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6. Spine MCQs

Practice Set 213 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 4241

Topic: 6. Spine

A 45-year-old man with a long history of ankylosing spondylitis presents to the ED after a minor fall complaining of neck pain. He has no neurologic deficits. Initial plain radiographs of the cervical spine are read as negative.

What is the next best step in management?

. Discharge with NSAIDs and a soft collar
. Flexion-extension cervical radiographs
. CT scan of the cervical spine
. Electromyography (EMG) of the upper extremities
. Immediate halo vest application

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. A CT scan of the spine is mandatory if they present with pain, as plain films are notoriously inadequate.

Question 4242

Topic: Thoracolumbar Spine & Deformity

A 40-year-old man is scheduled for an L5-S1 anterior lumbar interbody fusion (ALIF) for isthmic spondylolisthesis. During the approach, which structure is at highest risk of injury leading to retrograde ejaculation?

. Superior hypogastric plexus
. Ilioinguinal nerve
. Sympathetic trunk
. Parasympathetic pelvic splanchnic nerves
. Genitofemoral nerve

Correct Answer & Explanation

. Superior hypogastric plexus

Explanation

The superior hypogastric plexus lies anterior to the L5-S1 disc space. Injury to these sympathetic fibers during an anterior approach to L5-S1 can result in retrograde ejaculation in males.

Question 4243

Topic: 6. Spine

A 28-year-old man is involved in a high-speed MVC. Imaging reveals a bilateral pars interarticularis fracture of C2 with 4 mm of anterior translation and severe angulation (Levine and Edwards Type IIA).

What is the appropriate management?

. Application of skeletal traction to reduce the fracture followed by halo
. Immediate anterior C2-C3 fusion
. Application of a halo vest in slight compression and extension without traction
. Posterior C1-C2 fusion
. Rigid cervical collar for 12 weeks

Correct Answer & Explanation

. Application of skeletal traction to reduce the fracture followed by halo

Explanation

Type IIA Hangman's fractures feature significant angulation with disruption of the C2-C3 disc. Traction is strictly contraindicated as it will over-distract the unstable disc space; treatment is gentle reduction with extension and compression in a halo.

Question 4244

Topic: Cervical Spine

A 35-year-old construction worker presents with lower neck pain after forcefully lifting a heavy load. Plain radiographs show an avulsion fracture of the spinous process of C7.

There are no neurologic deficits. What is the most appropriate management?

. Anterior cervical discectomy and fusion at C6-C7
. Posterior instrumental fusion of C6-T1
. Halo vest immobilization for 6 weeks
. Symptomatic care with a soft collar and analgesics
. CT angiography to rule out vertebral artery injury

Correct Answer & Explanation

. Anterior cervical discectomy and fusion at C6-C7

Explanation

A Clay Shoveler's fracture is a stable avulsion fracture of the lower cervical or upper thoracic spinous processes. It is mechanically stable and treated symptomatically with relative rest and analgesia.

Question 4245

Topic: Thoracolumbar Spine & Deformity

A 45-year-old man falls from a height and sustains a thoracolumbar burst fracture at L1. He is neurologically intact. Radiographs show 20 degrees of kyphosis and 40% loss of vertebral body height. MRI shows an intact posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity Score (TLICS), what is the most appropriate management?

. Posterior spinal fusion
. Anterior corpectomy and fusion
. Thoracolumbosacral orthosis (TLSO)
. Short segment pedicle screw fixation
. Percutaneous vertebroplasty

Correct Answer & Explanation

. Posterior spinal fusion

Explanation

The TLICS score for this patient is 2 (burst fracture = 2, neurologically intact = 0, PLC intact = 0). A score of 3 or less implies nonoperative management is indicated, typically with a TLSO or hyperextension brace.

Question 4246

Topic: Thoracolumbar Spine & Deformity

In the evaluation of adult spinal deformity, which of the following spinopelvic parameters is considered a fixed, position-independent morphologic measurement?

. Pelvic tilt (PT)
. Sacral slope (SS)
. Lumbar lordosis (LL)
. Pelvic incidence (PI)
. Sagittal vertical axis (SVA)

Correct Answer & Explanation

. Pelvic tilt (PT)

Explanation

Pelvic incidence is a fixed anatomic parameter defined by the angle between a perpendicular line to the sacral plate and a line connecting the midpoint of the sacral plate to the bicoxofemoral axis. Unlike pelvic tilt and sacral slope, it does not change with patient positioning.

Question 4247

Topic: Thoracolumbar Spine & Deformity

A 65-year-old woman presents with adult degenerative scoliosis and severe mechanical back pain. Preoperative assessment reveals a Pelvic Incidence (PI) of 55 degrees. To optimize her postoperative sagittal alignment and minimize the risk of disability, what should be her target postoperative Lumbar Lordosis (LL)?

. 25 degrees
. 35 degrees
. 55 degrees
. 75 degrees
. 85 degrees

Correct Answer & Explanation

. 25 degrees

Explanation

To achieve optimal sagittal balance in adult spinal deformity, the lumbar lordosis (LL) should be restored to within 9 to 10 degrees of the patient's pelvic incidence (PI). Since her PI is 55 degrees, a target LL of approximately 55 degrees minimizes the PI-LL mismatch.

