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6. Spine MCQs

Practice Set 200 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 3981

Topic: 6. Spine

The Thoracolumbar Injury Classification and Severity (TLICS) score is used to guide the surgical management of thoracolumbar trauma. Which of the following is NOT one of the three main categories evaluated in the TLICS system?

. Morphology of the injury
. Neurologic status of the patient
. Integrity of the posterior ligamentous complex
. Degree of spinal canal compromise
. None of the above (all are categories)

Correct Answer & Explanation

. Degree of spinal canal compromise

Explanation

The TLICS system determines the need for surgery based on three components: injury morphology (compression, burst, translation/rotation, distraction), integrity of the posterior ligamentous complex (PLC), and neurologic status. The degree of spinal canal compromise is not a distinct scoring category in this system.

Question 3982

Topic: 6. Spine

A 52-year-old woman presents with neck pain radiating down her left arm. Physical examination demonstrates weakness in elbow extension and wrist flexion, along with an absent triceps reflex. She reports numbness primarily in her long (middle) finger. Which cervical nerve root is most likely compressed?

. C5
. C6
. C7
. C8
. T1

Correct Answer & Explanation

. C7

Explanation

Compression of the C7 nerve root typically results in weakness of the triceps (elbow extension) and wrist flexors, an absent or diminished triceps reflex, and sensory deficits localized to the long (middle) finger. This most commonly occurs from a C6-C7 disc herniation.

Question 3983

Topic: 6. Spine

A 60-year-old man with end-stage renal disease on hemodialysis presents with severe, unrelenting mid-back pain and fever. Laboratory tests show an ESR of 100 mm/h and a CRP of 50 mg/L. MRI of the spine with gadolinium reveals a dorsal epidural abscess causing moderate cord compression. What is the most common causative organism for this condition?

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

Correct Answer & Explanation

. Staphylococcus aureus

Explanation

Staphylococcus aureus is the most common causative pathogen for spontaneous spinal epidural abscesses and pyogenic vertebral osteomyelitis, accounting for more than half of all cases. Hematogenous spread is a common etiology, especially in patients with indwelling catheters or those on hemodialysis.

Question 3984

Topic: 6. Spine
A 30-year-old male is intubated following a high-speed motor vehicle collision. A trauma CT scan of the head and neck demonstrates a significantly increased basion-dens interval (>12 mm) and a Powers ratio greater than 1, diagnostic of atlanto-occipital dissociation (AOD). What is the definitive treatment for this highly unstable injury?
. Prolonged application of a halo vest
. Occipitocervical fusion
. C1-C2 posterior instrumented fusion
. Anterior transoral odontoid resection
. Rigid cervical collar for 12 weeks

Correct Answer & Explanation

. Occipitocervical fusion

Explanation

Atlanto-occipital dissociation (AOD) is a highly unstable, predominantly ligamentous injury with little capacity for spontaneous healing. Definitive management requires surgical occipitocervical fusion. Halo traction or immobilization is strictly contraindicated as it can cause fatal over-distraction of the spinal cord.

Question 3985

Topic: 6. Spine

A 70-year-old man presents with bilateral upper extremity weakness (hands greater than shoulders) and mild lower extremity clumsiness after a hyperextension injury during a fall.

What is the most appropriate initial hemodynamic management for this patient?

. Permissive hypotension
. Maintain Mean Arterial Pressure (MAP) > 85 mmHg for 7 days
. Administer high-dose methylprednisolone within 8 hours
. Immediate emergent cervical laminectomy
. Observe without continuous hemodynamic monitoring

Correct Answer & Explanation

. Maintain Mean Arterial Pressure (MAP) > 85 mmHg for 7 days

Explanation

This patient has Central Cord Syndrome, which often results from a hyperextension injury in a stenotic cervical spine. Current guidelines recommend maintaining a Mean Arterial Pressure (MAP) > 85 mmHg for 7 days to optimize spinal cord perfusion and limit secondary ischemic injury.

