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6. Spine MCQs

Practice Set 216 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 4301

Topic: Thoracolumbar Spine & Deformity

A 68-year-old woman presents with severe low back pain and an inability to stand upright. Standing full-length radiographs reveal a sagittal vertical axis (SVA) of +12 cm, a pelvic incidence (PI) of 60 degrees, and a lumbar lordosis (LL) of 20 degrees. What are the primary radiographic targets for surgical correction of her sagittal balance?

. Decrease SVA to < 5 cm and achieve PI-LL mismatch < 10 degrees
. Increase SVA to > 5 cm and achieve PI-LL mismatch > 20 degrees
. Achieve PI-LL mismatch < 20 degrees with no change in SVA
. Decrease PI by 10 degrees
. Increase pelvic tilt to > 30 degrees

Correct Answer & Explanation

. Decrease SVA to < 5 cm and achieve PI-LL mismatch < 10 degrees

Explanation

Proper sagittal balance correction in adult spinal deformity targets a Sagittal Vertical Axis (SVA) of less than 5 cm, a Pelvic Incidence to Lumbar Lordosis (PI-LL) mismatch of less than 10 degrees, and a Pelvic Tilt (PT) of less than 20 degrees.

Question 4302

Topic: 6. Spine

A 48-year-old man presents with severe right-sided anterior thigh pain, weakness in knee extension, and a diminished right patellar reflex. MRI demonstrates a right-sided far lateral (extraforaminal) disc herniation at L4-L5. Which nerve root is most likely compressed?

. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L3

Explanation

A far lateral (extraforaminal) disc herniation impinges the exiting nerve root at that level. At the L4-L5 level, a far lateral herniation will compress the exiting L4 nerve root, leading to quadriceps weakness and a diminished patellar reflex.

Question 4303

Topic: 6. Spine

A 16-year-old boy presents with aching back pain and a rounded thoracic spine. Standing lateral radiographs reveal a thoracic kyphosis of 80 degrees and anterior wedging of 3 consecutive vertebrae of 10 degrees each. What other radiographic finding is a classic hallmark of this condition?

. Pedicle widening
. Schmorl's nodes
. Spondylolysis
. Dural ectasia
. Bamboo spine

Correct Answer & Explanation

. Pedicle widening

Explanation

Scheuermann's kyphosis is characterized by rigid thoracic kyphosis >45 degrees, anterior wedging of at least 5 degrees in 3 or more consecutive vertebrae, irregular endplates, and Schmorl's nodes (disc herniations into the vertebral endplate).

Question 4304

Topic: 6. Spine

A 60-year-old woman is 5 years status post an L4-S1 posterior spinal fusion. She presents with new-onset neurogenic claudication. Imaging reveals severe L3-L4 spinal stenosis and degenerative spondylolisthesis. Which biomechanical factor most significantly contributes to adjacent segment disease following lumbar fusion?

. Decreased facet loading at the adjacent segment
. Increased segmental motion and intradiscal pressure at the adjacent level
. Decreased pedicle stress at the fused levels
. Sparing of the supraspinous ligament
. Increased overall flexibility of the lumbar spine

Correct Answer & Explanation

. Decreased facet loading at the adjacent segment

Explanation

Adjacent segment disease is driven by altered biomechanics following a rigid spinal fusion. The construct transfers stress, significantly increasing intradiscal pressure and segmental hypermobility at the unfused segments immediately adjacent to the fusion.

Question 4305

Topic: Thoracolumbar Spine & Deformity

A 12-year-old boy wearing a lap belt is involved in a high-speed motor vehicle collision. Radiographs reveal a flexion-distraction injury (Chance fracture) at L2. Which of the following associated injuries must be most highly suspected and urgently evaluated?

