Menu

6. Spine MCQs

Practice Set 241 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 4801

Topic: Cervical Spine

Twelve hours following an elective C4-C5 anterior cervical discectomy and fusion (ACDF), a 55-year-old male patient suddenly develops progressive difficulty swallowing, stridor, and significant anterior neck swelling. His oxygen saturation drops to 86% on room air, and he exhibits suprasternal retractions. What is the most critical and appropriate immediate next step in management?

. Administer IV dexamethasone and nebulized racemic epinephrine
. Obtain a stat CT scan of the soft tissues of the neck
. Perform an emergent bedside cricothyroidotomy
. Open the neck incision at the bedside to evacuate the hematoma
. Urgently transfer the patient to the operating room for re-exploration

Correct Answer & Explanation

. Open the neck incision at the bedside to evacuate the hematoma

Explanation

The patient is presenting with a life-threatening, rapidly expanding post-operative retropharyngeal hematoma causing acute airway compromise. In a post-ACDF patient presenting with stridor, hypoxia, and acute respiratory distress, the immediate life-saving maneuver is to open the surgical incision down to the fascial layer at the bedside to evacuate the hematoma and relieve the extrinsic compression on the airway. Waiting for a CT scan, transferring to the OR, or attempting complex intubations without decompressing the neck can result in anoxic brain injury or death. Once the hematoma is evacuated and the airway is secured, the patient can be safely transported to the OR for formal exploration and hemostasis.

Question 4802

Topic: 6. Spine

A 55-year-old male with a history of intravenous drug use presents with 2 weeks of severe mid-thoracic back pain, fevers, and new-onset inability to void. Examination reveals 3/5 motor strength in both lower extremities, diminished sensation below the umbilicus, and hyperreflexia at the knees and ankles. MRI of the spine reveals a large, peripherally enhancing fluid collection in the dorsal epidural space spanning T6 to T9, causing severe spinal cord compression. What is the most appropriate definitive management?

. CT-guided percutaneous aspiration and 6 weeks of intravenous antibiotics
. Emergent anterior corpectomy and decompression
. Emergent posterior laminectomy, abscess evacuation, and culture
. Empiric intravenous antibiotics and close neurological observation
. High-dose corticosteroids followed by delayed surgical decompression

Correct Answer & Explanation

. Emergent posterior laminectomy, abscess evacuation, and culture

Explanation

This patient has a spinal epidural abscess (SEA) presenting with progressive neurological deficits and cauda equina/conus/cord symptoms (inability to void, paraparesis). The presence of a neurological deficit is an absolute indication for emergent surgical decompression and evacuation of the abscess. Because the abscess is located in the dorsal epidural space, a posterior approach (laminectomy) is the standard and most direct method for decompression and evacuation. If the abscess were purely ventral, an anterior approach (like a corpectomy) might be necessary to avoid destabilizing the spine or to adequately reach the pathology without manipulating the spinal cord.

Question 4803

Topic: 6. Spine

A 65-year-old man undergoes a C3-C7 posterior cervical laminectomy and fusion for severe cervical spondylotic myelopathy. On postoperative day 1, he complains of new-onset right shoulder weakness. Examination reveals 2/5 strength in the right deltoid and biceps, while his grip strength and lower extremity motor function remain at baseline. What is the most widely accepted etiology of this specific postoperative complication?

. Intraoperative spinal cord contusion
. C5 nerve root tethering due to posterior spinal cord drift
. Postoperative epidural hematoma
. C4-C5 intraoperative foraminal fracture
. Iatrogenic retraction injury to the brachial plexus

Correct Answer & Explanation

. C5 nerve root tethering due to posterior spinal cord drift

Explanation

Postoperative C5 palsy is a well-documented complication of cervical decompression, particularly following posterior laminectomy and fusion. The most widely accepted mechanism is the 'tethering effect' on the C5 nerve root. Because the C5 root is relatively short and runs a more horizontal course, posterior drift of the spinal cord following decompression places tension on the root, leading to palsy. An epidural hematoma or cord contusion would typically present with more global or long-tract signs rather than an isolated single-root motor deficit.

