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6. Spine MCQs

Practice Set 225 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 4481

Topic: 6. Spine

A 25-year-old male is involved in a severe rollover motor vehicle crash. Examination reveals massive swelling over the left shoulder girdle. An AP chest radiograph demonstrates lateral displacement of the left scapula with a widened sternoclavicular joint and an intact clavicle. Which of the following associated injuries is most critical to evaluate in this patient?

. Brachial plexus avulsion and subclavian artery injury
. Cervical spine facet dislocation
. Thoracic duct rupture
. Isolated axillary nerve palsy
. Tracheobronchial tree disruption

Correct Answer & Explanation

. Brachial plexus avulsion and subclavian artery injury

Explanation

Lateral displacement of the scapula suggests scapulothoracic dissociation, a severe, high-energy injury. It is highly associated with devastating neurological (complete brachial plexus avulsion) and vascular (subclavian or axillary artery) injuries that can be life- or limb-threatening.

Question 4482

Topic: 6. Spine

A 30-year-old male is evaluated after striking his chin on the steering wheel during a frontal motor vehicle collision. Cervical spine imaging demonstrates bilateral fractures of the pars interarticularis of C2 with anterior displacement of C2 on C3. What is the classic mechanism of this specific injury?

. Hyperextension and axial loading
. Hyperflexion and rotation
. Pure axial distraction
. Lateral bending with sudden compression
. Direct posterior blow to the occiput

Correct Answer & Explanation

. Hyperextension and axial loading

Explanation

This injury describes a traumatic spondylolisthesis of the axis, commonly known as a Hangman's fracture. The classic mechanism in a motor vehicle collision (e.g., striking the chin) is severe hyperextension combined with axial loading.

Question 4483

Topic: Cervical Spine

An 82-year-old man presents with a Type II odontoid fracture after a ground-level fall. He has severe COPD and coronary artery disease. He is neurologically intact. What is the most appropriate initial management considering his age and fracture type?

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

Correct Answer & Explanation

. Halo vest immobilization

Explanation

In elderly patients with Type II odontoid fractures, rigid cervical collar immobilization is often preferred initially. This avoids the high morbidity and mortality associated with halo vests and surgical intervention in a frail population with multiple medical comorbidities.

Question 4484

Topic: Thoracolumbar Spine & Deformity

When evaluating a 65-year-old female for adult spinal deformity correction, which of the following radiographic parameters correlates most strongly with an improvement in health-related quality of life (HRQOL) scores postoperatively?

. Thoracic kyphosis < 40 degrees
. Pelvic tilt > 25 degrees
. Pelvic incidence minus lumbar lordosis (PI-LL) < 10 degrees
. Sagittal vertical axis (SVA) > 10 cm
. Coronal Cobb angle < 10 degrees

Correct Answer & Explanation

. Thoracic kyphosis < 40 degrees

Explanation

Achieving a PI-LL mismatch of less than 10 degrees is a primary goal in adult spinal deformity surgery. Along with an SVA < 5 cm and Pelvic Tilt < 20 degrees, this strongly correlates with improved postoperative HRQOL.

Question 4485

Topic: Thoracolumbar Spine & Deformity

According to the Thoracolumbar Injury Classification and Severity (TLICS) score, which of the following injury patterns warrants a score of 3 for the morphology category?

. Compression fracture
. Burst fracture
. Translation/rotation injury
. Distraction injury
. Transverse process fracture

Correct Answer & Explanation

. Compression fracture

Explanation

In the TLICS system, morphology is scored as follows: compression (1), burst (2), translation/rotation (3), and distraction (4). These points are added to neurologic status and posterior ligamentous complex integrity to guide operative vs nonoperative management.

Question 4486

Topic: 6. Spine

A 60-year-old man presents with deteriorating hand dexterity and a broad-based gait. On examination, rapid tapping of the distal phalanx of the middle finger elicits involuntary flexion of the thumb and index finger. This clinical sign indicates dysfunction in which of the following tracts?

. Spinothalamic tract
. Corticospinal tract
. Dorsal columns
. Spinocerebellar tract
. Vestibulospinal tract

Correct Answer & Explanation

. Spinothalamic tract

Explanation

The described exam finding is a positive Hoffmann sign, which indicates an upper motor neuron lesion such as cervical spondylotic myelopathy. Upper motor neuron signs result from compression or dysfunction of the corticospinal tract.

Question 4487

Topic: 6. Spine

A 45-year-old man presents with acute, severe right-sided anterior thigh pain and weakness in knee extension. MRI demonstrates a far lateral (extraforaminal) disc herniation at the L3-L4 level. Which nerve root is most likely compressed?

