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6. Spine MCQs

Practice Set 236 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 4701

Topic: 6. Spine

A 30-year-old male sustained a traumatic spondylolisthesis of the axis (Hangman's fracture). Imaging demonstrates a fracture line passing obliquely from anterior-inferior to posterior-superior with severe C2-C3 disc disruption and facet subluxation (Type IIa). Which of the following treatments is absolutely contraindicated in this specific subtype?

. Hard cervical collar
. Halo vest immobilization
. Cervical traction
. C2-C3 anterior cervical discectomy and fusion
. C1-C3 posterior instrumented fusion

Correct Answer & Explanation

. Hard cervical collar

Explanation

Type IIa Hangman's fractures involve a flexion-distraction injury mechanism, creating an atypical fracture line and severe C2-C3 disc disruption. Cervical traction is absolutely contraindicated because it will further distract the highly unstable C2-C3 disc space and stretch the spinal cord.

Question 4702

Topic: 6. Spine

A 68-year-old male with a known history of ankylosing spondylitis presents to the emergency department after a mechanical fall from standing. He reports severe lower cervical pain. Initial neurologic examination is normal. Two hours later, he develops progressive weakness in both upper and lower extremities. What is the most appropriate next step in management?

. Discharge with a rigid cervical collar and close outpatient follow-up
. Flexion-extension cervical radiographs
. Urgent MRI of the cervical spine
. CT angiogram of the neck

Correct Answer & Explanation

. Discharge with a rigid cervical collar and close outpatient follow-up

Explanation

Patients with ankylosing spondylitis are at high risk for occult, highly unstable fractures and epidural hematomas even following minor trauma. Urgent MRI is the gold standard when neurological deterioration occurs to evaluate for epidural hematoma or spinal cord compression.

Question 4703

Topic: Thoracolumbar Spine & Deformity

A 15-year-old female gymnast presents with persistent, activity-limiting low back pain for 8 months. Radiographs demonstrate bilateral L5 pars interarticularis defects with no evidence of spondylolisthesis. She has failed a 6-month trial of bracing, rest, and physical therapy. What is the most appropriate surgical management?

. L4-S1 posterior decompression without fusion
. L5-S1 instrumented posterolateral fusion
. Direct pars repair
. Anterior lumbar interbody fusion (ALIF)

Correct Answer & Explanation

. L4-S1 posterior decompression without fusion

Explanation

In a young athlete with a symptomatic pars defect (spondylolysis) without spondylolisthesis that has failed conservative care, a direct pars repair is indicated. This approach preserves the motion segment and allows a return to high-demand activities.

Question 4704

Topic: Cervical Spine

A 35-year-old male is brought to the trauma bay after a high-speed motor vehicle collision. He is awake, alert, and cooperative. Imaging reveals a bilateral cervical facet dislocation at C5-C6. Neurologic exam reveals 3/5 strength in the bilateral upper extremities and intact sensation. According to current guidelines, what is the most appropriate immediate step in management?

. Obtain an urgent MRI of the cervical spine
. Immediate closed reduction with cranial traction
. Urgent anterior cervical discectomy and fusion (ACDF)
. Urgent posterior cervical instrumented fusion

Correct Answer & Explanation

. Obtain an urgent MRI of the cervical spine

Explanation

In an awake, alert, and cooperative patient with a cervical facet dislocation and a neurologic deficit, immediate closed reduction with cranial traction is indicated prior to obtaining an MRI. MRI is indicated if the patient cannot cooperate, fails closed reduction, or deteriorates neurologically.

Question 4705

Topic: 6. Spine

Which of the following physical examination findings is highly specific for cervical spondylotic myelopathy and indicates both a lower motor neuron lesion at the level of compression and an upper motor neuron lesion below?

. Positive Lhermitte's sign
. Hoffmann's reflex
. Brachioradialis reflex inversion
. Positive Spurling's maneuver

Correct Answer & Explanation

. Positive Lhermitte's sign

Explanation

Brachioradialis reflex inversion (eliciting reflex finger flexion or triceps extension instead of elbow flexion) indicates a lower motor neuron lesion at C5/C6 and an upper motor neuron lesion below. It is a highly specific sign for cervical myelopathy.

Question 4706

Topic: 6. Spine

A 72-year-old male falls forward, striking his chin, resulting in a hyperextension injury of the neck. He subsequently develops weakness that is significantly more pronounced in his upper extremities than his lower extremities. This clinical presentation is primarily due to injury to which aspect of the spinal cord?

. Anterior spinothalamic tracts
. Medial aspect of the lateral corticospinal tracts
. Dorsal columns
. Ventral horn cells globally

Correct Answer & Explanation

. Anterior spinothalamic tracts

Explanation

Central cord syndrome typically injures the medial portion of the lateral corticospinal tracts. Due to somatotopic organization, this medial damage predominantly affects the motor function of the upper extremities over the lower extremities.

