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6. Spine MCQs

Practice Set 252 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 5021

Topic: 6. Spine

A 65-year-old woman is evaluated for neurogenic claudication secondary to a symptomatic Grade 1 degenerative spondylolisthesis at L4-L5. She is deciding between operative and nonoperative management. Based on the 8-year long-term results of the Spine Patient Outcomes Research Trial (SPORT) for degenerative spondylolisthesis, what should she be counseled regarding her treatment options?

. Surgery provides no significant functional benefit over nonoperative treatment at 8 years.
. Nonoperative treatment is associated with a 15% rate of progressive paralysis over 8 years.
. Surgery provides significantly greater improvement in pain and function compared to nonoperative treatment at 8 years.
. The complication rate of surgery outweighs the functional benefits after 4 years of follow-up.
. Both groups demonstrate an equal, severe decline in function by the 8-year follow-up.

Correct Answer & Explanation

. Surgery provides significantly greater improvement in pain and function compared to nonoperative treatment at 8 years.

Explanation

The Spine Patient Outcomes Research Trial (SPORT) evaluated surgical versus nonoperative treatment for degenerative spondylolisthesis. The long-term (8-year) results demonstrated that the surgical group maintained significantly greater improvement in pain, function, and satisfaction compared to patients treated nonoperatively. Progressive paralysis in the nonoperative group is exceedingly rare.

Question 5022

Topic: 6. Spine

A 28-year-old male is intubated following a high-speed motor vehicle collision. A lateral cervical spine radiograph reveals a basion-dental interval (BDI) of 14 mm and a basion-posterior axial line interval (BBAI) of 15 mm. A subsequent MRI demonstrates complete disruption of the tectorial membrane and alar ligaments. What is the definitive management for this injury?

. Rigid cervical collar immobilization for 12 weeks
. Halo vest immobilization for 12 weeks
. C1-C2 posterior instrumented fusion
. Occipitocervical fusion
. Anterior odontoid screw fixation

Correct Answer & Explanation

. Occipitocervical fusion

Explanation

The patient has an occipitocervical dissociation (craniocervical dislocation), indicated by the 'Rule of 12s' (BDI > 12 mm or BBAI > 12 mm on plain radiographs) and MRI confirmation of craniocervical ligamentous disruption (tectorial membrane, alar ligaments). This is a highly unstable injury that does not heal reliably with external immobilization. Definitive treatment requires rigid internal fixation via an occipitocervical fusion.

Question 5023

Topic: 6. Spine

A 72-year-old woman undergoes a T10 to pelvis posterior instrumented fusion for adult spinal deformity. Six months later, she returns with localized mechanical back pain at the thoracolumbar junction. Radiographs demonstrate an abnormal kyphotic angulation measuring 18 degrees between the upper instrumented vertebra (UIV) and the UIV+2 (compared to 4 degrees postoperatively). She is neurologically intact. Which of the following is the most significant modifiable surgical risk factor for this specific complication?

. Extensive soft tissue dissection disrupting the posterior ligamentous complex at and above the UIV
. The use of pedicle screws rather than sublaminar wires at the UIV
. Overcorrection of lumbar lordosis causing a reciprocal thoracic flatback
. Failure to use cross-links in the construct
. The use of rhBMP-2 at the lumbosacral junction

Correct Answer & Explanation

. Extensive soft tissue dissection disrupting the posterior ligamentous complex at and above the UIV

Explanation

The clinical scenario describes Proximal Junctional Kyphosis (PJK), defined as a proximal junctional sagittal Cobb angle >10 degrees and at least 10 degrees greater than the immediate postoperative measurement. A major modifiable intraoperative risk factor is the iatrogenic disruption of the posterior ligamentous complex (supraspinous/interspinous ligaments and facet capsules) at the UIV and adjacent proximal segments. Preserving these structures helps mitigate the risk of PJK.

Question 5024

Topic: 6. Spine

A 54-year-old man with uncontrolled diabetes presents with severe mid-back pain, fevers, and acute lower extremity weakness evolving over 24 hours. His temperature is 38.8°C. ESR is 95 mm/hr and CRP is 120 mg/L. Gadolinium-enhanced MRI reveals a T8-T9 discitis/osteomyelitis with a large ventral epidural abscess causing severe anterior compression of the thoracic spinal cord. What is the most appropriate initial surgical approach?

