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6. Spine MCQs

Practice Set 182 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 3621

Topic: 6. Spine

A 62-year-old man with a long-standing history of ankylosing spondylitis presents to the emergency department with severe back pain after a mechanical fall from standing height. Neurologic examination is normal. Radiographs and CT scan reveal a displaced extension-type fracture through the C7-T1 disc space. What is the most appropriate management?

. Cervicothoracic orthosis (CTO) for 12 weeks
. Halo vest immobilization for 12 weeks
. Anterior cervical discectomy and fusion (ACDF) at C7-T1
. Posterior spinal fusion 3 levels above and 3 levels below the fracture
. Laminectomy at C7-T1

Correct Answer & Explanation

. Posterior spinal fusion 3 levels above and 3 levels below the fracture

Explanation

Fractures in the ankylosed spine are highly unstable and behave biomechanically like long-bone fractures. Rigid internal fixation with long posterior constructs (typically 3 levels above and below) is required to prevent catastrophic neurologic injury and achieve union.

Question 3622

Topic: 6. Spine

A 55-year-old man of East Asian descent presents with progressive clumsiness in his hands, difficulty buttoning his shirts, and a broad-based gait. Examination reveals hyperreflexia, a positive Hoffmann sign, and positive Babinski reflex. Imaging shows a continuous band of ossification along the posterior aspect of the vertebral bodies from C3 to C6, causing spinal cord compression. His cervical spine alignment is lordotic (K-line positive). What is the most appropriate surgical approach?

. Anterior cervical corpectomy and fusion (ACCF) C3-C6
. Anterior cervical discectomy and fusion (ACDF) at C4-C5
. Posterior cervical laminoplasty C3-C6
. Posterior cervical laminectomy alone C3-C6
. Physical therapy and epidural steroid injections

Correct Answer & Explanation

. Posterior cervical laminoplasty C3-C6

Explanation

Multi-level OPLL (3 or more levels) with preserved cervical lordosis (K-line positive) is best managed with a posterior decompression such as laminoplasty. This approach decompresses the cord via indirect drift-back, avoiding the high risk of dural tears seen in multi-level anterior OPLL resections and preventing post-laminectomy kyphosis.

Question 3623

Topic: Cervical Spine
A previously healthy 35-year-old man was involved in a rollover motor vehicle accident 2 days ago. He was placed in a semi-rigid cervical orthosis. He now reports mostly axial neck pain with attempted range of motion. Examination reveals the mechanical neck pain but no obvious neurologic deficits. AP, flexion, and extension radiographs are shown in Figures 10a through 10c, and sagittal and coronal CT scans are shown in Figures 10d and 10e. What is the most appropriate management at this time?
. Continued immobilization in a semi-rigid cervical orthosis for 6 to 8 weeks
. Posterior occipital-cervical fusion with iliac crest bone graft
. Open reduction and internal fixation of the odontoid process with an anterior odontoid screw
. Resection of the odontoid process through a transoral approach
. Reduction with Gardner-Wells tong traction and 6 weeks of skeletal traction

Correct Answer & Explanation

. Open reduction and internal fixation of the odontoid process with an anterior odontoid screw

Explanation

Odontoid fractures can be classified based on the anatomic position of the fracture within the dens itself. Type I is an oblique fracture through the upper part of the odontoid process. Type II is a fracture that occurs at the base of the odontoid as it attaches to the body of C2; type III occurs when the fracture line extends through the body of the axis. Type I fractures typically can be treated nonsurgically with 6 to 8 weeks of immobilization with a semi-rigid cervical orthosis.

Question 3624

Topic: 6. Spine

A 45-year-old male presents with right arm pain radiating to his thumb. He has weakness in wrist extension and an absent brachioradialis reflex. Which cervical nerve root is most likely affected?

. C4
. C5
. C6
. C7
. C8

Correct Answer & Explanation

. C6

Explanation

C6 radiculopathy typically presents with pain and numbness in the thumb, weakness in wrist extension and elbow flexion, and an absent or diminished brachioradialis reflex.

Question 3625

Topic: 6. Spine

A 55-year-old male presents with progressive clumsiness of his hands and difficulty walking. Examination shows hyperreflexia in the lower extremities, a positive Hoffmann sign bilaterally, and an inability to tandem walk. What is the most appropriate next step in management?

. Physical therapy and NSAIDs
. Electromyography and nerve conduction studies
. CT scan of the cervical spine without contrast
. MRI of the cervical spine
. Lumbar puncture to assess for multiple sclerosis

Correct Answer & Explanation

. MRI of the cervical spine

Explanation

The patient's clinical presentation is classic for cervical spondylotic myelopathy. An MRI of the cervical spine is the gold standard diagnostic step to evaluate for spinal cord compression and cord signal changes.

Question 3626

Topic: 6. Spine

A 25-year-old female is involved in a high-speed MVC. She is neurologically intact but complains of severe neck pain. CT scan shows a fracture through the pars interarticularis of C2 bilaterally with 2 mm of displacement and no angulation. What is the most appropriate initial management?

