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6. Spine MCQs

Practice Set 232 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 4621

Topic: 6. Spine

A 70-year-old man with preexisting cervical spondylosis falls forward and strikes his forehead. He presents with bilateral upper extremity weakness that is worse distally, with relatively spared lower extremity motor function and preserved perianal sensation. What is the most likely pathophysiological mechanism of his neurological deficit?

. Hyperextension injury causing pinching of the spinal cord by the infolded ligamentum flavum
. Hyperflexion injury causing an acute anterior disc herniation
. Vertical compression causing a burst fracture and retropulsion
. Distraction-flexion injury causing a unilateral facet dislocation
. Avulsion of the brachial plexus due to lateral neck flexion

Correct Answer & Explanation

. Hyperextension injury causing pinching of the spinal cord by the infolded ligamentum flavum

Explanation

This patient's presentation is classic for central cord syndrome, which typically occurs in elderly patients with pre-existing spondylosis who sustain a hyperextension injury. The spinal cord is compressed between anterior osteophytes and the posterior buckling ligamentum flavum.

Question 4622

Topic: 6. Spine

A 68-year-old woman presents with severe bilateral leg and buttock pain that worsens with walking and prolonged standing, but improves when she leans forward over a shopping cart. Which of the following is the most consistent MRI finding for her condition?

. Hypertrophy of the ligamentum flavum and facet joint arthropathy
. Large posterolateral disc extrusion at L4-L5
. Isthmic pars defect at L5 bilaterally
. Conus medullaris terminating at the L3 level
. A synovial cyst at the L2-L3 neural foramen

Correct Answer & Explanation

. Hypertrophy of the ligamentum flavum and facet joint arthropathy

Explanation

The clinical presentation describes neurogenic claudication secondary to lumbar spinal stenosis. The most common underlying MRI findings are degenerative changes including ligamentum flavum hypertrophy, facet arthropathy, and disc bulging.

Question 4623

Topic: Cervical Spine

Which of the following radiographic measurements on a lateral cervical spine film is most indicative of an atlanto-occipital dissociation?

. Basion-dental interval (BDI) > 12 mm
. Atlanto-dens interval (ADI) > 3 mm in an adult
. Prevertebral soft tissue swelling > 7 mm at C2
. Power's ratio < 1
. Cervical lordosis measuring less than 10 degrees

Correct Answer & Explanation

. Basion-dental interval (BDI) > 12 mm

Explanation

A Basion-Dental Interval (BDI) greater than 12 mm on plain radiographs or CT is highly suggestive of atlanto-occipital dissociation. An ADI > 3 mm suggests transverse ligament injury, not occipitocervical dissociation.

Question 4624

Topic: 6. Spine

A 60-year-old man underwent an L4-L5 posterior spinal fusion 5 years ago. He now presents with new-onset severe L3 radiculopathy. MRI demonstrates L3-L4 spinal stenosis and a new degenerative spondylolisthesis. What biomechanical factor most likely contributed to this new pathology?

. Decreased motion at L4-L5 leading to increased stress and hypermobility at L3-L4
. Incomplete decompression during the index surgery
. Failure of the L4-L5 fusion mass to fully consolidate
. Postoperative infection at the surgical site
. Natural progression of systemic osteoporosis

Correct Answer & Explanation

. Decreased motion at L4-L5 leading to increased stress and hypermobility at L3-L4

Explanation

Adjacent segment disease occurs due to increased biomechanical stress and compensatory hypermobility at the spinal levels immediately adjacent to a fused segment. This accelerates degenerative changes, stenosis, and instability at the adjacent level.

Question 4625

Topic: 6. Spine

A 65-year-old female presents with neurogenic claudication and an L4-L5 grade I degenerative spondylolisthesis. She has failed 6 months of conservative management. According to the SPORT trial, what is the expected outcome of surgical decompression and fusion compared to continued non-operative treatment at 4 years?

. No significant difference in pain and functional outcomes
. Significantly improved pain and function in the surgically treated group
. Worse outcomes in the surgical group due to a high rate of adjacent segment disease
. High rates of pseudoarthrosis negating any clinical benefit of surgery
. Equal improvement in pain, but higher complication rates in the surgical cohort

Correct Answer & Explanation

. No significant difference in pain and functional outcomes

Explanation

The Spine Patient Outcomes Research Trial (SPORT) demonstrated that patients with degenerative spondylolisthesis and spinal stenosis who were treated surgically had significantly greater improvement in pain and function compared to those treated non-operatively.

