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6. Spine MCQs

Practice Set 2 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 21

Topic: 6. Spine

A 72-year-old male presents with deteriorating handwriting, frequent falls, and a broad-based gait. Examination demonstrates hyperreflexia, a positive Hoffmann sign bilaterally, and a positive inverted radial reflex. What is the most likely diagnosis?

. Amyotrophic lateral sclerosis
. Cervical spondylotic myelopathy
. Lumbar spinal stenosis
. Normal pressure hydrocephalus
. Guillain-Barre syndrome

Correct Answer & Explanation

. Cervical spondylotic myelopathy

Explanation

The combination of upper motor neuron signs, gait dysfunction, and upper extremity clumsiness strongly suggests cervical spondylotic myelopathy. The inverted radial reflex is a localizing upper motor neuron sign highly specific for a lesion at the C5-C6 level.

Question 22

Topic: Cervical Spine

In a throwing athlete, the primary restraint to valgus stress at the elbow during the late cocking and early acceleration phases of throwing is the:

. Posterior bundle of the ulnar collateral ligament
. Transverse ligament
. Anterior bundle of the ulnar collateral ligament
. Radial collateral ligament
. Flexor-pronator mass

Correct Answer & Explanation

. Anterior bundle of the ulnar collateral ligament

Explanation

The anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress at the elbow between 30 and 120 degrees of flexion. This corresponds to the extreme valgus loads seen during the late cocking and early acceleration phases of throwing.

Question 23

Topic: 6. Spine

An adolescent gymnast presents with insidious onset low back pain that is exacerbated by spine extension. Plain radiographs are completely normal. What is the most appropriate next step in imaging to evaluate for an acute pars interarticularis stress reaction?

. Computed Tomography (CT) scan of the lumbar spine
. Magnetic Resonance Imaging (MRI) of the lumbar spine without contrast
. Technetium-99m bone scan
. Diagnostic ultrasound
. Fluoroscopic facet joint injection

Correct Answer & Explanation

. Magnetic Resonance Imaging (MRI) of the lumbar spine without contrast

Explanation

MRI of the lumbar spine without contrast is highly sensitive for detecting marrow edema indicative of an acute pars stress reaction before a fracture line appears. It avoids the ionizing radiation associated with CT scans, making it the preferred choice in pediatric athletes.

Question 24

Topic: 6. Spine

A 16-year-old gymnast complains of chronic low back pain exacerbated by extension. Radiographs show a unilateral pars interarticularis defect at L5. What is the biomechanical mechanism most strongly associated with this condition?

. Repetitive spinal flexion and rotation
. Repetitive spinal hyperextension and rotation
. Axial loading in a flexed posture
. Acute hyperflexion injury
. Direct posterior impact trauma

Correct Answer & Explanation

. Repetitive spinal hyperextension and rotation

Explanation

Spondylolysis in athletes is a stress fracture of the pars interarticularis typically caused by repetitive spinal hyperextension and rotation. It is most common at the L5 level and frequently seen in gymnasts, weightlifters, and football linemen.

Question 25

Topic: 6. Spine

A 16-year-old gymnast complains of chronic lower back pain exacerbated by extension. Imaging reveals a pars interarticularis defect (spondylolysis). Which spinal level is most frequently affected in this population?

. L1
. L2
. L3
. L4
. L5

Correct Answer & Explanation

. L5

Explanation

Spondylolysis most commonly occurs at the L5 vertebral level. It is frequently seen in young athletes subjected to repetitive lumbar hyperextension, such as gymnasts and football linemen.

Question 26

Topic: 6. Spine

The quadriceps angle or Q angle is defined as the angle formed by a line connecting the:

. Anterior inferior iliac spine to the center of the patella and a line connecting the center of the patella to the center of the tibial tuberosity
. Anterior superior iliac spine to the center of the patella and a line connecting the center of the patella to the center of the tibial tuberosity
. Anterior inferior iliac spine to the lateral aspect of the patella and a line connecting the center of the patella to the center of the tibial tuberosity
. Anterior superior iliac spine to the center of the patella and a line connecting the center of the patella to the center of the ankle
. Anterior inferior iliac spine to the center of the patella and a line connecting the center of the patella to the center of the ankle

Correct Answer & Explanation

. Anterior superior iliac spine to the center of the patella and a line connecting the center of the patella to the center of the tibial tuberosity

Explanation

The quadriceps angle, or Q angle, is used to evaluate patellofemoral alignment. It is defined as the angle formed by a line connecting the anterior superior iliac spine to the center of the patella and a line connecting the center of the patella to the center of the tibial tuberosity. A normal angle is up to 10° in men and up to 15° in women. Unfortunately, no standard technique exists for measuring the Q angle, and its reliability and usefulness have recently come under question.

Question 27

Topic: Cervical Spine

A 22-year-old collegiate baseball pitcher presents with medial elbow pain during the acceleration phase of throwing. Physical examination reveals valgus instability at 90 degrees of elbow flexion. Which structure is most likely injured?