Question 4804

Topic: 6. Spine

In planning corrective surgery for an adult patient with significant sagittal spinal deformity, restoring appropriate spinopelvic parameters is critical to surgical success. If a 68-year-old woman presents with severe back pain and a forward-leaning posture and is found to have a pelvic incidence (PI) of 62 degrees, her postoperative lumbar lordosis (LL) should ideally be reconstructed to fall within what range to minimize the risk of mechanical failure?

. 10 to 20 degrees
. 30 to 40 degrees
. 52 to 72 degrees
. 80 to 90 degrees
. Greater than 90 degrees

Correct Answer & Explanation

. 52 to 72 degrees

Explanation

In the surgical management of adult spinal deformity, restoring sagittal balance is highly correlated with improved patient-reported outcomes. A key radiographic target is achieving a Pelvic Incidence to Lumbar Lordosis (PI-LL) mismatch of less than 10 degrees. Therefore, for a patient with a pelvic incidence of 62 degrees, the ideal reconstructed lumbar lordosis should be between 52 and 72 degrees.

Question 4805

Topic: Cervical Spine

A 78-year-old man with a history of severe COPD, ischemic heart disease, and osteoporosis sustains a Type II odontoid fracture after a ground-level fall. Radiographs demonstrate 2 mm of posterior displacement. He is neurologically intact. What is the most appropriate initial management?

. Halo vest immobilization for 12 weeks
. Rigid cervical collar immobilization
. Anterior odontoid screw fixation
. Posterior C1-C2 transarticular screw fixation
. Occipitocervical fusion with instrumentation

Correct Answer & Explanation

. Rigid cervical collar immobilization

Explanation

In elderly patients with Type II odontoid fractures, rigid cervical collar immobilization is increasingly favored as initial management over halo vest immobilization due to the high rates of morbidity and mortality associated with halo application in this demographic (e.g., respiratory decline, pin-site infections). Although surgical fixation (like posterior C1-C2 fusion) offers higher radiographic union rates, the perioperative risks are substantial. Current evidence supports collar immobilization as a safe strategy, as many elderly patients achieve a stable, asymptomatic fibrous nonunion.

Question 4806

Topic: 6. Spine

According to the results of the Spine Patient Outcomes Research Trial (SPORT) evaluating the treatment of degenerative spondylolisthesis with symptomatic spinal stenosis, which of the following statements most accurately reflects the study's long-term findings?

. Non-operative treatment provides superior long-term pain relief at 4 years.
. Surgical treatment shows a significant advantage in pain relief and functional improvement that is maintained at 4 years.
. There is no statistically significant difference in outcomes between surgery and non-operative care at the 1-year mark.
. Surgical decompression alone is proven superior to decompression combined with fusion.
. Epidural steroid injections proved equally effective to surgical intervention at 2 years.

Correct Answer & Explanation

. Surgical treatment shows a significant advantage in pain relief and functional improvement that is maintained at 4 years.

Explanation

The SPORT trial for degenerative spondylolisthesis demonstrated an as-treated analysis showing that patients treated surgically maintained significantly greater improvements in pain and function at 4 years (and beyond) compared to those managed non-operatively. The trial specifically looked at decompression and fusion vs. non-operative care.

Question 4807

Topic: 6. Spine

A 60-year-old man with known cervical spondylosis presents after a hyperextension injury in a motor vehicle collision. Examination reveals 3/5 strength in the upper extremities, predominantly affecting hand intrinsics, and 4/5 strength in the lower extremities.

MRI shows multi-level cervical stenosis and cord edema without fracture. What is the most appropriate initial management parameter for his neurological injury?