. Posterior laminectomy alone
. Posterior laminectomy with insertion of an epidural drain
. Percutaneous CT-guided drainage of the disc space
. Anterior corpectomy, debridement, and stabilization
. Intravenous broad-spectrum antibiotics and close observation

Correct Answer & Explanation

. Anterior corpectomy, debridement, and stabilization

Explanation

The patient has acute neurologic compromise secondary to a ventral epidural abscess and thoracic osteomyelitis, necessitating emergent surgical decompression. Because the pathology (infected bone/disc and abscess) is entirely ventral to the spinal cord, an anterior approach (corpectomy, debridement, and stabilization) provides direct decompression and eradicates the infected nidus. A posterior laminectomy for a ventral thoracic lesion is contraindicated as it fails to address the anterior pathology and often leads to catastrophic spinal destabilization and progressive kyphosis.

Question 5025

Topic: 6. Spine

A 42-year-old man presents with an acute onset of severe bilateral sciatica, saddle anesthesia, and urinary retention. Post-void residual volume is 600 mL. MRI demonstrates a massive central disc herniation at L4-L5 completely obliterating the thecal sac. Symptoms began 12 hours ago, and urgent surgical decompression is planned. What is the predominant pathophysiological mechanism causing nerve root injury in this syndrome?

. Primary demyelination of the dorsal root ganglia
. Direct axonal transection by the herniated disc material
. Autoimmune inflammatory cascade targeting the nucleus pulposus
. Venous congestion leading to intraneural edema and ischemic injury
. Cerebrospinal fluid leak causing traction on the dependent nerve roots

Correct Answer & Explanation

. Venous congestion leading to intraneural edema and ischemic injury

Explanation

Cauda Equina Syndrome occurs when massive compression of the lumbosacral nerve roots occurs. The cauda equina nerve roots have a poorly developed epineurium and rely on cerebrospinal fluid and a fine radicular vascular network for nutrition. Massive mechanical compression primarily leads to venous congestion, which causes interstitial edema, increased intraneural pressure, and subsequent ischemic injury to the nerve roots. Urgent decompression aims to restore perfusion and prevent irreversible ischemic necrosis.

Question 5026

Topic: 6. Spine

A 55-year-old man presents with progressive clumsiness in his hands and difficulty walking. He has a positive Hoffman's sign and hyperreflexia in the lower extremities. MRI shows multilevel cervical stenosis from C3 to C6. He has neutral sagittal alignment but prominent retrovertebral osteophytes. He undergoes a multilevel posterior cervical laminectomy and fusion. What is the most common postoperative neurologic complication specific to this posterior approach?

. C5 nerve root palsy
. Recurrent laryngeal nerve injury
. Esophageal perforation
. Vertebral artery injury
. Horner syndrome

Correct Answer & Explanation

. C5 nerve root palsy

Explanation

C5 palsy is a well-known complication after cervical decompression, particularly following posterior laminectomy and fusion. It is thought to occur due to the posterior shift of the spinal cord and subsequent traction on the tethered C5 nerve roots, or due to direct intraoperative trauma. Rates typically range from 5% to 15%. Recurrent laryngeal nerve injury, esophageal perforation, and Horner syndrome are common complications of the anterior approach to the cervical spine.

Question 5027

Topic: Thoracolumbar Spine & Deformity

A 35-year-old construction worker falls from a height of 15 feet and sustains a T12 burst fracture. On examination, he is neurologically intact with 5/5 motor strength and normal bowel/bladder function. Upright radiographs show 25 degrees of local kyphosis, and CT shows 40% canal compromise. An MRI reveals that the posterior ligamentous complex (PLC) is completely intact. What is the most appropriate management?

