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6. Spine MCQs

Practice Set 181 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 3601

Topic: 6. Spine

A 50-year-old man underwent an uncomplicated L4-L5 posterior instrumented fusion three years ago for degenerative spondylolisthesis. He now presents with new-onset severe left thigh pain and weakness in knee extension. Radiographs show solid fusion at L4-L5. What is the most likely diagnosis?

. Pseudarthrosis at L4-L5
. Hardware loosening
. Adjacent segment disease at L3-L4
. Adjacent segment disease at L5-S1
. Recurrent disc herniation at L4-L5

Correct Answer & Explanation

. Adjacent segment disease at L3-L4

Explanation

The patient is experiencing new L4 radicular symptoms (thigh pain, knee extension weakness) above a solid L4-L5 fusion. This is characteristic of adjacent segment disease at the L3-L4 level, which commonly develops due to increased biomechanical stress adjacent to a rigid construct.

Question 3602

Topic: 6. Spine

A 68-year-old man with a long-standing history of ankylosing spondylitis presents to the emergency department with severe lower neck and upper back pain after a low-speed motor vehicle collision. Neurologic examination is unremarkable. Initial anteroposterior and lateral radiographs of the cervical and thoracic spine show no obvious fracture. What is the most appropriate next step in management?

. Discharge with a soft cervical collar and NSAIDs
. Flexion and extension radiographs of the cervical spine
. Technetium-99m bone scan
. CT scan of the cervical and thoracic spine
. Discharge with physical therapy referral

Correct Answer & Explanation

. CT scan of the cervical and thoracic spine

Explanation

Patients with ankylosing spondylitis are at high risk for highly unstable, occult spinal fractures even after minor trauma. Due to altered bone density and overlapping anatomy, plain radiographs are inadequate; a CT scan is the preferred initial imaging modality to rule out fracture.

Question 3603

Topic: 6. Spine

A 65-year-old woman with a history of progressive neurogenic claudication over the past 2 years has failed extensive nonoperative management. Imaging shows an L4-L5 grade I degenerative spondylolisthesis with severe central canal and lateral recess stenosis. She undergoes an L4-L5 laminectomy and posterior spinal fusion. Compared to laminectomy alone, the addition of a fusion in this patient primarily decreases the risk of which of the following?

. Deep surgical site infection
. Postoperative epidural hematoma
. Progressive slip and recurrent stenosis
. Adjacent segment disease
. Postoperative deep vein thrombosis

Correct Answer & Explanation

. Progressive slip and recurrent stenosis

Explanation

Degenerative spondylolisthesis involves dynamic instability. Decompression (laminectomy) alone can destabilize the spine further, leading to progressive slippage and recurrent neurogenic claudication, which is significantly mitigated by adding a fusion.

Question 3604

Topic: 6. Spine

A 28-year-old man presents to the trauma bay after a diving accident. He is awake, alert, and cooperative. Examination reveals 0/5 strength in bilateral triceps, hand intrinsics, and finger flexors, but normal strength in deltoids, biceps, and wrist extensors. Sensation is absent below the C6 dermatome. Lateral cervical radiographs reveal a bilateral C6-C7 facet dislocation. What is the most appropriate next step in management?

. Urgent MRI of the cervical spine
. Awake closed reduction with cranial traction
. Anterior cervical discectomy and fusion
. Posterior cervical laminectomy and fusion
. Administration of high-dose methylprednisolone

Correct Answer & Explanation

. Awake closed reduction with cranial traction

Explanation

In an awake, alert, and cooperative patient with a cervical facet dislocation and a neurologic deficit, urgent awake closed reduction with cranial traction is indicated to decompress the spinal cord. MRI is recommended prior to reduction only if the patient is unexaminable (e.g., comatose) to rule out a compressive disc herniation.

Question 3605

Topic: 6. Spine

A 45-year-old man presents with severe right leg pain. Examination reveals a positive femoral nerve stretch test, 4/5 strength in right knee extension, and decreased sensation over the medial aspect of the right lower leg. An MRI of the lumbar spine reveals a far lateral (extraforaminal) disc herniation at the L4-L5 level on the right. Which nerve root is most likely compressed?

. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L3

Explanation

In the lumbar spine, a far lateral (extraforaminal) disc herniation compresses the exiting nerve root at that level. Therefore, a far lateral disc herniation at L4-L5 compresses the L4 nerve root, whereas a central or paracentral herniation at the same level would compress the traversing L5 nerve root.

Question 3606

Topic: 6. Spine

A 68-year-old woman is planning to undergo posterior spinal instrumentation and fusion for progressive adult spinal deformity and sagittal imbalance. Preoperative radiographic measurements reveal a pelvic incidence (PI) of 55 degrees. To optimize her postoperative sagittal balance and clinical outcomes, the surgical correction should aim for a lumbar lordosis (LL) measurement of approximately:

. 25 degrees
. 35 degrees
. 45 degrees
. 55 degrees
. 75 degrees

Correct Answer & Explanation

. 55 degrees

Explanation

To achieve optimal sagittal balance and reduce the risk of adjacent segment failure in adult spinal deformity, the lumbar lordosis (LL) should be restored to within 10 degrees of the patient's pelvic incidence (PI). Therefore, a goal LL of approximately 55 degrees is ideal.

Question 3607

Topic: Thoracolumbar Spine & Deformity

A 14-year-old boy is brought to the emergency department after a high-speed motor vehicle collision in which he was a rear-seat, lap-belted passenger. He complains of severe lower back pain. Radiographs and a CT scan reveal a flexion-distraction injury (Chance fracture) at L2. Given this injury pattern, what additional evaluation is most critical for this patient?

. MRI to evaluate for epidural hematoma
. CT angiography of the lower extremities
. Evaluation for intra-abdominal hollow viscus injury
. Urodynamic testing for neurogenic bladder
. DEXA scan

Correct Answer & Explanation

. Evaluation for intra-abdominal hollow viscus injury

Explanation

Chance fractures (flexion-distraction injuries) are frequently sustained by lap-belted passengers in motor vehicle collisions and are highly associated with concurrent intra-abdominal injuries. Approximately 30% to 50% of these cases present with a concomitant hollow viscus injury.

Question 3608

Topic: 6. Spine

A 65-year-old man presents with progressive gait instability and poor fine motor skills. Examination shows a positive Hoffmann sign and hyperreflexia. MRI reveals multi-level cervical stenosis from C3 to C6 with cord signal change, and dynamic radiographs show neutral sagittal alignment without instability. What is the most appropriate surgical intervention?

. Anterior cervical discectomy and fusion (ACDF) C3-C6
. Cervical laminectomy and fusion C3-C6
. Cervical laminoplasty C3-C6
. Anterior cervical corpectomy C4 and C5
. Posterior cervical foraminotomies

Correct Answer & Explanation

. Cervical laminoplasty C3-C6

Explanation

Cervical laminoplasty is an ideal motion-preserving option for multi-level cervical myelopathy in the absence of kyphosis or instability. It avoids the morbidity of a multi-level anterior approach and the pseudoarthrosis or adjacent segment risks of a long posterior fusion.

Question 3609

Topic: 6. Spine

A 40-year-old man falls from a height and sustains a T12 burst fracture. He is neurologically intact. CT scan shows 15 degrees of kyphosis, 40% loss of vertebral body height, and an intact posterior ligamentous complex. What is his Thoracolumbar Injury Classification and Severity (TLICS) score and recommended treatment?

. Score 2; nonoperative management with a TLSO
. Score 4; nonoperative management with a TLSO
. Score 5; posterior spinal fusion
. Score 7; anterior corpectomy and fusion
. Score 2; posterior spinal fusion

Correct Answer & Explanation

. Score 2; nonoperative management with a TLSO

Explanation

The TLICS score is calculated by injury morphology (burst = 2), neurologic status (intact = 0), and posterior ligamentous complex integrity (intact = 0). A score of 2 suggests nonoperative management with a brace is appropriate.

