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6. Spine MCQs

Practice Set 212 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 4221

Topic: 6. Spine

A patient sustains a Denis Zone 3 sacral fracture. Which of the following neurologic deficits is most commonly associated with this specific injury pattern?

. L4 radiculopathy
. L5 radiculopathy
. Bowel and bladder dysfunction
. Quadriceps weakness
. Foot drop

Correct Answer & Explanation

. L4 radiculopathy

Explanation

Denis Zone 3 sacral fractures involve the central sacral canal. They carry a high rate (up to 60%) of bowel, bladder, and sexual dysfunction due to direct injury to the central sacral nerve roots.

Question 4222

Topic: 6. Spine

A 32-year-old construction worker complains of posterior neck pain after forcefully shoveling dirt. Radiographs reveal an avulsion fracture of the C7 spinous process. What is the recommended treatment?

. Immediate halo vest application
. Posterior cervical fusion
. Rigid cervical orthosis for 12 weeks
. Symptomatic management with rest and analgesia
. Anterior cervical discectomy and fusion

Correct Answer & Explanation

. Immediate halo vest application

Explanation

A Clay Shoveler's fracture is an isolated, stable avulsion fracture of a lower cervical or upper thoracic spinous process. Because it does not compromise spinal stability, it is managed symptomatically.

Question 4223

Topic: Thoracolumbar Spine & Deformity

In a 70-year-old patient undergoing multi-level decompression and fusion for adult degenerative scoliosis, which of the following is an accepted indication for extending the fusion to the pelvis?

. L5-S1 disc degeneration with an intact L5-S1 facet joint
. L5 spondylolysis
. Apex of the curve at L2
. Lumbar lordosis of 45 degrees with pelvic incidence of 45 degrees
. Severe fractional curve at L4-S1 with coronal imbalance

Correct Answer & Explanation

. L5-S1 disc degeneration with an intact L5-S1 facet joint

Explanation

Extending a long fusion to the pelvis in adult deformity is indicated when there is significant L5-S1 pathology, a severe fractional curve causing coronal imbalance at the lumbosacral junction, or previous wide laminectomy at L5-S1.

Question 4224

Topic: 6. Spine

A 50-year-old diabetic man presents with severe, unrelenting back pain and fever. MRI confirms L3-L4 discitis with a small epidural abscess without spinal cord compression. He is neurologically intact.

What is the most appropriate initial management?

. Immediate emergent surgical decompression
. CT-guided needle biopsy and cultures
. Initiation of broad-spectrum empiric IV antibiotics
. Lumbar drain placement
. Anterior corpectomy and fusion

Correct Answer & Explanation

. Immediate emergent surgical decompression

Explanation

In a hemodynamically stable, neurologically intact patient with suspected pyogenic discitis/osteomyelitis, an image-guided biopsy should be performed to obtain a precise microbiologic diagnosis before initiating empiric antibiotics.

Question 4225

Topic: Thoracolumbar Spine & Deformity

A 65-year-old woman presents with severe mechanical back pain and an inability to stand up straight. When evaluating her sagittal spinopelvic alignment, which of the following formulas correctly describes the relationship between pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS)?

. PI = PT - SS
. PI = PT + SS
. PT = PI + SS
. SS = PI + PT
. PI = (PT + SS) / 2

Correct Answer & Explanation

. PI = PT - SS

Explanation

Pelvic incidence is a fixed morphological parameter defined as the sum of pelvic tilt and sacral slope (PI = PT + SS). It dictates the amount of lumbar lordosis required to maintain global sagittal balance.

Question 4226

Topic: Thoracolumbar Spine & Deformity

A 35-year-old man falls from a ladder. Examination reveals intact motor and sensory function. CT shows an L1 burst fracture with 40% canal compromise. MRI reveals an intact posterior ligamentous complex (PLC). What is his Thoracolumbar Injury Classification and Severity (TLICS) score, and the recommended treatment?

. Score 2, nonoperative management
. Score 4, operative management
. Score 5, operative management
. Score 2, operative management
. Score 4, nonoperative management

Correct Answer & Explanation

. Score 2, nonoperative management

Explanation

The TLICS score is 2: 1 point for a burst fracture mechanism, 0 points for intact neurology, and 0 points for an intact PLC. A score of 3 or less is typically treated nonoperatively with a brace or early mobilization.

Question 4227

Topic: Thoracolumbar Spine & Deformity

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

. Thoracic kyphosis > 40 degrees
. Coronal Cobb angle > 50 degrees
. Positive sagittal vertical axis (SVA) > 5 cm
. Pelvic tilt < 10 degrees
. Lumbar lordosis > 60 degrees

Correct Answer & Explanation

. Thoracic kyphosis > 40 degrees

Explanation

A positive sagittal vertical axis (SVA) greater than 5 cm is the radiographic parameter most highly correlated with adverse health-related quality of life outcomes in adult spinal deformity patients. Restoration of sagittal balance is the primary goal of reconstructive surgery.