. Radial collateral ligament
. Lateral ulnar collateral ligament
. Anterior bundle of the medial ulnar collateral ligament
. Posterior bundle of the medial ulnar collateral ligament
. Transverse ligament

Correct Answer & Explanation

. Anterior bundle of the medial ulnar collateral ligament

Explanation

The anterior bundle of the medial ulnar collateral ligament (MUCL) is the primary static restraint to valgus stress at the elbow between 30 and 120 degrees of flexion. It is most commonly injured in overhead throwing athletes.

Question 28

Topic: 6. Spine

In the subaxial cervical spine, the greatest amount of flexion-extension occurs at which of the following segmental levels?

. Occiput-C1
. C1-C2
. C4-C5
. C5-C6
. C7-T1

Correct Answer & Explanation

. C5-C6

Explanation

The C5-C6 level exhibits the greatest range of flexion-extension in the subaxial cervical spine. Because of this high mobility, it is also the most common level for degenerative cervical spondylosis and disc herniation.

Question 29

Topic: 6. Spine

A "stinger" (transient weakness of the upper extremity commonly seen after a blow to the head and shoulder in football) most commonly affects the:

. Spinal cord
. C -5/C -6 nerve roots
. C -7/C -8 nerve roots
. Axillary nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Spinal cord

Explanation

"Stingers" are common in football. They generally result from a transient stretch to the C -5/C -6 nerve roots resulting in temporary loss of strength of the biceps, deltoid, and spinatus muscles. It is generally safe to allow the athlete to return to participation, provided the cervical spine examination is normal and any neurological deficits have completely resolved.

Question 30

Topic: 6. Spine

C atastrophic cervical spine injuries occurring during contact sports are most commonly a result of:

. Hyperflexion
. Hyperextension
. Flexion/compression
. Rotation
. Distraction

Correct Answer & Explanation

. Hyperflexion

Explanation

Catastrophic injury of the cervical spine resulting in paralysis or death usually occurs from an axial loading mechanism, such as "spear" tackling in football. C ontroversy exists as to whether cervical spinal stenosis is a predisposing factor for catastrophic cervical spine injuries.

Question 31

Topic: 6. Spine

Following tibial eminence fractures in skeletally-immature patients, all of the following sequelae have been described except:

. Residual anterior cruciate ligament laxity
. Osteophytes near the tibial spine
. Loss of knee flexion
. Hypertrophy of the tibial spine
. Loss of terminal knee extension

Correct Answer & Explanation

. Loss of terminal knee extension

Explanation

The overall results following adequate reduction of the tibial spine are good to excellent. Loss of terminal knee extension is thought to occur due to hyperemia, subsequent hypertrophy or displacement of the tibial spine and resultant bony blockage.

Question 32

Topic: 6. Spine
Which of the following statements concerning neck pain is incorrect?
. Patients with traumatic neck injury and pain must be stabilized and assessed with a full neurologic examination while immobilized.
. Elderly patients may have symptoms of traumatic neck injury without a history of trauma.
. Rest, physical therapy, and prolonged immobilization of the neck with a collar are effective in managing patients with neck pain.
. Surgery for neck pain may be indicated for patients with a cervical spine fracture with evidence of instability, neoplastic disorders, spinal stenosis, and nerve root compression.
. Rest and physical therapy

Correct Answer & Explanation

. Rest, physical therapy, and prolonged immobilization of the neck with a collar are effective in managing patients with neck pain.

Explanation

Choices A, B, D, and E are correct and are important considerations with managing a patient with neck pain. Rest and physical therapy are important and effective in treating neck pain. Prolonged immobilization of the neck with a collar, however, can result in deconditioning of the cervical paraspinal musculature, which can increase the patient's risk for further neck injury.

Question 33

Topic: 6. Spine

A 34-year-old man presents to the emergency department after sustaining a low-velocity gunshot wound to the upper back. Radiologic studies reveal bullet fragments scattered throughout the T6 to T8 levels. No evidence of instability is present on conventional radiographs and computed tomography. The patient was stabilized and a full neurologic examination was performed, revealing no major neurologic deficits. Management of this patient should consist of:

. Removal of the bullet fragments from the T6 to T8 vertebral bodies
. Removal of the bullet fragments from the T6 to T8 vertebral bodies and instrumented fusion from T4 to T10
. High-dose intravenous methylprednisolone administration for 24 hours
. Broad-spectrum antibiotic administration for 7 days
. Nonoperative treatment (eg, thoracolumbosacral bracing) and regular observation for progression of any neurologic deficits

Correct Answer & Explanation

. Nonoperative treatment (eg, thoracolumbosacral bracing) and regular observation for progression of any neurologic deficits

Explanation

Removal of the bullet fragments from the T6 to T8 levels is not indicated because the patient does not have neurologic deficits and therefore does not require spinal cord decompression via bullet removal. Decompression via bullet removal for neural deficits in the thoracic spine has been shown to result in higher rates of complications compared with nonoperative management. High-dose steroid administration is not indicated in patients with gunshot wounds to the spine because the benefits of steroids are outweighed by the risks. The administration of broad-spectrum antibiotics is not indicated in this patient because the bullet did not pass through the gastrointestinal tract. Nonoperative management and regular observation for progression of neurologic deficits is important in this patient because of the localization of the bullet fragments to the thoracic spine, the lack of neurologic deficits, and the lack of instability.