Question 4248

Topic: Thoracolumbar Spine & Deformity

A 22-year-old man involved in a high-speed motor vehicle collision sustains a flexion-distraction injury (Chance fracture) of L2. Which of the following associated injuries must be highly suspected and ruled out?

. Aortic dissection
. Pulmonary contusion
. Hollow viscus injury
. Diaphragmatic rupture
. Renal artery thrombosis

Correct Answer & Explanation

. Aortic dissection

Explanation

Chance fractures are flexion-distraction injuries commonly caused by lap seatbelts during motor vehicle accidents. They are highly associated with intra-abdominal injuries, particularly to hollow organs such as the bowel, occurring in up to 50% of cases.

Question 4249

Topic: 6. Spine

A 75-year-old man with a history of long-standing ankylosing spondylitis presents with new-onset neck pain after a minor ground-level fall. Neurologic examination is unremarkable. Initial plain radiographs show marked deformity but no obvious fracture. What is the next most appropriate step in management?

. Discharge with a soft cervical collar
. Perform dynamic flexion-extension radiographs
. Obtain a cervical MRI or CT scan
. Prescribe NSAIDs and outpatient physical therapy
. Administer high-dose IV methylprednisolone

Correct Answer & Explanation

. Discharge with a soft cervical collar

Explanation

Patients with ankylosing spondylitis are at a high risk for highly unstable extension-type spinal fractures, even following minor trauma. Due to altered biomechanics, plain films are often inadequate; a CT or MRI must be obtained to definitively rule out an occult fracture or epidural hematoma.

Question 4250

Topic: Thoracolumbar Spine & Deformity



A 30-year-old construction worker falls off a ladder and sustains an L1 burst fracture. CT scan reveals a vertically oriented fracture of the lamina. What is the most critical implication of this specific posterior element fracture pattern?

. It increases the risk of a persistent cerebrospinal fluid leak post-healing
. It indicates an increased likelihood of dural tear and nerve root entrapment
. It requires anterior-only surgical stabilization
. It decreases the risk of post-traumatic kyphosis
. It guarantees the patient will develop conus medullaris syndrome

Correct Answer & Explanation

. It increases the risk of a persistent cerebrospinal fluid leak post-healing

Explanation

A vertical laminar fracture associated with a thoracolumbar burst fracture is highly predictive of a dural tear. During surgery, care must be taken to avoid over-distraction, which could lead to nerve roots being pulled into the fracture site and entrapped.

Question 4251

Topic: Thoracolumbar Spine & Deformity

A 68-year-old woman with a history of adult degenerative scoliosis presents with a progressive forward-leaning posture. Radiographs show a Sagittal Vertical Axis (SVA) of +12 cm. What is the primary compensatory mechanism utilizing the pelvis to maintain upright posture in this condition?

. Pelvic anteversion (decreased pelvic tilt)
. Pelvic retroversion (increased pelvic tilt)
. Decreased sacral slope with decreased pelvic tilt
. Increased lumbar lordosis
. Increased thoracic kyphosis

Correct Answer & Explanation

. Pelvic anteversion (decreased pelvic tilt)

Explanation

In the setting of positive sagittal imbalance, the body compensates to maintain an upright gaze. The primary pelvic compensatory mechanism is pelvic retroversion, which corresponds to an increased pelvic tilt (PT) and a decreased sacral slope (SS).

Question 4252

Topic: 6. Spine

A 42-year-old woman undergoes revision spine surgery for flatback syndrome secondary to previous Harrington rod instrumentation. A pedicle subtraction osteotomy (PSO) is planned at L3. Approximately how many degrees of sagittal correction can typically be expected from a single-level lumbar PSO?

. 5 to 10 degrees
. 10 to 15 degrees
. 30 to 35 degrees
. 50 to 55 degrees
. 60 to 70 degrees

Correct Answer & Explanation

. 5 to 10 degrees

Explanation

A pedicle subtraction osteotomy (PSO) is a closing wedge osteotomy through the posterior elements and vertebral body that hinges on the anterior cortex. It typically provides approximately 30 to 35 degrees of lordotic correction per level.

Question 4253

Topic: Thoracolumbar Spine & Deformity

A patient is evaluated for adult spinal deformity. Radiographic parameters reveal a Pelvic Incidence (PI) of 60 degrees, a Pelvic Tilt (PT) of 30 degrees, and a Sacral Slope (SS) of 30 degrees. Which of the following statements best describes the relationship of these spinopelvic parameters?

. PI = PT - SS
. PT = PI + SS
. SS = PI + PT
. PI = PT + SS
. PT = PI / SS

Correct Answer & Explanation

. PI = PT - SS

Explanation

Pelvic incidence (PI) is a fixed morphologic parameter representing the algebraic sum of the pelvic tilt (PT) and sacral slope (SS). The equation PI = PT + SS is fundamental in understanding spinopelvic alignment and calculating deformity correction targets.

Question 4254

Topic: 6. Spine

A 45-year-old construction worker falls from a height of 15 feet and complains of severe back pain.