. Right L2
. Right L3
. Right L4
. Right L5
. Right S1

Correct Answer & Explanation

. Right L2

Explanation

A far lateral (extraforaminal) disc herniation compresses the exiting nerve root at that specific level. Therefore, an L3-L4 far lateral disc compresses the L3 nerve root, causing anterior thigh pain and quadriceps weakness.

Question 4488

Topic: 6. Spine

A 68-year-old man with known cervical stenosis sustains a hyperextension injury. He presents with profound bilateral upper extremity weakness but retains antigravity strength in his lower extremities. What is the most likely prognosis for his neurologic recovery?

. Upper extremities will recover before lower extremities
. Bowel and bladder function are rarely preserved
. He has a greater than 50% chance of functional recovery of ambulation
. Hand dexterity usually recovers fully
. Prognosis is worse in younger patients

Correct Answer & Explanation

. Upper extremities will recover before lower extremities

Explanation

This patient has central cord syndrome. Most patients (>50%) regain the ability to ambulate, typically recovering lower extremity strength first, followed by bowel/bladder function, proximal upper extremity strength, and lastly fine hand dexterity.

Question 4489

Topic: 6. Spine

A 24-year-old male involved in a high-speed motor vehicle collision wearing a lap belt presents with a flexion-distraction injury of the L2 vertebra. Which of the following associated injuries is most highly correlated with this spinal fracture pattern?

. Aortic transection
. Intra-abdominal hollow viscus injury
. Pulmonary contusion
. Diaphragmatic rupture
. Renal artery thrombosis

Correct Answer & Explanation

. Aortic transection

Explanation

Flexion-distraction (Chance) fractures are highly associated with intra-abdominal hollow viscus injuries, particularly of the small bowel. This is due to the severe anterior shearing forces caused by lap belts.

Question 4490

Topic: 6. Spine

A 35-year-old male presents with bilateral jumped facets at C5-C6 after a diving accident. He is awake, alert, and cooperative but has 0/5 strength in his bilateral lower extremities. What is the most appropriate immediate step in management?

. Immediate MRI of the cervical spine
. Closed reduction with cranial traction
. Anterior cervical discectomy and fusion
. Posterior cervical fusion
. High-dose intravenous methylprednisolone

Correct Answer & Explanation

. Immediate MRI of the cervical spine

Explanation

In an awake, alert, and cooperative patient with a cervical facet dislocation and a neurologic deficit, emergent closed reduction with cranial traction is indicated. Waiting for an MRI delays critical decompression of the spinal cord.

Question 4491

Topic: Thoracolumbar Spine & Deformity

Which of the following radiographic criteria is strictly required to confirm the diagnosis of classic Scheuermann's disease?

. Thoracic kyphosis greater than 60 degrees
. Anterior wedging of at least 5 degrees in 3 or more consecutive vertebrae
. Presence of Schmorl's nodes in at least 5 levels
. Lumbar lordosis greater than 50 degrees
. Apical vertebral rotation of Grade II

Correct Answer & Explanation

. Thoracic kyphosis greater than 60 degrees

Explanation

Sorensen's criteria for diagnosing Scheuermann's kyphosis require the presence of anterior wedging of 5 degrees or more in at least three consecutive apical vertebrae.

Question 4492

Topic: 6. Spine

A 70-year-old man with a long history of Ankylosing Spondylitis suffers a minor fall and complains of new neck pain. Initial plain radiographs are negative for fracture. What is the most appropriate next step in management?

. Reassurance and NSAIDs
. Flexion-extension radiographs
. Discharge with a soft collar
. CT scan of the cervical spine
. Immediate Halo vest application

Correct Answer & Explanation

. Reassurance and NSAIDs

Explanation

Patients with Ankylosing Spondylitis are at an extremely high risk for highly unstable, occult spinal fractures even after minor trauma. If plain films are negative, advanced imaging such as a CT scan or MRI is mandatory to rule out a fracture.

Question 4493

Topic: 6. Spine

Traumatic spondylolisthesis of the axis (Hangman's fracture) typically occurs through which of the following anatomic structures of C2?

. Odontoid process
. Pars interarticularis
. Pedicle
. Lateral mass
. Spinous process

Correct Answer & Explanation

. Odontoid process

Explanation

A Hangman's fracture is a bilateral fracture through the pars interarticularis of C2 (the axis). It is classically caused by a mechanism of hyperextension and axial loading.

Question 4494

Topic: Thoracolumbar Spine & Deformity

A 66-year-old female undergoes surgical planning for adult spinal deformity. Her pelvic incidence (PI) is measured at 62 degrees. To achieve optimal sagittal balance and minimize the risk of adjacent segment disease, what should be her approximate target for postoperative lumbar lordosis (LL)?

. 20 degrees
. 35 degrees
. 45 degrees
. 55 degrees
. 75 degrees

Correct Answer & Explanation

. 20 degrees

Explanation

The formula for sagittal balance dictates that lumbar lordosis (LL) should be matched to within 9-10 degrees of the pelvic incidence (PI). Therefore, a PI of 62 degrees requires an LL target of approximately 52 to 62 degrees.

