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6. Spine MCQs

Practice Set 18 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 341

Topic: Cervical Spine

When evaluating a Jefferson burst fracture of the C1 atlas, which finding on the open-mouth odontoid radiograph best indicates rupture of the transverse atlantal ligament (TAL)?

. Total combined lateral overhang of the C1 lateral masses on C2 > 6.9 mm
. Fracture visible through the anterior arch only
. Asymmetry of the atlantodental interval
. Overhang of the lateral masses > 2.0 mm
. Retropharyngeal swelling > 10 mm

Correct Answer & Explanation

. Total combined lateral overhang of the C1 lateral masses on C2 > 6.9 mm

Explanation

According to Spence's rule, a combined lateral mass overhang of C1 on C2 greater than 6.9 mm on an open-mouth odontoid view implies incompetence or rupture of the transverse atlantal ligament, indicating high instability.

Question 342

Topic: Thoracolumbar Spine & Deformity

In an adult patient with degenerative lumbar scoliosis, which of the following radiographic parameters is the strongest predictor of future curve progression?

. Cobb angle > 30 degrees with apical rotation > Grade II
. Thoracic hyperkyphosis > 40 degrees
. Intervertebral disc height loss > 50%
. Pelvic tilt < 10 degrees
. L5-S1 facet arthropathy

Correct Answer & Explanation

. Cobb angle > 30 degrees with apical rotation > Grade II

Explanation

Risk factors for progression in adult degenerative scoliosis include a Cobb angle > 30 degrees, apical vertebral rotation greater than Grade II, lateral listhesis > 6 mm, and the L5 vertebral body seated above the intercrestal line.

Question 343

Topic: 6. Spine

Which of the following is a classic radiographic diagnostic criterion for Diffuse Idiopathic Skeletal Hyperostosis (DISH)?

. Sacroiliac joint erosion and fusion
. Flowing ossification along the anterolateral aspect of at least four contiguous vertebrae
. Marginal syndesmophytes bridging the intervertebral discs symmetrically
. Bamboo spine appearance with severe facet joint ankylosis
. Subchondral sclerosis of the facet joints only

Correct Answer & Explanation

. Flowing ossification along the anterolateral aspect of at least four contiguous vertebrae

Explanation

Resnick criteria for DISH include flowing continuous ossification of the anterolateral aspect of at least four contiguous vertebral bodies, preservation of disc height, and absence of sacroiliac joint erosions or facet ankylosis (which distinguishes it from ankylosing spondylitis).

Question 344

Topic: 6. Spine

A 40-year-old female presents with progressive myelopathy. MRI reveals a large, calcified, central disc herniation at T8-T9 causing severe cord compression. What is the safest surgical approach for decompression?

. Standard posterior laminectomy
. Minimally invasive posterior microdiscectomy
. Anterior transthoracic or lateral extracavitary approach
. Transforaminal lumbar interbody fusion (TLIF) approach
. Posterior cervical-thoracic fusion

Correct Answer & Explanation

. Anterior transthoracic or lateral extracavitary approach

Explanation

Approaching a calcified, central thoracic disc via a standard posterior laminectomy carries a very high risk of catastrophic spinal cord injury (paraplegia) due to the need to retract the fragile thoracic cord. An anterior, transthoracic, or lateral extracavitary approach safely allows direct ventral decompression without cord manipulation.

Question 345

Topic: 6. Spine

A 45-year-old man presents with acute leg pain. MRI reveals a far lateral disc herniation at the L4-L5 level. Which nerve root is most likely compressed, and what is the expected clinical motor deficit?

. L4 root, weakness in knee extension
. L5 root, weakness in great toe extension
. L4 root, weakness in ankle plantar flexion
. L5 root, weakness in knee extension
. L3 root, weakness in hip flexion

Correct Answer & Explanation

. L4 root, weakness in knee extension

Explanation

A far lateral disc herniation compresses the exiting nerve root at the same level. At L4-L5, the L4 root is compressed, presenting with quadriceps weakness and a diminished patellar reflex.

Question 346

Topic: Thoracolumbar Spine & Deformity

In sagittal balance evaluation of the spine, the pelvic incidence (PI) is a constant morphological parameter. Which of the following accurately describes the relationship between pelvic incidence, pelvic tilt (PT), and sacral slope (SS)?

. PI = PT - SS
. PI = SS - PT
. PI = PT + SS
. PI = (PT + SS) / 2
. PI = PT x SS

Correct Answer & Explanation

. PI = PT + SS

Explanation

Pelvic incidence is an anatomical constant for each individual and is defined as the sum of the pelvic tilt and the sacral slope (PI = PT + SS). It dictates the amount of lumbar lordosis required to maintain sagittal balance.

Question 347

Topic: 6. Spine

According to the Denis three-column classification of the spine, which of the following anatomical structures is considered part of the middle column?