. Short-segment posterior spinal fusion
. Anterior corpectomy and strut grafting
. Thoracolumbosacral orthosis (TLSO) bracing
. Balloon kyphoplasty
. Laminectomy alone

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing

Explanation

For neurologically intact patients with a thoracolumbar burst fracture and an intact posterior ligamentous complex (TLICS score <= 3), nonoperative management with a TLSO or hyperextension brace is the standard of care. Surgical stabilization is typically indicated if there is a progressive neurologic deficit, definite PLC injury (indicating instability), or severe progressive kyphotic collapse. Laminectomy alone is strictly contraindicated as it further destabilizes the fracture.

Question 5028

Topic: Thoracolumbar Spine & Deformity

A 65-year-old woman presents with severe low back pain and an inability to stand up straight, reporting progressive fatigue when walking. Radiographs reveal a degenerative lumbar scoliosis with marked sagittal imbalance. Her measured pelvic incidence (PI) is 65 degrees. For an optimal postoperative functional outcome in sagittal alignment, her lumbar lordosis (LL) should be surgically restored to approximately:

. 25 degrees
. 45 degrees
. 65 degrees
. 85 degrees
. 105 degrees

Correct Answer & Explanation

. 65 degrees

Explanation

The primary goal of sagittal realignment in adult spinal deformity surgery is to achieve a lumbar lordosis (LL) that is proportional to the patient's fixed pelvic incidence (PI). The widely accepted Schwab-SRS classification dictates that the target LL should be within 10 degrees of the PI (PI - LL = <10 degrees). Therefore, for a PI of 65 degrees, restoring the LL to approximately 65 degrees provides the most physiologic standing posture and minimizes adjacent segment stress.

Question 5029

Topic: 6. Spine

A 15-year-old male gymnast presents with a 3-week history of worsening low back pain that is significantly exacerbated by extension activities. Plain radiographs, including oblique views, show no definitive fracture lines. An MRI of the lumbar spine without contrast reveals increased T2/STIR signal (marrow edema) in the L5 pars interarticularis bilaterally, without a visible fracture gap on T1-weighted sequences. What is the most appropriate initial management?

. Bilateral pars interarticularis repair with pedicle screws
. Anterior lumbar interbody fusion at L5-S1
. Posterior spinal fusion of L5-S1
. Immediate cessation of sports and anti-lordotic bracing
. Fluoroscopically guided pars corticosteroid injections

Correct Answer & Explanation

. Immediate cessation of sports and anti-lordotic bracing

Explanation

The clinical presentation and MRI findings of isolated marrow edema in the pars interarticularis without a clear fracture defect are highly consistent with an acute pars stress reaction (early spondylolysis). The treatment of choice for acute/early pars stress reactions is nonoperative, consisting of strict activity modification (cessation of extension-heavy sports), rest, and frequently an anti-lordotic brace to allow the stress reaction to heal and prevent progression to a complete nonunion. Surgery is reserved for patients failing 6 months of conservative care.

Question 5030

Topic: Cervical Spine

An 82-year-old woman with a medical history of severe severe chronic obstructive pulmonary disease and recent myocardial infarction falls from standing height. She complains of isolated neck pain. A CT scan of the cervical spine reveals a Type II odontoid fracture with 2 mm of posterior displacement. She is neurologically intact. What is the most appropriate definitive management?

. Halo vest immobilization
. Hard cervical collar
. Anterior odontoid screw fixation
. Posterior C1-C2 transarticular screw fixation
. Occipitocervical fusion

Correct Answer & Explanation

. Hard cervical collar

Explanation

In elderly patients with severe medical comorbidities, the morbidity and mortality associated with surgical intervention or halo vest immobilization are unacceptably high. Halo vest placement in the elderly carries a mortality rate of up to 40% due to respiratory restrictions, aspiration, and pin site infections. The contemporary treatment of choice for an elderly, high-risk patient with a Type II odontoid fracture is a hard cervical collar. Even if a stable fibrous nonunion develops, it is typically well-tolerated and preferable to the risks of surgery or rigid external fixation.

Question 5031

Topic: 6. Spine

A 45-year-old man underwent an L4-L5 posterior lumbar interbody fusion (PLIF) 10 days ago for degenerative spondylolisthesis. He now presents to the emergency department with worsening incisional back pain, fever to 38.8°C, and new purulent drainage from the wound. Laboratory tests reveal a CRP of 150 mg/L and an ESR of 85 mm/h. MRI with gadolinium demonstrates an enhancing fluid collection deep to the fascia, adjacent to the spinal instrumentation. What is the next best step in management?

