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6. Spine MCQs

Practice Set 21 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 401

Topic: 6. Spine

A 32-year-old woman presents with severe back pain, bilateral sciatica, saddle anesthesia, and urinary retention. MRI confirms a massive L4-L5 disc herniation compressing the thecal sac. For optimal prognostic neurologic recovery, emergent surgical decompression should ideally be performed within:

. 12 hours
. 24 hours
. 48 hours
. 72 hours
. 1 week

Correct Answer & Explanation

. 48 hours

Explanation

Cauda equina syndrome is a surgical emergency. Decompression performed within 48 hours is associated with a significantly higher rate of resolution of sensory and motor deficits, as well as bladder and bowel dysfunction.

Question 402

Topic: 6. Spine

A 60-year-old man with neurogenic claudication finds significant relief of his leg pain when leaning forward on a shopping cart. This postural relief is anatomically explained by:

. A decrease in the bulging of the intervertebral disc
. An increase in the cross-sectional area of the spinal canal
. Relaxation of the paraspinal musculature
. Stretching of the ligamentum flavum leading to thickening
. Opening of the facet joints reducing nerve root tension

Correct Answer & Explanation

. An increase in the cross-sectional area of the spinal canal

Explanation

Flexion of the lumbar spine stretches the ligamentum flavum (making it thinner) and opens the interlaminar space, thereby increasing the cross-sectional area of the spinal canal and relieving pressure on the nerve roots.

Question 403

Topic: 6. Spine

In a patient with a suspected far lateral (extraforaminal) disc herniation at the L4-L5 level, which nerve root is most directly compressed?

. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L4

Explanation

A far lateral (extraforaminal) disc herniation impinges the exiting nerve root at that level. At L4-L5, the exiting root is L4, whereas a standard posterolateral herniation at L4-L5 would impinge the traversing L5 root.

Question 404

Topic: 6. Spine

An 80-year-old man with a history of prostate cancer presents with severe, unremitting low back pain that is worse at night. Anteroposterior plain radiographs reveal an absent right pedicle at L3. This radiographic finding is classically referred to as the:

. Bamboo spine appearance
. Scotty dog sign
. Winking owl sign
. Picture frame vertebra
. Rugger jersey spine

Correct Answer & Explanation

. Winking owl sign

Explanation

The "winking owl" sign occurs on an AP radiograph when one pedicle is destroyed (often by lytic metastatic disease), leaving only the contralateral pedicle visible, resembling a winking owl.

Question 405

Topic: 6. Spine

A 65-year-old patient with long-standing ankylosing spondylitis sustains a minor fall. He complains of new-onset mechanical neck pain but exhibits no neurologic deficits. Plain radiographs of the cervical spine are obscured by the shoulders and appear unremarkable. The most appropriate next step in management is:

. Discharge with NSAIDs and muscle relaxants
. Placement in a soft cervical collar and outpatient follow-up
. CT scan of the entire cervical spine
. Flexion-extension dynamic radiographs
. Electromyography of the upper extremities

Correct Answer & Explanation

. CT scan of the entire cervical spine

Explanation

Patients with ankylosing spondylitis have a highly rigid spine, making them highly susceptible to unstable fractures even from minor trauma. A CT scan is mandatory as plain radiographs often miss these fractures.

Question 406

Topic: 6. Spine

A 50-year-old woman presents with worsening clumsiness in her hands and difficulty maintaining balance while walking. Examination reveals a positive Hoffman's sign, hyperreflexia in the lower extremities, and a broad-based gait. The most likely diagnosis is:

. Amyotrophic lateral sclerosis
. Cervical spondylotic myelopathy
. Lumbar spinal stenosis
. Guillain-Barre syndrome
. Syringomyelia

Correct Answer & Explanation

. Cervical spondylotic myelopathy

Explanation

The triad of upper extremity clumsiness, gait instability, and upper motor neuron signs (Hoffman's, hyperreflexia) is the classic presentation of cervical spondylotic myelopathy.

Question 407

Topic: Cervical Spine

The Rule of Spence is utilized to evaluate the integrity of the transverse ligament in C1 ring (Jefferson) fractures. A ruptured transverse ligament is indicated if the combined lateral mass overhang on an open-mouth odontoid radiograph exceeds:

. 3.5 mm
. 5.0 mm
. 6.9 mm
. 8.5 mm
. 10.0 mm

Correct Answer & Explanation

. 6.9 mm

Explanation

According to the Rule of Spence, a combined overhang of the lateral masses of C1 on C2 of more than 6.9 mm indicates a rupture of the transverse alar ligament, signifying instability.