. Aortic dissection
. Intra-abdominal hollow viscus injury
. Renal artery thrombosis
. Diaphragmatic rupture
. Pelvic ring disruption

Correct Answer & Explanation

. Aortic dissection

Explanation

Chance fractures (flexion-distraction injuries) are frequently associated with seatbelt injuries. There is a high incidence (up to 40-50%) of concurrent intra-abdominal hollow viscus injuries, making urgent general surgery evaluation critical.

Question 4306

Topic: 6. Spine

A 15-year-old male athlete presents with chronic, severe axial low back pain exacerbated by extension. Imaging confirms bilateral L5 pars interarticularis defects without spondylolisthesis. MRI shows normal, hydrated discs. After 6 months of rest and core strengthening, pain prevents sports participation. What is the most appropriate surgical management?

. L5-S1 posterior spinal fusion
. Direct pars repair with bone grafting
. Laminectomy of L5
. L5-S1 anterior lumbar interbody fusion
. Corticosteroid injection and immediate return to play

Correct Answer & Explanation

. L5-S1 posterior spinal fusion

Explanation

Direct pars repair (e.g., Buck's, Scott's, or screw-hook constructs) is indicated for young patients with symptomatic pars defects without significant slip who fail conservative management and have healthy adjacent discs, as it preserves lumbar motion.

Question 4307

Topic: 6. Spine

A 55-year-old man with a 20-year history of ankylosing spondylitis presents with new severe neck pain after a low-speed rear-end motor vehicle collision. Radiographs appear unchanged from previous films, showing a continuous "bamboo spine". His neurologic exam is completely intact. What is the most appropriate next step in management?

. Discharge with a soft collar and NSAIDs
. Discharge with a hard collar and physical therapy
. Obtain a CT or MRI of the entire cervical and thoracic spine
. Proceed directly to prophylactic posterior cervical fusion
. Administer high-dose intravenous methylprednisolone

Correct Answer & Explanation

. Discharge with a soft collar and NSAIDs

Explanation

Patients with ankylosing spondylitis have a highly rigid spine that is extremely susceptible to unstable, catastrophic fractures from minor trauma. Advanced imaging (CT or MRI) is mandatory for any new pain after trauma to rule out occult fractures that standard radiographs easily miss.

Question 4308

Topic: 6. Spine

A 65-year-old man with pre-existing cervical spondylosis sustains a hyperextension injury. He has severe upper extremity weakness and mild lower extremity weakness. What is the most appropriate initial management for this incomplete spinal cord injury if there is no acute instability or worsening compression?

. Immediate surgical decompression within 4 hours
. High-dose methylprednisolone protocol
. Observation and maintenance of mean arterial pressure >85 mmHg
. Immediate closed reduction
. Cervical traction

Correct Answer & Explanation

. Immediate surgical decompression within 4 hours

Explanation

Central cord syndrome commonly occurs after hyperextension injuries in stenotic cervical spines. Initial management includes maintaining mean arterial pressure (MAP) >85 mmHg for spinal cord perfusion; routine early surgery or steroids are not strictly indicated without progressive deterioration.

Question 4309

Topic: 6. Spine

When correcting adult spinal deformity, which of the following pelvic parameters represents a morphologic constant that dictates the required amount of lumbar lordosis (LL) for a balanced spine?

. Pelvic tilt (PT)
. Sacral slope (SS)
. Pelvic incidence (PI)
. Sagittal vertical axis (SVA)
. T1 pelvic angle (TPA)

Correct Answer & Explanation

. Pelvic tilt (PT)

Explanation

Pelvic incidence (PI) is a fixed morphologic parameter of the pelvis that does not change with posture. A well-balanced spine typically requires the lumbar lordosis (LL) to be within 10 degrees of the PI (PI - LL < 10 degrees).

Question 4310

Topic: 6. Spine

A 32-year-old involved in a motor vehicle accident presents with neck pain and right C6 radiculopathy. Radiographs reveal an isolated right unilateral C5-C6 facet dislocation. What is the most appropriate next step prior to closed reduction?

