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6. Spine MCQs

Practice Set 235 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 4681

Topic: 6. Spine

What is the most common neurologic complication following a multilevel posterior cervical laminectomy and fusion for cervical spondylotic myelopathy?

. Vertebral artery injury
. C5 nerve root palsy
. Pseudarthrosis
. Horner syndrome
. Dural tear

Correct Answer & Explanation

. Vertebral artery injury

Explanation

C5 palsy is a well-documented complication occurring in 5-10% of patients following posterior cervical decompression. It is believed to be caused by posterior cord shift and tethering of the relatively short C5 nerve roots.

Question 4682

Topic: Thoracolumbar Spine & Deformity

A 35-year-old man falls from a height and sustains a thoracolumbar fracture. CT shows a burst fracture of L1 with splaying of the posterior elements indicating a posterior ligamentous complex (PLC) injury. Neurologic examination is normal. Based on the Thoracolumbar Injury Classification and Severity Score (TLICS), what is the most appropriate treatment?

. TLSO brace and early mobilization
. Bed rest for 6 weeks
. Posterior spinal instrumentation and fusion
. Stand-alone anterior vertebrectomy
. Epidural steroid injection

Correct Answer & Explanation

. TLSO brace and early mobilization

Explanation

This patient has a burst fracture (2 points), a disrupted PLC indicated by splayed posterior elements (3 points), and intact neurology (0 points), totaling a TLICS score of 5. A score greater than 4 is an indication for surgical stabilization.

Question 4683

Topic: 6. Spine

A 75-year-old man with long-standing ankylosing spondylitis presents with severe back pain after a minor fall. Plain radiographs show no obvious fracture. What is the most appropriate next step in management?

. Discharge with NSAIDs
. Order a DEXA scan
. Prescribe a rigid TLSO brace
. Obtain a CT or MRI of the entire spine
. Perform a bone scan

Correct Answer & Explanation

. Discharge with NSAIDs

Explanation

Patients with ankylosing spondylitis have a highly rigid, osteoporotic spine and are at high risk for unstable, occult fractures even after minor trauma. Advanced imaging (CT or MRI) of the entire spine is mandatory if a fracture is suspected to avoid devastating neurologic injury.

Question 4684

Topic: 6. Spine

A 40-year-old man presents with bilateral radicular leg pain, saddle anesthesia, and urinary retention for the past 12 hours. MRI confirms a massive L4-L5 central disc herniation. Within what timeframe from symptom onset should surgical decompression ideally be performed to maximize the recovery of bladder/bowel function?

. 6 hours
. 12 hours
. 24 hours
. 48 hours
. 72 hours

Correct Answer & Explanation

. 6 hours

Explanation

Surgical decompression for cauda equina syndrome should ideally be performed within 48 hours of symptom onset. Decompression within this window maximizes the likelihood of significant neurologic recovery, particularly for sphincter function.

Question 4685

Topic: 6. Spine

A 60-year-old woman with advanced rheumatoid arthritis presents with progressively worsening neck pain and myelopathic symptoms (clumsiness in her hands). Radiographs reveal an anterior atlantodental interval (ADI) of 11 mm. What is the most appropriate definitive management?

. Rigid cervical collar
. Corticosteroid injections
. Posterior C1-C2 fusion
. Occipitocervical fusion
. Anterior odontoid screw fixation

Correct Answer & Explanation

. Rigid cervical collar

Explanation

An ADI greater than 9 mm in a patient with rheumatoid arthritis, or the presence of clinical myelopathy, indicates a high risk for irreversible neurologic compromise. Posterior C1-C2 fusion is the preferred surgical treatment for isolated atlantoaxial instability.

Question 4686

Topic: 6. Spine

What is the primary mechanism of injury causing a Chance fracture of the thoracolumbar spine?

. Axial loading
. Flexion-distraction
. Hyperextension
. Lateral compression
. Torsional shear

Correct Answer & Explanation

. Axial loading

Explanation

A Chance fracture is a flexion-distraction injury, classically associated with lap-belt use in motor vehicle accidents. It typically features a horizontal fracture line through the spinous process, pedicles, and vertebral body.

Question 4687

Topic: 6. Spine

In patients who sustain a flexion-distraction (Chance) fracture of the lumbar spine, which of the following associated injuries must be highly suspected?

. Aortic dissection
. Gastrointestinal hollow viscus injury
. Renal artery thrombosis
. Pulmonary contusion
. Diaphragmatic rupture

Correct Answer & Explanation

. Aortic dissection

Explanation

Flexion-distraction injuries (Chance fractures) have a very high association with intra-abdominal trauma. Hollow viscus injuries, particularly of the small bowel, occur in up to 40% of these cases.

