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6. Spine MCQs

Practice Set 211 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 4201

Topic: 6. Spine

A 30-year-old intubated and sedated polytrauma patient has a normal, high-quality multidetector CT scan of the cervical spine. According to current Eastern Association for the Surgery of Trauma (EAST) guidelines, what is the most appropriate next step regarding cervical spine clearance?

. Obtain dynamic flexion-extension fluoroscopy
. Perform a screening bedside MRI of the cervical spine
. Discontinue the cervical collar based on the negative high-quality CT scan
. Maintain the collar until the patient is extubated for a reliable clinical exam
. Empirically treat with a halo vest until consciousness normalizes

Correct Answer & Explanation

. Obtain dynamic flexion-extension fluoroscopy

Explanation

Current EAST guidelines state that a high-quality, normal multidetector CT scan is highly sensitive for detecting clinically significant cervical spine injuries. In obtunded patients, the cervical collar can be safely removed based on the negative CT scan alone.

Question 4202

Topic: 6. Spine

When planning surgical correction for adult spinal deformity, the primary goal for regional sagittal alignment is to achieve a Lumbar Lordosis (LL) that is within what range of the Pelvic Incidence (PI)?

. +/- 10 degrees
. +/- 20 degrees
. +/- 30 degrees
. PI and LL are independent parameters that do not correlate
. LL should be exactly half of the PI

Correct Answer & Explanation

. +/- 10 degrees

Explanation

For optimal sagittal balance in adult spinal deformity, the goal is to achieve a Lumbar Lordosis (LL) within 10 degrees of the patient's Pelvic Incidence (PI). Mismatches greater than 10 degrees are highly correlated with poor health-related quality of life scores.

Question 4203

Topic: 6. Spine

A 55-year-old woman presents with increasing back pain, a forward leaning posture, and fatigue when walking. She underwent a posterior spinal fusion with Harrington rods for adolescent idiopathic scoliosis 35 years ago. Which of the following surgical strategies is most appropriate to restore her sagittal balance?

. Anterior lumbar interbody fusion (ALIF) alone
. Extension of the fusion to the pelvis without osteotomies
. Pedicle subtraction osteotomy (PSO) at the apex of the lumbar deformity
. Multiple Smith-Petersen osteotomies in the thoracic spine
. Placement of an interspinous distraction device

Correct Answer & Explanation

. Anterior lumbar interbody fusion (ALIF) alone

Explanation

Iatrogenic flatback syndrome is typically rigid and best treated with an asymmetrical, closing wedge osteotomy like a Pedicle Subtraction Osteotomy (PSO). This can provide 30-35 degrees of lordosis at a single level to correct fixed sagittal imbalance.

Question 4204

Topic: Thoracolumbar Spine & Deformity

A 24-year-old male is involved in a high-speed motor vehicle collision while wearing only a lap belt. Radiographs and CT show a transverse fracture through the L1 spinous process, pedicles, and vertebral body. Which of the following associated injuries must be highly suspected and ruled out?

. Diaphragmatic rupture
. Aortic tear
. Hollow viscus injury
. Renal laceration
. Pancreatic transection

Correct Answer & Explanation

. Diaphragmatic rupture

Explanation

Chance fractures (flexion-distraction injuries) have a high association (up to 50%) with intra-abdominal injuries. Hollow viscus injuries, particularly bowel perforations, must be actively suspected and ruled out.

Question 4205

Topic: Thoracolumbar Spine & Deformity

In a 60-year-old patient with adult de novo degenerative lumbar scoliosis, which of the following radiographic findings is most predictive of rapid curve progression?

. Cobb angle of 15 degrees
. Lateral listhesis greater than 6 mm
. Nash-Moe Grade 1 apical rotation
. L5-S1 disc space narrowing
. Presence of multiple Schmorl's nodes

Correct Answer & Explanation

. Cobb angle of 15 degrees

Explanation

Risk factors for rapid progression in adult degenerative scoliosis include a Cobb angle greater than 30 degrees, apical rotation of Grade II or III, and lateral listhesis greater than 6 mm at any level.

Question 4206

Topic: Thoracolumbar Spine & Deformity

According to the Thoracolumbar Injury Classification and Severity (TLICS) score, which of the following combinations automatically meets the threshold (score >= 5) for operative intervention?

. Compression fracture, intact PLC, normal neurology
. Burst fracture, suspected PLC injury, normal neurology
. Translation/rotation injury, intact PLC, normal neurology
. Burst fracture, intact PLC, incomplete spinal cord injury
. Compression fracture, suspected PLC injury, normal neurology

Correct Answer & Explanation

. Compression fracture, intact PLC, normal neurology

Explanation

A burst fracture (2 points) combined with an incomplete neurological deficit (3 points) yields a total TLICS score of 5. A score of 5 or greater favors operative management.

Question 4207

Topic: Thoracolumbar Spine & Deformity



A 68-year-old man presents with progressive stooped posture and low back pain. Radiographic analysis reveals a significant mismatch between pelvic incidence and lumbar lordosis. Which of the following compensatory mechanisms allows this patient to maintain horizontal gaze and an upright stance despite a positive sagittal vertical axis?