. Immediate administration of high-dose intravenous methylprednisolone
. Emergent anterior cervical discectomy and fusion (ACDF) within 4 hours
. Maintenance of mean arterial pressure (MAP) between 85-90 mmHg for 5-7 days
. Emergent posterior cervical laminectomy
. Application of skull tongs with continuous cervical traction

Correct Answer & Explanation

. Maintenance of mean arterial pressure (MAP) between 85-90 mmHg for 5-7 days

Explanation

This patient presents with Central Cord Syndrome, characterized by a disproportionately greater motor impairment in the upper extremities compared to the lower extremities, typically following a hyperextension injury in a stenotic cervical spine. Current guidelines strongly recommend strict blood pressure augmentation, maintaining the mean arterial pressure (MAP) between 85-90 mmHg for 5-7 days to optimize spinal cord perfusion and reduce secondary ischemic injury. Steroids are no longer standard of care due to complication profiles, and emergent surgery is not universally mandated unless there is progressive deficit or gross instability.

Question 4808

Topic: 6. Spine

A 55-year-old male with poorly controlled diabetes mellitus presents with 2 weeks of worsening mid-back pain. He now reports new-onset inability to walk and urinary retention. Examination demonstrates 2/5 strength in the bilateral iliopsoas and quadriceps. MRI of the thoracic spine reveals a T8-T9 discitis with an anterior epidural abscess causing severe spinal cord compression. What is the most appropriate next step in management?

. CT-guided needle biopsy, withholding antibiotics until cultures are finalized
. Immediate administration of broad-spectrum intravenous antibiotics and close neuromonitoring
. Emergent surgical decompression and debridement
. Intravenous high-dose corticosteroids followed by targeted antibiotics
. Placement of a lumbar drain to reduce intrathecal pressure

Correct Answer & Explanation

. Emergent surgical decompression and debridement

Explanation

Spinal epidural abscess presenting with acute, profound, or progressive neurological deficits (such as myelopathy, severe weakness, and bowel/bladder dysfunction) constitutes an absolute surgical emergency. Emergent surgical decompression and debridement are required to relieve cord compression and maximize the chance of neurological recovery. While antibiotics are essential, relying on them alone in the face of profound acute neurological deficit is inappropriate.

Question 4809

Topic: Thoracolumbar Spine & Deformity

A 30-year-old construction worker falls from scaffolding. A CT of the lumbar spine reveals an L1 burst fracture with 40% loss of anterior vertebral body height and 30% canal compromise. The posterior elements are intact. He is neurologically intact (ASIA E), and a subsequent MRI confirms an intact posterior ligamentous complex (PLC). Using the Thoracolumbar Injury Classification and Severity (TLICS) system, what is his total score and the generally recommended treatment?

. Score 2; non-operative management
. Score 4; surgeon's choice of operative or non-operative management
. Score 5; surgical management
. Score 3; surgeon's choice of operative or non-operative management
. Score 2; surgical management

Correct Answer & Explanation

. Score 2; non-operative management

Explanation

The TLICS score is calculated based on morphology, neurological status, and PLC integrity. For this patient: Morphology = Burst fracture (2 points); Neurological status = Intact (0 points); PLC = Intact (0 points). Total score = 2. A TLICS score of 3 or less suggests non-operative management. A score of 4 is indeterminate, and a score of 5 or more suggests operative intervention.

Question 4810

Topic: Thoracolumbar Spine & Deformity

A 14-year-old elite female gymnast presents with progressive, activity-limiting lower back pain and tight hamstrings. Radiographs reveal a Grade II isthmic spondylolisthesis at L5-S1. Despite 6 months of comprehensive conservative management including rest, bracing, and targeted physical therapy, her pain remains debilitating. What is the most appropriate surgical intervention?