. Soft cervical collar for 2 weeks
. Rigid cervical orthosis for 6 to 12 weeks
. Halo vest placement
. Anterior cervical discectomy and fusion
. Posterior C1-C2 instrumentation and fusion

Correct Answer & Explanation

. Rigid cervical orthosis for 6 to 12 weeks

Explanation

This describes a Type I traumatic spondylolisthesis of the axis (Hangman's fracture), which features a pars fracture with less than 3 mm of translation and no angulation. It is a stable fracture pattern best managed non-operatively with a rigid cervical collar.

Question 3627

Topic: 6. Spine
An 80-year-old male with pre-existing cervical spondylosis falls forward and strikes his forehead. He presents with profound weakness in his bilateral upper extremities (1/5) and mild weakness in his lower extremities (4/5). Perianal sensation and rectal tone are intact. What is the most likely diagnosis?
. Anterior cord syndrome
. Brown-Séquard syndrome
. Central cord syndrome
. Posterior cord syndrome
. Cauda equina syndrome

Correct Answer & Explanation

. Central cord syndrome

Explanation

Central cord syndrome is the most common incomplete spinal cord injury, typically occurring after a hyperextension injury in older adults with cervical spondylosis. It classically causes greater motor impairment in the upper extremities compared to the lower extremities.

Question 3628

Topic: 6. Spine

A 40-year-old male complains of severe left anterior thigh pain. Examination reveals weakness in left knee extension and a decreased patellar reflex. Which of the following lumbar disc herniations is most likely responsible?

. Central L2-L3
. Paracentral L2-L3
. Far lateral L4-L5
. Paracentral L4-L5
. Paracentral L5-S1

Correct Answer & Explanation

. Far lateral L4-L5

Explanation

A far lateral (extraforaminal) disc herniation at L4-L5 compresses the exiting L4 nerve root. L4 radiculopathy manifests with anterior thigh pain, quadriceps weakness, and an asymmetrical or diminished patellar reflex.

Question 3629

Topic: 6. Spine

What is the most common neurologic complication following cervical laminectomy and laminoplasty?

. C5 nerve root palsy
. C6 nerve root palsy
. Recurrent laryngeal nerve palsy
. Horner's syndrome
. Vertebral artery injury

Correct Answer & Explanation

. C5 nerve root palsy

Explanation

C5 nerve root palsy is the most common neurologic complication following cervical decompression without fusion (such as laminoplasty), occurring in up to 10% of cases. It is believed to be caused by tethering of the C5 nerve root as the spinal cord drifts posteriorly.

Question 3630

Topic: Thoracolumbar Spine & Deformity

A 30-year-old unrestrained driver is involved in an MVC. CT of the lumbar spine shows a flexion-distraction injury (Chance fracture) at L1. Which of the following associated injuries must be carefully ruled out?

. Aortic transection
. Intra-abdominal hollow viscus injury
. Diaphragmatic rupture
. Splenic laceration
. Renal contusion

Correct Answer & Explanation

. Intra-abdominal hollow viscus injury

Explanation

Chance fractures are flexion-distraction injuries commonly associated with seatbelt use. Up to 50% of patients with these fractures have concomitant intra-abdominal injuries, most commonly involving hollow viscous organs like the small bowel.

Question 3631

Topic: 6. Spine

A 65-year-old man undergoes a C3-C7 posterior cervical laminectomy and fusion for cervical spondylotic myelopathy. On postoperative day 2, he develops profound weakness of the deltoid and biceps unilaterally, with no other neurologic deficits. Which of the following is the most likely etiology of this complication?

. Intraoperative spinal cord contusion
. Posterior shift of the spinal cord causing C5 root tethering
. Epidural hematoma
. Hardware malposition
. Vascular watershed ischemia

Correct Answer & Explanation

. Posterior shift of the spinal cord causing C5 root tethering

Explanation

C5 palsy is a known complication of posterior cervical decompression procedures, occurring in roughly 5-10% of cases. It is widely thought to be caused by tethering of the C5 nerve root due to the posterior drift of the spinal cord after decompression.

Question 3632

Topic: 6. Spine

A 45-year-old man presents with severe sharp right-leg pain radiating to the anterior thigh and medial leg. Examination reveals 4/5 strength in right knee extension and a diminished patellar reflex. MRI of the lumbar spine reveals a far-lateral disc herniation at L4-L5. 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, an L4-L5 far-lateral disc herniation compresses the L4 nerve root, leading to anterior thigh pain and quadriceps weakness.

Question 3633

Topic: 6. Spine

A 72-year-old woman with a history of cervical stenosis sustains a hyperextension injury to her neck in a motor vehicle collision. She complains of severe weakness in her bilateral upper extremities and mild weakness in her lower extremities. Proprioception and sensation are partially preserved. What is the most likely diagnosis?