Radiographs and a CT scan reveal an L1 burst fracture. Which of the following radiographic findings is most specifically indicative of a concomitant posterior ligamentous complex (PLC) injury, thereby increasing the indication for operative stabilization?

. Loss of anterior vertebral body height greater than 50%
. Retropulsion of bone fragments into the spinal canal greater than 30%
. Widening of the interspinous distance on the AP radiograph
. Sagittal plane kyphosis of 10 degrees
. Fractures of the transverse processes

Correct Answer & Explanation

. Loss of anterior vertebral body height greater than 50%

Explanation

Widening of the interspinous distance on an AP radiograph indicates severe flexion-distraction forces and disruption of the posterior ligamentous complex (PLC). PLC disruption implies significant mechanical instability in a burst fracture, serving as a strong indication for surgical stabilization.

Question 4255

Topic: Thoracolumbar Spine & Deformity

In surgical planning for a 65-year-old woman with adult degenerative scoliosis and severe sagittal imbalance, restoring physiological alignment is critical to minimize mechanical failure. Which of the following best represents the ideal relationship between pelvic incidence (PI) and lumbar lordosis (LL) for optimal postoperative sagittal balance?

. LL should be restored to within 10 degrees of the PI
. LL should be precisely half of the PI measurement
. PI should be surgically reduced to match the patient's LL
. Pelvic tilt (PT) should be maximized to compensate for a PI-LL mismatch
. LL should exceed PI by at least 20 degrees

Correct Answer & Explanation

. LL should be restored to within 10 degrees of the PI

Explanation

Optimal sagittal balance in adult spinal deformity surgery is achieved when Lumbar Lordosis (LL) is restored to within 10 degrees of the Pelvic Incidence (PI). Pelvic Incidence is a fixed morphological parameter that cannot be changed surgically, necessitating the appropriate correction of LL to match it.

Question 4256

Topic: 6. Spine

A 65-year-old man presents with progressive clumsiness in his hands and difficulty walking. Examination reveals hyperreflexia and a positive Hoffman sign. What is the most sensitive physical examination finding for early cervical spondylotic myelopathy?

. Lhermitte's sign
. Hoffman's sign
. Babinski reflex
. Inverted radial reflex
. Sustained clonus

Correct Answer & Explanation

. Lhermitte's sign

Explanation

Hoffman's sign is considered one of the most sensitive upper motor neuron signs for early cervical spondylotic myelopathy. It typically indicates cervical spinal cord compression above the C6 level.

Question 4257

Topic: 6. Spine

A 72-year-old woman complains of neurogenic claudication. She fails 6 months of nonoperative management. A decompressive laminectomy is planned. Which of the following anatomic structures is the primary contributor to central canal stenosis in this condition?

. Ligamentum flavum hypertrophy
. Posterior disc herniation
. Facet joint synovial cyst
. Pedicle shortening
. Pars interarticularis defect

Correct Answer & Explanation

. Ligamentum flavum hypertrophy

Explanation

Hypertrophy of the ligamentum flavum, along with facet arthropathy, is the primary contributor to central canal stenosis in degenerative lumbar stenosis. The ligament buckles into the canal as the disc space collapses.

Question 4258

Topic: Thoracolumbar Spine & Deformity

A 35-year-old man falls from a roof and sustains an L1 burst fracture. He is neurologically intact. Which of the following radiographic parameters is the most important determinant for surgical intervention based on the TLICS classification?

. 10% loss of anterior vertebral body height
. 15 degrees of focal kyphosis
. Posterior ligamentous complex (PLC) disruption
. 20% spinal canal compromise
. Presence of a vertical laminar fracture

Correct Answer & Explanation

. 10% loss of anterior vertebral body height

Explanation

In the Thoracolumbar Injury Classification and Severity (TLICS) score, PLC disruption is a critical determinant of instability. A neurologically intact patient with an definitively ruptured PLC is generally recommended for surgical stabilization.

Question 4259

Topic: Thoracolumbar Spine & Deformity

When evaluating a patient with adult spinal deformity, which of the following spinopelvic parameters is a fixed morphologic feature of the pelvis that does not change with patient position?

. Pelvic tilt
. Sacral slope
. Pelvic incidence
. Lumbar lordosis
. Sagittal vertical axis

Correct Answer & Explanation

. Pelvic tilt

Explanation

Pelvic incidence is a fixed anatomic parameter unique to each individual and does not change with postural position. It is defined geometrically as the sum of pelvic tilt and sacral slope.

Question 4260

Topic: Thoracolumbar Spine & Deformity

A 60-year-old woman presents with lower back pain and left leg pain. Imaging reveals a grade 1 L4-5 degenerative spondylolisthesis. Which of the following is the most significant structural risk factor for the development of degenerative spondylolisthesis?

. Male sex
. Sagittal facet orientation
. Pars interarticularis stress fracture
. Previous lumbar discectomy
. Severe osteoporosis

Correct Answer & Explanation

. Male sex

Explanation

A more sagittal orientation of the facet joints is a strong predisposing factor for the development of degenerative spondylolisthesis, particularly at L4-L5. Female sex and advancing age are also major risk factors.

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