Question 4495

Topic: Thoracolumbar Spine & Deformity

Pelvic incidence (PI) is a fundamental morphologic parameter in adult spinal deformity evaluation. What is the correct mathematical relationship between PI, pelvic tilt (PT), and sacral slope (SS)?

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

Correct Answer & Explanation

. PI = PT + SS

Explanation

Pelvic incidence is a fixed anatomical parameter defined as the algebraic sum of pelvic tilt and sacral slope (PI = PT + SS). It dictates the required lumbar lordosis for a patient, typically targeted at PI ± 9 degrees.

Question 4496

Topic: 6. Spine

A 65-year-old man with a known history of ankylosing spondylitis presents with severe neck pain following a ground-level fall. Neurological examination is intact. CT scan reveals a through-and-through fracture of the C6-C7 disc space extending into the posterior elements. What is the most appropriate management?

. Rigid cervical orthosis for 12 weeks
. Anterior cervical discectomy and fusion (ACDF)
. Posterior cervical instrumented fusion from C4 to T2
. Halo vest immobilization
. Anterior plating alone

Correct Answer & Explanation

. Rigid cervical orthosis for 12 weeks

Explanation

Patients with ankylosing spondylitis are at high risk for unstable, highly displaced extension-distraction fractures even from minor trauma. Long-segment posterior instrumented fusion is required due to the long lever arms and poor bone quality.

Question 4497

Topic: 6. Spine

Which of the following is the most frequently encountered neurological complication following posterior cervical laminectomy and instrumented fusion for cervical spondylotic myelopathy?

. Horner's syndrome
. C5 palsy
. C8 palsy
. Recurrent laryngeal nerve injury
. Phrenic nerve palsy

Correct Answer & Explanation

. Horner's syndrome

Explanation

C5 nerve root palsy is the most common neurological complication following posterior cervical decompression (incidence ~5-10%), often presenting as deltoid and biceps weakness. It is thought to result from posterior spinal cord drift and nerve root tethering.

Question 4498

Topic: Thoracolumbar Spine & Deformity

According to the Thoracolumbar Injury Classification and Severity (TLICS) score, which of the following injury patterns strictly warrants surgical stabilization (score > 4)?

. Compression fracture with intact posterior ligamentous complex and normal neurology
. Burst fracture with indeterminate posterior ligamentous complex and normal neurology
. Burst fracture with complete disruption of the posterior ligamentous complex and normal neurology
. Transverse process fractures with normal neurology
. Spinous process fracture with intact neurology

Correct Answer & Explanation

. Compression fracture with intact posterior ligamentous complex and normal neurology

Explanation

A burst fracture (2 points) with posterior ligamentous complex disruption (3 points) yields a TLICS score of 5, which dictates operative management. A score of 4 can be treated operatively or non-operatively, while < 4 is managed non-operatively.

Question 4499

Topic: 6. Spine

A 68-year-old woman undergoes T10-pelvis fusion for adult spinal deformity. Six months postoperatively, she develops proximal junctional kyphosis (PJK). Which of the following is considered a significant risk factor for the development of PJK?

. Preoperative sagittal vertical axis (SVA) < 2 cm
. Stopping the construct at the apex of thoracic kyphosis
. Overcorrection of lumbar lordosis relative to pelvic incidence
. Use of hooks instead of pedicle screws at the uppermost instrumented vertebra
. Undertreatment of pelvic tilt

Correct Answer & Explanation

. Preoperative sagittal vertical axis (SVA) < 2 cm

Explanation

Stopping a long fusion construct at the apex of thoracic kyphosis is a major risk factor for PJK. Construct endpoints should ideally fall in neutral or lordotic segments to avoid high biomechanical stress at the upper instrumented vertebra.

Question 4500

Topic: 6. Spine

A 62-year-old female presents with neurogenic claudication and an L4-L5 degenerative spondylolisthesis. She elects to undergo surgical intervention after failing conservative management. Based on the Spine Patient Outcomes Research Trial (SPORT), what is the expected long-term outcome comparing operative to non-operative treatment?

. Surgery provides no significant difference in pain relief at 4 years
. Surgery provides superior pain relief and functional outcomes at 4 years
. Non-operative treatment provides better functional outcomes at 8 years
. Decompression alone is superior to decompression and fusion
. Epidural injections provide equivalent 2-year outcomes to surgery

Correct Answer & Explanation

. Surgery provides no significant difference in pain relief at 4 years

Explanation

The SPORT trial demonstrated that patients with symptomatic degenerative spondylolisthesis treated operatively had significantly greater improvement in pain and function compared to non-operative cohorts, a benefit maintained at long-term follow-up.

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