6. Spine MCQs

A 66-year-old man presents with progressive clumsiness in his hands, difficulty buttoning his shirt, and a wide-based gait. Physical examination demonstrates a positive Hoffmann sign bilaterally. An MRI of the cervical spine is performed to evaluate for cervical spondylotic myelopathy. Which of the following specific MRI findings is associated with the poorest prognosis for neurologic recovery following surgical decompression?

A 22-year-old restrained passenger is involved in a high-speed motor vehicle collision. He reports severe back pain.

Figure 6 shows a lateral radiograph of the thoracolumbar spine revealing a flexion-distraction injury (Chance fracture) at L2. What is the most commonly associated concomitant injury with this specific fracture pattern?

A 60-year-old man with a long-standing history of Ankylosing Spondylitis is brought to the emergency department after a minor fall at home. He complains of new-onset lower cervical neck pain. Neurologic examination is unremarkable. Standard orthogonal plain radiographs of the cervical spine are interpreted by the on-call radiologist as showing 'no acute fracture, typical bamboo spine changes'. What is the most appropriate next step in management?

A 35-year-old woman presents to the emergency department with acute onset severe lower back pain, bilateral lower extremity sciatica, perineal numbness, and urinary retention. Bladder ultrasound reveals a post-void residual of 500 mL. MRI confirms a massive L4-L5 central disc herniation causing severe cauda equina compression. According to current literature, surgical decompression should ideally be performed within what time frame from the onset of autonomic symptoms to maximize the probability of bladder function recovery?

A 68-year-old woman with advanced rheumatoid arthritis is being evaluated preoperatively before a total knee arthroplasty. She denies any radicular pain, weakness, or changes in bowel/bladder function. Flexion-extension radiographs of the cervical spine reveal atlantoaxial instability. Which of the following radiographic findings represents an absolute indication for prophylactic posterior C1-C2 fusion prior to her elective knee surgery?

A 60-year-old man presents with progressive cervical myelopathy secondary to multi-level Ossification of the Posterior Longitudinal Ligament (OPLL). When determining the surgical approach (anterior vs. posterior), the 'K-line' is evaluated on the lateral cervical radiograph. Which of the following scenarios is considered a definitive contraindication to performing a stand-alone posterior cervical laminoplasty for this patient?

A 65-year-old man presents with progressive hand clumsiness, difficulty buttoning his shirts, and frequent tripping. On examination, flicking the volar aspect of the distal phalanx of his middle finger results in reflexive flexion of his ipsilateral thumb and index finger. This physical examination finding indicates compression of which of the following structures?

A 35-year-old woman is involved in a motor vehicle collision and sustains a burst fracture of L1. Her neurological examination demonstrates full strength and normal sensation in her bilateral lower extremities (ASIA E). An MRI is obtained which definitively demonstrates disruption of the posterior ligamentous complex (PLC). Based on the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the most appropriate management?

Figure 4 demonstrates the standing full-length spine radiograph of a 68-year-old woman presenting with severe lower back pain, forward stooping, and early satiety. When planning corrective surgery for adult spinal deformity, which of the following represents the optimal goal for the relationship between Pelvic Incidence (PI) and Lumbar Lordosis (LL)?

Figure 11 shows a lateral radiograph of a 14-year-old female gymnast with chronic, mechanical low back pain. Radiographs reveal a Grade II isthmic spondylolisthesis at L5-S1. She has failed 6 months of physical therapy, activity modification, and bracing. Which of the following is the most appropriate surgical treatment?

Figure 15 shows the cervical spine radiograph of a 52-year-old man with a long history of ankylosing spondylitis who presents with neck pain after a minor fall. He is neurologically intact on presentation. Which of the following statements is true regarding this patient's condition?

In evaluating a patient with metastatic disease to the thoracic spine, the Spinal Instability Neoplastic Score (SINS) is utilized to guide referral for surgical stabilization. Which of the following radiographic or clinical findings contributes the highest number of points to the SINS score?

Figure 8 demonstrates the sagittal CT scan of a 55-year-old man of Japanese descent who presents with progressive gait instability, hyperreflexia, and a positive Hoffman sign. He is diagnosed with Ossification of the Posterior Longitudinal Ligament (OPLL). If a posterior approach (e.g., laminoplasty) is chosen for definitive management, which of the following factors provides the primary anatomic rationale for this surgical selection?

Figure 13 shows the axial MRI of a 42-year-old man presenting with severe bilateral leg pain, saddle anesthesia, and acute urinary retention. He is taken for emergent surgical decompression. Which of the following factors is most strongly associated with a poor prognosis for the return of normal bladder function?

A 60-year-old Asian man presents with progressive clumsiness in his hands, broad-based gait, and bilateral hyperreflexia. A lateral radiograph and sagittal CT of the cervical spine demonstrate continuous ossification of the posterior longitudinal ligament (OPLL) from C3 to C6. The cervical spine has maintained a lordotic alignment, and the K-line is positive. What is the most appropriate surgical intervention?

Figure 10 shows the imaging of a 35-year-old woman who fell from a height of 10 feet. She has severe midline back pain but is neurologically entirely intact. CT and MRI of the thoracolumbar spine show an L1 burst fracture with 15 degrees of local kyphosis and 30% canal compromise. The posterior ligamentous complex (PLC) is intact on MRI STIR sequences. Based on the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the most appropriate management?

A 65-year-old woman with a history of hypertension and diabetes presents with 1 year of neurogenic claudication and lower back pain. Imaging confirms an L4-L5 grade I degenerative spondylolisthesis with severe central canal stenosis. She has failed 6 months of structured physical therapy, NSAIDs, and epidural steroid injections. According to the Spine Patient Outcomes Research Trial (SPORT) for degenerative spondylolisthesis, what outcome is expected if she chooses surgical intervention compared to continued non-operative management?

A 25-year-old man presents to the trauma bay after a shallow water diving accident. An open-mouth odontoid radiograph demonstrates a lateral mass displacement of C1 on C2 totaling 8 mm. Subsequent MRI confirms a mid-substance rupture of the transverse atlantal ligament (TAL). He is neurologically intact. What is the most appropriate definitive management?

Figure 6 relates to a 62-year-old man with a known history of advanced ankylosing spondylitis who presents with new-onset, severe neck pain following a minor ground-level fall. He is neurologically intact. Initial lateral cervical spine radiographs in the emergency department are read as "normal with extensive bridging syndesmophytes." What is the most appropriate next step in his management?