Question 4688

Topic: 6. Spine

A patient undergoes an anterior cervical discectomy and fusion (ACDF) for C6-C7 radiculopathy. Postoperatively, the patient is noted to have a hoarse voice that does not resolve. Which nerve was most likely injured during the surgical approach?

. Hypoglossal nerve
. Superior laryngeal nerve
. Glossopharyngeal nerve
. Recurrent laryngeal nerve
. Vagus nerve trunk

Correct Answer & Explanation

. Hypoglossal nerve

Explanation

The recurrent laryngeal nerve is at risk during the anterior approach to the lower cervical spine. Injury results in vocal cord paralysis and persistent hoarseness, and is historically more common with right-sided approaches.

Question 4689

Topic: 6. Spine

A 68-year-old man is diagnosed with lumbar spinal stenosis. He reports neurogenic claudication that limits his walking distance to one block. Which of the following postural changes typically relieves his leg symptoms?

. Lumbar extension
. Walking downhill
. Lumbar flexion
. Standing upright for prolonged periods
. Lying prone

Correct Answer & Explanation

. Lumbar extension

Explanation

Neurogenic claudication is characteristically relieved by lumbar flexion (e.g., sitting or leaning forward on a shopping cart). Flexion increases the cross-sectional area of the spinal canal and neural foramina, temporarily relieving nerve root compression.

Question 4690

Topic: 6. Spine

Which of the following MRI sequences is most sensitive and specific for the early detection of spinal epidural abscess and discitis/osteomyelitis?

. T1-weighted without contrast
. T2-weighted without contrast
. STIR (Short Tau Inversion Recovery)
. T1-weighted with Gadolinium contrast
. Gradient echo sequence

Correct Answer & Explanation

. T1-weighted without contrast

Explanation

A T1-weighted MRI with Gadolinium enhancement is the gold standard and most sensitive imaging modality for evaluating discitis and epidural abscesses. It demonstrates characteristic enhancement of the infected tissues.

Question 4691

Topic: 6. Spine

A 30-year-old man presents with a gunshot wound to the T12 level resulting in complete paraplegia (ASIA A) below the umbilicus. A CT scan shows a bullet fragment retained entirely within the spinal canal. There is no cerebrospinal fluid leak. What is the recommended surgical management?

. Immediate laminectomy and bullet removal
. Anterior corpectomy and fusion
. Intravenous antibiotics and no spinal surgery
. Posterior spinal fusion with instrumentation
. Emergent dural repair

Correct Answer & Explanation

. Immediate laminectomy and bullet removal

Explanation

In complete spinal cord injuries (ASIA A) caused by gunshot wounds without an active CSF leak or severe mechanical instability, surgical extraction of the bullet provides no neurologic benefit. Surgery may only increase the risk of complications such as infection.

Question 4692

Topic: 6. Spine

Ossification of the posterior longitudinal ligament (OPLL) is most commonly found in which region of the spine and in which demographic group?

. Lumbar spine; Caucasian females
. Thoracic spine; African American males
. Cervical spine; East Asian males
. Lumbar spine; Hispanic males
. Cervical spine; Caucasian females

Correct Answer & Explanation

. Lumbar spine; Caucasian females

Explanation

OPLL most commonly affects the cervical spine and has the highest prevalence in East Asian populations, particularly Japanese males. It causes progressive narrowing of the spinal canal, leading to cervical myelopathy.

Question 4693

Topic: 6. Spine

A 68-year-old man with underlying cervical spondylosis sustains a hyperextension injury. He presents with 2/5 motor strength in his upper extremities and 4/5 in his lower extremities. The disproportionate upper extremity weakness is primarily due to damage to which of the following spinal cord tracts?

. Dorsal columns
. Spinothalamic tract
. Lateral corticospinal tract
. Anterior corticospinal tract
. Rubrospinal tract

Correct Answer & Explanation

. Dorsal columns

Explanation

Central cord syndrome preferentially affects the medial aspect of the lateral corticospinal tracts, which contain motor fibers innervating the upper extremities. Lower extremity fibers are located more laterally within the tract and are relatively spared.

Question 4694

Topic: Thoracolumbar Spine & Deformity

A 22-year-old female presents after a high-speed motor vehicle collision. Radiographs demonstrate a flexion-distraction injury (Chance fracture) at L1. Which of the following is the most commonly associated concomitant injury?

. Aortic transection
. Renal laceration
. Intra-abdominal hollow viscus injury
. Pulmonary contusion
. Pelvic ring disruption

Correct Answer & Explanation

. Aortic transection

Explanation

Chance fractures are typically caused by seatbelt injuries and involve failure of the posterior and middle columns under tension. They have a high association (up to 40-50%) with intra-abdominal hollow viscus injuries, such as bowel perforations.