Question 4626

Topic: 6. Spine

A 25-year-old male sustains a severe hyperflexion injury to the cervical spine. He is awake, alert, and cooperative, but presents with a C6 ASIA A spinal cord injury. Radiographs show a bilateral facet dislocation at C6-C7. What is the most appropriate initial management in the trauma bay?

. Immediate posterior open reduction and stabilization without prior imaging
. Closed awake skeletal traction reduction with serial neurological monitoring
. Anterior cervical discectomy and fusion (ACDF) strictly within 4 hours
. High-dose methylprednisolone administration alone and observation
. Halo vest application and delayed surgical intervention

Correct Answer & Explanation

. Immediate posterior open reduction and stabilization without prior imaging

Explanation

In an awake, alert, and cooperative patient with a cervical facet dislocation, closed skeletal traction is safe and effective for rapid reduction to decompress the spinal cord. It should be performed urgently with serial neurologic exams.

Question 4627

Topic: 6. Spine

A 50-year-old man presents with severe, burning anterior thigh pain and weakness in knee extension. Examination reveals a diminished patellar reflex. MRI demonstrates a far-lateral (extraforaminal) disc herniation at the L3-L4 level. Which nerve root is primarily being compressed?

. L2
. L3
. L4
. L5
. S1

Correct Answer & Explanation

. L2

Explanation

In the lumbar spine, a far-lateral (extraforaminal) disc herniation compresses the exiting nerve root at that level. Therefore, an L3-L4 far-lateral herniation will compress the L3 nerve root.

Question 4628

Topic: 6. Spine

During an L4-L5 laminectomy for severe spinal stenosis, an incidental dural tear occurs. It is successfully repaired primarily with a 4-0 non-absorbable suture, and a Valsalva maneuver demonstrates a watertight seal. What is the most appropriate postoperative management protocol?

. Strict flat bed rest for 72 hours to prevent CSF leak
. Placement of a subfascial lumbar drain for 5 days
. Immediate revision surgery to reinforce the tear with a muscle patch
. Early mobilization as tolerated without specific bed rest restrictions
. Prophylactic broad-spectrum intravenous antibiotics for 14 days

Correct Answer & Explanation

. Strict flat bed rest for 72 hours to prevent CSF leak

Explanation

Recent literature shows that prolonged bed rest following primary, watertight repair of an incidental dural tear does not decrease the rate of subsequent CSF leaks. Early mobilization as tolerated is recommended and reduces complications associated with prolonged immobility.

Question 4629

Topic: 6. Spine

A 28-year-old male is comatose (GCS 6) following a high-speed motorcycle collision. A high-quality multi-detector CT scan of the cervical spine with sagittal and coronal reconstructions reveals no fractures or malalignment. According to current trauma guidelines, what is the appropriate next step regarding his cervical collar?

. Maintain the collar until an MRI can be obtained to rule out ligamentous injury.
. Remove the cervical collar as a high-quality negative CT is sufficient for clearance.
. Maintain the collar until the patient awakens and can participate in a clinical exam.
. Perform flexion-extension fluoroscopy in the intensive care unit.
. Keep the collar on for 6 weeks as a precaution against missed injuries.

Correct Answer & Explanation

. Maintain the collar until an MRI can be obtained to rule out ligamentous injury.

Explanation

Current guidelines, including those from EAST, state that a normal high-quality CT scan of the cervical spine is sufficient to clear the cervical spine in an obtunded or unexaminable trauma patient. Routine MRI or maintaining the collar is no longer recommended.

Question 4630

Topic: 6. Spine

A 45-year-old male is brought to the emergency department after a motor vehicle collision. He is awake, alert, and cooperative. Neurologic examination reveals an incomplete quadriparesis (ASIA C). Cervical spine radiographs demonstrate a bilateral facet dislocation at C5-C6. What is the most appropriate next step in management?

. Immediate magnetic resonance imaging (MRI) of the cervical spine
. Immediate closed cranial traction reduction
. Anterior cervical discectomy and fusion (ACDF)
. Posterior cervical instrumented fusion
. Application of a halo vest

Correct Answer & Explanation

. Immediate magnetic resonance imaging (MRI) of the cervical spine

Explanation

In an awake, alert, and cooperative patient with a cervical facet dislocation and a neurologic deficit, immediate closed cranial traction reduction is indicated to decompress the spinal cord. MRI is not required prior to reduction in a cooperative patient who can provide reliable neurologic exams during the procedure.