Question 408

Topic: 6. Spine

A 72-year-old woman falls and strikes her chin, forcing her neck into severe hyperextension. She develops profound motor weakness in her arms and hands, but retains relatively preserved motor strength in her legs. Which incomplete spinal cord syndrome does this represent?

. Anterior cord syndrome
. Posterior cord syndrome
. Central cord syndrome
. Brown-Sequard syndrome
. Conus medullaris syndrome

Correct Answer & Explanation

. Central cord syndrome

Explanation

Central cord syndrome typically occurs after a hyperextension injury in patients with preexisting cervical stenosis. It predominantly affects the centrally located cervical tracts, causing upper extremity weakness out of proportion to the lower extremities.

Question 409

Topic: Thoracolumbar Spine & Deformity
A 25-year-old male presents with severe mechanical back pain. Standing lateral lumbar radiographs reveal a pars interarticularis defect with a 35% anterior translation of L5 on S1. According to the Meyerding classification, this represents:
. Grade I spondylolisthesis
. Grade II spondylolisthesis
. Grade III spondylolisthesis
. Grade IV spondylolisthesis
. Spondyloptosis

Correct Answer & Explanation

. Grade II spondylolisthesis

Explanation

The Meyerding classification grades the percentage of slip: Grade I (0-25%), Grade II (26-50%), Grade III (51-75%), Grade IV (76-100%), and Grade V (>100%, spondyloptosis). A 35% slip is Grade II.

Question 410

Topic: 6. Spine

A 40-year-old male sustains a stab wound to the right side of his thoracic spine. He subsequently exhibits loss of ipsilateral motor function and proprioception, and loss of contralateral pain and temperature sensation below the lesion level. This presentation is characteristic of:

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

Correct Answer & Explanation

. Brown-Sequard syndrome

Explanation

Brown-Sequard syndrome results from spinal cord hemisection. It features ipsilateral loss of motor function (corticospinal tract) and dorsal column function (proprioception), with contralateral loss of spinothalamic function (pain/temperature).

Question 411

Topic: 6. Spine

In a patient suffering from central lumbar spinal stenosis, the hypertrophy of which specific posterior ligament significantly contributes to the dorsal narrowing of the spinal canal?

. Anterior longitudinal ligament
. Posterior longitudinal ligament
. Ligamentum flavum
. Interspinous ligament
. Supraspinous ligament

Correct Answer & Explanation

. Ligamentum flavum

Explanation

The ligamentum flavum lines the posterior aspect of the spinal canal. Its hypertrophy and buckling with age, along with facet arthropathy, are primary contributors to acquired degenerative central spinal stenosis.

Question 412

Topic: 6. Spine

A patient presenting with an acute posterolateral disc herniation at the C5-C6 level will most likely exhibit weakness in which of the following actions?

. Shoulder abduction
. Wrist extension
. Elbow extension
. Finger flexion
. Finger abduction

Correct Answer & Explanation

. Wrist extension

Explanation

A C5-C6 disc herniation compresses the exiting C6 nerve root. The C6 root supplies the extensor carpi radialis longus and brevis (wrist extension) and the biceps/brachioradialis (elbow flexion).

Question 413

Topic: 6. Spine

Which of the following physical examination maneuvers is considered a Waddell sign, indicating a non-organic component to a patient's low back pain presentation?

. Pain elicited on a straight leg raise test at 30 degrees
. Severe pain behavior elicited upon simulated axial downward loading on the skull
. Relief of leg pain with forward spinal flexion
. Exacerbation of lower back pain with spinal extension
. Radicular pain radiating down past the knee

Correct Answer & Explanation

. Severe pain behavior elicited upon simulated axial downward loading on the skull

Explanation

Waddell signs test for non-organic (psychological or exaggerated) pain. Simulated axial loading of the skull causing lower back pain is a classic non-organic sign, as this maneuver does not physiologically load the lumbar spine.

Question 414

Topic: Thoracolumbar Spine & Deformity

A 14-year-old female gymnast presents with persistent, activity-related lower back pain. Oblique lumbar radiographs reveal a "collared Scotty dog" appearance. This radiographic sign specifically indicates:

. Spondylolisthesis
. Spondylolysis
. Herniated nucleus pulposus
. Facet arthropathy
. Discitis

Correct Answer & Explanation

. Spondylolysis

Explanation

The "collared Scotty dog" sign seen on oblique lumbar radiographs represents a defect or fracture in the pars interarticularis, which is the definition of spondylolysis.