. Anterior half of the intervertebral disc
. Anterior longitudinal ligament
. Ligamentum flavum
. Posterior longitudinal ligament
. Facet joints

Correct Answer & Explanation

. Posterior longitudinal ligament

Explanation

The Denis middle column consists of the posterior half of the vertebral body, the posterior annulus fibrosus, and the posterior longitudinal ligament (PLL). The ligamentum flavum and facet joints belong to the posterior column.

Question 348

Topic: Thoracolumbar Spine & Deformity

A 12-year-old boy restrained by a lap belt sustains a flexion-distraction injury (Chance fracture) of L2 during a motor vehicle collision. Which of the following associated injuries has the highest incidence in this scenario?

. Aortic transection
. Renal artery thrombosis
. Hollow viscus organ injury
. Pulmonary contusion
. Splenic rupture

Correct Answer & Explanation

. Hollow viscus organ injury

Explanation

Lap-belt flexion-distraction injuries (Chance fractures) are highly associated with concurrent intra-abdominal injuries, most commonly hollow viscus gastrointestinal tears. Up to 40% of patients with this fracture pattern will have an associated abdominal injury.

Question 349

Topic: Thoracolumbar Spine & Deformity

A 35-year-old female presents with an L1 burst fracture following a fall. She is neurologically intact. MRI demonstrates an intact posterior ligamentous complex (PLC). Based on the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the total score and recommended treatment?

. Score 2, non-operative management
. Score 3, non-operative management
. Score 4, surgeon's preference
. Score 5, operative management
. Score 7, operative management

Correct Answer & Explanation

. Score 2, non-operative management

Explanation

In the TLICS system, a burst fracture is scored 2 points for morphology. An intact neurologic status is 0 points, and an intact PLC is 0 points, yielding a total score of 2 which indicates non-operative management.

Question 350

Topic: 6. Spine

A 55-year-old male presents to the emergency department with acute lower back pain, bilateral sciatica, and saddle anesthesia. Which of the following is the most sensitive early clinical indicator of cauda equina syndrome?

. Absent bilateral Achilles reflexes
. Loss of anal sphincter tone
. Urinary retention
. Fecal incontinence
. Bilateral foot drop

Correct Answer & Explanation

. Urinary retention

Explanation

Urinary retention is the most sensitive early clinical symptom of cauda equina syndrome. A post-void residual volume greater than 100-200 mL is highly suggestive and should prompt immediate MRI evaluation.

Question 351

Topic: 6. Spine

A 40-year-old man presents with progressive myelopathy due to a large central T8-T9 disc herniation. What is the most appropriate surgical approach?

. Standard posterior laminectomy and discectomy
. Posterior laminoplasty
. Anterior thoracotomy and discectomy
. Microendoscopic posterior discectomy
. Lumbar puncture and epidural steroid injection

Correct Answer & Explanation

. Anterior thoracotomy and discectomy

Explanation

Central thoracic disc herniations causing myelopathy should be approached anteriorly (e.g., thoracotomy) or anterolaterally. A standard posterior laminectomy carries an unacceptably high risk of catastrophic spinal cord injury due to the need for cord retraction.

Question 352

Topic: 6. Spine

A 68-year-old man complains of bilateral leg cramping that worsens with walking. Which of the following history findings is most indicative of neurogenic claudication secondary to lumbar spinal stenosis rather than vascular claudication?

. Leg pain that is worse when walking uphill
. Leg pain that resolves immediately upon standing still
. Leg pain that is relieved when pushing a shopping cart
. Decreased posterior tibial pulses
. Trophic skin changes of the lower extremities

Correct Answer & Explanation

. Leg pain that is relieved when pushing a shopping cart

Explanation

Neurogenic claudication is typically relieved by lumbar flexion, such as pushing a shopping cart or leaning forward, which increases the spinal canal volume. Walking uphill is also better tolerated than downhill for the same reason.

Question 353

Topic: 6. Spine

A 72-year-old man with acute onset low back pain with increased severity during the night should be evaluated by:

. History and physical examination only
. Magnetic resonance imaging of the lumbar spine
. History, examination, and urine protein electrophoresis
. C omputed tomography of the lumbar spine
. Plain radiographs of the lumbar spine

Correct Answer & Explanation

. Plain radiographs of the lumbar spine

Explanation

An elderly patient with unsolicited low back pain is suggestive of a primary malignancy or metastatic disease of the lumbar spine. A thorough history and physical examination are indicated, as well as imaging to evaluate the lumbar spinal axis and the neural elements.

