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6. Spine MCQs

Practice Set 23 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 441

Topic: 6. Spine

A 45-year-old female presents with progressive weakness in her bilateral lower extremities. MRI of the thoracic spine reveals a centrally located intramedullary spinal cord lesion with a "hemosiderin cap" and an associated syrinx. What is the most likely diagnosis?

. Astrocytoma
. Ependymoma
. Hemangioblastoma
. Meningioma
. Schwannoma

Correct Answer & Explanation

. Ependymoma

Explanation

Ependymomas are the most common intramedullary spinal cord tumors in adults. They typically present centrally within the cord, often with an associated syrinx and a characteristic hemosiderin cap on T2-weighted MRI due to microhemorrhages.

Question 442

Topic: 6. Spine

An 8-year-old boy presents with back pain. Radiographs demonstrate a "vertebra plana" of the T8 vertebral body. The child is neurologically intact. Which of the following is the most appropriate initial management?

. Anterior corpectomy and fusion
. Posterior spinal fusion with instrumentation
. Observation and symptomatic treatment
. Systemic chemotherapy and stem cell rescue
. Emergent palliative radiotherapy

Correct Answer & Explanation

. Observation and symptomatic treatment

Explanation

Vertebra plana in a child is classically caused by Langerhans Cell Histiocytosis (Eosinophilic Granuloma). In the absence of progressive neurologic deficit or severe instability, observation and bracing are recommended, as the vertebral height often reconstitutes over time.

Question 443

Topic: 6. Spine

A 55-year-old woman presents with progressive myelopathy. MRI reveals an intradural, extramedullary mass in the thoracic spine with homogeneous enhancement and a characteristic "dural tail". The most likely diagnosis is:

. Ependymoma
. Astrocytoma
. Meningioma
. Schwannoma
. Neurofibroma

Correct Answer & Explanation

. Meningioma

Explanation

Meningiomas are typically intradural extramedullary tumors that most commonly occur in the thoracic spine of middle-aged women. A "dural tail" on contrast-enhanced MRI is a classic pathognomonic finding.

Question 444

Topic: 6. Spine

A 45-year-old woman undergoes a spine CT for an unrelated abdominal issue. An incidental lesion is found in the L2 vertebral body demonstrating a "polka-dot" pattern on axial views and vertical striations on sagittal views. What is the most appropriate management?

. CT-guided biopsy
. Preoperative embolization and resection
. Observation
. Radiation therapy
. Systemic bisphosphonates

Correct Answer & Explanation

. Observation

Explanation

The imaging findings are classic for a spinal hemangioma showing vertical trabeculations or "jailhouse" striations. Asymptomatic lesions require no further intervention and can be safely observed.

Question 445

Topic: 6. Spine

Which of the following scoring systems is specifically designed to assess neoplastic spine instability and guide the need for surgical stabilization in patients with spinal metastases?

. Tokuhashi score
. Tomita score
. SINS (Spinal Instability Neoplastic Score)
. Frankel grade
. Karnofsky Performance Status

Correct Answer & Explanation

. SINS (Spinal Instability Neoplastic Score)

Explanation

The Spinal Instability Neoplastic Score (SINS) evaluates 6 components to determine structural stability and the need for surgical consultation in neoplastic disease.

Question 446

Topic: 6. Spine

A routine AP radiograph of the lumbar spine in a 65-year-old man with a history of prostate cancer reveals the "winking owl" sign. This radiographic finding indicates destruction of which anatomical structure?

. Vertebral body
. Spinous process
. Transverse process
. Pedicle
. Pars interarticularis

Correct Answer & Explanation

. Pedicle

Explanation

The "winking owl" sign is seen on an AP radiograph when one of the pedicles is destroyed by a lytic process, most commonly a spinal metastasis.

Question 447

Topic: 6. Spine

In comparing osteoblastoma to osteoid osteoma of the spine, which of the following features is more characteristic of osteoblastoma?