. L5-S1 laminectomy alone
. Pars interarticularis repair with local bone grafting
. L5-S1 in situ posterolateral fusion
. Anterior lumbar interbody fusion (ALIF) at L4-L5
. Minimally invasive sacroiliac joint fusion

Correct Answer & Explanation

. L5-S1 in situ posterolateral fusion

Explanation

In adolescents with symptomatic Grade I or II isthmic spondylolisthesis that is recalcitrant to conservative measures, the gold standard surgical treatment is an L5-S1 posterolateral fusion (with or without instrumentation). Pars repair is generally reserved for patients with a pars defect (spondylolysis) without significant listhesis, typically at L4 or above. Laminectomy alone is contraindicated in pediatric isthmic spondylolisthesis as it significantly increases the risk of progressive slip.

Question 4811

Topic: 6. Spine

A 45-year-old woman presents with severe right-sided neck and arm pain. Physical examination demonstrates a positive Spurling's test reproducing pain radiating down the posterior aspect of her right arm into her middle finger. Motor testing reveals weakness with elbow extension, and her triceps reflex is absent. Which cervical nerve root is most likely compressed, and at which intervertebral disc level does this typically occur?

. C6 nerve root; C5-C6 disc
. C7 nerve root; C6-C7 disc
. C8 nerve root; C7-T1 disc
. C6 nerve root; C6-C7 disc
. C7 nerve root; C5-C6 disc

Correct Answer & Explanation

. C7 nerve root; C6-C7 disc

Explanation

The clinical signs of pain radiating to the middle finger, weakness in elbow extension (triceps), and an absent or diminished triceps reflex are classic pathognomonic findings of a C7 radiculopathy. In the cervical spine, the exiting nerve roots are named for the pedicle below them. Therefore, the C7 nerve root exits through the C6-C7 intervertebral foramen, making a C6-C7 disc herniation the most common cause of C7 radiculopathy.

Question 4812

Topic: 6. Spine

A 72-year-old man with a known history of Diffuse Idiopathic Skeletal Hyperostosis (DISH) presents to the emergency department after a minor mechanical fall. He complains of severe neck pain but exhibits no neurological deficits. Initial plain radiographs of the cervical spine show flowing anterior bridging osteophytes but no obvious fracture.

What is the most critical next step in his management?

. Discharge home with a soft cervical collar and oral analgesics
. Obtain a CT scan of the entire cervical spine
. Administer high-dose intravenous steroids
. Perform dynamic flexion-extension radiographs to assess stability
. Schedule an outpatient MRI of the cervical spine within 2 weeks

Correct Answer & Explanation

. Obtain a CT scan of the entire cervical spine

Explanation

Patients with ankylosing spinal disorders such as DISH or Ankylosing Spondylitis possess highly rigid spines that act as long lever arms, making them extremely susceptible to highly unstable fractures even from low-energy mechanisms. These fractures are notoriously difficult to visualize on plain radiographs due to the altered bony anatomy. Therefore, a CT scan of the spine is mandatory in these patients following any trauma, even minor, to rule out an occult, highly unstable fracture. Dynamic radiographs are contraindicated in the acute trauma setting for this population due to the risk of iatrogenic neurological injury.

Question 4813

Topic: 6. Spine

A 42-year-old male presents with acute onset of bilateral lower extremity weakness, saddle anesthesia, and urinary retention that began 12 hours ago. MRI confirms a massive L4-L5 central disc herniation. What is the most critical prognostic factor for full recovery of bowel and bladder function following surgical decompression?

. Patient age at the time of presentation
. Preoperative duration and severity of the neurological deficit
. Absolute cross-sectional area of the spinal canal on preoperative MRI
. Use of intraoperative neuromonitoring during decompression
. Concomitant presence of dense lower extremity motor weakness

Correct Answer & Explanation

. Preoperative duration and severity of the neurological deficit

Explanation

The duration and severity of the preoperative neurological deficit, specifically urinary dysfunction (e.g., retention vs. incontinence), are the most significant predictors of recovery in cauda equina syndrome. Urgent decompression is generally recommended, as prolonged compression worsens the prognosis for sphincter recovery.