Question 354

Topic: 6. Spine

An otherwise healthy 56-year-old patient with suspected spinal stenosis after history and physical examination undergoes plain radiography that is unremarkable for spondylolisthesis. The next feasible imaging modality that is indicated in aiding the diagnosis is:

. No more imaging studies are needed
. A computed tomography myelogram
. Magnetic resonance imaging
. Ultrasound
. Spinal angiogram

Correct Answer & Explanation

. Magnetic resonance imaging

Explanation

Although a computed tomography myelogram is slightly more specific and sensitive than magnetic resonance imaging (MRI) in evaluating lumbar stenosis, MRI is almost as sensitive and it is noninvasive. Therefore, in an otherwise healthy patient without contraindications, an MRI should be considered as the next imaging modality.

Question 355

Topic: 6. Spine
Which of the following is NOT a routinely used imaging modality for evaluation of spinal pathology?
. Plain radiography
. Computed tomography
. Magnetic resonance imaging
. Diskography
. Myelogram

Correct Answer & Explanation

. Diskography

Explanation

Diskography is a diagnostic technique that has been used since the 1950s. The study involves injection of dye into an intervertebral disk space. A positive study is one in which the injected dye is not contained within the disk space or in which the injection reproduces the characteristic distribution of the patient's pain. The current role of diskography remains undefined and, at this time, diskography is not a first-line diagnostic study in the evaluation of patients with low back pain.

Question 356

Topic: Thoracolumbar Spine & Deformity

Which of the following is the most common type of spondylolisthesis seen in the adult population:

. Degenerative
. Isthmic
. C ongenital
. Traumatic
. Pathologic

Correct Answer & Explanation

. Degenerative

Explanation

The prevalence of degenerative spondylolisthesis is 2% to 5%; the prevalence increases with age. Symptomatic patients usually present in the fourth decade of life or later. The disease is five times more common in the female sex. The African American population, diabetics, and patients with sacralization of the L5 vertebrae are also at increased risk for developing symptomatic spondylolisthesis.

Question 357

Topic: Thoracolumbar Spine & Deformity

Which of the following is the most common location of adult degenerative spondylolisthesis:

. L1-L2 interspace
. L2-L3 interspace
. L3-L4 interspace
. L4-L5 interspace
. L5-S1 interspace

Correct Answer & Explanation

. L4-L5 interspace

Explanation

The L4-L5 interspace is the most common location of adult degenerative spondylolisthesis.

Question 358

Topic: 6. Spine

Which of the following statements is true regarding the initial diagnostic radiographic evaluation of patients with spondylolisthesis:

. Initial diagnostic radiographic evaluation includes plain radiographic imaging of lumbar spine with flexion and extension.
. C omputed tomography of the lumbar spine region is the first order diagnostic imaging study.
. Spondylolisthesis is a clinical diagnosis; no imaging studies are indicated.
. Initial diagnostic radiographic evaluation includes magnetic resonance imaging of the lumbar spine to evaluate spinal stenosis and nerve root compression.
. If spondylolisthesis is suspected, myelogram is necessary for diagnosis.

Correct Answer & Explanation

. Initial diagnostic radiographic evaluation includes plain radiographic imaging of lumbar spine with flexion and extension.

Explanation

Plain radiographs should be performed in a standing position as some cases of spondylolisthesis can be missed if x-rays are taken in a supine position. Forward displacement of L4 on L5 and more rarely L5 on S1 or L3 on L4, without a pars interarticularis defect is often demonstrated. Other radiologic findings of osteophyte formation, such as disk-space narrowing, endplate sclerosis, vacuum disk sign, facet sclerosis and hypertrophy, are consistent with long-standing degenerative disease. Hemisacralization of L5 may be revealed. Flexion, extension, and lateral bending films often reveal hypermobility.

Question 359

Topic: 6. Spine

Initial nonoperative management of adult degenerative spondylolisthesis includes all of the following except:

. Physical therapy
. Anti-inflammatory medication
. Modified activity
. Strict bed rest
. Support brace

Correct Answer & Explanation

. Strict bed rest

Explanation

Conservative treatment for degenerative spondylolisthesis is consistent with the conservative care of most degenerative spinal disorders. It includes modified activity, physical therapy (conditioning exercises emphasizing lumbar flexion and progression to aerobic conditioning), anti-inflammatory medication, and sometimes spinal support with a corset or light-weight brace.

Question 360

Topic: Thoracolumbar Spine & Deformity

Which of the following statements is true regarding lumbar degenerative scoliosis:

. Lumbar degenerative scoliosis is most commonly distributed to the left.
. Lumbar degenerative scoliosis is most commonly distributed to the right.
. Lumbar degenerative scoliosis is most commonly evenly distributed between left and right.
. The distribution of lumbar degenerative scoliosis depends on age of patient at the time of onset.
. No data are available.

Correct Answer & Explanation

. Lumbar degenerative scoliosis is most commonly evenly distributed between left and right.

Explanation

Degenerative lumbar scoliosis occurs in approximately the same number of women as men. Lumbar curves are generally smaller than those in idiopathic scoliosis and are more evenly distributed between left and right, also in contrast to idiopathic curves that occur predominantly to the left.

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