Question 34

Topic: Cervical Spine
The majority of studies confirm the presence of atlanto-axial subluxation (AAS) when:
. Anterior atlantodental intervals (AADI) > 0 mm or posterior atlantodental intervals (PADI) < 18 mm
. AADI > 1 mm or PADI ≤ 14 mm
. AADI > 2 mm or PADI ≤ 16 mm
. AADI > 3 mm or PADI ≤ 14 mm
. AADI > 4 mm or PADI ≤ 18 mm

Correct Answer & Explanation

. AADI > 3 mm or PADI ≤ 14 mm

Explanation

As described by Puttlitz and colleagues, AAS is defined as an AADI greater than 3 mm or a PADI less than 14 mm.

Question 35

Topic: Cervical Spine
The most common traumatic indications for occipitocervical fusion include type III occipital condyle fractures and:
. Basilar invagination
. Atlanto-axial subluxation
. Odontoid fracture
. Atlanto-axial dissociation
. C1-C2 instability

Correct Answer & Explanation

. Atlanto-axial dissociation

Explanation

Basilar invagination and atlanto-axial subluxation are more commonly present in degenerative disorders and less in trauma. Odontoid fractures are usually treated via C1-C2 fusion or odontoid screw fixation, although less commonly occipitocervical fusion is required. C1-C2 instability, similarly, is usually treated via C1-C2 stabilization. A more common traumatic indication for occipitocervical fusion is atlanto-axial dissociation.

Question 36

Topic: 6. Spine

Which approach(es) will provide access to the middle and anterior columns of the thoracic spine:

. Posterior
. Anterior (thoracotomy)
. Anterior and posterolateral (costotransversectomy)
. Interlaminar
. None of the above

Correct Answer & Explanation

. Anterior and posterolateral (costotransversectomy)

Explanation

The anterior and posterolateral approaches provide access to the vertebral body (the anterior and middle columns of the spine) for performance of a corpectomy procedure, for example.

Question 37

Topic: 6. Spine

What percentage of patients with cervical myelopathy living in North America exhibit ossification of the posterior longitudinal ligament:

. 1%
. 5%
. 10%
. 25%
. 50%

Correct Answer & Explanation

. 25%

Explanation

Although ossification of the posterior longitudinal ligament is considered most common in the Japanese population, 25% of North Americans with cervical myelopathy exhibit signs of this condition.

Question 38

Topic: 6. Spine

A 46-year-old patient with cervical myelopathy undergoes a multilevel posterior cervical laminectomy from C 3 to C 7. The risk of post laminectomy kyphosis is greatest with removal of which of the following structures:

. More than 80% of the lamina
. More than 50% of each facet joint
. Interspinous ligament
. Facet joint capsules
. Ligamentum flavum

Correct Answer & Explanation

. More than 50% of each facet joint

Explanation

Post laminectomy kyphosis is often seen in patients who have removal of more than 50% of each facet joint or 100% of one facet joint. It is not commonly seen with removal of the ligamentum flavum or interspinous ligament. Less frequently, post laminectomy kyphosis is seen with removal of more than 80% of the lamina or excision of the facet joint capsules.

Question 39

Topic: 6. Spine

A 65-year-old male presents with deteriorating handwriting and difficulty buttoning his shirt. Examination reveals a positive inverted brachioradialis reflex. This sign indicates a spinal cord lesion at which specific cervical level?

. C3
. C4
. C5
. C6
. C7

Correct Answer & Explanation

. C5

Explanation

The inverted brachioradialis reflex localizes a compressive lesion to the C5-C6 spinal level. It manifests as paradoxical finger flexion instead of normal elbow flexion and supination when the brachioradialis tendon is tapped.

Question 40

Topic: 6. Spine

According to Sorensen's criteria, the radiographic diagnosis of classic Scheuermann's kyphosis requires which of the following?

. Anterior wedging of at least 5 degrees in three or more consecutive vertebrae
. Anterior wedging of at least 10 degrees in two consecutive vertebrae
. Schmorl's nodes in at least four continuous vertebral bodies
. A thoracic kyphosis greater than 40 degrees with normal vertebral body shape
. A single wedged vertebra of 15 degrees at the thoracolumbar junction

Correct Answer & Explanation

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

Explanation

Sorensen's criteria define Scheuermann's kyphosis as structural thoracic kyphosis > 40 degrees with anterior wedging of at least 5 degrees in three or more consecutive vertebrae. Endplate irregularities and Schmorl's nodes are common but not strict diagnostic criteria.

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