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6. Spine MCQs

Practice Set 22 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 421

Topic: 6. Spine

A 65-year-old man with a history of prostate cancer complains of progressive bilateral leg weakness and hyperreflexia. Plain radiographs show diffuse osteoblastic lesions in the thoracic spine. What is the most critical next step in management?

. Bone scan to identify other metastatic sites
. Whole-spine MRI to evaluate for spinal cord compression
. PSA level testing and urology consult
. Immediate radiation therapy to the thoracic spine
. Initiation of intravenous bisphosphonates

Correct Answer & Explanation

. Whole-spine MRI to evaluate for spinal cord compression

Explanation

The patient presents with signs of myelopathy (leg weakness, hyperreflexia) in the setting of known metastatic prostate cancer. An urgent whole-spine MRI is required to rule out and evaluate impending or actual spinal cord compression.

Question 422

Topic: Thoracolumbar Spine & Deformity

A 25-year-old man falls from a 10-foot ladder. CT reveals an L1 burst fracture with 30% canal compromise. He is neurologically intact, and the posterior ligamentous complex is intact (TLICS score = 2). Which of the following is the most appropriate treatment?

. Short-segment posterior instrumentation and fusion
. Anterior corpectomy and strut grafting
. Thoracolumbosacral orthosis (TLSO) bracing and early mobilization
. Strict bed rest for 6 weeks
. Percutaneous vertebroplasty

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing and early mobilization

Explanation

According to the Thoracolumbar Injury Classification and Severity (TLICS) score, a score of 3 or less is an indication for non-operative management. A neurologically intact burst fracture with an intact posterior ligamentous complex is safely treated with a TLSO brace.

Question 423

Topic: 6. Spine

A 70-year-old man with long-standing ankylosing spondylitis presents with severe neck pain after a minor low-energy fall. Initial standard cervical radiographs appear negative. What is the most appropriate next step in his evaluation?

. Discharge with a soft cervical collar and NSAIDs
. Reassurance and physical therapy
. Flexion-extension radiographs of the cervical spine
. CT scan of the entire cervical spine
. Bone scintigraphy

Correct Answer & Explanation

. CT scan of the entire cervical spine

Explanation

Patients with ankylosing spondylitis have rigid, osteoporotic spines making them highly susceptible to fractures from minor trauma. Standard radiographs can miss up to 30% of these fractures; therefore, a CT scan is mandatory for any patient with AS complaining of post-traumatic spinal pain.

Question 424

Topic: 6. Spine

A 50-year-old man of Japanese descent presents with progressive upper extremity numbness, clumsy hands, and a spastic gait. CT imaging demonstrates a dense, continuous osseous mass posterior to the vertebral bodies from C3 to C6. What is the primary pathophysiology?

. Diffuse idiopathic skeletal hyperostosis (DISH)
. Ankylosing spondylitis
. Ossification of the posterior longitudinal ligament (OPLL)
. Cervical spondylotic myelopathy
. Paget disease of bone

Correct Answer & Explanation

. Ossification of the posterior longitudinal ligament (OPLL)

Explanation

The presentation and CT findings are pathognomonic for OPLL, which frequently causes cervical myelopathy. It has a high prevalence in Asian populations and is characterized by the ossification of the ligament directly posterior to the vertebral bodies.

Question 425

Topic: Thoracolumbar Spine & Deformity

In the evaluation of a patient with adult spinal deformity, which of the following spinopelvic parameters is considered a fixed, morphologic parameter that does not change with patient positioning?

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

Correct Answer & Explanation

. Pelvic incidence (PI)

Explanation

Pelvic incidence (PI) is an anatomical parameter defined by the relationship of the sacrum to the femoral heads and remains constant after skeletal maturity. It mathematically equals the sum of pelvic tilt and sacral slope (PI = PT + SS).

Question 426

Topic: 6. Spine

An 80-year-old man presents with bilateral upper extremity weakness and numbness following a fall in which he struck his forehead, causing hyperextension of the neck. His lower extremities have near-normal strength. What is the most likely diagnosis?

. Anterior cord syndrome
. Central cord syndrome
. Brown-Sequard syndrome
. Posterior cord syndrome
. Spinal shock

Correct Answer & Explanation

. Central cord syndrome

Explanation

Central cord syndrome typically occurs after a hyperextension injury in older individuals with pre-existing cervical spondylosis. It characteristically produces motor weakness in the upper extremities that is disproportionately greater than in the lower extremities.

Question 427

Topic: 6. Spine

A 40-year-old man complains of neck pain radiating down his arm to his middle finger. Examination reveals weakness in elbow extension (triceps) and wrist flexion, with an absent triceps reflex. Which cervical nerve root is most likely affected?

. C5
. C6
. C7
. C8
. T1

Correct Answer & Explanation

. C7

Explanation

A C7 radiculopathy presents with pain radiating to the middle finger, weakness in the triceps and wrist flexors, and a diminished or absent triceps reflex. C6 typically affects wrist extension and the brachioradialis reflex.

