6. Spine MCQs

A 54-year-old man presents with progressive clumsiness in his hands and a feeling of unsteadiness while walking over the past 6 months. Examination reveals hyperreflexia in the lower extremities, a positive Hoffmann sign bilaterally, and an inverted brachioradialis reflex. MRI of the cervical spine shows severe stenosis with cord signal change at C4-C5.

Without surgical intervention, what is the most likely natural history of his condition?

A 50-year-old man with a history of intravenous drug use presents with severe lower back pain, fever, and progressive weakness in both legs over the last 48 hours. Laboratory studies show an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). MRI reveals a fluid collection in the epidural space at L3-L4 compressing the thecal sac.

Which of the following is the most likely causative organism?

A 35-year-old man falls from a roof and sustains a T12 burst fracture. He is neurologically intact on examination. CT of the spine shows 40% loss of anterior vertebral body height, 15 degrees of local kyphosis, and no evidence of posterior ligamentous complex (PLC) injury. MRI confirms the PLC is intact. According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the recommended treatment?

A 45-year-old man presents with acute right anterior thigh pain and weakness in knee extension following a lifting injury. Physical examination reveals a diminished right patellar reflex and a positive femoral nerve stretch test. MRI of the lumbar spine reveals a large, far lateral (extraforaminal) disc herniation at the L4-L5 level on the right. Which of the following nerve roots is most likely being compressed?

A 62-year-old man with a 30-year history of ankylosing spondylitis presents to the emergency department with severe back pain after a mechanical fall from standing height. Neurologic examination is unremarkable. Radiographs and CT scans reveal a transverse fracture through the T10-T11 disc space extending through the fused posterior elements.

What is the most appropriate management for this patient?

A 16-year-old male gymnast has a 9-month history of localized lower back pain that worsens with extension. He has no radicular symptoms and his neurologic examination is normal. He has failed a comprehensive regimen of rest, NSAIDs, physical therapy, and a trial of bracing. Radiographs reveal a Grade 1 isthmic spondylolisthesis at L5-S1. What is the most appropriate surgical intervention?

A 65-year-old man presents with deteriorating handwriting, frequent dropping of objects, and a broad-based, unsteady gait. Physical examination reveals an inverted brachioradialis reflex. This highly specific finding is indicative of pathology at which of the following spinal levels?

A 54-year-old man with poorly controlled diabetes mellitus presents with severe, unrelenting mid-back pain, fevers, and new-onset bilateral leg weakness that has progressed over the last 12 hours. MRI with contrast reveals a large, dorsally located epidural collection from T6 to T9 with significant cord compression. What is the most appropriate next step in management?

An 8-year-old boy with Down syndrome is brought in by his parents for medical clearance to participate in gymnastics. He is completely asymptomatic and his neurologic exam is normal. Flexion-extension radiographs of the cervical spine demonstrate an atlantodens interval (ADI) of 7 mm. What is the most appropriate recommendation?

A 65-year-old female presents with progressive low back pain and difficulty standing upright. She has to bend her knees to look straight ahead. Radiographic analysis reveals a pelvic incidence (PI) of 60 degrees, a lumbar lordosis (LL) of 25 degrees, and a sagittal vertical axis (SVA) of +12 cm. She has failed all conservative management. What is the most critical radiographic goal of her surgical correction?

A 70-year-old male with progressive gait clumsiness and hand dexterity issues undergoes a C3-C6 cervical laminectomy and instrumented fusion. On postoperative day 2, he reports isolated profound bilateral deltoid and biceps weakness (Medical Research Council grade 2/5). Sensation and lower extremity function remain completely unchanged. Which of the following is the most likely etiology of this patient's new neurologic deficit?

A 35-year-old construction worker falls from a 15-foot scaffolding, sustaining severe middle back pain. Neurological examination is intact bilaterally (ASIA E). A CT scan of the thoracic spine demonstrates a T12 burst fracture with 40% loss of anterior vertebral body height, 15 degrees of focal kyphosis, and a vertical splitting fracture of the lamina. An MRI reveals fluid signal and disruption of the posterior ligamentous complex (PLC). Based on the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the most appropriate management?

A 14-year-old female gymnast presents with a 6-month history of mechanical low back pain. Radiographs demonstrate a Grade II L5-S1 spondylolisthesis. Advanced imaging confirms bilateral pars interarticularis defects at L5. She has failed 6 months of physical therapy, bracing, and NSAIDs. Her pain restricts her activities of daily living and sports. What is the most appropriate surgical treatment?

An 82-year-old male falls from a standing height. He has severe neck pain but a normal neurologic examination. CT scan reveals a Type II odontoid fracture with 2 mm of posterior displacement. Comorbidities include severe COPD, diabetes mellitus, and severe osteoporosis. Which of the following treatments provides the best balance of safety and efficacy for this specific patient?

A 45-year-old male with a long-standing history of ankylosing spondylitis presents to the emergency department after a low-speed motor vehicle collision. He complains of new-onset neck pain. Neurologic examination is unremarkable. Standard AP, lateral, and open-mouth odontoid plain radiographs are negative for fracture or dislocation. What is the most appropriate next step in the management of this patient?

A 60-year-old diabetic patient presents with acute worsening back pain, low-grade fevers, and progressive bilateral lower extremity weakness over the last 48 hours. ESR and CRP are markedly elevated. MRI with contrast shows L3-L4 discitis/osteomyelitis with an associated anterior epidural abscess causing severe thecal sac compression. Blood cultures are pending. Examination reveals 3/5 strength in hip flexion and knee extension bilaterally. What is the most appropriate immediate management?

A 72-year-old male presents with bilateral leg pain and cramping that worsens with walking. The pain reliably improves when he sits down or leans over a shopping cart. To distinguish between neurogenic claudication and vascular claudication, the physician performs a stationary bicycle test (van Gelderen bicycle test). Which of the following findings during the test is most characteristic of neurogenic claudication?

A 65-year-old woman presents with severe low back pain and leaning forward when walking. Standing lateral radiographs show a Pelvic Incidence (PI) of 60 degrees, Pelvic Tilt (PT) of 35 degrees, and Lumbar Lordosis (LL) of 20 degrees. Her Sagittal Vertical Axis (SVA) is +12 cm. What is the goal of surgical correction for this patient based on the SRS-Schwab classification?

A 78-year-old man presents with neck pain after a ground-level fall. CT scan reveals a Type II odontoid fracture with 3 mm of posterior displacement. He is neurologically intact. He has a history of severe COPD, congestive heart failure, and coronary artery disease. What is the most appropriate management?