Question 3986

Topic: Thoracolumbar Spine & Deformity

A 35-year-old man falls from a roof, sustaining an L1 burst fracture. His neurological examination is completely intact. MRI demonstrates an intact posterior ligamentous complex (PLC). The fracture exhibits 15 degrees of local kyphosis. Based on the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the recommended management?

. Posterior short-segment instrumented fusion
. Anterior corpectomy and fusion
. Thoracolumbosacral orthosis (TLSO) bracing
. Laminectomy alone
. Percutaneous pedicle screw fixation

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing

Explanation

The TLICS score is 2 (burst fracture morphology = 2, intact PLC = 0, intact neurological status = 0). A TLICS score of less than 4 indicates that non-operative management, such as TLSO bracing and early mobilization, is appropriate.

Question 3987

Topic: 6. Spine

Which of the following preoperative factors is the most reliable negative prognostic indicator for postoperative neurological recovery in a patient undergoing surgical decompression for degenerative cervical spondylotic myelopathy?

. Age greater than 50 years
. Presence of a positive Hoffmann sign
. Duration of symptoms greater than 18 months
. Hyperintense spinal cord signal on T2-weighted MRI alone
. Cervical lordosis of 10 degrees

Correct Answer & Explanation

. Duration of symptoms greater than 18 months

Explanation

A prolonged duration of symptoms (typically greater than 12-18 months) prior to surgical decompression is a well-established negative predictor for neurological recovery in cervical myelopathy. Hypointense T1 signal changes are also a strong negative prognostic sign, whereas T2 changes alone are less definitive.

Question 3988

Topic: Cervical Spine

An 82-year-old man sustains a Type II odontoid fracture after a ground-level fall. He is neurologically intact. Which of the following stabilization methods is associated with the highest risk of severe morbidity and mortality in this specific patient population?

. Rigid cervical collar
. Halo vest immobilization
. Posterior C1-C2 instrumented fusion
. Anterior odontoid screw fixation
. Minerva cast

Correct Answer & Explanation

. Posterior C1-C2 instrumented fusion

Explanation

Halo vest immobilization in the elderly (typically defined as over 65-70 years) is associated with unacceptably high rates of morbidity and mortality, primarily due to respiratory complications, dysphagia, and falls. If surgery is indicated, posterior C1-C2 fusion is often preferred.

Question 3989

Topic: 6. Spine

A 65-year-old woman presents with severe neurogenic claudication and low back pain. Radiographs demonstrate a Grade I L4-L5 degenerative spondylolisthesis that increases to Grade II on dynamic flexion films. What is the most appropriate surgical intervention if a 6-month trial of conservative management fails?

. L4-L5 laminectomy alone
. L4-L5 decompression and instrumented fusion
. Stand-alone anterior lumbar interbody fusion (ALIF)
. Interspinous process spacer placement
. L4-L5 microdiscectomy

Correct Answer & Explanation

. L4-L5 decompression and instrumented fusion

Explanation

In the presence of a mobile or unstable degenerative spondylolisthesis associated with spinal stenosis, performing decompression combined with instrumented fusion provides superior long-term clinical outcomes and prevents progressive slip compared to decompression alone.

Question 3990

Topic: 6. Spine

A 22-year-old restrained passenger in a high-speed motor vehicle collision sustains a flexion-distraction (Chance) fracture of L2. Due to the mechanism of this injury, which of the following associated injuries must be aggressively ruled out?

. Aortic transection
. Gastrointestinal hollow viscus injury
. Renal artery thrombosis
. Pulmonary contusion
. Diaphragmatic rupture

Correct Answer & Explanation

. Gastrointestinal hollow viscus injury

Explanation

Chance fractures (flexion-distraction injuries) result from a seatbelt fulcrum effect acting on the abdominal wall and spine. They have a high association (up to 40-50%) with intra-abdominal injuries, particularly hollow viscus injuries like bowel perforations.