Question 3610

Topic: 6. Spine
A 72-year-old man with known cervical spondylosis presents after a hyperextension injury. He has severe weakness in his bilateral hands and arms (1/5 strength) but retains 4/5 strength in his lower extremities. Sensation is intact. What is the most likely diagnosis?
. Anterior cord syndrome
. Central cord syndrome
. Brown-Sรฉquard syndrome
. Posterior cord syndrome
. Complete spinal cord injury

Correct Answer & Explanation

. Central cord syndrome

Explanation

Central cord syndrome typically occurs after a hyperextension injury in patients with preexisting cervical spondylosis. It affects the centrally located cervical motor tracts more severely, resulting in disproportionately greater upper extremity weakness compared to the lower extremities.

Question 3611

Topic: 6. Spine

A 62-year-old woman presents with neurogenic claudication and a grade I degenerative spondylolisthesis at L4-L5. Dynamic radiographs demonstrate 4 mm of translation on flexion-extension. She has failed 6 months of conservative care. What is the most appropriate surgical treatment?

. L4-L5 laminectomy alone
. L4-L5 laminectomy with instrumented posterolateral fusion
. L4-L5 microscopic discectomy
. Interspinous process spacer placement
. Anterior lumbar interbody fusion (ALIF) alone

Correct Answer & Explanation

. L4-L5 laminectomy with instrumented posterolateral fusion

Explanation

Laminectomy with instrumented posterolateral fusion is the gold standard for symptomatic degenerative spondylolisthesis with dynamic instability. Decompression alone in the setting of instability leads to a high rate of progressive slip and need for revision surgery.

Question 3612

Topic: 6. Spine

A 45-year-old man develops severe, acute right anterior thigh pain and weakness in knee extension. Reflex examination shows a diminished right patellar reflex. MRI shows a far-lateral (extraforaminal) disc herniation at the L4-L5 level. Which nerve root is most likely compressed?

. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L3

Explanation

A far-lateral (extraforaminal) disc herniation compresses the exiting nerve root at that level. At L4-L5, the exiting nerve root is L4, leading to anterior thigh pain, quadriceps weakness, and a diminished patellar reflex.

Question 3613

Topic: 6. Spine

A 60-year-old man with a long-standing history of ankylosing spondylitis presents with back pain after a minor fall. Radiographs appear unchanged from his baseline, but he reports new-onset leg weakness. What is the most appropriate next step in management?

. Discharge with muscle relaxants and physical therapy
. Reassurance and follow-up in 2 weeks
. CT or MRI of the entire spine
. Epidural steroid injection
. DEXA scan to evaluate for osteoporosis

Correct Answer & Explanation

. CT or MRI of the entire spine

Explanation

Patients with ankylosing spondylitis are at high risk for unstable, highly displaced fractures even from low-energy trauma. Plain radiographs are notoriously unreliable in these patients, making advanced imaging (CT or MRI of the entire spine) mandatory to rule out occult fractures and epidural hematomas.

Question 3614

Topic: Cervical Spine

A 25-year-old man is brought to the ED after a motor vehicle collision. He is awake, alert, and cooperative. Examination reveals intact motor and sensory function in all extremities. Cervical spine imaging demonstrates a right-sided unilateral C5-C6 facet dislocation. What is the recommended initial management?

. Immediate anterior cervical discectomy and fusion (ACDF)
. Urgent MRI prior to any attempted reduction
. Awake closed reduction using cranial traction
. Posterior cervical fusion
. Application of a halo vest and discharge

Correct Answer & Explanation

. Awake closed reduction using cranial traction

Explanation

In an awake, cooperative, and neurologically intact patient with a cervical facet dislocation, urgent awake closed reduction via cranial traction is recommended. MRI is generally reserved for patients who fail closed reduction, have an altered mental status, or develop neurologic deficits during traction.

Question 3615

Topic: Thoracolumbar Spine & Deformity

A 68-year-old woman with adult degenerative scoliosis is undergoing evaluation for corrective surgery. Her pelvic incidence (PI) is 60 degrees. To achieve optimal sagittal balance and minimize the risk of adjacent segment disease and mechanical failure, her lumbar lordosis (LL) should be reconstructed to approximately what value?

. 20 degrees
. 40 degrees
. 50 degrees
. 60 degrees
. 80 degrees

Correct Answer & Explanation

. 50 degrees

Explanation

Optimal sagittal balance requires the lumbar lordosis (LL) to be within 10 degrees of the pelvic incidence (PI). Therefore, for a PI of 60 degrees, the LL should be reconstructed to approximately 50-60 degrees to prevent flatback deformity.