Question 428

Topic: 6. Spine

Initially, the most appropriate method to evaluate a patient with suspected peripheral nerve injury involves:

. An imaging study, preferably magnetic resonance imaging (MRI), of the injured region
. Electromyography and nerve conduction velocity studies
. A doppler ultrasound to study blood flow to the injured area
. An MRI of the entire spine to evaluate possible spinal cord injury
. A detailed neurologic evaluation noting distal motor function

Correct Answer & Explanation

. A detailed neurologic evaluation noting distal motor function

Explanation

After a traumatic injury to peripheral nerves, early clinical examination is imperative. The key is to test for motor function in the most distal aspect of the nerve and be able to localize the site of injury. Imaging studies are far less sensitive than clinical examinations. Electromyography and nerve conduction velocity studies are usually performed during the follow-up examination to assess for residual, or recovery of, function.

Question 429

Topic: 6. Spine
Which of the following is the anatomic origin of the Brown-Séquard syndrome?
. Ischemic damage to the periphery of the cord
. Shear injury to the central cord
. Contusion to the dorsal cord
. Traumatic hemisection of the cord
. Complete transection of the cord

Correct Answer & Explanation

. Traumatic hemisection of the cord

Explanation

Brown-Séquard syndrome often results from penetrating wounds that cause anatomical hemisection of the cord. Shear injury to the central cord usually results in the central cord syndrome. Contusions to the spinal cord lead to level-specific and long-tract findings depending on the location of contusion. Complete transection leads to complete neurologic loss.

Question 430

Topic: 6. Spine

Which of the following is the most common cause of and the treatment for conus medullaris syndrome:

. Traumatic injury treated with steroids
. Ischemic injury treated by medical management
. C hronic metabolic treated by correcting the underlying cause
. C ompressive lesion treated by surgical decompression
. Idiopathic, no treatment is needed

Correct Answer & Explanation

. C ompressive lesion treated by surgical decompression

Explanation

Conus medullaris syndrome is caused by upper and lower motor neuron injury because of a combined spinal cord and nerve root injury caused by thoracolumbar injuries (levels between T-11 and L-1). Causative agents are compressive in nature such as a compression fracture or herniated disk. Treatment is emergent surgical decompression. The prognosis is better for incomplete injuries.

Question 431

Topic: 6. Spine

Which of the following is the most important prognostic sensory modality during examination of a patient with a spinal cord injury:

. Pain and temperature sensation carried by the spinothalamic tracts
. Light touch and joint position carried by the dorsal column tracts
. Joint position carried by the spinocerebellar tract
. All modalities carry the same prognostic value
. Sensory examination has no prognostic value in evaluation of spinal cord injury patients

Correct Answer & Explanation

. Pain and temperature sensation carried by the spinothalamic tracts

Explanation

The most important prognostic sensory modalities are those carried in the lateral spinothalamic tract rather than dorsal columns.

Question 432

Topic: 6. Spine

Which of the following is the time window from the time of injury during which treatment of nonpenetrating spinal cord injury with methylprednisolone is indicated:

. 2 hours
. 4 hours
. 8 hours
. 12 hours
. 24 hours

Correct Answer & Explanation

. 8 hours

Explanation

Administration of methylprednisolone within 8 hours of injury provides benefit to patients with spinal cord injury. Treatment of patients arriving after 8 hours of treatment has been shown to worsen morbidity. Therefore, patients arriving at trauma centers within this time receive methylprednisolone treatment as part of the standard of care. The exception is the group of patients with penetrating spinal cord injuries where the risk of treatment outweighs the potential benefits.

Question 433

Topic: 6. Spine

Pain from a herniated lumbar disk is caused by:

. Rupture of the thecal sac
. Local instability due to a ruptured nucleus pulposus
. Ischemia and potential necrosis of the nerve root
. Associated spinal stenosis
. Herniated nucleus pulposus and the resulting local inflammation

Correct Answer & Explanation

. Herniated nucleus pulposus and the resulting local inflammation

Explanation

The annulus is composed of alternating laminae that are primarily composed of type I and type II collagen. The annulus is thinnest posterolaterally and thickest anteriorly. As the disk is loaded, the nucleus transfers axial loads to the annulus in the form of hoop stresses. With degenerative or traumatic processes, fissures or tears may develop in the annulus and the nucleus can become herniated. A herniated nucleus pulposus is a foreign material to the surrounding structures. The combination of mechanical pressure on a nerve root and local inflammation can lead to neurologic signs and symptoms.

