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6. Spine MCQs

Practice Set 197 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 3921

Topic: 6. Spine

A 60-year-old man presents with progressive clumsiness in his hands and difficulty walking. Examination reveals a positive Hoffmann sign and hyperreflexia in the lower extremities. MRI shows severe cervical stenosis at C4-C5 and C5-C6. Which of the following MRI findings is the most significant predictor of a poor neurological recovery following surgical decompression?

. Loss of cervical lordosis
. T2-weighted hyperintensity spanning multiple levels
. T1-weighted focal hypointensity within the spinal cord
. Modic type I changes in the adjacent vertebral bodies
. Hypertrophy of the ligamentum flavum

Correct Answer & Explanation

. T1-weighted focal hypointensity within the spinal cord

Explanation

A focal T1-weighted hypointensity in the spinal cord indicates myelomalacia or cystic necrosis. It is the strongest MRI predictor of poor neurological recovery and irreversible cord damage after surgical decompression.

Question 3922

Topic: Thoracolumbar Spine & Deformity

A 45-year-old man falls from a height and sustains an L1 burst fracture. He is neurologically intact. MRI demonstrates that the integrity of the posterior ligamentous complex (PLC) is indeterminate. Based on the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the most appropriate management approach?

. Immediate open reduction and internal fixation
. Conservative management with prolonged bed rest
. The score is 4, so surgical or nonoperative management are both acceptable
. Posterior decompression alone without instrumentation
. Anterior corpectomy and fusion

Correct Answer & Explanation

. The score is 4, so surgical or nonoperative management are both acceptable

Explanation

The TLICS score assigns 2 points for a burst fracture morphology, 0 points for intact neurology, and 2 points for an indeterminate PLC, totaling 4 points. A total score of 4 suggests that either surgical or nonoperative management is appropriate based on surgeon and patient preference.

Question 3923

Topic: 6. Spine
A 68-year-old man with known cervical spondylosis presents after a hyperextension injury to his neck. He is able to ambulate but has profound motor weakness in his hands and arms. Perianal sensation and bladder function are intact. What is the most likely diagnosis?
. Anterior cord syndrome
. Brown-Sรฉquard syndrome
. Central cord syndrome
. Posterior cord syndrome
. Cauda equina syndrome

Correct Answer & Explanation

. Central cord syndrome

Explanation

Central cord syndrome typically occurs following a hyperextension injury in patients with pre-existing cervical spondylosis. It classically presents with disproportionate motor weakness in the upper extremities compared to the lower extremities.

Question 3924

Topic: 6. Spine

A 55-year-old man with longstanding ankylosing spondylitis sustains a minor ground-level fall. He has severe neck pain but is neurologically intact. Radiographs demonstrate a displaced extension-type fracture through the C6-C7 disc space. What is the standard of care for definitive management?

. Rigid cervical collar for 12 weeks
. Halo vest immobilization
. Stand-alone anterior cervical discectomy and fusion (ACDF)
. Long-segment posterior cervical instrumentation and fusion
. Physical therapy and NSAIDs

Correct Answer & Explanation

. Long-segment posterior cervical instrumentation and fusion

Explanation

Spinal fractures in ankylosing spondylitis are highly unstable due to the rigid, osteopenic nature of the fused spine. Long-segment posterior instrumentation and fusion is required to prevent catastrophic displacement and secondary neurological injury.

Question 3925

Topic: 6. Spine

In a patient with ankylosing spondylitis who sustains an acute cervical spine fracture, which of the following is the most common occult complication leading to delayed neurological deterioration?

. Vertebral artery dissection
. Spinal epidural hematoma
. Retropharyngeal abscess
. Traumatic dural tear with pseudomeningocele
. Post-traumatic syringomyelia

Correct Answer & Explanation

. Spinal epidural hematoma

Explanation

Spinal epidural hematomas are a frequent and potentially devastating complication of spinal fractures in ankylosing spondylitis. Because the bleeding can cause delayed neurological deterioration, an MRI is critical if the patient experiences a change in exam.

Question 3926

Topic: 6. Spine

A 60-year-old woman with severe rheumatoid arthritis is evaluated prior to a total knee arthroplasty. Flexion-extension cervical radiographs reveal an anterior atlantodental interval (ADI) of 11 mm. What is the most appropriate next step in her management?

. Proceed with total knee arthroplasty using regional anesthesia
. Perform an MRI of the cervical spine to evaluate for cord compression
. Clear the patient for surgery provided a hard cervical collar is worn
. Proceed with total knee arthroplasty using fiberoptic intubation
. Immediate prophylactic C1-C2 posterior fusion

Correct Answer & Explanation

. Perform an MRI of the cervical spine to evaluate for cord compression

Explanation

An ADI > 9-10 mm in a patient with rheumatoid arthritis indicates significant atlantoaxial instability with a high risk of spinal cord compression. An MRI is required to assess the posterior atlantodental interval (PADI) and check for myelomalacia before elective surgery.