Question 3991

Topic: 6. Spine

A patient sustains a traumatic spondylolisthesis of the axis (Hangman's fracture). Imaging demonstrates severe angulation with minimal translation, consistent with a Levine-Edwards Type IIA fracture. Which of the following management steps is strictly contraindicated?

. Application of longitudinal cervical traction
. Application of a hard cervical collar
. Gentle extension and compression in a halo vest
. Surgical stabilization with C2 pars screws
. CT angiogram to assess the vertebral arteries

Correct Answer & Explanation

. Application of longitudinal cervical traction

Explanation

Type IIA Hangman's fractures result from a flexion-distraction mechanism. Application of longitudinal cervical traction is strictly contraindicated as it exacerbates the injury, increases displacement, and stretches the spinal cord by widening the posterior disc space.

Question 3992

Topic: 6. Spine

A 30-year-old man presents neurologically intact but with severe neck pain following a football tackle. CT demonstrates a unilateral C5-C6 facet dislocation. He is awake, cooperative, and able to follow commands perfectly. What is the next most appropriate step in management?

. Immediate MRI of the cervical spine
. Awake closed reduction with skeletal traction
. Emergent posterior cervical fusion without reduction
. Emergent anterior cervical discectomy and fusion
. Application of a halo vest without reduction

Correct Answer & Explanation

. Awake closed reduction with skeletal traction

Explanation

In an awake, cooperative, and neurologically examinable patient with a cervical facet dislocation, rapid awake closed reduction via skeletal traction is safely indicated. Pre-reduction MRI is mandatory if the patient is unexaminable (e.g., obtunded) or fails closed reduction, to rule out a compressive herniated disc.

Question 3993

Topic: 6. Spine

A 60-year-old man with a 30-year history of ankylosing spondylitis presents with new-onset mechanical neck pain after a minor fall from a chair. Initial plain radiographs of the cervical spine are read as normal. His neurological exam is intact. What is the most appropriate next step?

. Discharge with NSAIDs and physical therapy
. Flexion-extension cervical radiographs
. CT scan of the entire cervical spine
. Reassurance and follow-up in 4 weeks
. Application of a soft collar

Correct Answer & Explanation

. CT scan of the entire cervical spine

Explanation

Patients with ankylosing spondylitis have brittle, fused spines and are at extremely high risk for unstable, through-and-through occult spinal fractures even after trivial trauma. If plain films are negative or obscured, a CT scan (or MRI) of the spine is mandatory to definitively rule out a fracture.

Question 3994

Topic: 6. Spine

A 45-year-old man presents with right arm pain and weakness following a weightlifting injury. Examination reveals a diminished brachioradialis reflex, weakness in wrist extension, and numbness over the dorsal web space 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 typically presents with weakness in wrist extension and elbow flexion, a diminished brachioradialis reflex, and sensory changes in the thumb and index finger. This is most commonly caused by a herniated disc at the C5-C6 level.

Question 3995

Topic: 6. Spine

A 50-year-old man presents with severe left-sided anterior thigh pain. Examination reveals profound weakness in left knee extension and a diminished left patellar reflex. Sensation is decreased over the medial aspect of the leg. MRI demonstrates a far lateral (extraforaminal) disc herniation. At which level is this herniation most likely located?

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

Correct Answer & Explanation

. L4-L5

Explanation

A far lateral (extraforaminal) disc herniation at the L4-L5 level compresses the exiting L4 nerve root, leading to L4 radiculopathy symptoms (quadriceps weakness, decreased patellar reflex, medial leg numbness). A paracentral disc at the same level would compress the traversing L5 root.

Question 3996

Topic: Cervical Spine

An 82-year-old woman falls from a standing height and presents with severe neck pain. Radiographs reveal a Type II odontoid fracture with 3 mm of posterior displacement. She has a history of severe COPD and ischemic heart disease. What is the most appropriate non-operative management for this patient?