. Size less than 1.5 cm
. Dramatic pain relief with NSAIDs
. Location predominantly in the vertebral body
. Higher risk of progressive neurologic deficit and recurrence
. Presence of an ivory vertebra on radiographs

Correct Answer & Explanation

. Higher risk of progressive neurologic deficit and recurrence

Explanation

Osteoblastomas are larger (> 2 cm), locally aggressive, less responsive to NSAIDs, and have a higher propensity for causing neurologic deficits and recurring after curettage.

Question 448

Topic: 6. Spine

A 35-year-old male undergoes an MRI of the lumbar spine for chronic back pain. The scan incidentally reveals a T1-hyperintense, T2-hyperintense vertebral body lesion at L2 with a "polka-dot" appearance on axial CT. No cortical breakthrough is noted. What is the most appropriate management?

. CT-guided biopsy
. Marginal surgical resection
. Radiation therapy
. Observation
. Embolization followed by curettage

Correct Answer & Explanation

. Observation

Explanation

The findings describe a classic asymptomatic vertebral hemangioma, characterized by increased signal on T1 and T2 MRI and a "polka-dot" or "corduroy" appearance on CT. Asymptomatic lesions require no further intervention and are observed.

Question 449

Topic: 6. Spine

In the evaluation of suspected spinal tumors, which imaging modality is considered the gold standard for characterizing intramedullary lesions and assessing the full extent of spinal cord involvement?

. Non-contrast CT scan
. CT myelography
. Magnetic Resonance Imaging (MRI) with and without gadolinium
. Technetium-99m bone scan
. Positron Emission Tomography (PET)

Correct Answer & Explanation

. Magnetic Resonance Imaging (MRI) with and without gadolinium

Explanation

Contrast-enhanced MRI is the gold standard for evaluating spinal tumors. It provides unmatched soft-tissue resolution to differentiate intramedullary, extramedullary, and extradural lesions.

Question 450

Topic: 6. Spine

When evaluating thoracolumbar burst fractures, it is important to remember that the spinal cord ends in the conus medullaris, which typically is present at what level:

. T10
. L1
. L2
. L3
. L4

Correct Answer & Explanation

. L1

Explanation

While the conus medullaris can end anywhere from T12 to L3, in the majority of patients it is present at the L1 level. Injury at this level is much different from injury to the spinal cord or the cauda equina.

Question 451

Topic: 6. Spine

Canal compromise in burst fractures (Slide) is caused by:

. Lamina fracture and anterior migration
. Migration of the posteroinferior vertebral body
. Retropulsion of the posterosuperior vertebral body
. Narrowing of the interpedicular distance
. Herniated disk material

Correct Answer & Explanation

. Retropulsion of the posterosuperior vertebral body

Explanation

An essential component of burst fractures, as described first by Denis, is the involvement of the middle column. Typically, the posterosuperior vertebral body is separated from the remainder of the body and encroaches into the spinal canal, causing damage to the neural elements. No other part of the middle column is a standard component of the injury.

Question 452

Topic: 6. Spine

A 16-year-old boy sustains a burst fracture of L2. Radiographs indicate loss of approximately 20% of vertebral height anteriorly and 10° of kyphosis. He is neurologically intact. Management should include:

. Anterior decompression and strut graft reconstruction
. Posterior indirect decompression with transpedicular instrumentation and fusion
. Laminectomy, open reduction of the bony intrusion, and fusion
. An initial period of bed rest, monitoring the patient for ileus, and early mobilization in an extension orthosis or body cast
. Delayed reconstruction of the spine when the initial injury has been determined

Correct Answer & Explanation

. An initial period of bed rest, monitoring the patient for ileus, and early mobilization in an extension orthosis or body cast

Explanation

Burst fractures represent 17% of major spine fractures. Instability and failure occur in the anterior and middle columns. Fifty percent of patients have a neurologic deficit. These fractures are considered unstable if there is more than 50% to 60% anterior compression, 20° to 25° of kyphosis, more than 50% of canal compromise, and posterior injury. Incomplete or progressive neurologic deficits require early decompression and stabilization. Treatment of the stable fracture without neurologic deficit is hyperextension bracing for 3 to 4 months.