Question 3927

Topic: Thoracolumbar Spine & Deformity

A 65-year-old woman presents with neurogenic claudication and a grade 1 degenerative spondylolisthesis at L4-L5. Which of the following anatomic features is most strongly implicated in the pathogenesis of her spondylolisthesis?

. Bilateral pars interarticularis defects
. Sagittal orientation of the facet joints
. Coronal orientation of the facet joints
. Hypertrophy of the ligamentum flavum
. Congenitally dysplastic pedicles

Correct Answer & Explanation

. Sagittal orientation of the facet joints

Explanation

Degenerative spondylolisthesis most commonly occurs at L4-L5. A more sagittal orientation of the facet joints renders them less capable of resisting shear forces, allowing anterior translation as the intervertebral disc degenerates.

Question 3928

Topic: 6. Spine

A 25-year-old man involved in a high-speed motor vehicle collision while wearing a lap belt sustains a flexion-distraction injury (Chance fracture) of the L2 vertebra. Which associated injury must be strongly suspected and ruled out?

. Aortic dissection
. Intra-abdominal hollow viscus injury
. Diaphragmatic rupture
. Renal artery thrombosis
. Pelvic ring fracture

Correct Answer & Explanation

. Intra-abdominal hollow viscus injury

Explanation

Chance fractures (flexion-distraction injuries) are heavily associated with lap-belt use in motor vehicle collisions. Up to 50% of these patients will have concomitant intra-abdominal injuries, particularly to hollow viscous organs such as the small bowel.

Question 3929

Topic: 6. Spine

A 32-year-old man presents with severe neck pain and right-sided C6 radiculopathy after a motorcycle crash. Lateral cervical radiographs reveal an anterior subluxation of C5 on C6 of approximately 25 percent. What is the primary mechanism of injury?

. Flexion-distraction
. Flexion-rotation
. Hyperextension
. Vertical compression
. Lateral bending

Correct Answer & Explanation

. Flexion-rotation

Explanation

A unilateral facet dislocation typically results from a flexion-rotation mechanism. On lateral radiographs, it is characterized by anterior translation of the superior vertebral body of approximately 25%, as opposed to 50% seen in bilateral facet dislocations.

Question 3930

Topic: 6. Spine

A 15-year-old boy presents with progressive mid-back pain and a rounded posture. Lateral radiographs of the thoracic spine demonstrate anterior wedging of 7 degrees at T7, T8, and T9, along with prominent Schmorl's nodes. He has a flexible kyphosis measuring 60 degrees. What is the most appropriate initial management?

. Extension bracing (e.g., Milwaukee brace)
. Observation with annual standing radiographs
. Posterior spinal fusion alone
. Combined anterior and posterior spinal fusion
. Physical therapy focusing exclusively on core strengthening

Correct Answer & Explanation

. Extension bracing (e.g., Milwaukee brace)

Explanation

This patient meets the radiographic criteria for Scheuermann's kyphosis (anterior wedging > 5 degrees in at least three consecutive vertebrae). For a skeletally immature patient with progressive, symptomatic kyphosis > 50 degrees, an extension brace is the recommended first-line treatment.

Question 3931

Topic: 6. Spine

A 58-year-old man underwent an L4-S1 posterior instrumented fusion 5 years ago. He now presents with new-onset L3 radiculopathy due to adjacent segment disease. Which of the following intraoperative factors during the index surgery is most strongly associated with accelerated adjacent segment degeneration?

. Use of interbody cages at the fused levels
. Violation of the superior facet joint capsule during screw insertion
. Application of rhBMP-2
. Over-distraction of the intervertebral disc spaces
. Inadequate decortication of the transverse processes

Correct Answer & Explanation

. Violation of the superior facet joint capsule during screw insertion

Explanation

Violation of the adjacent superior facet joint capsule during pedicle screw placement disrupts the biomechanics of the unfused level. This iatrogenic injury significantly increases the risk and accelerates the onset of adjacent segment disease.

Question 3932

Topic: 6. Spine

A 40-year-old man sustains a traumatic spondylolisthesis of the axis (Hangman's fracture) following a high-speed motor vehicle rollover. The classic mechanism of injury responsible for this fracture pattern is:

. Flexion-distraction
. Hyperextension and axial loading
. Hyperflexion and rotation
. Vertical compression
. Lateral bending

Correct Answer & Explanation

. Hyperextension and axial loading

Explanation

A Hangman's fracture classically results from hyperextension and axial loading forces. This combined mechanism fractures the pars interarticularis of C2, commonly seen in modern motor vehicle collisions or shallow-water diving accidents.

Question 3933

Topic: 6. Spine

A 42-year-old man presents with right leg pain radiating down the lateral aspect of his calf to the dorsum of his foot, accompanied by weakness in great toe extension. MRI of the lumbar spine reveals a paracentral disc herniation. At which level is the disc herniation most likely located?

