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6. Spine MCQs

Practice Set 203 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 4041

Topic: Thoracolumbar Spine & Deformity

When evaluating a patient with adult spinal deformity, achieving appropriate sagittal balance is a primary surgical goal. Which of the following spinopelvic parameter relationships correlates most closely with favorable health-related quality of life (HRQOL) scores?

. Pelvic incidence (PI) minus Lumbar lordosis (LL) < 10 degrees
. Pelvic tilt (PT) > 25 degrees
. Sacral slope (SS) < 20 degrees
. Thoracic kyphosis (TK) > 50 degrees
. Sagittal vertical axis (SVA) > 10 cm

Correct Answer & Explanation

. Pelvic incidence (PI) minus Lumbar lordosis (LL) < 10 degrees

Explanation

A PI-LL mismatch of less than 10 degrees is strongly correlated with improved HRQOL scores in adult spinal deformity patients. Other goals include a sagittal vertical axis (SVA) of < 5 cm and a pelvic tilt (PT) of < 20 degrees.

Question 4042

Topic: Thoracolumbar Spine & Deformity

A 35-year-old man sustains an L1 burst fracture in a motor vehicle collision. He is neurologically intact. Radiographs and CT show 20 degrees of local kyphosis, 40% loss of anterior vertebral body height, and 30% retropulsion of the posterior cortex into the canal. The posterior ligamentous complex is intact on MRI. What is the most appropriate treatment?

. Strict bed rest for 6 weeks
. Thoracolumbosacral orthosis (TLSO) brace
. Anterior corpectomy and fusion
. Posterior pedicle screw fixation
. Laminectomy alone

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) brace

Explanation

In a neurologically intact patient with a stable burst fracture (intact posterior ligamentous complex), nonoperative management with a TLSO or hyperextension brace yields clinical outcomes equivalent to surgery. The degree of canal compromise does not strictly correlate with late neurologic deterioration.

Question 4043

Topic: 6. Spine

A 45-year-old man develops severe right lower extremity radiculopathy. MRI reveals a far lateral (extraforaminal) disc herniation at the L4-L5 level on the right side. 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 compresses the exiting nerve root at that level. Therefore, an L4-L5 far lateral herniation will compress the L4 nerve root, whereas a paracentral herniation compresses the descending L5 root.

Question 4044

Topic: Cervical Spine

An 82-year-old man falls from a standing height and sustains a Type II odontoid fracture with 2 mm of posterior displacement. He is neurologically intact. Given his age and significant medical comorbidities, what is the most appropriate initial management considering the high nonunion rate?

. Halo vest immobilization
. Rigid cervical collar
. Anterior odontoid screw fixation
. Posterior C1-C2 fusion
. Transoral odontoidectomy

Correct Answer & Explanation

. Rigid cervical collar

Explanation

Although Type II odontoid fractures in the elderly have a high nonunion rate, halo vest immobilization carries an unacceptably high morbidity and mortality rate in this population. A rigid cervical collar is the preferred initial nonoperative management for a poor surgical candidate.

Question 4045

Topic: 6. Spine

A 55-year-old man with a long-standing history of ankylosing spondylitis presents to the emergency department complaining of new-onset neck pain after a minor fall. Plain radiographs show typical osteophyte formation and bamboo spine, but no clear fracture. He has no neurologic deficits. What is the mandatory next step in management?

. Discharge with NSAIDs and a soft collar
. Flexion-extension cervical spine radiographs
. Computed tomography (CT) or MRI of the entire cervical spine
. Steroid injection of the cervical facets
. Halo vest application

Correct Answer & Explanation

. Computed tomography (CT) or MRI of the entire cervical spine

Explanation

Patients with ankylosing spondylitis have highly rigid spines susceptible to unstable fractures even from minor trauma. Because plain radiographs are notoriously difficult to interpret in these patients, an advanced imaging study (CT or MRI) is mandatory to rule out an occult fracture.

Question 4046

Topic: 6. Spine

A 30-year-old man sustains a traumatic spondylolisthesis of the axis (Hangman's fracture) following a motor vehicle collision. Radiographs show a bilateral fracture of the C2 with 4 mm of anterior displacement of C2 on C3 and severe angulation. This injury involves disruption of which primary anatomic structure?