Question 4631

Topic: 6. Spine

Based on the outcomes of the Spine Patient Outcomes Research Trial (SPORT), which of the following statements is most accurate regarding the surgical treatment of degenerative spondylolisthesis with spinal stenosis?

. Surgical treatment provides no significant advantage over nonoperative treatment at 4 years.
. Decompression alone provides equivalent long-term outcomes to decompression with instrumented fusion.
. Patients treated surgically show significantly greater improvement in pain and function at 4 years compared to nonoperative cohorts.
. The benefit of surgery over nonoperative treatment diminishes completely by 2 years postoperative.
. Nonoperative treatment has a significantly lower rate of cross-over to surgery than in the lumbar disc herniation cohorts.

Correct Answer & Explanation

. Surgical treatment provides no significant advantage over nonoperative treatment at 4 years.

Explanation

The SPORT trial demonstrated that patients treated surgically for degenerative spondylolisthesis with spinal stenosis maintained significantly greater improvement in pain and function at 4 years compared to those treated nonoperatively. Decompression with fusion is generally preferred over decompression alone to prevent progressive instability.

Question 4632

Topic: Cervical Spine

An 82-year-old male presents with severe neck pain following a ground-level fall. CT of the cervical spine reveals a Type II odontoid fracture with 2 mm of posterior displacement. He is neurologically intact but has multiple medical comorbidities, including severe COPD and congestive heart failure. What is the most appropriate initial management?

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

Correct Answer & Explanation

. Rigid cervical collar

Explanation

In elderly patients (typically >80 years) with multiple medical comorbidities, rigid cervical collar immobilization is the preferred initial treatment for Type II odontoid fractures. Surgery and halo vest immobilization carry exceptionally high morbidity and mortality in this specific patient population.

Question 4633

Topic: 6. Spine

Which of the following findings is considered the most reliable indicator for early diagnosis of cauda equina syndrome in a patient presenting with acute low back pain and bilateral radiculopathy?

. Unilateral absent ankle reflex
. Positive straight leg raise test bilaterally
. Post-void residual bladder volume > 200 mL
. Saddle anesthesia
. Loss of the bulbocavernosus reflex

Correct Answer & Explanation

. Unilateral absent ankle reflex

Explanation

Urinary retention is the most consistent and often the earliest sign of cauda equina syndrome. A post-void residual volume greater than 200-500 mL in the setting of acute low back pain and radiculopathy is highly suspicious and warrants emergent MRI.

Question 4634

Topic: 6. Spine

A 25-year-old male sustains a traumatic spondylolisthesis of the axis (Hangman's fracture) following a motor vehicle collision. Radiographs show significant angular deformity but minimal translation, and the C2-C3 disc space is widened posteriorly. According to the Levine and Edwards classification, this is a Type IIa fracture. What is the appropriate initial management?

. Immediate cranial traction with heavy weights
. Application of a halo vest in slight distraction
. Application of a halo vest with mild compression and extension
. Anterior C2-C3 discectomy and fusion
. Posterior C1-C3 instrumented fusion

Correct Answer & Explanation

. Immediate cranial traction with heavy weights

Explanation

Type IIa Hangman's fractures involve severe angulation with minimal translation and indicate a flexion-distraction injury with an incompetent C2-C3 disc. Traction is strictly contraindicated as it will worsen the deformity; they should be reduced with gentle compression and extension in a halo vest.

Question 4635

Topic: Thoracolumbar Spine & Deformity

A 45-year-old female presents with persistent, severe lower back and bilateral L5 radicular pain that has failed 6 months of conservative management. Radiographs demonstrate a Grade II isthmic spondylolisthesis at L5-S1. What is the most appropriate surgical intervention?

. L5 laminectomy and Gill procedure alone
. L5-S1 anterior lumbar interbody fusion (ALIF) without posterior instrumentation
. L5-S1 posterior decompression and instrumented posterolateral fusion
. Pars interarticularis repair (Buck's or Scott wiring)
. L4-S1 uninstrumented posterolateral fusion

Correct Answer & Explanation

. L5 laminectomy and Gill procedure alone

Explanation

In adult patients with symptomatic low-grade isthmic spondylolisthesis failing conservative care, the standard surgical treatment is decompression of the neural elements combined with an instrumented posterolateral fusion (with or without interbody fusion). Pars repair is generally reserved for young patients (under 20) with minimal slip.