Question 4695

Topic: 6. Spine

A 65-year-old male with long-standing ankylosing spondylitis presents with severe neck pain following a ground-level fall. Initial plain radiographs of the cervical spine are read as 'unremarkable.' His neurologic exam is intact. What is the most appropriate next step in management?

. Discharge with a soft collar and NSAIDs
. Flexion-extension cervical spine radiographs
. Computed tomography (CT) of the entire spine
. Magnetic resonance imaging (MRI) of the cervical spine
. Physical therapy referral for neck strengthening

Correct Answer & Explanation

. Discharge with a soft collar and NSAIDs

Explanation

Patients with ankylosing spondylitis have highly brittle, osteopenic spines and are at extreme risk for highly unstable fractures even from low-energy trauma. Plain films routinely miss these fractures due to altered anatomy, making a CT scan of the entire spine the gold standard for initial evaluation.

Question 4696

Topic: 6. Spine

A 71-year-old woman complains of bilateral posterior leg pain and cramping that worsens after walking two blocks. Which of the following historical or physical examination findings most reliably differentiates neurogenic claudication from vascular claudication?

. Diminished dorsalis pedis pulses
. Relief of symptoms when leaning forward over a shopping cart
. Pain radiating below the knees
. Symptom exacerbation upon standing still
. Presence of a positive straight leg raise test

Correct Answer & Explanation

. Diminished dorsalis pedis pulses

Explanation

Leaning forward flexes the lumbar spine, which increases the cross-sectional area of the spinal canal and neural foramina, temporarily relieving symptoms of neurogenic claudication. Vascular claudication is relieved by resting or standing still, regardless of spine posture.

Question 4697

Topic: 6. Spine

In a patient presenting with an L4-L5 degenerative spondylolisthesis, which specific neural structure is most commonly compressed, leading to radicular symptoms?

. L3 nerve root in the neural foramen
. L4 nerve root in the lateral recess
. L4 nerve root in the neural foramen
. L5 nerve root in the lateral recess
. L5 nerve root in the neural foramen

Correct Answer & Explanation

. L3 nerve root in the neural foramen

Explanation

Degenerative spondylolisthesis typically causes lateral recess stenosis rather than severe foraminal stenosis. At the L4-L5 level, this lateral recess narrowing most commonly compresses the traversing L5 nerve root.

Question 4698

Topic: 6. Spine

A 45-year-old male presents with severe acute lower back pain, bilateral sciatica, and perineal numbness. Which of the following is the most sensitive early clinical indicator of cauda equina syndrome?

. Loss of anal sphincter tone
. Urinary retention
. Bilateral Achilles tendon reflex absence
. Saddle anesthesia
. Fecal incontinence

Correct Answer & Explanation

. Loss of anal sphincter tone

Explanation

Urinary retention, often evaluated via a post-void residual ultrasound, is the most sensitive early symptom of cauda equina syndrome, with a sensitivity exceeding 90%. Fecal incontinence and profound motor deficits are typically late signs.

Question 4699

Topic: 6. Spine

A patient with cervical spondylotic myelopathy demonstrates a positive Hoffmann sign. This clinical finding indicates compression or dysfunction of which of the following structures?

. Dorsal columns
. Spinothalamic tract
. Cervical nerve roots
. Corticospinal tract
. Anterior horn cells

Correct Answer & Explanation

. Dorsal columns

Explanation

A positive Hoffmann sign represents an upper motor neuron lesion and indicates compression of the corticospinal tract in the cervical spinal cord. It manifests as reflexive flexion of the thumb and index finger when the middle finger distal phalanx is flicked.

Question 4700

Topic: 6. Spine

A 24-year-old male arrives in the trauma bay following a C5 ASIA A spinal cord injury. His blood pressure is 85/50 mmHg and heart rate is 52 bpm. What is the primary pathophysiologic mechanism responsible for his hemodynamic instability?

. Loss of parasympathetic tone from the vagus nerve
. Hypovolemia from occult intra-abdominal bleeding
. Loss of sympathetic vasomotor tone
. Cardiogenic failure due to myocardial contusion
. Systemic inflammatory response to spinal cord injury

Correct Answer & Explanation

. Loss of parasympathetic tone from the vagus nerve

Explanation

Neurogenic shock occurs due to disruption of descending sympathetic pathways in the cervical or upper thoracic cord, leading to loss of sympathetic vasomotor tone. This results in unopposed parasympathetic vagal tone, causing the classic triad of hypotension, bradycardia, and peripheral vasodilation.

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