Question 415

Topic: Thoracolumbar Spine & Deformity

Following a motor vehicle collision, a 30-year-old man sustains a burst fracture of L1. According to the Denis three-column concept of spinal stability, the middle column comprises the:

. Anterior longitudinal ligament and anterior half of the vertebral body
. Posterior half of the vertebral body, posterior annulus, and posterior longitudinal ligament
. Pedicles, facets, and pars interarticularis
. Spinous processes and supraspinous ligament
. Ligamentum flavum and neural arch

Correct Answer & Explanation

. Posterior half of the vertebral body, posterior annulus, and posterior longitudinal ligament

Explanation

In the Denis three-column theory, the middle column consists of the posterior half of the vertebral body, the posterior portion of the annulus fibrosus, and the posterior longitudinal ligament. Disruption of this column characterizes a burst fracture.

Question 416

Topic: 6. Spine

A 55-year-old man presents with progressive clumsiness in his hands, frequent dropping of objects, and a wide-based gait. Examination reveals hyperreflexia in the lower extremities and a positive Hoffmann sign bilaterally. Which of the following is the most appropriate initial diagnostic imaging modality?

. CT scan of the cervical spine without contrast
. MRI of the brain
. MRI of the cervical spine
. Electromyography (EMG) of the upper extremities
. Radiographs of the thoracic spine

Correct Answer & Explanation

. MRI of the cervical spine

Explanation

The patient's symptoms and signs (clumsiness, wide-based gait, hyperreflexia, positive Hoffmann sign) are classic for cervical spondylotic myelopathy. MRI of the cervical spine is the gold standard for evaluating spinal cord compression.

Question 417

Topic: 6. Spine

A 45-year-old man develops acute right leg pain radiating to the anterior thigh following heavy lifting. Physical examination demonstrates weakness in knee extension and a diminished patellar tendon reflex. An MRI of the lumbar spine reveals a far lateral 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 compresses the exiting nerve root at that level. Therefore, a far lateral disc at L4-L5 compresses the L4 nerve root, leading to anterior thigh pain, quadriceps weakness, and a decreased patellar reflex.

Question 418

Topic: Thoracolumbar Spine & Deformity

A 14-year-old female gymnast presents with progressive low back pain. Examination reveals a palpable step-off at the lumbosacral junction. Radiographs demonstrate a Grade 2 isthmic spondylolisthesis at L5-S1. Neurological examination is normal. What is the most appropriate initial management?

. In situ posterolateral fusion of L5-S1
. Reduction and pedicle screw fixation
. Activity modification, physical therapy, and bracing
. Laminectomy of L5
. Epidural steroid injection

Correct Answer & Explanation

. Activity modification, physical therapy, and bracing

Explanation

Initial management of low-grade (Grade 1 and 2) isthmic spondylolisthesis without neurological deficits in an adolescent is conservative. This involves activity modification, physical therapy emphasizing core stabilization, and potentially bracing.

Question 419

Topic: 6. Spine

A 60-year-old man presents to the emergency department with severe acute lower back pain, bilateral sciatica, and perineal numbness. Which of the following clinical findings is the most sensitive indicator of cauda equina syndrome?

. Bilateral absence of the Achilles reflex
. Decreased rectal tone on digital examination
. Urinary retention with a post-void residual greater than 100-200 mL
. Bilateral positive straight leg raise test
. Loss of bulbocavernosus reflex

Correct Answer & Explanation

. Urinary retention with a post-void residual greater than 100-200 mL

Explanation

Urinary retention is the most consistent and sensitive finding in cauda equina syndrome. A normal post-void residual bladder volume effectively rules out the diagnosis in most cases.

Question 420

Topic: 6. Spine

A 35-year-old intravenous drug user presents with fever, severe focal mid-back pain, and elevated inflammatory markers. MRI reveals an anterior epidural abscess at T8. The empirical antibiotic regimen should primarily target which of the following microorganisms?

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

Correct Answer & Explanation

. Staphylococcus aureus

Explanation

Staphylococcus aureus is the most common causative organism in spinal epidural abscesses and vertebral osteomyelitis, particularly in intravenous drug users. Empirical coverage must include MRSA along with gram-negative coverage until cultures are finalized.

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