Question 4228

Topic: 6. Spine

A 19-year-old woman involved in a high-speed motor vehicle collision wearing only a lap belt sustains a flexion-distraction injury of the L2 vertebra.

Which of the following concomitant injuries must be ruled out with highest priority?

. Aortic dissection
. Hollow viscus injury
. Pelvic ring fracture
. Diaphragmatic rupture
. Renal artery thrombosis

Correct Answer & Explanation

. Aortic dissection

Explanation

Flexion-distraction injuries (Chance fractures) are highly associated with intra-abdominal injuries, particularly to hollow viscous organs like the small bowel. Prompt general surgery evaluation is critical to prevent sepsis and mortality.

Question 4229

Topic: Thoracolumbar Spine & Deformity

A patient with severe adult degenerative scoliosis and a profound loss of lumbar lordosis develops a progressive positive sagittal vertical axis.

What are the expected primary compensatory mechanisms utilized by the patient to maintain an upright posture and horizontal gaze?

. Pelvic anteversion and knee extension
. Pelvic retroversion and knee flexion
. Pelvic anteversion and hip extension
. Decreased thoracic kyphosis and knee extension
. Increased sacral slope and hip flexion

Correct Answer & Explanation

. Pelvic anteversion and knee extension

Explanation

To compensate for a positive sagittal balance (forward pitch), patients will characteristically retrovert the pelvis (increasing pelvic tilt) and flex their knees. This biomechanically shifts the center of gravity posteriorly.

Question 4230

Topic: 6. Spine

A 25-year-old man falls from a roof and sustains a sacral fracture extending medially to the sacral foramina, involving the central spinal canal. According to the Denis classification, what is the most likely neurologic complication associated with this specific injury zone?

. L5 nerve root palsy
. S1 radiculopathy isolated to motor function
. Bowel, bladder, and sexual dysfunction
. Complete paraplegia below T12
. No neurologic deficit is typically expected

Correct Answer & Explanation

. L5 nerve root palsy

Explanation

This describes a Denis Zone III (central) sacral fracture. Zone III fractures carry the highest risk of neurologic injury (up to 60%), typically manifesting as cauda equina syndrome with profound bowel and bladder dysfunction.

Question 4231

Topic: 6. Spine

A 60-year-old man with advanced ankylosing spondylitis presents with acute neck and back pain after a minor fall.

CT imaging reveals a fracture through the C7-T1 disc space. Which of the following represents the most appropriate management?

. Rigid cervical collar for 12 weeks
. Halo vest immobilization
. Anterior cervical discectomy and fusion
. Posterior long-segment instrumented fusion
. Conservative management with NSAIDs and physical therapy

Correct Answer & Explanation

. Rigid cervical collar for 12 weeks

Explanation

Fractures in ankylosing spondylitis are highly unstable, three-column injuries (often extension-type) due to the rigidly fused spine. They carry a high risk of neurologic decline and typically require long-segment posterior instrumented fusion for adequate stabilization.

Question 4232

Topic: 6. Spine

Which of the following surgical strategies or patient factors most significantly increases the risk of developing proximal junctional kyphosis (PJK) after a long-segment fusion to the pelvis for adult spinal deformity?

. Preoperative diagnosis of osteoporosis
. Ending the construct at the upper thoracic spine (T2-T4) instead of the thoracolumbar junction
. Under-correction of the sagittal vertical axis (SVA)
. Use of hook constructs at the upper instrumented vertebra (UIV)
. Teriparatide therapy started preoperatively

Correct Answer & Explanation

. Preoperative diagnosis of osteoporosis

Explanation

Low bone mineral density (osteoporosis) is a major independent risk factor for PJK and proximal junctional failure. Over-correction (not under-correction) of sagittal balance also significantly increases PJK risk by shifting excessive mechanical stress to the adjacent segment.

Question 4233

Topic: Thoracolumbar Spine & Deformity

A 65-year-old woman presents with severe low back pain and difficulty standing upright. Radiographs reveal adult degenerative scoliosis. Which of the following radiographic parameters correlates most closely with poor health-related quality of life (HRQOL) scores in this patient?

. Coronal Cobb angle > 30 degrees
. Pelvic tilt > 10 degrees
. Sagittal vertical axis (SVA) > 5 cm
. Lumbar lordosis greater than pelvic incidence
. Sacral slope < 20 degrees

Correct Answer & Explanation

. Coronal Cobb angle > 30 degrees

Explanation

In adult spinal deformity, positive sagittal balance (SVA > 5 cm) has been shown to be the most reliable radiographic predictor of poor clinical outcomes and decreased health-related quality of life (HRQOL) scores.

Question 4234

Topic: Thoracolumbar Spine & Deformity

A 45-year-old man falls from a height and sustains an L1 burst fracture. Exam shows normal neurologic function. CT shows 40% loss of vertebral height and retropulsion, with an intact posterior ligamentous complex (PLC) confirmed on MRI. What is his Thoracolumbar Injury Classification and Severity (TLICS) score and the recommended treatment?