. Hip flexion and knee extension
. Pelvic retroversion (increased Pelvic Tilt)
. Pelvic anteversion (decreased Pelvic Tilt)
. Thoracic hyperkyphosis
. Lumbar hyperlordosis

Correct Answer & Explanation

. Hip flexion and knee extension

Explanation

In the setting of positive sagittal imbalance, patients compensate by retroverting the pelvis, which increases Pelvic Tilt (PT). Additional compensatory mechanisms include decreasing thoracic kyphosis and flexing the knees and hips.

Question 4208

Topic: 6. Spine

A 35-year-old man presents after a high-speed MVC. CT imaging demonstrates bilateral pars interarticularis fractures of C2 with 4 mm of anterior translation and 12 degrees of angulation of C2 on C3. The C2-C3 disc space is disrupted. According to the Levine-Edwards classification, what is the most appropriate management?

. Rigid cervical collar for 6 weeks
. Closed reduction with gentle traction, followed by halo vest immobilization
. Immediate anterior C2-C3 ACDF without traction
. Extreme weight traction to over-distract the fracture fragments
. C1-C2 posterior instrumented fusion

Correct Answer & Explanation

. Rigid cervical collar for 6 weeks

Explanation

This is a Type II Hangman's fracture, characterized by disruption of the C2-C3 disc with angulation and translation. Initial management involves gentle traction and reduction followed by halo vest immobilization.

Question 4209

Topic: 6. Spine

A 62-year-old woman undergoes a T10 to Pelvis posterior spinal fusion for adult degenerative scoliosis. One year postoperatively, she presents with palpable hardware prominence and back pain at the upper aspect of her incision. Radiographs show a 20-degree kyphotic angle between T9 and T10. Which of the following intraoperative factors most increases the risk of this complication?

. Stopping the proximal construct at the apex of the thoracic kyphosis
. Using pedicle screws instead of hooks at the uppermost instrumented vertebra
. Fusing to the pelvis rather than stopping at L5
. Preserving the supraspinous ligament at the upper instrumented vertebra
. Achieving optimal pelvic incidence to lumbar lordosis matching

Correct Answer & Explanation

. Stopping the proximal construct at the apex of the thoracic kyphosis

Explanation

Proximal junctional kyphosis (PJK) is heavily influenced by construct selection. Terminating a long fusion construct exactly at the apex of thoracic kyphosis significantly increases the mechanical risk of PJK.

Question 4210

Topic: Thoracolumbar Spine & Deformity

In the evaluation of a thoracolumbar burst fracture, disruption of the middle column is the defining characteristic. Which of the following anatomical structures forms the middle column according to the Denis three-column theory?

. Anterior half of the vertebral body, anterior annulus, and anterior longitudinal ligament (ALL)
. Posterior half of the vertebral body, posterior annulus, and posterior longitudinal ligament (PLL)
. Pedicles, facet joints, and ligamentum flavum
. Spinous processes, interspinous ligaments, and supraspinous ligaments
. Transverse processes and intertransverse ligaments

Correct Answer & Explanation

. Anterior half of the vertebral body, anterior annulus, and anterior longitudinal ligament (ALL)

Explanation

The Denis middle column consists of the posterior half of the vertebral body, the posterior aspect of the annulus fibrosus, and the posterior longitudinal ligament (PLL).

Question 4211

Topic: Thoracolumbar Spine & Deformity

A 45-year-old man falls from a roof and sustains an L1 burst fracture with 60% canal compromise and an intact neurologic examination. MRI demonstrates that the posterior ligamentous complex is intact. Which management strategy is most appropriate?

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

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO)

Explanation

Neurologically intact patients with a thoracolumbar burst fracture and an intact posterior ligamentous complex (TLICS score < 4) can be successfully managed nonoperatively with a TLSO. Surgery is generally reserved for neurologic deficits or ligamentous instability.

Question 4212

Topic: Thoracolumbar Spine & Deformity

In the evaluation of adult spinal deformity, which of the following radiographic parameters correlates most closely with poor health-related quality of life (HRQOL) scores?

. Coronal Cobb angle greater than 40 degrees
. Sagittal vertical axis (SVA) greater than 5 cm
. Lumbar lordosis equal to pelvic incidence
. Sacral slope less than 20 degrees
. Thoracic kyphosis greater than 50 degrees

Correct Answer & Explanation

. Coronal Cobb angle greater than 40 degrees

Explanation

A positive Sagittal Vertical Axis (SVA) greater than 5 cm is the radiographic parameter most strongly correlated with adverse health-related quality of life outcomes and pain in adult spinal deformity.

Question 4213

Topic: Thoracolumbar Spine & Deformity

A 22-year-old woman involved in a high-speed motor vehicle collision while wearing a lap seatbelt sustains a flexion-distraction injury of T12.

What associated injury must be most highly suspected and ruled out?