Question 453

Topic: Thoracolumbar Spine & Deformity

Normal sagittal thoracic alignment is:

. 5° to 10° of kyphosis due to the adjacent lordotic cervical and lumbar segments
. Straight because of the rib cage
. Lordotic to support the body weight anteriorly
. 20° to 50° of kyphosis between T1 and T10
. 60° to 80° of kyphosis between T1 and T10

Correct Answer & Explanation

. 20° to 50° of kyphosis between T1 and T10

Explanation

Thoracic kyphosis has contributions from the trapezoidal shapes of the thoracic vertebrae, from the intevertebral disk positions, and from the stiffness of the ribs and sternum. The reported normal values range from 20° to 50°.

Question 454

Topic: 6. Spine
A 70-year-old man complains of severe, burning pain in both calves after he ambulates approximately one block. He denies significant back pain. He has long-standing, insulin-dependent diabetes mellitus and a history of coronary artery disease. The patient has smoked two packs of cigarettes each day for more than 30 years. What questions from his history can help differentiate vascular from neurogenic claudication?
. Distribution of pain
. Pattern of sensory loss
. Posture changes
. Relief of pain with rest
. Timing of symptom onset

Correct Answer & Explanation

. Relief of pain with rest

Explanation

Pain distribution may be similar in vascular and neurogenic claudication. The pattern of patient-reported sensory loss is unlikely to be contributory due to the patient's history of insulin-dependent diabetes and, presumably, a diabetic peripheral neuropathy. In both syndromes, pain is relieved with rest. Usually, pain relief is quicker in vascular claudication. In neurogenic claudication, standing alone may not relieve patient symptoms; sitting is usually required. Timing of symptom onset is variable in both syndromes. Vascular claudication usually produces less variability in exercise tolerance. Relief of pain with changes in posture (bending over a walker or shopping cart) is found only in neurogenic claudication.

Question 455

Topic: 6. Spine
A 70-year-old man complains of severe, burning pain in both calves after he ambulates approximately one block. He denies significant back pain. He has long-standing, insulin-dependent diabetes mellitus and a history of coronary artery disease. The patient has smoked two packs of cigarettes each day for more than 30 years. The patient is diagnosed with neurogenic claudication. What is the most likely source of his symptoms?
. Herniated lumbar disk
. Isthmic spondylolisthesis
. Degenerative spinal stenosis at L3-L4
. Degenerative spinal stenosis at L4-L5
. Metastatic tumor

Correct Answer & Explanation

. Degenerative spinal stenosis at L4-L5

Explanation

The most common cause of neurogenic claudication in this patient is degenerative stenosis. L4-L5 is the most commonly affected level. Herniated lumbar disk is less likely. Although a metastatic tumor is possible, especially in light of the patient's smoking history, the absence of back pain makes this unlikely.

Question 456

Topic: 6. Spine

A 70-year-old man complains of severe, burning pain in both calves after he ambulates approximately one block. He denies significant back pain. He has long-standing, insulin-dependent diabetes mellitus and a history of coronary artery disease. The patient has smoked two packs of cigarettes each day for more than 30 years. A magnetic resonance image (MRI) of the patient is obtained (Slide). What does the MRI show:

. C ritically severe stenosis at L3-L4 and L4-L5
. Moderate lumbar spinal stenosis at L3-L4 and L4-L5
. Herniated lumbar disk
. Moderate lumbar stenosis at L3-L4, L4-L5, and L5-S1
. Lumbar metastatic disease

Correct Answer & Explanation

. Moderate lumbar spinal stenosis at L3-L4 and L4-L5

Explanation

The MRI shows moderately severe lumbar stenosis at L3-L4 and L4-L5. While the degree or severity of stenosis remains subjective, terming this stenosis critical is an exaggeration. The section of the axial images at L5-S1 is not in plane with the disk, hence there appears to be lateral recess stenosis at this level also. The sagittal images, however, do not confirm this diagnosis. There is no evident lumbar disk herniation, and there are no findings indicative of lumbar metastatic disease.

