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6. Spine MCQs

Practice Set 20 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 381

Topic: 6. Spine

A 65-year-old male presents with global spine stiffness but minimal pain. Radiographs reveal flowing ossification along the anterolateral aspect of five contiguous vertebral bodies in the thoracic spine, with relative preservation of intervertebral disc height and normal sacroiliac joints. What is the most likely diagnosis?

. Ankylosing spondylitis
. Diffuse idiopathic skeletal hyperostosis (DISH)
. Ossification of the posterior longitudinal ligament (OPLL)
. Severe degenerative osteoarthritis
. Scheuermann's disease

Correct Answer & Explanation

. Diffuse idiopathic skeletal hyperostosis (DISH)

Explanation

DISH is characterized by flowing anterolateral osteophytes involving at least four contiguous vertebral bodies, preserved disc height, and the absence of sacroiliac joint erosion. It is distinct from ankylosing spondylitis, which classically involves the sacroiliac joints.

Question 382

Topic: 6. Spine

A 16-year-old male football lineman complains of localized low back pain exacerbating with spinal extension. Plain radiographs are normal. Which imaging modality is currently preferred to definitively detect an early, acute pars interarticularis stress reaction (marrow edema) without exposing the patient to ionizing radiation?

. Computed tomography (CT) scan
. Magnetic resonance imaging (MRI)
. Bone scintigraphy (SPECT)
. Dynamic ultrasound
. DEXA scan

Correct Answer & Explanation

. Magnetic resonance imaging (MRI)

Explanation

MRI, specifically utilizing STIR or T2 fat-suppressed sequences, is highly sensitive for detecting bone marrow edema indicative of an acute pars stress reaction. It is preferred over SPECT or CT because it avoids radiation exposure in the adolescent population.

Question 383

Topic: 6. Spine

A 32-year-old intravenous drug user presents with progressive, unrelenting back pain. MRI confirms hematogenous pyogenic discitis-osteomyelitis at the L3-L4 level. Based on the vascular anatomy of the adult spine, which region of the spinal segment is typically the initial site of bacterial seeding?

. The center of the nucleus pulposus
. The annulus fibrosus
. The pars interarticularis
. The vertebral endplate
. The anterior longitudinal ligament

Correct Answer & Explanation

. The vertebral endplate

Explanation

In adults, the intervertebral disc is avascular. Hematogenous infection initially seeds the highly vascularized subchondral bone of the vertebral endplate, subsequently destroying the endplate and spreading into the adjacent avascular disc.

Question 384

Topic: 6. Spine

A patient presents with severe right-sided neck pain radiating down the arm. Examination reveals weakness in right wrist extension, an absent brachioradialis reflex, and decreased sensation over the dorsal aspect of the thumb and index finger. Which cervical nerve root is most likely compressed?

. C4
. C5
. C6
. C7
. C8

Correct Answer & Explanation

. C6

Explanation

A C6 radiculopathy classically presents with weakness in wrist extension, sensory deficits over the thumb and index finger, and a diminished brachioradialis reflex. C5 affects the deltoid/biceps, while C7 primarily affects triceps and wrist flexion.

Question 385

Topic: 6. Spine
A 50-year-old female presents with progressive myelopathy due to a large, centrally located, calcified thoracic disc herniation at T8-T9. Which of the following surgical approaches is generally contraindicated due to the unacceptably high risk of catastrophic spinal cord injury?
. Costotransversectomy
. Anterior transthoracic corpectomy
. Posterior laminectomy
. Lateral extracavitary approach
. Thoracoscopic discectomy

Correct Answer & Explanation

. Posterior laminectomy

Explanation

A simple posterior laminectomy is contraindicated for a central thoracic disc herniation due to the need to retract the delicate thoracic spinal cord to access the disc, resulting in an unacceptably high risk of permanent paraplegia. Anterior or posterolateral approaches are required.

Question 386

Topic: 6. Spine

A traumatic spondylolisthesis of the axis, historically termed a 'Hangman's fracture', classically involves bilateral fractures passing through which anatomical structure of the C2 vertebra?

. Odontoid process
. Lateral masses
. Pars interarticularis
. Spinous process
. Anterior arch

Correct Answer & Explanation

. Pars interarticularis

Explanation

A Hangman's fracture is defined as bilateral fractures through the pars interarticularis of the C2 vertebra. It is typically caused by a hyperextension and axial loading mechanism.

Question 387

Topic: 6. Spine

A 45-year-old male presents with right leg pain radiating down the lateral calf to the dorsum of the foot. Examination reveals 3/5 strength in the extensor hallucis longus and decreased sensation over the first dorsal web space. Which nerve root is most likely compressed?

. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L5

Explanation

A posterolateral disc herniation at L4-L5 typically compresses the traversing L5 nerve root. This presents with weakness in the EHL and sensory deficits over the first dorsal web space.

Question 388

Topic: 6. Spine

A 65-year-old female with known degenerative spondylolisthesis at L4-L5 presents with worsening back and leg pain. She reports a new onset of urinary incontinence. Post-void residual bladder volume is 400 mL. The most appropriate immediate management is:

. Epidural steroid injection
. Lumbar MRI and emergent decompression
. Foley catheter and physical therapy
. Oral dexamethasone taper
. Immediate lumbar fusion without decompression

Correct Answer & Explanation

. Lumbar MRI and emergent decompression

Explanation

The patient exhibits classic signs of cauda equina syndrome, including urinary retention/incontinence and a high post-void residual. Emergent MRI and surgical decompression are indicated to prevent permanent neurological deficits.

Question 389

Topic: Thoracolumbar Spine & Deformity

An 11-year-old gymnast presents with persistent lower back pain exacerbated by extension. Oblique lumbar radiographs demonstrate a "collar on the Scotty dog." What is the most appropriate initial management?

. Immediate in-situ posterolateral fusion
. Activity modification and rigid bracing
. Translaminar screw fixation
. Corticosteroid injections
. Laminectomy

Correct Answer & Explanation

. Activity modification and rigid bracing

Explanation

The radiograph finding indicates a pars interarticularis defect (spondylolysis). Initial management for symptomatic pediatric spondylolysis without significant slip is non-operative, primarily consisting of activity restriction and bracing.

Question 390

Topic: 6. Spine

In evaluating a patient with cervical spondylotic myelopathy, which of the following physical exam findings is considered the earliest clinical sign of disease progression?

. Loss of bowel and bladder control
. Bilateral foot drop
. Hoffman sign and loss of fine motor dexterity
. Severe neck pain radiating to the shoulders
. Absent deep tendon reflexes in the lower extremities

Correct Answer & Explanation

. Hoffman sign and loss of fine motor dexterity

Explanation

Subtle loss of hand dexterity (e.g., difficulty buttoning shirts) and upper motor neuron signs like the Hoffman sign are often the earliest clinical indicators of cervical myelopathy.

Question 391

Topic: 6. Spine

A 55-year-old male with long-standing ankylosing spondylitis presents to the emergency department after a low-energy fall. He complains of severe lower neck pain but has a normal neurologic exam. Plain radiographs of the cervical spine are difficult to interpret due to marked deformity. What is the most critical next step in imaging?

. Flexion-extension cervical radiographs
. CT scan of the entire cervical and upper thoracic spine
. Bone scintigraphy
. Diagnostic ultrasound
. Lateral decubitus plain films

Correct Answer & Explanation

. CT scan of the entire cervical and upper thoracic spine

Explanation

Patients with ankylosing spondylitis are at high risk for highly unstable "chalk-stick" fractures even from minor trauma. A CT scan of the affected spinal region is critical as plain radiographs often miss these fractures.

Question 392

Topic: 6. Spine

A 70-year-old man presents with neurogenic claudication. He reports his bilateral leg pain improves when leaning forward on a shopping cart. This postural relief is primarily due to:

. Increased cross-sectional area of the spinal canal
. Decreased pressure on the intervertebral discs
. Stretching of the tight hamstring muscles
. Opening of the anterior longitudinal ligament
. Reduction of an anterior pelvic tilt

Correct Answer & Explanation

. Increased cross-sectional area of the spinal canal

Explanation

Flexion of the lumbar spine increases the cross-sectional area of the spinal canal and neural foramina. This relieves the dynamic compression on the nerve roots, characteristic of lumbar spinal stenosis.

Question 393

Topic: 6. Spine

A 60-year-old woman is undergoing a lumbar laminectomy for spinal stenosis. During the procedure, an incidental durotomy occurs. What is the most appropriate management?

. Leave the tear open and place a closed suction drain
. Primary repair with non-absorbable suture and watertight closure
. Packing the defect with bone wax
. Immediate termination of the surgery without repair
. Application of topical antibiotics only

Correct Answer & Explanation

. Primary repair with non-absorbable suture and watertight closure

Explanation

Incidental durotomies should be repaired primarily with a watertight closure to prevent cerebrospinal fluid leaks. Placing a subfascial drain on suction is generally contraindicated as it can exacerbate the leak.