. Perform an MRI of the cervical spine
. Administer high-dose steroids
. Apply a halo vest
. Perform an immediate anterior cervical discectomy and fusion
. Obtain a CT angiogram of the neck

Correct Answer & Explanation

. Perform an MRI of the cervical spine

Explanation

In an awake, alert patient with a unilateral facet dislocation and a radicular deficit, an MRI should be obtained prior to closed reduction to rule out a herniated disc. If a large disc herniation is present, anterior decompression should be performed prior to reduction to prevent cord injury.

Question 4311

Topic: Cervical Spine

An 82-year-old man sustains a Type II odontoid fracture after a fall from standing. He is neurologically intact but has severe neck pain. He has multiple comorbidities including severe COPD. What is the most appropriate management?

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

Correct Answer & Explanation

. Halo vest immobilization

Explanation

In elderly patients (especially >80 years) with significant comorbidities, halo vest immobilization has an unacceptably high morbidity and mortality rate. Rigid cervical collar immobilization is often preferred for Type II odontoid fractures in this specific demographic despite lower union rates, prioritizing survival.

Question 4312

Topic: 6. Spine

A 25-year-old man wearing a lap seatbelt sustains a flexion-distraction injury to the L2 vertebra. Which of the following associated injuries is most highly correlated with this fracture pattern?

. Aortic transection
. Renal artery thrombosis
. Intra-abdominal hollow viscus injury
. Diaphragmatic rupture
. Splenic laceration

Correct Answer & Explanation

. Aortic transection

Explanation

Chance fractures (flexion-distraction injuries) commonly occur with lap seatbelts when the fulcrum of flexion is anterior to the spine. They have a high association (up to 50%) with intra-abdominal hollow viscus injuries, making prompt general surgery evaluation crucial.

Question 4313

Topic: 6. Spine

A 55-year-old man undergoes a posterior cervical laminectomy and fusion from C3-C7 for cervical spondylotic myelopathy. On postoperative day 2, he develops profound isolated weakness in right shoulder abduction and external rotation. What is the most likely etiology?

. Inadequate C4-C5 decompression
. Iatrogenic spinal cord injury
. C5 nerve root tethering from spinal cord drift
. Epidural hematoma
. Screw malposition at C5

Correct Answer & Explanation

. Inadequate C4-C5 decompression

Explanation

Postoperative C5 palsy frequently occurs after posterior cervical decompression due to posterior drift of the spinal cord and subsequent tethering or stretching of the short, horizontally oriented C5 nerve roots. It usually recovers spontaneously over several months with conservative care.

Question 4314

Topic: 6. Spine

A 65-year-old woman presents with neurogenic claudication and L4-L5 degenerative spondylolisthesis. She fails conservative management. According to the SPORT trial, what is the expected outcome of surgical decompression and fusion compared to nonoperative care?

. No significant difference in pain or function at 4 years
. Significantly greater improvement in pain and function at 4 years
. Higher rate of adjacent segment disease within 1 year
. Similar improvement in symptoms but with higher mortality
. Slower initial recovery but equal outcomes at 1 year

Correct Answer & Explanation

. No significant difference in pain or function at 4 years

Explanation

The Spine Patient Outcomes Research Trial (SPORT) demonstrated that patients treated surgically for degenerative spondylolisthesis maintained significantly greater improvement in pain and physical function at 4 years compared to those treated nonoperatively.

Question 4315

Topic: 6. Spine

Which of the following radiographic criteria is strictly required for the classical diagnosis of Scheuermann's kyphosis?

. Thoracic kyphosis > 40 degrees with isolated anterior wedging of 5 degrees in one vertebra
. Thoracic kyphosis > 45 degrees with anterior wedging of at least 5 degrees in three consecutive vertebrae
. Lumbar lordosis > 60 degrees with anterior wedging of at least 10 degrees in two vertebrae
. Thoracic kyphosis > 50 degrees with Schmorl's nodes in five consecutive vertebrae
. Cervical kyphosis > 10 degrees with anterior wedging of at least 5 degrees in three vertebrae

Correct Answer & Explanation

. Thoracic kyphosis > 40 degrees with isolated anterior wedging of 5 degrees in one vertebra

Explanation

Sorensen's criteria for classic Scheuermann's disease stipulate a thoracic kyphosis > 45 degrees accompanied by anterior wedging of > 5 degrees in at least three consecutive vertebrae.

