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6. Spine MCQs

Practice Set 19 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 361

Topic: 6. Spine

Which of the following is the most common complaint in patients with degenerative lumbar scoliosis:

. Radicular pain radiating to one or the other leg
. Mechanical pain during motion
. Low back pain and reduced tolerance for walking
. Urinary incontinence
. Sensory changes at the dorsal feet bilaterally

Correct Answer & Explanation

. Low back pain and reduced tolerance for walking

Explanation

Patients with degenerative lumbar scoliosis typically complain of symptoms related to the associated spinal stenosis. These symptoms commonly include (with approximate incidence rates): low back pain (100%), reduced tolerance for standing and walking (85% to 100%), neurogenic claudication (50%), and radicular or pseudoradicular pain radiating into the buttocks or thighs (40% to 60%).

Question 362

Topic: 6. Spine

Bony contribution to the lumbar lordotic curvature is provided by:

. Spinous processes
. Articulating facets
. Lamina
. Pars interarticularis
. Vertebral body

Correct Answer & Explanation

. Vertebral body

Explanation

The anterior portion of each body has a slightly increased height that contributes to the sagittal lumbar lordosis. The posterior vertebral arch consists of the paired pedicles, laminae, and a midline dorsal spinal process.

Question 363

Topic: 6. Spine

Superior articulating facets in the lumbosacral spine differ from those in the thoracic spine because facets in the lumbosacral spine:

. Face posteriorly
. Face dorsomedially
. Have a thicker facet joint capsule
. Face superolaterally
. Are fused and are not true joints

Correct Answer & Explanation

. Face dorsomedially

Explanation

The paired superior articular facets are directed dorsomedially with their corresponding inferior articular processes directed ventrolaterally. These diarthrodial articulations possess thin, lax joint capsules capable of a limited gliding articulation between adjoining vertebrae. They permit flexion, lateral bending and extension, but resist rotation due to both size and facet orientation. The facets alone can bear up to 18% of the compressive load.

Question 364

Topic: 6. Spine

Limitation of hyperextension in the lumbosacral spine is controlled by the:

. Posterior longitudinal ligament
. Anterior longitudinal ligament
. Ligamentum flavum
. Interspinous ligament
. Intertransverse ligament

Correct Answer & Explanation

. Anterior longitudinal ligament

Explanation

More flexion-extension motion occurs in the caudal segments of the lumbar spine than in the upper and middle levels. The welldeveloped anterior longitudinal ligament and the anterior portion of the annulus fibrosus are important inhibitors of hyperextension.

Question 365

Topic: 6. Spine

Which of the following is the most common cause of lumbar stenosis:

. Congenital
. Posttraumatic
. Degenerative
. Iatrogenic
. Idiopathic

Correct Answer & Explanation

. Degenerative

Explanation

Degenerative lumbar stenosis is the most common cause of lumbar stenosis. With normal aging of the disk, the water-binding capacity of the nucleus pulposus is dissipated, diminishing its ability to withstand normal compressive and rotational forces. With progressive degeneration of the disk, collapse occurs. This collapse results in overriding of the facet joints and relative lengthening of adjacent capsular and ligamentous structures. Continued instability, which may be multidirectional, results in hypertrophic changes about the periphery of the vertebral body at its annular attachments. Radiographically, these are seen as traction osteophytes. Similarly, osteophytes form about the facet joints, which lead to compromise of the neural canal. With disease progression, hypertrophic changes predominate, leading to ankylosis and auto stabilization. In patients with less than optimal canal configurations or dimensions or those with excessive hypertrophic degenerative changes, narrowing of the spinal canal, lateral recesses, and neural foramina may result in neurogenic signs and symptoms.

Question 366

Topic: 6. Spine

Which of the following is the most common presentation of a patient with lumbar stenosis:

. Foot drop
. Acute onset of pain in bilateral lower extremities
. C hronic low back pain with neurogenic claudication
. Saddle anesthesia
. Intermittent urinary incontinence

Correct Answer & Explanation

. C hronic low back pain with neurogenic claudication

Explanation

The most common complaint in patients with spinal stenosis is chronic low back pain with worsening and lower extremity weakness after ambulation (claudication). Symptoms are often resolved by rest and/or leaning forward.

Question 367

Topic: 6. Spine

A 45-year-old male presents to the emergency department with acute onset saddle anesthesia, bowel and bladder incontinence, and bilateral lower extremity weakness. MRI demonstrates a massive extruded L4-L5 disc herniation compressing the thecal sac. What is the most appropriate management to maximize the potential for neurological recovery?