. Hard cervical collar
. Halo vest immobilization
. Minerva cast
. Soft cervical collar
. Observation with no immobilization

Correct Answer & Explanation

. Hard cervical collar

Explanation

In elderly patients with Type II odontoid fractures, halo vest immobilization is associated with high morbidity and a mortality rate approaching 40%. A hard cervical collar is the preferred non-operative treatment, despite a higher risk of nonunion, because it is much better tolerated and has significantly lower complication rates.

Question 3997

Topic: 6. Spine

A 65-year-old man sustains a hyperextension injury to his cervical spine during a motor vehicle collision. On examination, he has motor weakness in all four extremities, but his upper extremities (especially the hands) are significantly weaker than his lower extremities. What is the typical pattern of functional recovery in this syndrome?

. Hand function recovers first, followed by lower extremities
. Bowel and bladder function rarely recover
. Lower extremity function recovers first, followed by proximal upper extremities
. Most patients remain permanently non-ambulatory
. Upper extremity fine motor skills fully normalize in over 90% of patients

Correct Answer & Explanation

. Lower extremity function recovers first, followed by proximal upper extremities

Explanation

This patient has Central Cord Syndrome. The typical pattern of neurological recovery proceeds from the lower extremities to bowel/bladder function, then to the proximal upper extremities, with fine motor function of the hands being the last and least likely to recover fully.

Question 3998

Topic: 6. Spine

A 70-year-old man presents with bilateral leg pain and fatigue that worsens after walking two blocks. Which of the following clinical findings most reliably differentiates neurogenic claudication from vascular claudication?

. Pain relieved by standing completely still
. Pain exacerbated by walking uphill
. Pain relieved by sitting or leaning forward over a shopping cart
. Absent dorsalis pedis pulses
. Cramping, tightening pain confined solely to the calves

Correct Answer & Explanation

. Pain relieved by sitting or leaning forward over a shopping cart

Explanation

Neurogenic claudication due to lumbar spinal stenosis is classically relieved by sitting or forward lumbar flexion (the "shopping cart sign"), which increases the cross-sectional area of the spinal canal. Vascular claudication is typically relieved by simply standing still and is exacerbated by the increased metabolic demand of walking uphill.

Question 3999

Topic: 6. Spine

A 55-year-old man presents with difficulty buttoning his shirts and a wide-based, unsteady gait. Physical examination reveals a positive Hoffmann's sign. Which of the following additional physical examination findings is most specific for this patient's underlying condition?

. Lhermitte's sign
. Inverted supinator reflex
. Spurling's sign
. Absent biceps reflex
. Tinel's sign at the wrist

Correct Answer & Explanation

. Inverted supinator reflex

Explanation

The patient has symptoms of cervical spondylotic myelopathy, characterized by upper motor neuron signs. The inverted supinator reflex (brachioradialis reflex testing causing finger flexion) is a highly specific upper motor neuron sign, whereas Spurling's indicates radiculopathy and Lhermitte's is non-specific.

Question 4000

Topic: Thoracolumbar Spine & Deformity

A 25-year-old woman involved in a high-speed motor vehicle collision presents with a transverse ecchymosis across her abdomen (seatbelt sign). Radiographs reveal an osseous flexion-distraction injury (Chance fracture) of L2. What associated injury must be most urgently and specifically ruled out?

. Aortic dissection
. Intra-abdominal hollow viscus injury
. Pelvic ring disruption
. Diaphragmatic rupture
. Renal laceration

Correct Answer & Explanation

. Intra-abdominal hollow viscus injury

Explanation

Flexion-distraction injuries (Chance fractures) are highly associated with intra-abdominal injuries, particularly hollow viscus injuries like bowel rupture, which occur in up to 40-50% of cases. A thorough abdominal evaluation, usually with CT, is strictly required.

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