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6. Spine MCQs

Practice Set 179 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 3561

Topic: 6. Spine

A 65-year-old female presents with progressive difficulty manipulating buttons, frequent dropping of objects, and a broad-based gait. Physical examination reveals a positive Hoffmann sign and hyperreflexia in the lower extremities. MRI confirms severe spinal cord compression at C4-C5. What is the most appropriate next step in management?

. Physical therapy focusing on gait training
. Epidural steroid injection
. NSAIDs and observation
. Carpal tunnel release
. Anterior cervical discectomy and fusion

Correct Answer & Explanation

. Anterior cervical discectomy and fusion

Explanation

The patient is presenting with classic signs of cervical spondylotic myelopathy (CSM). Surgical decompression (such as ACDF) is indicated to halt the progression of neurologic decline, as conservative measures are ineffective for progressive myelopathy.

Question 3562

Topic: Thoracolumbar Spine & Deformity

During the surgical planning for an adult patient with severe sagittal imbalance, the surgeon evaluates the spinopelvic parameters. Which of the following formulas correctly describes the fixed anatomic relationship of the pelvis?

. Pelvic Incidence = Pelvic Tilt + Sacral Slope
. Pelvic Tilt = Pelvic Incidence + Sacral Slope
. Sacral Slope = Pelvic Incidence + Pelvic Tilt
. Pelvic Incidence = Pelvic Tilt / Sacral Slope
. Pelvic Incidence = Sacral Slope - Pelvic Tilt

Correct Answer & Explanation

. Pelvic Incidence = Pelvic Tilt + Sacral Slope

Explanation

Pelvic Incidence (PI) is a fixed morphologic parameter that does not change with positioning. It is the algebraic sum of the position-dependent parameters: Pelvic Tilt (PT) and Sacral Slope (SS).

Question 3563

Topic: 6. Spine

A 70-year-old male reports bilateral leg heaviness, pain, and paresthesias that worsen after walking 50 yards. He notes that the symptoms are significantly relieved when he leans forward on a shopping cart or walks uphill, but worsen when walking downhill. What is the most likely diagnosis?

. Peripheral arterial disease
. Lumbar disc herniation
. Lumbar spinal stenosis
. Diabetic neuropathy
. Hip osteoarthritis

Correct Answer & Explanation

. Lumbar spinal stenosis

Explanation

The symptoms describe classic neurogenic claudication caused by lumbar spinal stenosis. Flexion of the spine (leaning on a shopping cart, walking uphill) increases the cross-sectional area of the spinal canal, relieving symptoms, whereas extension (walking downhill) exacerbates them.

Question 3564

Topic: 6. Spine

A 55-year-old male with long-standing ankylosing spondylitis presents to the emergency department complaining of neck pain following a minor ground-level fall. He is neurologically intact. Plain radiographs of the cervical spine are interpreted as negative for acute fracture. What is the most appropriate next step?

. Discharge with NSAIDs and muscle relaxants
. Flexion-extension radiographs of the cervical spine
. Reassurance and application of a soft collar
. CT or MRI of the entire cervical spine
. Provocative discography

Correct Answer & Explanation

. CT or MRI of the entire cervical spine

Explanation

Patients with ankylosing spondylitis have a highly rigid, brittle spine and are at significant risk for unstable fractures and epidural hematomas even after minor trauma. Advanced imaging (CT or MRI) is mandatory because these fractures are frequently missed on plain radiographs.

Question 3565

Topic: Thoracolumbar Spine & Deformity

A 14-year-old female gymnast complains of insidious onset, activity-related low back pain. Radiographs demonstrate a Grade 1 isthmic spondylolisthesis at L5-S1 with an identifiable pars interarticularis defect. She has no neurologic deficits. What is the most appropriate initial management?