. Epidural steroid injection followed by physical therapy
. Trial of oral corticosteroids and strict bed rest for 48 hours
. Emergent surgical decompression
. Lumbar traction and neuropathic pain modulators
. Observation with serial neurological examinations

Correct Answer & Explanation

. Emergent surgical decompression

Explanation

This patient presents with acute cauda equina syndrome, which is a surgical emergency. Emergent surgical decompression is mandatory, ideally within 24 to 48 hours of symptom onset, to maximize the recovery of bowel, bladder, and lower extremity motor function.

Question 368

Topic: 6. Spine

A 38-year-old woman presents with a 4-week history of severe right-sided sciatica. She is neurologically intact. MRI demonstrates a large, sequestered L5-S1 disc herniation. If managed conservatively, what is the most likely natural history of the extruded disc material?

. Progressive ossification of the fragment
. Spontaneous resorption over time
. Migration into the epidural space causing cord compression
. Induction of adjacent segment disease
. Permanent encapsulation with chronic inflammatory changes

Correct Answer & Explanation

. Spontaneous resorption over time

Explanation

Large, sequestered disc herniations have the highest rate of spontaneous resorption among disc herniation types. The extruded nucleus pulposus is recognized as foreign material, triggering a macrophage-mediated inflammatory response that typically leads to clinical improvement and radiographic resorption.

Question 369

Topic: 6. Spine

Which of the following clinical features is most reliable for differentiating neurogenic claudication caused by lumbar spinal stenosis from vascular claudication?

. Pain relieved promptly by standing completely still
. Pain exacerbated by walking up an incline
. Diminished lower extremity pulses
. Pain relieved by spine flexion, such as leaning forward on a shopping cart
. A stocking-glove pattern of sensory deficit

Correct Answer & Explanation

. Pain relieved by spine flexion, such as leaning forward on a shopping cart

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 strictly exertion-related and relieved by simply resting (standing still) without postural changes.

Question 370

Topic: 6. Spine

A 55-year-old male with long-standing ankylosing spondylitis presents after a ground-level fall. He complains of severe neck pain but remains neurologically intact. Initial standard anteroposterior and lateral cervical radiographs are interpreted as unremarkable. What is the most appropriate next step in his management?

. Discharge home with a soft cervical collar and NSAIDs
. Perform flexion-extension cervical spine radiographs
. Obtain a computed tomography (CT) scan of the cervical spine
. Schedule an outpatient MRI in 2 weeks
. Reassure the patient that no further imaging is needed

Correct Answer & Explanation

. Obtain a computed tomography (CT) scan of the cervical spine

Explanation

Patients with ankylosing spondylitis are at extremely high risk for occult, highly unstable extension-type fractures (chalk stick fractures) even after low-energy trauma. A CT scan of the entire cervical spine is mandatory, as plain radiographs often miss these fractures due to altered anatomy and osteopenia.

Question 371

Topic: Thoracolumbar Spine & Deformity

During a posterior lumbar instrumented fusion, the surgeon prepares to place a pedicle screw at the L4 level. What is the standard anatomical starting point for the insertion of an L4 pedicle screw?

. The medial border of the superior articular process at the base of the lamina
. The intersection of the middle of the transverse process and the lateral border of the superior articular process
. The inferior tip of the spinous process and medial border of the pars interarticularis
. The superior articular process perfectly centered between the superior and inferior facets
. The exact center of the lumbar lamina

Correct Answer & Explanation

. The intersection of the middle of the transverse process and the lateral border of the superior articular process

Explanation

The standard starting point for a lumbar pedicle screw is at the intersection of a horizontal line bisecting the transverse process and a vertical line corresponding to the lateral border of the superior articular process.

Question 372

Topic: 6. Spine

A 62-year-old diabetic male presents with a 5-day history of severe localized back pain, fever, and progressive lower extremity weakness. Laboratory markers show elevated ESR and CRP. An MRI reveals a spinal epidural abscess. What is the most likely causative organism?

. Escherichia coli
. Mycobacterium tuberculosis
. Staphylococcus aureus
. Pseudomonas aeruginosa
. Streptococcus pneumoniae

Correct Answer & Explanation

. Staphylococcus aureus

Explanation

Staphylococcus aureus is the most common causative organism in spinal epidural abscesses. The classic clinical triad of an epidural abscess consists of back pain, fever, and neurological deficits.

Question 373

Topic: 6. Spine

A 72-year-old man with pre-existing cervical spondylosis sustains a hyperextension injury to his neck in a motor vehicle collision. On examination, he demonstrates significant weakness in his upper extremities, particularly the hands, with relatively preserved motor strength in his lower extremities. What is the most likely diagnosis?

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

Correct Answer & Explanation

. Central cord syndrome

Explanation

Central cord syndrome is the most common incomplete spinal cord injury, typically occurring after hyperextension injuries in older patients with cervical spondylosis. It is characterized by disproportionately greater motor impairment in the upper extremities compared to the lower extremities.