Question 394

Topic: 6. Spine

Which of the following Modic changes on MRI of the lumbar spine is characterized by high signal intensity on T1-weighted images and intermediate-to-high signal intensity on T2-weighted images?

. Type 1
. Type 2
. Type 3
. Type 4
. Type 5

Correct Answer & Explanation

. Type 2

Explanation

Modic Type 2 changes represent fatty replacement of the red marrow adjacent to the endplates. Fat shows high signal intensity on T1 and intermediate-high signal on T2.

Question 395

Topic: 6. Spine

A 24-year-old male is involved in a motor vehicle collision and sustains a hyper-flexion injury to the cervical spine. MRI shows a unilateral facet dislocation at C5-C6. He has right-sided upper extremity weakness. What is the sequence of management?

. Closed reduction with cranial traction in the awake patient followed by MRI if neurologic status changes
. Immediate posterior cervical fusion without reduction
. Immediate anterior cervical discectomy without reduction
. Application of a soft collar and outpatient follow-up
. Observation until the weakness resolves

Correct Answer & Explanation

. Closed reduction with cranial traction in the awake patient followed by MRI if neurologic status changes

Explanation

In an awake, cooperative patient with a cervical facet dislocation, rapid closed reduction using cranial traction is safe and effective. An MRI is required if the patient fails reduction or develops worsening neurologic symptoms.

Question 396

Topic: 6. Spine

During a posterolateral approach to the lower lumbar spine, a surgeon encounters excessive bleeding from a venous plexus located within the spinal canal. This bleeding is most likely originating from the:

. Artery of Adamkiewicz
. Batson's venous plexus
. Internal iliac vein
. Segmental medullary arteries
. Basivertebral vein

Correct Answer & Explanation

. Batson's venous plexus

Explanation

Batson's venous plexus is a valveless network of veins located in the epidural space of the spinal canal. It is frequently encountered and can be a source of significant bleeding during spinal surgery.

Question 397

Topic: 6. Spine

In evaluating a patient with a traumatic spinal cord injury, the physical exam reveals loss of motor function and proprioception on the right side of the lower body, and loss of pain and temperature sensation on the left side. This presentation is characteristic of:

. Central cord syndrome
. Anterior cord syndrome
. Brown-Sequard syndrome
. Posterior cord syndrome
. Cauda equina syndrome

Correct Answer & Explanation

. Brown-Sequard syndrome

Explanation

Brown-Sequard syndrome results from a functional hemisection of the spinal cord. It presents with ipsilateral loss of motor function and proprioception, and contralateral loss of pain and temperature sensation.

Question 398

Topic: 6. Spine

A 35-year-old male presents with severe mid-thoracic back pain and myelopathy. Imaging reveals a massive, calcified central disc herniation at T7-T8 compressing the spinal cord. What is the safest surgical approach for decompression?

. Standard posterior laminectomy
. Transforaminal lumbar interbody fusion approach
. Costotransversectomy or transthoracic approach
. Posterior interlaminar approach
. Endoscopic interlaminar approach

Correct Answer & Explanation

. Costotransversectomy or transthoracic approach

Explanation

A standard posterior laminectomy for a central thoracic disc herniation is highly contraindicated due to the risk of spinal cord traction and paraplegia. Anterior or lateral approaches (e.g., costotransversectomy or transthoracic) are required to safely remove the disc without retracting the cord.

Question 399

Topic: Thoracolumbar Spine & Deformity

Degenerative spondylolisthesis most commonly occurs at which level, and is largely attributed to the sagittal orientation of the facet joints?

. L2-L3
. L3-L4
. L4-L5
. L5-S1
. C5-C6

Correct Answer & Explanation

. L4-L5

Explanation

Degenerative spondylolisthesis most frequently occurs at the L4-L5 level. It is commonly associated with a more sagittal orientation of the facet joints, which provides less resistance to anterior shear forces.

Question 400

Topic: 6. Spine

The "danger space" in the cervical spine is a potential space that allows for the spread of infection from the neck directly into the mediastinum. It is located between the:

. Alar fascia and prevertebral fascia
. Buccopharyngeal fascia and alar fascia
. Platysma and superficial cervical fascia
. Carotid sheath and investing fascia
. Pretracheal fascia and strap muscles

Correct Answer & Explanation

. Alar fascia and prevertebral fascia

Explanation

The danger space is located between the alar fascia anteriorly and the prevertebral fascia posteriorly. It extends from the skull base down to the diaphragm, serving as a conduit for infections to spread into the posterior mediastinum.

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