Question 4636

Topic: 6. Spine

A 30-year-old male sustains a Jefferson burst fracture of C1. On the open-mouth odontoid radiograph, the lateral masses of C1 are displaced laterally relative to the lateral masses of C2. According to Spence's rule, a combined lateral mass overhang exceeding what value suggests an incompetent transverse atlantal ligament?

. 3.5 mm
. 5.2 mm
. 6.9 mm
. 8.5 mm
. 10.0 mm

Correct Answer & Explanation

. 3.5 mm

Explanation

Spence's rule states that a combined overhanging of the C1 lateral masses on C2 of 6.9 mm or greater on an AP open-mouth radiograph indicates a rupture of the transverse atlantal ligament. Subsequent MRI studies have suggested that >8.1 mm may be more accurate, but 6.9 mm remains the classic threshold tested on boards.

Question 4637

Topic: 6. Spine

A 68-year-old male complains of bilateral posterior leg pain and heaviness that worsens with walking. Which of the following historical or physical examination findings most reliably differentiates neurogenic claudication from vascular claudication?

. Pain radiating proximal to distal
. Symptom relief while leaning forward on a shopping cart or riding a stationary bicycle
. Diminished pedal pulses
. Symptom relief within seconds of standing still
. Presence of leg cramping during rest

Correct Answer & Explanation

. Pain radiating proximal to distal

Explanation

Neurogenic claudication is classically relieved by lumbar flexion (e.g., leaning on a shopping cart, cycling), which opens the spinal canal and neuroforamina. Vascular claudication is typically relieved simply by resting or standing still, regardless of spinal posture.

Question 4638

Topic: Thoracolumbar Spine & Deformity

A 22-year-old male is involved in a rugby tackle resulting in a neck injury. Lateral cervical radiographs demonstrate a unilateral facet dislocation at C5-C6. What is the typical radiographic appearance of a unilateral facet dislocation regarding vertebral body translation?

. Anterior translation of the superior vertebral body by less than 25% of the vertebral body width
. Anterior translation of the superior vertebral body by approximately 50% of the vertebral body width
. Posterior translation of the superior vertebral body by 25%
. Anterior translation of the superior vertebral body by greater than 75%
. No translation, only angular kyphosis

Correct Answer & Explanation

. Anterior translation of the superior vertebral body by less than 25% of the vertebral body width

Explanation

Unilateral facet dislocations typically exhibit less than 25% anterior translation of the superior vertebral body over the inferior body on lateral radiographs. Bilateral facet dislocations typically present with 50% or greater anterior translation.

Question 4639

Topic: 6. Spine

In the Subaxial Cervical Spine Injury Classification (SLIC) system, which of the following parameters assigns the highest point value towards the total score?

. Compression morphology
. Indeterminate disco-ligamentous complex status
. Complete neurologic deficit
. Incomplete neurologic deficit
. Nerve root injury

Correct Answer & Explanation

. Compression morphology

Explanation

In the SLIC system, an incomplete neurologic deficit is assigned 3 points, which is the highest score in the neurologic status category (Complete deficit = 2 points, Root injury = 1 point). This highlights the urgency and potential for recovery in incomplete cord injuries.

Question 4640

Topic: 6. Spine

A 35-year-old trauma patient undergoes an L4-L5 laminectomy and medial facetectomy for severe lateral recess stenosis. During the decompression, an incidental durotomy occurs. What is the most appropriate immediate management of this complication?

. Placement of a lumbar subarachnoid drain and immediate closure
. Primary water-tight suture repair of the dura
. Application of an absorbable gelatin sponge and early mobilization
. Conversion to an open instrumented fusion
. Leave the durotomy open and place a closed suction drain deep to the fascia

Correct Answer & Explanation

. Placement of a lumbar subarachnoid drain and immediate closure

Explanation

The most appropriate immediate management of an intraoperative incidental durotomy is a primary, water-tight suture repair. This minimizes the risk of cerebrospinal fluid leak, pseudomeningocele formation, and persistent postural headaches.

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