. Aortic dissection
. Intra-abdominal hollow viscus injury
. Diaphragmatic rupture
. Renal artery avulsion
. Sternoclavicular dislocation

Correct Answer & Explanation

. Aortic dissection

Explanation

Chance fractures (flexion-distraction injuries) are highly associated with intra-abdominal injuries. Hollow viscus injuries, such as bowel rupture, occur in up to 50% of these patients.

Question 4214

Topic: 6. Spine

A 35-year-old man presents with bilateral jumped facets at C5-C6 following a diving accident. He has a complete C5 spinal cord injury. Which of the following is the most appropriate next step in management after securing the airway and maintaining hemodynamic stability?

. Immediate MRI of the cervical spine
. Closed reduction with cranial traction
. Open posterior reduction and fusion
. Open anterior cervical discectomy and fusion
. Administration of high-dose methylprednisolone

Correct Answer & Explanation

. Immediate MRI of the cervical spine

Explanation

In an awake, cooperative patient with a cervical facet dislocation and a neurologic deficit, emergent closed reduction with cranial traction is indicated to decompress the spinal cord as rapidly as possible before obtaining an MRI.

Question 4215

Topic: Thoracolumbar Spine & Deformity

When planning surgical correction for a 65-year-old woman with adult degenerative scoliosis, the surgeon aims to restore sagittal balance. The patient has a pelvic incidence of 55 degrees. What is the optimal target lumbar lordosis?

. 25 degrees
. 35 degrees
. 45 degrees
. 55 degrees
. 65 degrees

Correct Answer & Explanation

. 25 degrees

Explanation

To achieve optimal sagittal balance, the lumbar lordosis (LL) should be matched to within 9 degrees of the pelvic incidence (PI). Therefore, a target LL of approximately 55 degrees is appropriate.

Question 4216

Topic: Cervical Spine

An 80-year-old man sustains a Type II odontoid fracture after a ground-level fall. Displacement is 2 mm. He has severe medical comorbidities. What is the most appropriate management?

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

Correct Answer & Explanation

. Halo vest immobilization

Explanation

In elderly patients with significant comorbidities and minimally displaced Type II odontoid fractures, rigid cervical collar immobilization is preferred. Halo vests carry an unacceptably high morbidity and mortality rate in this population.

Question 4217

Topic: 6. Spine

A 25-year-old man is brought to the ED after a severe motorcycle crash. He is flaccid and areflexic below the C6 level. Blood pressure is 80/50 mmHg and heart rate is 50 bpm. What is the primary pathophysiologic cause of his hemodynamic status?

. Loss of sympathetic tone
. Hypovolemia from hemorrhage
. Loss of parasympathetic tone
. Decreased cardiac contractility due to myocardial contusion
. Adrenal insufficiency

Correct Answer & Explanation

. Loss of sympathetic tone

Explanation

Neurogenic shock is characterized by hypotension and bradycardia resulting from a loss of sympathetic vascular tone. It is typically seen in complete or high-grade spinal cord injuries above the T6 level.

Question 4218

Topic: 6. Spine

Which of the following factors most significantly increases the risk of proximal junctional kyphosis (PJK) following long posterior spinal fusion for adult spinal deformity?

. Stopping the fusion construct at the thoracolumbar junction
. Preserving the posterior interspinous ligaments at the Upper Instrumented Vertebra (UIV)
. Terminating the construct at T2 rather than T10
. Under-correction of sagittal balance
. Stopping the fusion at the upper end vertebra of the thoracic curve

Correct Answer & Explanation

. Stopping the fusion construct at the thoracolumbar junction

Explanation

Terminating a long fusion construct at the thoracolumbar junction (T11-L1) is a major risk factor for PJK because it forces the transition zone into a highly mobile and mechanically stressed region.

Question 4219

Topic: 6. Spine

A patient with a C6 spinal cord injury has intact anal sensation but no voluntary anal sphincter contraction. Motor function is grade 0/5 below the C6 level. What is the ASIA Impairment Scale grade?

. ASIA A
. ASIA B
. ASIA C
. ASIA D
. ASIA E

Correct Answer & Explanation

. ASIA A

Explanation

ASIA B indicates a sensory incomplete spinal cord injury. Sensory function (including sacral segments S4-S5) is preserved, but no motor function is preserved more than three levels below the motor level.

Question 4220

Topic: 6. Spine

A 60-year-old man with advanced ankylosing spondylitis presents with new-onset neck pain after a minor fall. Initial plain radiographs of the cervical spine are unremarkable.

What is the most appropriate next step in management?

. Discharge with NSAIDs and a soft collar
. Perform flexion-extension radiographs
. Obtain an MRI or CT of the cervical spine
. Prescribe physical therapy
. Perform a bone scan

Correct Answer & Explanation

. Discharge with NSAIDs and a soft collar

Explanation

Patients with ankylosing spondylitis are at high risk for highly unstable, occult spinal fractures even after minor trauma. Advanced imaging (CT or MRI) is mandatory when there is clinical suspicion, as plain radiographs often miss these fractures.

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