Question 4707

Topic: 6. Spine

A 54-year-old male presents with severe right leg pain. MRI of the lumbar spine reveals a far lateral (extraforaminal) disc herniation at the L4-L5 level. Which nerve root is most likely compressed by this specific herniation?

. L3
. L4
. L5
. S1

Correct Answer & Explanation

. L3

Explanation

In the lumbar spine, an extraforaminal (far lateral) disc herniation compresses the exiting nerve root at that specific level. At L4-L5, the L4 root is the exiting root, whereas a paracentral herniation at the same level would affect the traversing L5 root.

Question 4708

Topic: Cervical Spine

An 84-year-old female with multiple medical comorbidities sustains a Type II odontoid fracture with 3 mm of posterior displacement following a low-energy fall. She is neurologically intact. What is the most appropriate initial management?

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

Correct Answer & Explanation

. Halo vest immobilization

Explanation

In frail, elderly patients with Type II odontoid fractures, there is an unacceptably high morbidity and mortality associated with both halo vest application and surgical intervention. A rigid cervical orthosis is the preferred initial treatment for this demographic.

Question 4709

Topic: Thoracolumbar Spine & Deformity

A 28-year-old male is evaluated after a fall from a height of 10 feet. CT scans show an L1 burst fracture with 20 degrees of kyphosis and 30% canal compromise. The posterior ligamentous complex is intact. He is neurologically intact. Using the Thoracolumbar Injury Classification and Severity (TLICS) system, what is the recommended management?

. TLSO bracing and early mobilization
. Short-segment posterior spinal fusion
. Anterior corpectomy and fusion
. Posterior laminectomy alone

Correct Answer & Explanation

. TLSO bracing and early mobilization

Explanation

The TLICS score for this patient is 2: burst fracture mechanism (2), intact neurology (0), and intact posterior ligamentous complex (0). Scores of 3 or less dictate non-operative management, typically with a TLSO brace.

Question 4710

Topic: 6. Spine

A 62-year-old female who underwent an L4-S1 posterior instrumented fusion 5 years ago now presents with new-onset L3 radiculopathy. Imaging reveals significant stenosis and listhesis at L3-L4. Which of the following is considered the most significant surgical risk factor for developing adjacent segment disease (ASD)?

. Sagittal malalignment
. Patient history of smoking
. Post-operative NSAID use
. Use of polyetheretherketone (PEEK) interbody spacers

Correct Answer & Explanation

. Sagittal malalignment

Explanation

Sagittal malalignment, specifically the failure to restore adequate lumbar lordosis during the index fusion procedure, is the most significant biomechanical risk factor for accelerating adjacent segment disease.

Question 4711

Topic: Thoracolumbar Spine & Deformity

A 22-year-old female involved in a head-on motor vehicle collision while wearing a lap-only seatbelt sustains a flexion-distraction injury (Chance fracture) of L2. Based on the mechanism of injury, she should be urgently evaluated for which highly associated concomitant injury?

. Thoracic aortic tear
. Intra-abdominal hollow viscus injury
. Diaphragmatic rupture
. Renal artery thrombosis

Correct Answer & Explanation

. Thoracic aortic tear

Explanation

Chance fractures are flexion-distraction injuries commonly caused by a lap seatbelt acting as a fulcrum. They carry a 40-50% association with concurrent intra-abdominal injuries, particularly hollow viscus ruptures.

Question 4712

Topic: 6. Spine

A 45-year-old male presents with right-sided neck pain radiating to the thumb and index finger. On physical examination, he has a diminished brachioradialis reflex and 4/5 strength in wrist extension. Which cervical disc level is most likely herniated?

. C4-C5
. C5-C6
. C6-C7
. C7-T1

Correct Answer & Explanation

. C4-C5

Explanation

A C5-C6 disc herniation compresses the C6 nerve root. A C6 radiculopathy classically presents with weakness in wrist extension, a diminished brachioradialis reflex, and paresthesias in the thumb and index finger.

Question 4713

Topic: 6. Spine

A 70-year-old male presents with dysphagia and mild neck stiffness. Lateral cervical spine radiographs demonstrate flowing anterior osteophytes with preservation of the intervertebral disc spaces. To meet the Resnick and Niwayama radiographic criteria for Diffuse Idiopathic Skeletal Hyperostosis (DISH), flowing ossification must involve at least how many contiguous vertebral bodies?

. Two
. Three
. Four
. Five

Correct Answer & Explanation

. Two

Explanation

The Resnick and Niwayama criteria for DISH require the presence of flowing osteophytes over at least four contiguous vertebral bodies, relative preservation of disc height, and the absence of facet joint ankylosis.