. L3-L4
. L4-L5
. L5-S1
. L2-L3
. S1-S2

Correct Answer & Explanation

. L4-L5

Explanation

Weakness in the extensor hallucis longus (EHL) and sensory changes over the dorsum of the foot are classic signs of an L5 radiculopathy. A paracentral disc herniation at the L4-L5 level will impinge the traversing L5 nerve root.

Question 3934

Topic: 6. Spine

A 65-year-old woman presents with severe neurogenic claudication and an L4-L5 degenerative spondylolisthesis. She has failed 6 months of supervised physical therapy and epidural steroid injections. What is the most appropriate surgical intervention to optimize long-term clinical outcomes?

. Decompression laminectomy alone
. Decompression laminectomy with instrumented posterolateral fusion
. Stand-alone anterior lumbar interbody fusion
. Microdiscectomy alone
. Placement of an interspinous process spacer

Correct Answer & Explanation

. Decompression laminectomy with instrumented posterolateral fusion

Explanation

According to the SPORT trial and other long-term studies, decompression combined with instrumented fusion provides significantly better outcomes for degenerative spondylolisthesis than decompression alone. Laminectomy alone risks iatrogenic instability and progression of the slip.

Question 3935

Topic: Thoracolumbar Spine & Deformity

In the assessment of adult spinal deformity, which of the following spinopelvic parameters is considered a fixed morphological characteristic of the pelvis that remains constant regardless of patient positioning?

. Pelvic Tilt (PT)
. Sacral Slope (SS)
. Pelvic Incidence (PI)
. Lumbar Lordosis (LL)
. Sagittal Vertical Axis (SVA)

Correct Answer & Explanation

. Pelvic Incidence (PI)

Explanation

Pelvic incidence (PI) is a constant anatomical parameter unique to each individual and does not change with posture. It dictates the relationship between pelvic tilt and sacral slope, represented by the formula PI = PT + SS.

Question 3936

Topic: Thoracolumbar Spine & Deformity

A 35-year-old man sustains an L1 burst fracture after falling from a ladder. He is neurologically intact. Imaging reveals 15 degrees of kyphosis, 30% canal compromise, and an intact posterior ligamentous complex (PLC). What is the most appropriate treatment?

. Thoracolumbosacral orthosis (TLSO) bracing and early mobilization
. Posterior instrumented spinal fusion
. Anterior corpectomy and fusion
. Percutaneous short-segment pedicle screws
. Laminectomy and facetectomy

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing and early mobilization

Explanation

Stable thoracolumbar burst fractures (neurologically intact, intact PLC, acceptable kyphosis < 20-30 degrees) are typically treated non-operatively with a TLSO brace. Outcomes for stable burst fractures treated with bracing are equivalent to surgical stabilization.

Question 3937

Topic: 6. Spine

A 45-year-old man presents with severe right thigh pain and weakness in knee extension. MRI reveals 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

. L4

Explanation

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

Question 3938

Topic: 6. Spine

During the physical examination of a patient with progressive gait difficulties, flicking the volar nail of the middle finger results in brisk flexion of the thumb and index finger. This clinical sign indicates an upper motor neuron lesion typically located where?

. Thoracic spinal cord
. Lumbar spine
. Cervical spinal cord
. Median nerve at the carpal tunnel
. Brachial plexus

Correct Answer & Explanation

. Cervical spinal cord

Explanation

The described maneuver is Hoffmann's sign, which is indicative of an upper motor neuron lesion or cervical myelopathy. It points to compression or pathology within the cervical spinal cord.

Question 3939

Topic: 6. Spine

A 70-year-old man with advanced ankylosing spondylitis presents to the emergency department complaining of neck pain after a low-speed motor vehicle collision. Initial plain radiographs of the cervical spine demonstrate an ossified anterior longitudinal ligament but no obvious fracture. What is the most appropriate next step in management?

. Discharge with a soft cervical collar and NSAIDs
. Obtain dynamic flexion-extension cervical radiographs
. Perform a CT scan of the entire cervical spine
. Initiate high-dose intravenous steroids
. Reassurance and outpatient physical therapy

Correct Answer & Explanation

. Perform a CT scan of the entire cervical spine

Explanation

Patients with ankylosing spondylitis are at extremely high risk for occult "chalk stick" fractures, which are often missed on plain radiographs. A CT scan of the entire cervical spine (and often an MRI to rule out epidural hematoma) is mandatory even after minor trauma.

Question 3940

Topic: 6. Spine

A patient is diagnosed with a Levine-Edwards Type IIA traumatic spondylolisthesis of the axis (Hangman's fracture). Which of the following conservative management techniques is strictly contraindicated for this specific injury pattern?

. Halo vest immobilization with mild compression
. Cervical traction
. Rigid cervical collar
. Prolonged bed rest
. Surgical internal fixation

Correct Answer & Explanation

. Cervical traction

Explanation

Type IIA Hangman's fractures show severe angulation with minimal translation and denote significant disc space disruption. Cervical traction is strictly contraindicated as it will distract the fracture site and worsen the deformity.

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