Question 457

Topic: 6. Spine

A 70-year-old man complains of severe, burning pain in both calves after he ambulates approximately one block. He denies significant back pain. He has long-standing, insulin-dependent diabetes mellitus and a history of coronary artery disease. The patient has smoked two packs of cigarettes each day for more than 30 years. A magnetic resonance image (MRI) of the patient is obtained, as well as a myelogram (Slide). Conservative options in this patient include:

. Medication
. Epidural steroids
. C onditioning exercise
. All of the above
. None of the above, proceed to surgery

Correct Answer & Explanation

. All of the above

Explanation

The myelogram confirms the diagnosis of lumbar spinal stenosis at L3-L4 and L4-L5. There is no myelographic block, although the stenosis is significant. A trial of conservative therapy is appropriate for this patient.

Question 458

Topic: 6. Spine
A 70-year-old man complains of severe, burning pain in both calves after he ambulates approximately one block. He denies significant back pain. He has long-standing, insulin-dependent diabetes mellitus and a history of coronary artery disease. The patient has smoked two packs of cigarettes each day for more than 30 years. Based upon the patient's history, magnetic resonance image (MRI) (Slide 1), and computed tomography (CT)-myelogram (Slide 2) available for your review, what is the correct diagnosis in this patient?
. Lumbar metastatic disease
. Lumbar spinal stenosis
. Lumbar herniated disk
. Degenerative lumbar spondylolisthesis
. Ankylosing spondylitis

Correct Answer & Explanation

. Lumbar spinal stenosis

Explanation

There is no evidence of lumbar metastases in this patient. The CT-myelogram shows compression arising posterior to the thecal sac, making a disk herniation less likely. Similarly, there is no evidence of a lumbar disk herniation on MRI. The patient's sagittal alignment is well maintained, with no spondylolisthesis evident. Ankylosing spondylitis generally presents in younger patients, and the classic radiographic finding of spontaneous arthrodesis is not present.

Question 459

Topic: 6. Spine
A 75-year-old woman presents with low back pain that is worse with motion and bilateral lower extremity pain that is worse with ambulation. She notes that the pain extends down the posterior aspects of her lower extremities, from the buttocks to the calves. The pain limits her activity—she can only ambulate approximately one block before having to rest. She reports that lumbar flexion, notably leaning over a walker or a shopping cart, considerably diminishes her lower extremity pain. She has a significant past medical history of coronary artery disease, and she has had previous angioplasty of her coronary vessels. On examination, her lower extremity pulses are easily palpable. What would you expect to find on this patient's neurological examination?
. No abnormal findings on the neurological examination
. Mild proximal lower extremity weakness
. Severe proximal lower extremity weakness
. Mild distal lower extremity weakness
. Severe distal lower extremity weakness

Correct Answer & Explanation

. No abnormal findings on the neurological examination

Explanation

Lumbar spinal stenosis is a dynamic process. Patients classically have no deficit until they are physically active. Therefore, this patient may not have a deficit during her clinic examination. It would be unusual for her to present with a fixed lower extremity deficit.

Question 460

Topic: 6. Spine
A 75-year-old woman presents with low back pain that is worse with motion and bilateral lower extremity pain that is worse with ambulation. She notes that the pain extends down the posterior aspects of her lower extremities, from the buttocks to the calves. The pain limits her activity—she can only ambulate approximately one block before having to rest. She reports that lumbar flexion, notably leaning over a walker or a shopping cart, considerably diminishes her lower extremity pain. She has a significant past medical history of coronary artery disease, and she has had previous angioplasty of her coronary vessels. On examination, her lower extremity pulses are easily palpable. What radiographic evaluation would you obtain to best establish her diagnosis?
. Plain L-spine films
. Angiogram of lower extremity vessels
. MRI of cervical spine
. Computed tomography (CT) of lumbar spine
. Magnetic resonance image (MRI) of lumbar spine

Correct Answer & Explanation

. Magnetic resonance image (MRI) of lumbar spine

Explanation

The most efficacious and least invasive means of evaluation for lumbar spinal stenosis is MRI. A CT scan, while showing bony anatomy well, may not provide adequate information about soft tissue structures. Plain films are nonspecific and, although they are often used as an initial evaluation, may not yield adequate diagnosis. This patient's symptom complex does not correlate with vascular claudication.

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