. Dens of the axis
. Transverse ligament
. Pars interarticularis of C2
. Alar ligament
. Apical ligament

Correct Answer & Explanation

. Pars interarticularis of C2

Explanation

A Hangman's fracture is a traumatic spondylolisthesis of the axis characterized by bilateral fractures through the pars interarticularis (or pedicles) of C2. It is typically caused by hyperextension and axial loading.

Question 4047

Topic: Cervical Spine

A 26-year-old man presents after a diving accident. He is awake, alert, and cooperative. He complains of severe neck pain and has right-sided upper extremity weakness (C6 distribution). Radiographs reveal a right unilateral facet dislocation at C5-C6. What is the most appropriate initial management?

. Immediate anterior cervical discectomy and fusion (ACDF)
. Immediate posterior cervical fusion
. Closed reduction with awake cranial traction
. Administration of high-dose corticosteroids
. MRI followed by observation

Correct Answer & Explanation

. Closed reduction with awake cranial traction

Explanation

In an awake, alert, and cooperative patient with a cervical facet dislocation, rapid closed reduction using cranial traction is the recommended initial management. An MRI is not strictly required prior to closed reduction if the patient is fully awake and examinable.

Question 4048

Topic: 6. Spine

A 16-year-old boy presents with progressive mid-back pain and a noticeable rounding of his back. Standing lateral radiographs reveal a thoracic kyphosis of 60 degrees. Which of the following radiographic criteria is required to confirm a diagnosis of classic Scheuermann's disease?

. Schmorl's nodes in at least one vertebra
. Anterior wedging of at least 5 degrees in three or more consecutive vertebrae
. Spondylolysis of the L5 pars interarticularis
. Loss of lumbar lordosis > 20 degrees
. Cobb angle > 75 degrees on the AP radiograph

Correct Answer & Explanation

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

Explanation

The classic Sorensen criteria for Scheuermann's kyphosis require the presence of anterior wedging of 5 degrees or more in at least three consecutive vertebrae. Other common but non-diagnostic findings include Schmorl's nodes and endplate irregularities.

Question 4049

Topic: Thoracolumbar Spine & Deformity

A 15-year-old female gymnast complains of 6 months of low back pain that is exacerbated by extension activities. Radiographs demonstrate a pars interarticularis defect at L5 bilaterally and a 15% anterior translation of L5 on S1. Her neurologic examination is normal. What is the most appropriate initial management?

. In situ posterolateral fusion of L5-S1
. L5 laminectomy
. Activity modification, core strengthening, and physical therapy
. Transforaminal lumbar interbody fusion (TLIF)
. Epidural steroid injection

Correct Answer & Explanation

. Activity modification, core strengthening, and physical therapy

Explanation

This patient has a symptomatic Grade 1 isthmic spondylolisthesis. Initial management for low-grade, symptomatic isthmic spondylolisthesis in adolescents is nonoperative, focusing on activity modification (avoiding hyperextension) and core strengthening physical therapy.

Question 4050

Topic: 6. Spine

A 42-year-old man presents with 24 hours of severe lower back pain, bilateral lower extremity weakness, and new-onset urinary incontinence. Perianal sensation is significantly decreased. MRI confirms a massive extruded L4-L5 disc herniation compressing the thecal sac. What is the most critical prognostic factor for his return of bowel and bladder function following surgical decompression?

. The exact size of the disc herniation on MRI
. The patient's preoperative functional status
. The presence or absence of a positive straight leg raise
. The time from onset of autonomic symptoms to surgical decompression
. The use of high-dose perioperative corticosteroids

Correct Answer & Explanation

. The time from onset of autonomic symptoms to surgical decompression

Explanation

This patient presents with acute cauda equina syndrome. The most critical prognostic factor for the recovery of bowel, bladder, and sexual function is the timing of surgical decompression, ideally performed within 24 to 48 hours of symptom onset.

Question 4051

Topic: 6. Spine

A 65-year-old woman presents with severe neurogenic claudication and low back pain. Upright lateral flexion-extension radiographs demonstrate a Grade 1 spondylolisthesis at L4-L5 with 4 mm of dynamic translation. After failing 6 months of comprehensive nonoperative management, what is the most appropriate surgical treatment?