Question 374

Topic: 6. Spine

During the neurological examination of a 60-year-old patient with suspected cervical spondylotic myelopathy, you rapidly flick the distal phalanx of the middle finger downward, eliciting a reflexive flexion of the thumb and index finger. What is the name of this upper motor neuron sign?

. Babinski sign
. Hoffmann sign
. Lhermitte sign
. Wartenberg sign
. Spurling sign

Correct Answer & Explanation

. Hoffmann sign

Explanation

The Hoffmann sign is elicited by flicking the distal phalanx of the middle finger, which causes reflexive flexion of the thumb and index finger. It indicates upper motor neuron dysfunction, commonly seen in cervical myelopathy.

Question 375

Topic: Thoracolumbar Spine & Deformity

A 14-year-old female gymnast presents with severe chronic low back pain limiting her participation in sports. Radiographs demonstrate a Grade II L5-S1 isthmic spondylolisthesis. After 6 months of supervised physical therapy, bracing, and NSAIDs, her severe pain persists. What is the most appropriate surgical intervention?

. L5 laminectomy without fusion
. Direct pars interarticularis repair (Buck's procedure)
. L5-S1 posterior spinal fusion
. L4-L5 microdiscectomy
. Sacral laminectomy

Correct Answer & Explanation

. L5-S1 posterior spinal fusion

Explanation

Symptomatic Grade II isthmic spondylolisthesis at L5-S1 that fails conservative management is best treated with an L5-S1 spinal fusion. Direct pars repair (e.g., Buck's procedure) is generally reserved for isolated pars defects or Grade I slips at higher lumbar levels (L1-L4) without significant disc degeneration.

Question 376

Topic: Thoracolumbar Spine & Deformity

A 25-year-old male is involved in a high-speed collision wearing only a lap belt. Radiographs reveal a severe flexion-distraction injury (Chance fracture) at L1. Which of the following associated injuries must be most carefully excluded in this patient?

. Aortic transection
. Intra-abdominal visceral injury
. Pelvic ring disruption
. Diaphragmatic rupture
. Cervical facet dislocation

Correct Answer & Explanation

. Intra-abdominal visceral injury

Explanation

Chance fractures (flexion-distraction injuries) are highly associated with lap-belt mechanisms and carry a very high incidence (up to 50%) of concomitant intra-abdominal injuries, particularly hollow viscus ruptures.

Question 377

Topic: 6. Spine

A 68-year-old male with a history of prostate cancer presents with progressive back pain. An anteroposterior (AP) radiograph of the lumbar spine reveals the absence of the cortical outline of the right L3 pedicle. What is this radiographic finding commonly termed?

. Bamboo spine sign
. Scotty dog sign
. Teardrop sign
. Winking owl sign
. Vacuum cleft sign

Correct Answer & Explanation

. Winking owl sign

Explanation

The missing pedicle on an AP radiograph of the spine is known as the "winking owl sign." It is highly suggestive of metastatic disease involving the vertebral pedicle.

Question 378

Topic: Thoracolumbar Spine & Deformity

When evaluating the sagittal alignment of an adult patient with spinal deformity, which of the following spinopelvic parameters is considered a fixed morphological feature that remains constant regardless of patient positioning?

. Pelvic tilt
. Sacral slope
. Pelvic incidence
. Lumbar lordosis
. Sagittal vertical axis

Correct Answer & Explanation

. Pelvic incidence

Explanation

Pelvic incidence is a fixed morphological parameter defined after skeletal maturity and does not change with posture. It is calculated mathematically as the sum of pelvic tilt and sacral slope (PI = PT + SS).

Question 379

Topic: Cervical Spine

Which of the following factors is most strongly associated with an increased risk of non-union in a Type II odontoid fracture treated with non-operative management?

. Age less than 30 years
. Displacement greater than 5 mm
. Mechanism of injury being a low-energy fall
. Posterior displacement of 2 mm
. Concomitant fractures of the C1 anterior arch

Correct Answer & Explanation

. Displacement greater than 5 mm

Explanation

Initial fracture displacement greater than 5 mm is a major risk factor for non-union in Type II odontoid fractures. Other significant risk factors include patient age greater than 50 years and posterior displacement.

Question 380

Topic: 6. Spine

A trauma patient arrives at the emergency department with a complete T4 spinal cord injury. Vital signs reveal profound hypotension and bradycardia, and his extremities are warm and flushed. This clinical presentation is most characteristic of:

. Spinal shock
. Cardiogenic shock
. Hypovolemic shock
. Neurogenic shock
. Septic shock

Correct Answer & Explanation

. Neurogenic shock

Explanation

Neurogenic shock results from the loss of sympathetic autonomic tone following severe cervical or upper thoracic cord injury, leading to unchecked vagal tone, bradycardia, and profound hypotension with warm extremities. Spinal shock, by contrast, refers to the temporary loss of spinal reflexes below the injury level.

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