. Anterior cord syndrome
. Posterior cord syndrome
. Central cord syndrome
. Brown-Sequard syndrome
. Complete spinal cord injury

Correct Answer & Explanation

. Central cord syndrome

Explanation

Central cord syndrome typically occurs after a hyperextension injury in a patient with pre-existing cervical spondylosis. It classically presents with motor deficits that are more severe in the upper extremities than in the lower extremities.

Question 3634

Topic: Thoracolumbar Spine & Deformity

A 24-year-old man wearing a lap belt is involved in a high-speed motor vehicle collision. Radiographs demonstrate a flexion-distraction injury (Chance fracture) at L1. Which of the following associated injuries is most critical to rule out in this patient?

. Aortic dissection
. Diaphragmatic rupture
. Gastrointestinal hollow viscus injury
. Splenic laceration
. Reninal artery thrombosis

Correct Answer & Explanation

. Gastrointestinal hollow viscus injury

Explanation

Chance fractures (flexion-distraction injuries) are highly associated with intra-abdominal injuries, particularly to hollow viscous organs like the bowel, due to the acute compression from the lap belt. A thorough abdominal evaluation is mandatory.

Question 3635

Topic: 6. Spine

Traumatic spondylolisthesis of the axis (Hangman's fracture) is typically caused by which of the following mechanisms of injury?

. Flexion and distraction
. Axial loading and hyperflexion
. Hyperextension and axial loading
. Lateral bending
. Direct posterior blow

Correct Answer & Explanation

. Hyperextension and axial loading

Explanation

A Hangman's fracture involves bilateral pars interarticularis fractures of C2. In modern scenarios like motor vehicle collisions, it is most commonly caused by hyperextension combined with axial loading.

Question 3636

Topic: 6. Spine

A 32-year-old man dives into a shallow pool and sustains a Jefferson burst fracture of C1. On the open-mouth odontoid view, the sum of the lateral mass displacement of C1 on C2 is measured. A transverse ligament rupture is highly suspected if this combined displacement exceeds which of the following thresholds?

. 2.0 mm
. 3.5 mm
. 5.0 mm
. 6.9 mm
. 9.5 mm

Correct Answer & Explanation

. 6.9 mm

Explanation

The Rule of Spence states that a combined lateral mass overhang of C1 on C2 of greater than 6.9 mm on an AP open-mouth radiograph indicates a high likelihood of rupture of the transverse alar ligament.

Question 3637

Topic: 6. Spine
A 28-year-old man sustains a stab wound to the midthoracic spine. He exhibits loss of motor function and proprioception in his right lower extremity, and loss of pain and temperature sensation in his left lower extremity. Which of the following incomplete spinal cord syndromes does he have?
. Central cord syndrome
. Anterior cord syndrome
. Posterior cord syndrome
. Brown-Séquard syndrome
. Cauda equina syndrome

Correct Answer & Explanation

. Brown-Séquard syndrome

Explanation

Brown-Séquard syndrome results from spinal cord hemisection, characterized by ipsilateral loss of motor function and proprioception, and contralateral loss of pain and temperature sensation. It carries the best prognosis for ambulation among incomplete spinal cord injuries.

Question 3638

Topic: 6. Spine

A 35-year-old unrestrained driver is involved in a head-on collision. Lateral cervical spine radiographs show a C5 on C6 translation of approximately 60%. What is the most likely mechanism of this injury?

. Axial load
. Hyperextension
. Hyperflexion
. Flexion and rotation
. Distraction and extension

Correct Answer & Explanation

. Hyperflexion

Explanation

Bilateral facet dislocations are typically caused by severe hyperflexion injuries. They present with greater than 50% anterior subluxation of the vertebral body on the lateral radiograph.

Question 3639

Topic: 6. Spine

A 68-year-old man presents with bilateral leg and buttock pain that worsens with walking. Which of the following clinical features most strongly differentiates neurogenic claudication from vascular claudication?

. Pain is relieved by standing still
. Pain is worse when walking uphill
. Pain is relieved by leaning forward (e.g., on a shopping cart)
. Absent pedal pulses
. Trophic skin changes

Correct Answer & Explanation

. Pain is relieved by leaning forward (e.g., on a shopping cart)

Explanation

Neurogenic claudication is typically relieved by lumbar flexion, such as leaning on a shopping cart or sitting, because flexion increases the cross-sectional area of the spinal canal. Vascular claudication is typically relieved simply by resting or standing still.

Question 3640

Topic: 6. Spine

A 42-year-old man presents with sudden onset of severe lower back pain, bilateral sciatica, saddle anesthesia, and urinary retention. Which of the following is the most appropriate next step in management?

. Epidural steroid injection
. Urgent MRI of the lumbar spine and surgical decompression
. Oral steroids and physical therapy
. CT myelogram scheduled for the next week
. Bed rest for 48 hours

Correct Answer & Explanation

. Urgent MRI of the lumbar spine and surgical decompression

Explanation

This patient presents with classic signs of cauda equina syndrome. This is a surgical emergency requiring an urgent MRI followed by emergent surgical decompression to prevent permanent neurologic deficits, particularly bladder and bowel dysfunction.

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