. Lumbar laminectomy alone
. Lumbar laminectomy with posterolateral instrumented fusion
. Stand-alone anterior lumbar interbody fusion
. Placement of an interspinous process spacer
. Lumbar laminectomy with dynamic stabilization

Correct Answer & Explanation

. Lumbar laminectomy with posterolateral instrumented fusion

Explanation

Laminectomy with instrumented fusion is the gold standard for symptomatic lumbar spinal stenosis with concomitant dynamic instability (degenerative spondylolisthesis). Laminectomy alone in this setting has an unacceptably high risk of progressive instability and clinical failure.

Question 4052

Topic: Cervical Spine

A 58-year-old man of East Asian descent presents with progressive clumsiness in his hands, hyperreflexia, and gait instability. Radiographs and MRI show continuous ossification of the posterior longitudinal ligament (OPLL) from C3 to C6, causing severe multilevel cord compression. His cervical alignment is lordotic. What is the most appropriate surgical intervention?

. Anterior cervical discectomy and fusion (ACDF) C3-C6
. Cervical laminectomy without fusion
. Posterior cervical laminoplasty
. Anterior cervical corpectomy C3-C6
. Bilateral posterior cervical foraminotomies

Correct Answer & Explanation

. Posterior cervical laminoplasty

Explanation

Cervical laminoplasty is the ideal procedure for multilevel cord compression due to OPLL in patients with neutral or lordotic alignment. Anterior approaches for multilevel OPLL carry a significantly higher risk of dural tears and neurological injury.

Question 4053

Topic: Thoracolumbar Spine & Deformity

A 35-year-old man falls from a height of 10 feet and sustains an L1 burst fracture. He is neurologically intact with normal perianal tone. MRI demonstrates an intact posterior ligamentous complex (PLC). His Thoracolumbar Injury Classification and Severity (TLICS) score is calculated. What is the most appropriate management?

. Short-segment posterior pedicle screw fixation
. Long-segment posterior pedicle screw fixation
. Anterior corpectomy and strut grafting
. Thoracolumbosacral orthosis (TLSO) bracing and early mobilization
. Posterolateral uninstrumented fusion in situ

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing and early mobilization

Explanation

This patient has a TLICS score of 2 (1 point for compression morphology, 0 for neurologically intact, 1 for intact PLC). A score of 3 or less is an absolute indication for nonoperative management, typically with a TLSO brace and early mobilization.

Question 4054

Topic: Cervical Spine

An 82-year-old man with advanced dementia and severe chronic obstructive pulmonary disease presents after a ground-level fall. CT scan reveals a Type II odontoid fracture with 3 mm of posterior displacement. He is neurologically intact. What is the recommended initial management?

. Halo vest immobilization
. Rigid cervical collar
. Anterior odontoid screw fixation
. Posterior C1-C2 transarticular screws
. Posterior C1-C2 Harms technique fusion

Correct Answer & Explanation

. Rigid cervical collar

Explanation

In elderly patients with severe medical comorbidities, a rigid cervical collar provides adequate stabilization and has significantly lower morbidity and mortality compared to halo vest immobilization or surgical intervention. Although nonunion rates are higher, clinical outcomes remain acceptable.

Question 4055

Topic: Thoracolumbar Spine & Deformity

A 62-year-old woman is planning to undergo reconstructive surgery for adult spinal deformity. Preoperative measurements show her pelvic incidence (PI) is 60 degrees. To achieve optimal sagittal balance postoperatively, what should her target lumbar lordosis (LL) ideally be?

. 10 degrees
. 30 degrees
. 50 degrees
. 70 degrees
. 90 degrees

Correct Answer & Explanation

. 50 degrees

Explanation

To maintain appropriate sagittal balance and prevent flatback deformity, the postoperative lumbar lordosis should ideally be matched within 10 degrees of the patient's pelvic incidence (PI = LL +/- 10 degrees). Therefore, 50 degrees is the optimal target among the choices.

Question 4056

Topic: 6. Spine

A 24-year-old woman involved in a high-speed motor vehicle collision wearing only a lap belt sustains a flexion-distraction injury (Chance fracture) at L2. She is neurologically intact. What associated injury must be rigorously ruled out before definitive spinal management?

