deficit. A PADI of less than 14 mm is associated with a high risk of neurologic compromise.

Question 3531

Topic: 6. Spine

A 58-year-old man with advanced ankylosing spondylitis presents with severe neck pain following a ground-level fall. Neurological examination is intact. Plain radiographs of the cervical spine appear normal. What is the next most appropriate step in management?

. Discharge with NSAIDs and a soft cervical collar
. Perform a dynamic flexion-extension radiograph
. Obtain a CT scan of the entire cervical spine
. Administer high-dose intravenous methylprednisolone
. Schedule outpatient physical therapy

Correct Answer & Explanation

. Obtain a CT scan of the entire cervical spine

Explanation

Patients with ankylosing spondylitis have highly rigid spines susceptible to highly unstable fractures even from low-energy trauma. If plain radiographs are normal or inconclusive, a CT scan is mandatory to rule out occult fractures, particularly at the cervicothoracic junction.

Question 3532

Topic: Cervical Spine

A 30-year-old male dives into a shallow pool and sustains a C1 Jefferson fracture. Open-mouth odontoid radiographs reveal lateral displacement of the lateral masses. According to the Rule of Spence, rupture of the transverse ligament is highly suspected if the combined lateral mass overhang exceeds:

. 3.1 mm
. 5.1 mm
. 6.9 mm
. 8.1 mm
. 10.0 mm

Correct Answer & Explanation

. 6.9 mm

Explanation

The Rule of Spence dictates that a combined lateral mass overhang of C1 on C2 greater than 6.9 mm on an open-mouth AP radiograph suggests a ruptured transverse ligament. MRI is typically used in modern practice to confirm this ligamentous disruption.

Question 3533

Topic: Thoracolumbar Spine & Deformity

In adult spinal deformity surgery, achieving proper sagittal balance is highly correlated with improved Health-Related Quality of Life (HRQOL) outcomes. Which of the following radiographic targets is generally recommended?

. Sagittal Vertical Axis (SVA) < 10 cm
. Pelvic Incidence minus Lumbar Lordosis (PI-LL) < 10 degrees
. Pelvic Tilt (PT) > 25 degrees
. Thoracic Kyphosis > 60 degrees
. Sacral Slope < 20 degrees

Correct Answer & Explanation

. Pelvic Incidence minus Lumbar Lordosis (PI-LL) < 10 degrees

Explanation

Favorable outcomes in adult spinal deformity are associated with an SVA < 5 cm, PT < 20 degrees, and a PI-LL mismatch of less than 10 degrees. These parameters optimize standing posture and minimize energy expenditure.

Question 3534

Topic: 6. Spine

A 24-year-old male is intubated and obtunded following a severe motor vehicle collision. Radiographs demonstrate a unilateral facet dislocation at C5-C6. What is the most appropriate next step prior to attempted surgical reduction?

. Awake closed cranial traction reduction
. Urgent MRI of the cervical spine
. Immediate posterior cervical fusion in situ
. Somatosensory evoked potential (SSEP) monitoring setup
. Administration of high-dose methylprednisolone

Correct Answer & Explanation

. Urgent MRI of the cervical spine

Explanation

In an un-evaluable or obtunded patient with a cervical facet dislocation, an MRI must be obtained prior to reduction to rule out a concomitant disc herniation that could cause neurologic injury during reduction.

Question 3535

Topic: 6. Spine

A 65-year-old man presents with progressive clumsiness in his hands and difficulty walking. Examination reveals a positive Hoffman's sign and generalized hyperreflexia.

What is the most common gait abnormality seen in patients with this condition?

. Shuffling gait
. Steppage gait
. Broad-based, unsteady, spastic gait
. Trendelenburg gait
. Antalgic gait

Correct Answer & Explanation

. Broad-based, unsteady, spastic gait

Explanation

The most common and often earliest gait abnormality in cervical spondylotic myelopathy is a broad-based, unsteady, and stiff (spastic) gait due to upper motor neuron dysfunction.

Question 3536

Topic: Thoracolumbar Spine & Deformity

A 40-year-old male falls from a height and sustains an L1 burst fracture. He is neurologically intact.

Which of the following parameters is the strongest indication for operative stabilization over nonoperative management?

. 15 degrees of focal kyphosis
. 20% anterior vertebral body height loss
. 30% spinal canal compromise
. Posterior ligamentous complex (PLC) injury
. Pedicle widening of 2 mm

Correct Answer & Explanation

. Posterior ligamentous complex (PLC) injury

Explanation

Injury to the posterior ligamentous complex (PLC) indicates a highly unstable injury pattern (earning 3 points on the TLICS scale) and is a strong indication for surgical stabilization in thoracolumbar burst fractures.

Question 3537

Topic: Thoracolumbar Spine & Deformity

In surgical planning for adult spinal deformity, achieving optimal spinopelvic harmony is critical. Which formula represents the ideal relationship between pelvic incidence (PI) and lumbar lordosis (LL)?

. PI = LL ± 10 degrees
. LL = PI ± 10 degrees
. PI = Pelvic Tilt + Sacral Slope
. LL = Pelvic Tilt - Sacral Slope
. PI = LL + 20 degrees

Correct Answer & Explanation

. PI = LL ± 10 degrees

Explanation

For optimal spinopelvic harmony and improved functional outcomes, the lumbar lordosis (LL) should match the pelvic incidence (PI) within 10 degrees (PI = LL ± 10 degrees).

Question 3538

Topic: 6. Spine

Three years following an L4-L5 posterior lumbar interbody fusion (PLIF), a patient develops adjacent segment degeneration at L3-L4. Which biomechanical change at the adjacent segment is most directly responsible?

. Decreased facet joint loading
. Increased intradiscal pressure and hypermobility
. Decreased sagittal translation
. Shift of the instantaneous axis of rotation posteriorly
. Ossification of the posterior longitudinal ligament

Correct Answer & Explanation

. Increased intradiscal pressure and hypermobility

Explanation

Spinal fusion creates a rigid segment that significantly increases biomechanical stress, intradiscal pressure, and segmental mobility at the adjacent un-fused levels, accelerating degeneration.

Question 3539

Topic: Thoracolumbar Spine & Deformity

A 16-year-old female wearing a lap belt in an MVA sustains a flexion-distraction injury (Chance fracture) of L2.

Which of the following associated injuries must be aggressively ruled out?

. Aortic transection
. Renal artery thrombosis
. Intra-abdominal hollow viscus injury
. Pulmonary contusion
. Pelvic ring disruption

Correct Answer & Explanation

. Intra-abdominal hollow viscus injury

Explanation

Chance fractures are highly associated with intra-abdominal injuries, particularly hollow viscus injuries (e.g., bowel perforations), which occur in up to 50% of cases due to extreme lap-belt compression.

Question 3540

Topic: 6. Spine

A 15-year-old boy presents with progressive mid-back pain. Radiographs show a thoracic kyphosis of 55 degrees. Which radiographic criteria is strictly required to diagnose Scheuermann's kyphosis?

. Anterior wedging of at least 5 degrees in 3 consecutive vertebrae
. Thoracic kyphosis greater than 40 degrees with Schmorl's nodes
. Anterior wedging of at least 10 degrees in 1 vertebra
. Thoracic kyphosis greater than 60 degrees
. Vertebral endplate irregularity in 2 non-consecutive vertebrae

Correct Answer & Explanation

. Anterior wedging of at least 5 degrees in 3 consecutive vertebrae

Explanation

Sorensen's classic criteria for diagnosing Scheuermann's kyphosis require anterior wedging of at least 5 degrees in three or more consecutive vertebral bodies.

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