. L5-S1 in situ fusion
. Activity modification and bracing
. L5 pars repair
. L5-S1 reduction and fusion
. Epidural steroid injection

Correct Answer & Explanation

. Activity modification and bracing

Explanation

Initial management for symptomatic, low-grade (Grade 1 or 2) isthmic spondylolisthesis in an adolescent is nonoperative. This includes a period of activity modification, physical therapy, and potentially bracing (TLSO) to allow symptoms to resolve.

Question 3566

Topic: Thoracolumbar Spine & Deformity

When utilizing the Thoracolumbar Injury Classification and Severity (TLICS) score to determine the indication for surgery in a thoracolumbar burst fracture, which of the following radiographic parameters is heavily weighted and strongly drives the recommendation toward surgical stabilization?

. Posterior ligamentous complex integrity
. Loss of anterior vertebral height greater than 50%
. Spinal canal compromise greater than 50%
. Interpedicular widening
. Fracture of the transverse process

Correct Answer & Explanation

. Posterior ligamentous complex integrity

Explanation

In the TLICS system, disruption of the posterior ligamentous complex (PLC) assigns 3 points (if indeterminate, 2 points) and strongly pushes the score toward operative management. Degree of height loss and canal compromise are not directly scored in TLICS, distinguishing it from older classification systems.

Question 3567

Topic: 6. Spine

A 45-year-old male presents with severe radicular leg pain. MRI reveals a far lateral (extraforaminal) disc herniation at the L4-L5 level. Which nerve root is most likely compressed by this specific herniation?

. Traversing L5
. Exiting L5
. Traversing S1
. Exiting L3
. Exiting L4

Correct Answer & Explanation

. Exiting L4

Explanation

In the lumbar spine, a far lateral (extraforaminal) disc herniation impinges the exiting nerve root at that level. Therefore, a far lateral L4-L5 disc herniation will compress the exiting L4 nerve root.

Question 3568

Topic: 6. Spine

A 72-year-old male with known cervical spondylosis falls forward and strikes his chin, forcefully hyperextending his neck. He arrives at the ER with significant weakness in his upper extremities and relatively preserved motor function in his lower extremities. Which incomplete spinal cord syndrome has he developed?

. Anterior cord syndrome
. Brown-Sequard syndrome
. Central cord syndrome
. Posterior cord syndrome
. Conus medullaris syndrome

Correct Answer & Explanation

. Central cord syndrome

Explanation

Central cord syndrome is typically caused by a hyperextension injury in an older patient with pre-existing cervical spondylosis. The pathognomonic presentation is motor weakness that is more severe in the upper extremities than in the lower extremities.

Question 3569

Topic: 6. Spine

Which of the following describes the accepted radiographic criteria established by Sorensen for the diagnosis of typical Scheuermann's kyphosis?

. Anterior wedging of at least 5 degrees in 3 consecutive vertebrae
. Anterior wedging of at least 10 degrees in 2 consecutive vertebrae
. Anterior wedging of at least 15 degrees in 1 vertebra
. Anterior wedging of at least 5 degrees in 5 consecutive vertebrae
. Anterior wedging of at least 10 degrees in 3 consecutive vertebrae

Correct Answer & Explanation

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

Explanation

Sorensen criteria for classic Scheuermann's kyphosis requires thoracic kyphosis greater than 40 degrees along with anterior wedging of at least 5 degrees in 3 or more consecutive vertebrae.

Question 3570

Topic: 6. Spine

A 60-year-old male of Japanese descent undergoes an anterior cervical corpectomy for progressive myelopathy caused by severe Ossification of the Posterior Longitudinal Ligament (OPLL). Which of the following is the most frequent intraoperative complication specifically associated with anterior resection of this pathology?

. Vertebral artery injury
. Recurrent laryngeal nerve palsy
. Esophageal perforation
. Dural tear with cerebrospinal fluid leak
. Horner's syndrome

Correct Answer & Explanation

. Dural tear with cerebrospinal fluid leak

Explanation

OPLL frequently merges with and ossifies the underlying dura mater. Consequently, attempted anterior resection of the ossified mass has a notoriously high risk of dural tears and subsequent CSF leaks.