Question 434

Topic: 6. Spine

Common presentations of cauda equina syndrome include:

. Severe low back pain with nausea and vomiting
. Acute onset unilateral foot drop
. Progressive chronic low back pain radiating to the gluteal region
. Saddle anesthesia and bowel and/or bladder dysfunction
. Fever, photophobia, and nuchal rigidity

Correct Answer & Explanation

. Saddle anesthesia and bowel and/or bladder dysfunction

Explanation

In patients with suspected central herniated nucleus pulposus, cauda equina syndrome must not be missed as it could cause irreversible neurological damage. C auda equina syndrome presents with saddle anesthesia and bowel or bladder changes.

Question 435

Topic: 6. Spine
The predominant cause of low back pain in the general population, aside from the general sprain and strains of the paraspinal structures, is attributed to:
. Spondylolisthesis
. Herniated nucleus pulposus
. Spinal stenosis
. Degenerative disk disease
. Vascular insufficiency

Correct Answer & Explanation

. Degenerative disk disease

Explanation

The consequences of normal aging of the spine include progressive disk dehydration, chemical alterations and subsequent mechanical incompetence of the intervertebral disk, which may be manifested in low back pain, although an exact correlation between disk degeneration and low back pain has not been established. Nevertheless, many believe that the predominant cause of persistent low back pain is degeneration of the disk.

Question 436

Topic: 6. Spine

Initial work-up of an otherwise healthy individual with acute onset low back pain should include:

. A complete history, physical examination, and follow-up imaging studies only if indicated
. A complete history, physical examination, and plain radiographs
. A magnetic resonance imaging study of the lumbar spine
. A computed tomography of the lumbar spine
. No evaluation is needed on initial visit as most low back pain resolves spontaneously

Correct Answer & Explanation

. A complete history, physical examination, and follow-up imaging studies only if indicated

Explanation

All patients presenting with back pain should have a thorough history taken and a complete physical exam including a detailed neurologic exam. In the recently published Agency for Health C are Policy and Research C linical Practice Guideline on Acute Low Back Pain Problems in Adults, it was concluded that a focused physical exam was sufficient to assess a patient with acute or recurrent low back pain of fewer than 4 weeks duration, unless findings suggested an underlying tumor, or an infectious, a traumatic or a major neurologic syndrome.

Question 437

Topic: 6. Spine

A 45-year-old woman presents with progressive bilateral lower extremity weakness and sensory loss. MRI of the thoracic spine reveals a well-circumscribed, centrally located intramedullary lesion with a prominent cleavage plane and polar cysts. It demonstrates intense enhancement with gadolinium. What is the most likely diagnosis?

. Astrocytoma
. Ependymoma
. Hemangioblastoma
. Schwannoma
. Meningioma

Correct Answer & Explanation

. Ependymoma

Explanation

Ependymomas are the most common intramedullary spinal cord tumors in adults. They are typically centrally located, well-circumscribed with a distinct cleavage plane allowing for gross total resection, and often feature polar cysts.

Question 438

Topic: 6. Spine

A 60-year-old female presents with thoracic myelopathy. MRI reveals an intradural, extramedullary mass with a broad base attached to the dura. The mass enhances homogeneously with contrast and displays a 'dural tail' sign. Punctate calcifications are noted on CT. What is the most likely diagnosis?

. Meningioma
. Neurofibroma
. Metastatic breast carcinoma
. Hemangioma
. Astrocytoma

Correct Answer & Explanation

. Meningioma

Explanation

Spinal meningiomas occur predominantly in middle-aged or elderly women, most often in the thoracic spine. Key imaging features include a broad dural attachment, a dural tail on contrast MRI, and psammomatous calcifications.

Question 439

Topic: 6. Spine

A 35-year-old patient with a known history of von Hippel-Lindau disease presents with myelopathy. MRI of the cervical spine reveals an intramedullary mass with an associated cyst and prominent signal flow voids. What is the most appropriate surgical strategy for this lesion?

. En bloc wide marginal resection
. Incisional biopsy and primary radiation
. Microsurgical resection of the mural nodule only
. Resection of the cyst wall leaving the nodule
. Observation until neurologic deficit becomes severe

Correct Answer & Explanation

. Microsurgical resection of the mural nodule only

Explanation

Hemangioblastomas are highly vascular intramedullary tumors associated with VHL disease. Surgical treatment consists of resecting the highly vascular mural nodule; the cyst wall is non-neoplastic and does not require resection.

Question 440

Topic: 6. Spine

A 5-year-old boy presents with localized back pain and a torticollis. Radiographs reveal a complete collapse of the C4 vertebral body (vertebra plana) with relative preservation of the adjacent disc spaces. Laboratory results are normal. Which of the following is the most appropriate initial management?

. Emergent anterior cervical corpectomy
. High-dose systemic corticosteroids and chemotherapy
. Observation and use of a cervical collar
. Radiation therapy
. Posterior cervical spinal fusion

Correct Answer & Explanation

. Observation and use of a cervical collar

Explanation

Eosinophilic granuloma often presents as vertebra plana in children. It is typically a self-limiting condition, and initial management consists of observation, immobilization (bracing/collar), and symptomatic pain control.

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