Question 3616

Topic: 6. Spine

A 16-year-old boy presents with back pain and a rounded back. Radiographs reveal a thoracic kyphosis of 65 degrees. According to Sorensen's criteria, which of the following radiographic findings confirms the diagnosis of Scheuermann's kyphosis?

. Anterior wedging of at least 5 degrees in one vertebra
. Anterior wedging of at least 5 degrees in three consecutive vertebrae
. Schmorl's nodes in the lumbar spine only
. Apical vertebral rotation greater than 20 degrees
. Spondylolisthesis at L5-S1

Correct Answer & Explanation

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

Explanation

Sorensen's criteria for the diagnosis of Scheuermann's kyphosis require anterior wedging of 5 degrees or more in at least three consecutive vertebrae. It is often accompanied by Schmorl's nodes and endplate irregularities.

Question 3617

Topic: 6. Spine

A 70-year-old man complains of bilateral calf and buttock pain that worsens with walking. He states that leaning forward on a shopping cart completely relieves his symptoms. He has normal lower extremity pulses. Which of the following differentiates neurogenic claudication from vascular claudication?

. Pain relief with standing still
. Pain exacerbation with cycling
. Pain relief with lumbar flexion
. Decreased ankle-brachial index (ABI)
. Absent popliteal pulses

Correct Answer & Explanation

. Pain relief with lumbar flexion

Explanation

Neurogenic claudication is characteristically relieved by lumbar flexion (e.g., leaning on a shopping cart or sitting), which increases the cross-sectional area of the spinal canal. Vascular claudication is typically relieved simply by resting or standing still and worsens with muscle exertion regardless of posture.

Question 3618

Topic: 6. Spine

A 14-year-old boy with non-ambulatory spastic cerebral palsy presents with a 75-degree thoracolumbar scoliotic curve and severe pelvic obliquity causing skin breakdown over his ischial tuberosity. What is the most appropriate surgical strategy?

. Anterior spinal fusion to L4
. Posterior spinal fusion from the upper thoracic spine to the pelvis
. Growth-friendly magnetically controlled growing rods
. Selective thoracic fusion
. Observation and wheelchair modification

Correct Answer & Explanation

. Posterior spinal fusion from the upper thoracic spine to the pelvis

Explanation

In non-ambulatory patients with neuromuscular scoliosis and significant pelvic obliquity, long posterior spinal fusion extending from the upper thoracic spine down to the pelvis is required. This extensive fusion corrects the obliquity, restores sitting balance, and prevents pressure ulcers.

Question 3619

Topic: 6. Spine

A 22-year-old woman involved in a high-speed motor vehicle collision while wearing a lap belt sustains a flexion-distraction (Chance) injury at L2. She is hemodynamically stable and neurologically intact. What concomitant injury is most highly associated with this fracture pattern?

. Aortic transection
. Intra-abdominal hollow viscus injury
. Pulmonary contusion
. Cervical spine fracture
. Pelvic ring disruption

Correct Answer & Explanation

. Intra-abdominal hollow viscus injury

Explanation

Chance fractures (flexion-distraction injuries) are frequently caused by lap seatbelts acting as a fulcrum. They are highly associated with intra-abdominal injuries, particularly to hollow viscous organs (e.g., bowel perforations), which occur in up to 50% of these patients.

Question 3620

Topic: 6. Spine

A 65-year-old woman presents with right L5 radiculopathy. MRI reveals a cystic structure arising from the L4-L5 facet joint severely compressing the thecal sac and right traversing L5 nerve root. Dynamic radiographs demonstrate grade I degenerative spondylolisthesis at L4-L5. What is the best definitive surgical treatment?

. CT-guided cyst aspiration
. Microscopic cyst excision alone
. L4-L5 laminectomy and instrumented fusion
. Epidural steroid injection
. Minimally invasive tubular discectomy

Correct Answer & Explanation

. L4-L5 laminectomy and instrumented fusion

Explanation

Synovial facet cysts are a hallmark of underlying facet joint instability. While excision alone removes the compression, recurrence is high if the underlying instability is not addressed; therefore, decompression with instrumented fusion is the most definitive treatment.

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