Question 3571

Topic: 6. Spine

A 28-year-old male presents with severe neck pain and C6 radiculopathy after a high-speed rollover collision. Lateral radiographs reveal approximately 25% anterior translation of the C5 vertebral body over C6. What is the most likely mechanism of this injury?

. Axial load
. Flexion-distraction with rotation
. Hyperextension
. Extension-compression
. Lateral bending

Correct Answer & Explanation

. Flexion-distraction with rotation

Explanation

Anterior translation of approximately 25% of the vertebral body width is characteristic of a unilateral facet dislocation. The mechanism of injury for a unilateral facet dislocation is typically flexion-distraction combined with a rotational force.

Question 3572

Topic: 6. Spine

A 55-year-old man with long-standing ankylosing spondylitis sustains a low-energy mechanical fall. He complains of severe back pain but has a normal neurologic exam. Initial AP and lateral radiographs of the thoracic and lumbar spine show no obvious fracture. What is the most appropriate next step in management?

. Discharge with NSAIDs and muscle relaxants
. Rigid bracing and outpatient physical therapy
. Flexion-extension radiographs of the lumbar spine
. CT scan or MRI of the entire spine
. Technetium-99m bone scan

Correct Answer & Explanation

. CT scan or MRI of the entire spine

Explanation

Patients with ankylosing spondylitis are at high risk for highly unstable, occult chalk-stick fractures even from low-energy trauma. A CT scan or MRI of the entire neuroaxis is required when they present with new-onset axial pain after a fall, as these fractures can easily be missed on plain radiographs.

Question 3573

Topic: 6. Spine

A 72-year-old woman with pre-existing cervical spondylosis falls forward, striking her chin. She presents with upper extremity weakness (motor grade 2/5) and lower extremity weakness (motor grade 4/5), along with preserved sacral sensation. Which spinal cord tracts are primarily involved in this classic neurologic pattern?

. Dorsal columns
. Lateral spinothalamic tracts
. Medial portions of the lateral corticospinal tracts
. Ventral spinothalamic tracts
. Anterior horn cells alone

Correct Answer & Explanation

. Medial portions of the lateral corticospinal tracts

Explanation

This patient has central cord syndrome, characterized by upper extremity weakness that is more severe than lower extremity weakness. It predominantly affects the central gray matter and the medial portions of the lateral corticospinal tracts, which are somatotopically organized with the cervical tracts located more medially.

Question 3574

Topic: 6. Spine

A 45-year-old man presents with 4 weeks of radiating right arm pain. Examination reveals weakness in wrist extension, a diminished brachioradialis reflex, and altered sensation over the dorsal web space of the hand. Which cervical disc level is most likely herniated?

. C4-C5
. C5-C6
. C6-C7
. C7-T1
. T1-T2

Correct Answer & Explanation

. C5-C6

Explanation

The clinical presentation describes a C6 radiculopathy, which includes weak wrist extension, diminished brachioradialis reflex, and numbness in the thumb, index finger, or dorsal web space. In the cervical spine, the exiting nerve root corresponds to the lower vertebral level, meaning a C5-C6 disc herniation affects the C6 root.

Question 3575

Topic: Thoracolumbar Spine & Deformity

A 45-year-old man falls from a roof and sustains an L1 burst fracture. Neurologic examination is normal. Radiographs and CT show 40% loss of anterior vertebral body height and 25% canal compromise. The posterior ligamentous complex is intact on MRI. According to the Thoracolumbar Injury Classification and Severity (TLICS) scale, what is his total score and recommended treatment?

. Score 2, Nonoperative management with an orthosis
. Score 4, Operative management
. Score 5, Operative management
. Score 3, Nonoperative management
. Score 2, Operative management

Correct Answer & Explanation

. Score 2, Nonoperative management with an orthosis

Explanation

The TLICS score assigns 2 points for a burst fracture, 0 points for intact neurologic status, and 0 points for an intact posterior ligamentous complex, totaling 2. A score of 3 or less is an indication for nonoperative management.