. 2 points, nonoperative
. 4 points, operative
. 5 points, operative
. 2 points, operative
. 4 points, nonoperative

Correct Answer & Explanation

. 2 points, nonoperative

Explanation

The TLICS score is 2: morphology is burst (2 points), neurology is intact (0 points), and PLC is intact (0 points). A score of less than 4 generally indicates nonoperative management.

Question 4235

Topic: Thoracolumbar Spine & Deformity

A 24-year-old woman is involved in a high-speed motor vehicle collision while wearing a lap belt. She sustains a T12 Chance fracture.

Which of the following associated injuries must be most highly suspected and ruled out?

. Aortic dissection
. Hollow viscus injury
. Diaphragmatic rupture
. Splenic laceration
. Renal artery thrombosis

Correct Answer & Explanation

. Aortic dissection

Explanation

Chance fractures (flexion-distraction injuries) are frequently associated with lap seatbelt use and have a high incidence (up to 40-50%) of concomitant intra-abdominal injuries, particularly hollow viscus ruptures.

Question 4236

Topic: Thoracolumbar Spine & Deformity

A 55-year-old woman who underwent a T10 to L5 posterior spinal fusion 10 years ago now complains of progressive forward posture and thigh pain when walking. Her pelvic incidence is 55 degrees and her lumbar lordosis is 25 degrees. What is the primary cause of her symptoms?

. Adjacent segment disease at L5-S1
. Pseudarthrosis at L4-L5
. Iatrogenic flatback syndrome with PI-LL mismatch
. Proximal junctional kyphosis
. Degenerative hip osteoarthritis

Correct Answer & Explanation

. Adjacent segment disease at L5-S1

Explanation

The patient has a pelvic incidence to lumbar lordosis (PI-LL) mismatch of 30 degrees (normal target is within 10 degrees). Previous lumbar fusions failing to restore lordosis often result in iatrogenic flatback syndrome and compensatory mechanisms.

Question 4237

Topic: 6. Spine

When planning a long posterior spinal fusion to the sacrum for adult degenerative scoliosis, what is the primary biomechanical advantage of adding bilateral iliac screws?

. Decreased risk of proximal junctional kyphosis
. Prevention of S1 screw pullout by resisting cantilever forces
. Enhanced coronal plane correction
. Decreased operative blood loss
. Elimination of the need for interbody fusion at L5-S1

Correct Answer & Explanation

. Decreased risk of proximal junctional kyphosis

Explanation

Long spinal constructs ending at S1 have a high failure rate due to significant cantilever forces causing S1 screw pullout. Iliac screws provide robust distal fixation anterior to the pivot point, protecting the S1 screws.

Question 4238

Topic: Cervical Spine

An 82-year-old man presents with neck pain after a low-energy fall. CT demonstrates a Type II odontoid fracture with 2 mm of posterior displacement.

He has no neurologic deficits and has significant cardiac comorbidities. What is the most appropriate management?

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

Correct Answer & Explanation

. Halo vest immobilization

Explanation

In elderly patients with significant comorbidities, rigid cervical collar immobilization is often preferred for Type II odontoid fractures to avoid the high morbidity and mortality associated with surgical intervention and halo vests.

Question 4239

Topic: 6. Spine

A 30-year-old man presents with a unilateral C5-C6 facet dislocation following a diving accident. He is awake, alert, and has a dense C6 radiculopathy but no central spinal cord injury. What is the most appropriate management regarding closed reduction?

. Immediate closed reduction under fluoroscopy
. MRI of the cervical spine prior to attempted closed reduction
. Immediate anterior cervical discectomy and fusion without reduction
. Posterior open reduction without MRI
. Halo vest application and delayed MRI

Correct Answer & Explanation

. Immediate closed reduction under fluoroscopy

Explanation

In an awake, alert patient with a neurological deficit, an MRI should be obtained prior to closed reduction to rule out a compressive disc herniation that could cause spinal cord injury during reduction maneuvers.

Question 4240

Topic: 6. Spine

A 68-year-old woman undergoes a T10-pelvis posterior spinal fusion. Six months postoperatively, radiographs reveal a 15-degree kyphotic angle between T9 and T10.

Which of the following is considered a primary risk factor for developing proximal junctional kyphosis (PJK)?

. Under-correction of lumbar lordosis
. Disruption of the posterior ligamentous complex at the uppermost instrumented vertebra (UIV)
. Use of titanium rods instead of cobalt chrome
. Fusion stopping at T4 instead of T10
. Over-correction of the coronal Cobb angle

Correct Answer & Explanation

. Under-correction of lumbar lordosis

Explanation

Proximal junctional kyphosis (PJK) is a common complication after long fusions. Risk factors include disruption of the interspinous ligaments at the UIV, significant sagittal overcorrection, and poor bone quality.

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