Question 4316

Topic: 6. Spine

In the Thoracolumbar Injury Classification and Severity (TLICS) score, which neurologic status receives the highest numerical value?

. Intact
. Nerve root injury
. Complete spinal cord injury
. Incomplete spinal cord injury
. Transient neuropraxia

Correct Answer & Explanation

. Intact

Explanation

Under the TLICS system, incomplete spinal cord injuries or cauda equina syndrome receive 3 points, which is higher than a complete spinal cord injury (2 points). This higher score reflects the potential benefit and urgency of surgical decompression for incomplete injuries.

Question 4317

Topic: 6. Spine

During an L4-L5 laminectomy for severe spinal stenosis, a 1 cm incidental durotomy occurs dorsally. What is the most appropriate intraoperative management?

. Primary repair with 4-0 or 5-0 nonabsorbable suture
. Leave open and place a subfascial drain on high suction
. Cover with a fat graft and no closure
. Immediate placement of a lumbar subarachnoid drain
. Abort the procedure without completing the decompression

Correct Answer & Explanation

. Primary repair with 4-0 or 5-0 nonabsorbable suture

Explanation

Incidental durotomies recognized intraoperatively should be primarily repaired with fine nonabsorbable sutures (e.g., prolene or nylon) in a watertight fashion. Avoidance of high-suction drains is also recommended to prevent CSF fistula formation.

Question 4318

Topic: Thoracolumbar Spine & Deformity

A 14-year-old gymnast presents with persistent low back pain. Radiographs demonstrate a Grade II isthmic spondylolisthesis at L5-S1. Conservative treatment fails. What is the most common nerve root affected in this condition that causes radicular symptoms?

. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L3

Explanation

In isthmic spondylolisthesis at L5-S1, the fibrocartilaginous tissue at the pars interarticularis defect (Gill nodule) hypertrophies. This mass commonly compresses the exiting L5 nerve root within the neuroforamen.

Question 4319

Topic: 6. Spine

A 60-year-old man presents with progressive hand clumsiness and broad-based gait. MRI of the cervical spine shows severe stenosis at C4-C5 with T2 hyperintensity within the spinal cord. What does this MRI finding indicate regarding his prognosis?

. Higher likelihood of complete neurologic recovery
. Presence of myelomalacia, which correlates with poorer neurologic recovery
. Acute disc herniation requiring emergency surgery
. Infection (discitis/osteomyelitis) as the primary etiology
. Spontaneous resolution without surgical intervention

Correct Answer & Explanation

. Higher likelihood of complete neurologic recovery

Explanation

T2 hyperintensity in the spinal cord on MRI represents edema or myelomalacia. In the setting of cervical spondylotic myelopathy, it indicates chronic cord injury and is highly associated with a poorer prognosis and limited functional recovery following decompression.

Question 4320

Topic: Cervical Spine

A 55-year-old woman with a 20-year history of rheumatoid arthritis presents with neck pain and occipital headaches. Flexion-extension radiographs reveal an anterior atlantodental interval (ADI) of 11 mm. What is the most appropriate definitive management?

. Observation and NSAIDs
. Soft cervical collar
. Posterior C1-C2 fusion
. Anterior C1-C2 fusion
. Halo vest immobilization

Correct Answer & Explanation

. Observation and NSAIDs

Explanation

An anterior atlantodental interval (ADI) > 9-10 mm in a patient with rheumatoid arthritis indicates a high risk for neurologic compromise and disruption of the alar and transverse ligaments. Posterior C1-C2 fusion is indicated to stabilize the atlantoaxial joint.

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