Question 3576

Topic: 6. Spine

A 65-year-old woman complains of low back pain and neurogenic claudication. Standing radiographs demonstrate a grade I degenerative spondylolisthesis at L4-L5. Dynamic views show 4 mm of translation. She has failed 6 months of conservative treatment. Based on the SPORT trial, what is the most appropriate surgical intervention?

. Decompression alone
. Decompression with posterolateral spinal fusion
. Anterior lumbar interbody fusion (ALIF) alone
. Total disc arthroplasty
. Stand-alone interspinous spacer

Correct Answer & Explanation

. Decompression with posterolateral spinal fusion

Explanation

The SPORT trial demonstrated that for degenerative spondylolisthesis with spinal stenosis, decompression and arthrodesis yield superior long-term outcomes compared to nonoperative care or decompression alone.

Question 3577

Topic: 6. Spine

A 72-year-old man with cervical spondylotic myelopathy is scheduled for surgery. MRI demonstrates T2 signal changes within the cord at C4-C5. Which MRI finding portends the worst prognosis for neurologic recovery after surgical decompression?

. T2 hyperintensity involving multiple levels
. Broad T2 hyperintensity with corresponding T1 hypointensity
. Focal T2 hyperintensity
. Loss of cervical lordosis on sagittal images
. T2 hypointensity with T1 hyperintensity

Correct Answer & Explanation

. Broad T2 hyperintensity with corresponding T1 hypointensity

Explanation

While T2 hyperintensity alone indicates edema or myelomalacia, the combination of broad T2 hyperintensity and T1 hypointensity indicates permanent cystic necrosis of the cord, portending a poor prognosis.

Question 3578

Topic: 6. Spine

A 55-year-old man with long-standing ankylosing spondylitis presents with severe neck pain after a minor fall. Neurologic examination is intact. Plain radiographs of the cervical spine appear unchanged from baseline due to marked osteopenia and deformity. What is the most appropriate next step in management?

. Discharge with a soft collar and follow-up in 2 weeks
. MRI of the cervical spine without contrast
. CT scan of the entire cervical spine
. Flexion-extension radiographs
. Halo vest application

Correct Answer & Explanation

. CT scan of the entire cervical spine

Explanation

Patients with ankylosing spondylitis are at high risk for highly unstable extension-distraction fractures even with minor trauma. A CT scan of the entire cervical spine is mandatory to rule out occult fractures not visible on plain radiographs.

Question 3579

Topic: 6. Spine

A 15-year-old gymnast presents with a 3-month history of mechanical low back pain. Radiographs are normal. MRI shows bilateral marrow edema in the pars interarticularis of L5 but no obvious fracture line on T1-weighted images. What is the recommended initial management?

. Diagnostic pars injection
. Posterolateral spinal fusion
. Bilateral pars repair
. Cessation of offending activity and rigid bracing until pain resolves
. Continued participation with physical therapy

Correct Answer & Explanation

. Cessation of offending activity and rigid bracing until pain resolves

Explanation

MRI showing marrow edema without a definitive fracture line indicates an early stress reaction. Management consists of rest, cessation of hyperextension activities, and often a TLSO brace until symptoms resolve to prevent progression to a complete fracture.

Question 3580

Topic: Thoracolumbar Spine & Deformity

In planning surgical correction for adult degenerative scoliosis, the surgeon measures the pelvic incidence (PI). If the patient's PI is 55 degrees, what should be the approximate target for lumbar lordosis (LL) to achieve optimal sagittal balance?

. 20 to 30 degrees
. 35 to 45 degrees
. 45 to 55 degrees
. 60 to 70 degrees
. 75 to 85 degrees

Correct Answer & Explanation

. 45 to 55 degrees

Explanation

To achieve harmonious sagittal balance, the lumbar lordosis (LL) should match the pelvic incidence (PI) within 9 degrees (PI - LL < 10 degrees). Therefore, a target LL of 45 to 55 degrees is appropriate.

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