. Traumatic aortic dissection
. Extraperitoneal bladder rupture
. Intra-abdominal hollow viscus injury
. Diaphragmatic hernia
. Pelvic ring disruption

Correct Answer & Explanation

. Intra-abdominal hollow viscus injury

Explanation

Chance fractures (flexion-distraction injuries) are frequently associated with the 'seatbelt syndrome,' which carries a high risk (up to 50%) of concurrent intra-abdominal hollow viscus injuries. Prompt general surgical evaluation is critical.

Question 4057

Topic: 6. Spine

A 55-year-old man with a 20-year history of ankylosing spondylitis presents with acute, severe localized lower back pain after a minor slip and fall. Initial radiographs are equivocal, but a CT scan demonstrates a transdiscal fracture at T11-T12. He is neurologically intact. What is the most appropriate definitive management?

. TLSO bracing for 12 weeks
. Early mobilization with intensive physical therapy
. Short-segment posterior instrumentation
. Long-segment posterior instrumentation and fusion
. Anterior lumbar interbody fusion alone

Correct Answer & Explanation

. Long-segment posterior instrumentation and fusion

Explanation

Fractures in the ankylosed spine act as highly unstable shear injuries and have a substantial risk of secondary neurological decline or epidural hematoma. Long-segment posterior instrumentation (at least three levels above and below) is required due to the long lever arms of the rigid spine.

Question 4058

Topic: 6. Spine

A 65-year-old man presents with progressive difficulty buttoning his shirts, frequent tripping, and bilateral hand numbness. Physical examination reveals a positive Hoffmann sign bilaterally, hyperreflexia in the lower extremities, and an unsteady, wide-based gait. MRI of the cervical spine shows severe canal stenosis at C4-C5 and C5-C6 with T2 signal changes in the spinal cord. What is the most appropriate next step in management?

. Physical therapy and oral NSAIDs
. Epidural steroid injection
. Anterior cervical discectomy and fusion (ACDF) or posterior decompression
. Carpal tunnel release
. Observation with serial MRIs

Correct Answer & Explanation

. Anterior cervical discectomy and fusion (ACDF) or posterior decompression

Explanation

This patient presents with classic signs of cervical spondylotic myelopathy (CSM). Once myelopathy is clinically apparent and progressive, surgical decompression (anterior, posterior, or combined) is indicated to prevent further neurological decline.

Question 4059

Topic: 6. Spine

When evaluating a 60-year-old female for adult degenerative scoliosis and severe low back pain, standing full-length spine radiographs are obtained. Which of the following radiographic parameters is most closely correlated with improved health-related quality of life (HRQOL) scores following corrective surgery?

. Cobb angle of the primary coronal curve
. Apical vertebral rotation
. Sagittal vertical axis (SVA) less than 5 cm
. Pelvic incidence (PI) magnitude
. Lumbar lordosis (LL) exceeding pelvic incidence (PI) by 20 degrees

Correct Answer & Explanation

. Sagittal vertical axis (SVA) less than 5 cm

Explanation

In adult spinal deformity, restoration of sagittal balance is the primary driver of improved clinical outcomes. An SVA of less than 5 cm and a Pelvic Incidence to Lumbar Lordosis (PI-LL) mismatch of less than 10 degrees are the most critical parameters to achieve.

Question 4060

Topic: Cervical Spine

An 82-year-old man falls from a standing height and sustains a Type II odontoid fracture with 3 mm of posterior displacement. He is neurologically intact but has severe neck pain. He has a history of severe COPD, ischemic heart disease, and osteoporosis. What is the most appropriate initial management?

. Rigid cervical collar immobilization
. Halo vest immobilization for 12 weeks
. Posterior C1-C2 instrumental fusion
. Anterior odontoid screw fixation
. Minerva cast application

Correct Answer & Explanation

. Rigid cervical collar immobilization

Explanation

In elderly patients with significant comorbidities, rigid cervical collar immobilization is generally preferred for Type II odontoid fractures. Operative morbidity and halo vest complication rates (e.g., pneumonia, aspiration, death) are exceptionally high in this demographic.

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