Question 4814

Topic: Cervical Spine

A 55-year-old female undergoes a C4-C7 Anterior Cervical Discectomy and Fusion (ACDF). Postoperatively, she develops severe and progressive dysphagia, requiring reintubation. Which of the following factors is most strongly associated with an increased risk of severe, life-threatening postoperative dysphagia and airway edema in this setting?

. Use of a standalone interbody cage without an anterior plate
. Off-label use of recombinant human bone morphogenetic protein-2 (rhBMP-2)
. Use of a left-sided surgical approach instead of a right-sided approach
. Intravenous dexamethasone administration immediately preoperatively
. Placement of a closed-suction drain in the prevertebral space

Correct Answer & Explanation

. Off-label use of recombinant human bone morphogenetic protein-2 (rhBMP-2)

Explanation

The use of rhBMP-2 in the anterior cervical spine is associated with a significantly increased risk of severe prevertebral soft tissue swelling, which can lead to life-threatening airway compromise and severe dysphagia. The FDA issued a public health warning in 2008 regarding this specific off-label use due to these catastrophic complications.

Question 4815

Topic: 6. Spine

A 16-year-old male presents with worsening mid-back pain and a noticeable hyperkyphosis.

To meet the classic Sorensen radiographic criteria for Scheuermann's kyphosis, his standing lateral spine radiograph must demonstrate which of the following?

. Thoracic kyphosis > 40 degrees with anterior wedging of > 5 degrees in 3 or more consecutive vertebrae
. Thoracic kyphosis > 50 degrees with anterior wedging of > 10 degrees in a single apical vertebra
. Presence of Schmorl's nodes in at least 5 consecutive vertebral bodies
. Lumbar lordosis > 60 degrees with compensatory thoracic kyphosis and Grade II spondylolisthesis
. Apical vertebral rotation > Grade II with a Cobb angle of > 45 degrees in the coronal plane

Correct Answer & Explanation

. Thoracic kyphosis > 40 degrees with anterior wedging of > 5 degrees in 3 or more consecutive vertebrae

Explanation

The classic Sorensen criteria for diagnosing Scheuermann's disease include a thoracic kyphosis greater than 40 degrees accompanied by anterior wedging of at least 5 degrees in three or more consecutive vertebrae. Schmorl's nodes and endplate irregularities are common but are not the defining geometric criteria.

Question 4816

Topic: 6. Spine
A 35-year-old male is involved in a high-speed motor vehicle collision. A CT scan of the cervical spine demonstrates a bilateral pars interarticularis fracture of C2 with severe angulation and > 3mm of translation of C2 on C3, accompanied by bilateral C2-C3 facet dislocation. According to the Levine and Edwards classification, what is the most appropriate management?
. Rigid cervical collar for 6 weeks
. Halo vest immobilization with immediate cervical traction
. Open reduction and internal fixation
. C1-C2 posterior fusion
. Anterior odontoid screw fixation

Correct Answer & Explanation

. Open reduction and internal fixation

Explanation

This describes a Type III Hangman's fracture (bilateral pars fractures with bilateral C2-C3 facet dislocation). These are highly unstable injuries. Cervical traction is strictly contraindicated as it may exacerbate the displacement and stretch the spinal cord. The recommended treatment is surgical open reduction and internal fixation (typically a posterior C2-C3 instrumented fusion).

Question 4817

Topic: 6. Spine

In the surgical evaluation of adult spinal deformity, achieving appropriate sagittal balance is strongly correlated with favorable health-related quality of life (HRQOL) outcomes. According to the Schwab classification, what is the target goal for the relationship between Pelvic Incidence (PI) and Lumbar Lordosis (LL)?