Question 4714

Topic: 6. Spine

A 25-year-old male strikes his chin on the steering wheel during a motor vehicle collision. Radiographs demonstrate a displaced, angulated fracture through the bilateral pars interarticularis of C2 (Type II Hangman's fracture). What is the primary mechanism of injury for this fracture pattern?

. Hyperextension and axial loading
. Flexion and distraction
. Lateral bending
. Axial loading alone

Correct Answer & Explanation

. Hyperextension and axial loading

Explanation

A Hangman's fracture (traumatic spondylolisthesis of the axis) typically results from sudden hyperextension combined with axial loading, driving the occiput into the posterior elements of C2.

Question 4715

Topic: 6. Spine

A 25-year-old male is brought to the emergency department after a motor vehicle collision. He is awake, alert, and cooperative. Examination reveals a C6 ASIA B incomplete spinal cord injury. Radiographs show a C5-C6 bilateral facet dislocation. What is the most appropriate next step in management?

. Urgent MRI of the cervical spine
. Immediate closed reduction with skull tongs
. Immediate anterior cervical discectomy and fusion
. Administration of high-dose methylprednisolone

Correct Answer & Explanation

. Urgent MRI of the cervical spine

Explanation

In an awake and testable patient with an acute spinal cord injury and cervical facet dislocation, immediate closed reduction with awake serial neurologic exams is indicated. An MRI is not required prior to reduction in an alert, cooperative patient.

Question 4716

Topic: Thoracolumbar Spine & Deformity

A 40-year-old male falls from a ladder and sustains an L2 burst fracture. He is neurologically intact. An MRI confirms disruption of the posterior ligamentous complex (PLC). What is his Thoracolumbar Injury Classification and Severity (TLICS) score and recommended treatment?

. Score 2; Nonoperative management with a TLSO brace
. Score 4; Surgeon's choice of operative or nonoperative management
. Score 5; Operative management
. Score 7; Operative management

Correct Answer & Explanation

. Score 2; Nonoperative management with a TLSO brace

Explanation

The TLICS score is 5: morphology is burst (2 points), neurological status is intact (0 points), and the PLC is disrupted (3 points). A score of 5 or greater is an indication for operative stabilization.

Question 4717

Topic: 6. Spine

A 60-year-old male with cervical spondylotic myelopathy is being evaluated for surgical decompression. Which of the following preoperative radiographic findings is considered a strict biomechanical contraindication to cervical laminoplasty?

. Myelopathy duration greater than 1 year
. Ossification of the posterior longitudinal ligament (OPLL)
. Fixed cervical kyphosis greater than 13 degrees
. Multilevel spondylotic changes involving 3 or more levels

Correct Answer & Explanation

. Myelopathy duration greater than 1 year

Explanation

Cervical laminoplasty relies on the dorsal drift of the spinal cord away from anterior compressive lesions. Fixed cervical kyphosis >13 degrees prevents this dorsal drift, rendering the procedure ineffective and potentially worsening the deformity.

Question 4718

Topic: Thoracolumbar Spine & Deformity

An 18-year-old restrained passenger in a high-speed collision presents with severe lower back pain. Radiographs demonstrate a transverse fracture through the L2 pedicles and vertebral body with posterior element distraction. Which of the following associated conditions must be most urgently evaluated?

. Aortic transection
. Blunt cardiac injury
. Intra-abdominal hollow viscus injury
. Diaphragmatic rupture

Correct Answer & Explanation

. Aortic transection

Explanation

The patient has a Chance fracture (flexion-distraction injury), which is highly associated with seatbelt injuries. There is a high incidence (up to 50%) of concurrent intra-abdominal hollow viscus injuries that require urgent general surgery evaluation.

Question 4719

Topic: 6. Spine

A 45-year-old male presents with acute severe right anterior thigh pain, weakness in knee extension, and a diminished patellar reflex. He reports no central back pain. MRI reveals a right-sided far lateral (extraforaminal) disc herniation at the L3-L4 level. Which nerve root is primarily compressed?

. L2
. L3
. L4
. L5

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 disc herniation compresses the L3 nerve root.

Question 4720

Topic: Thoracolumbar Spine & Deformity

When evaluating the sagittal balance of a patient presenting with degenerative lumbar spondylolisthesis, which of the following formulas accurately describes the relationship between key spinopelvic parameters?

. Pelvic Incidence = Pelvic Tilt + Sacral Slope
. Pelvic Tilt = Pelvic Incidence + Sacral Slope
. Sacral Slope = Pelvic Incidence + Pelvic Tilt
. Pelvic Incidence = Pelvic Tilt - Sacral Slope

Correct Answer & Explanation

. Pelvic Incidence = Pelvic Tilt + Sacral Slope

Explanation

Pelvic incidence (PI) is a fixed anatomical parameter defined as the sum of pelvic tilt (PT) and sacral slope (SS). This equation (PI = PT + SS) is fundamental in planning deformity correction and sagittal realignment.

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