. PI minus LL mismatch of less than 2 degrees
. PI minus LL mismatch of less than 10 degrees
. PI minus LL mismatch of less than 20 degrees
. PI minus LL mismatch of greater than 30 degrees
. PI minus LL mismatch of greater than 40 degrees

Correct Answer & Explanation

. PI minus LL mismatch of less than 10 degrees

Explanation

The Schwab classification for adult spinal deformity established that a PI-LL mismatch of less than 10 degrees (ideally PI = LL ± 9 degrees) is a primary goal to optimize sagittal alignment, improve patient-reported HRQOL scores, and minimize the risk of adjacent segment disease and hardware failure.

Question 4818

Topic: 6. Spine

A 14-year-old gymnast presents with chronic lower back pain that worsens significantly with extension. Radiographs show a Meyerding Grade II L5-S1 isthmic spondylolisthesis. If she subsequently develops radicular symptoms, which nerve root is most likely to be compressed, and what is the typical anatomical site of compression?

. L4 nerve root within the central canal
. L5 nerve root within the neural foramen
. S1 nerve root in the lateral recess
. L5 nerve root within the central canal
. S1 nerve root within the neural foramen

Correct Answer & Explanation

. L5 nerve root within the neural foramen

Explanation

In isthmic spondylolisthesis at L5-S1, the primary defect is in the pars interarticularis. The exiting L5 nerve root is most commonly compressed within the L5-S1 neural foramen by fibrocartilaginous hypertrophic tissue at the pars defect (Gill nodule) or by the descent of the L5 pedicle as the vertebra slips forward. S1 radiculopathy is more characteristic of a paramedian disc herniation.

Question 4819

Topic: 6. Spine

A 52-year-old active intravenous drug user presents with severe back pain. MRI reveals L3-L4 pyogenic spondylodiscitis with a 1 cm epidural abscess, but there is no evidence of spinal cord or cauda equina compression. The neurological examination is entirely normal. Blood cultures grow methicillin-sensitive Staphylococcus aureus (MSSA), and targeted intravenous antibiotics are initiated. What is the strongest indication to abandon medical management and proceed with surgical debridement and stabilization?

. Persistently elevated ESR and CRP after 1 week of targeted intravenous antibiotics
. Progression of mechanical back pain when assuming an upright posture
. The mere presence of the epidural abscess on the initial MRI, regardless of size
. The development of progressive lower extremity neurological deficits
. Positive surveillance blood cultures drawn at 48 hours post-initiation of antibiotics

Correct Answer & Explanation

. The development of progressive lower extremity neurological deficits

Explanation

Most cases of pyogenic spondylodiscitis, including those with small epidural abscesses that do not compress neural elements, can be successfully managed with IV antibiotics. Absolute indications for surgery include the development of progressive neurological deficits, significant epidural compression of the spinal cord or cauda equina, progressive spinal instability/deformity, or definitive failure of medical management (intractable pain and unremitting infection despite prolonged, appropriate antibiotic therapy).

Question 4820

Topic: 6. Spine

A 24-year-old male is brought to the trauma bay after a diving accident. He is awake, alert, cooperative, and complains of severe neck pain. His neurological examination is completely normal.

A lateral cervical radiograph demonstrates a unilateral C5-C6 facet dislocation. What is the most appropriate initial step in management?

. Immediate open posterior reduction and fusion without obtaining a pre-reduction MRI
. Obtain an urgent MRI before attempting any closed or open reduction maneuvers
. Attempt closed reduction with cranial traction under awake, serial neurological monitoring
. Application of a rigid cervical collar and discharge with urgent outpatient clinic follow-up
. Immediate open anterior reduction, discectomy, and fusion without prior MRI

Correct Answer & Explanation

. Attempt closed reduction with cranial traction under awake, serial neurological monitoring

Explanation

In an awake, alert, and cooperative patient with a cervical facet dislocation, rapid closed reduction using cranial traction with serial neurological examinations is the standard of care. An MRI is not mandated prior to closed reduction because the patient can reliably communicate any neurological changes during traction. If the patient is obtunded or uncooperative, an MRI is required prior to reduction to evaluate for a herniated disc that could cause catastrophic spinal cord compression during reduction.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page