. Broad-spectrum intravenous antibiotics and close observation
. CT-guided percutaneous aspiration of the fluid collection
. Return to the operating room for irrigation and debridement
. Immediate surgical removal of all spinal instrumentation
. Suppressive long-term oral antibiotics

Correct Answer & Explanation

. Return to the operating room for irrigation and debridement

Explanation

The patient presents with an acute postoperative deep surgical site infection (SSI). The gold standard for an acute, deep postoperative spine infection is a prompt return to the operating room for aggressive irrigation and debridement (I&D). Spinal instrumentation that is well-fixed should be retained during the early postoperative period, as its removal can lead to catastrophic spinal instability and nonunion. I&D must be followed by targeted intravenous antibiotics based on intraoperative cultures.

Question 5032

Topic: 6. Spine

A 42-year-old man with a 15-year history of ankylosing spondylitis presents to the trauma bay after a minor, low-speed motor vehicle collision. He complains of moderate lower neck pain. Neurological examination is unremarkable. Standard anteroposterior, lateral, and open-mouth odontoid radiographs are obtained and read as normal. What is the most appropriate next step in his evaluation?

. Reassurance and discharge with a soft cervical collar
. Dynamic flexion-extension cervical spine radiographs
. CT scan of the entire cervical and thoracic spine
. MRI of the cervical spine without contrast
. Technetium-99m bone scintigraphy

Correct Answer & Explanation

. CT scan of the entire cervical and thoracic spine

Explanation

Patients with ankylosing spondylitis have fused, highly brittle, and biomechanically altered spines. They are at an extremely high risk for highly unstable extension-distraction fractures even after trivial trauma. These fractures are notoriously difficult to visualize on plain radiographs, especially at the cervicothoracic junction due to overlapping shoulder anatomy. A CT scan of the entire cervical and thoracic spine is mandatory to definitively rule out an occult fracture. Delayed diagnosis can result in catastrophic neurologic deterioration.

Question 5033

Topic: 6. Spine

A 40-year-old construction worker presents with a 2-year history of debilitating low back pain and bilateral L5 radiculopathy that has failed comprehensive conservative management. Upright radiographs demonstrate a Grade II L5-S1 isthmic spondylolisthesis. MRI confirms bilateral severe L5 foraminal stenosis. What is the most appropriate surgical treatment?

. L5 Gill laminectomy alone
. L5 laminectomy with posterolateral fusion in situ
. Anterior L5-S1 interbody fusion alone
. Posterior decompression and L5-S1 instrumented fusion
. Translaminar screw fixation

Correct Answer & Explanation

. Posterior decompression and L5-S1 instrumented fusion

Explanation

In adult patients with symptomatic isthmic spondylolisthesis (pars defect) that has failed conservative treatment, surgical decompression of the exiting nerve roots combined with an instrumented fusion is the standard of care. Decompression alone (Gill procedure) increases spinal instability and often leads to progressive slip and recurrent pain. The addition of pedicle screw instrumentation significantly improves fusion rates and clinical outcomes compared to non-instrumented (in situ) posterolateral fusion.

Question 5034

Topic: 6. Spine

A 6-year-old girl is brought to the clinic by her parents. She is holding her head tilted to the right and rotated to the left. Her parents report this deformity occurred suddenly following a mild upper respiratory tract infection 2 weeks ago. She has tenderness over the upper cervical spine. An open-mouth odontoid view and dynamic CT scan confirm atlantoaxial rotatory subluxation (AARS) Fielding Type I. What is the initial treatment of choice?

. Surgical C1-C2 posterior instrumented fusion
. Halo gravity traction followed by cast application
. Halter cervical traction, muscle relaxants, and analgesics
. Aggressive physical therapy for sternocleidomastoid stretching
. Occipitocervical fusion

Correct Answer & Explanation

. Halter cervical traction, muscle relaxants, and analgesics

Explanation

The patient is presenting with Grisel syndrome, which is a non-traumatic atlantoaxial rotatory subluxation (AARS) secondary to an inflammatory process in the head and neck. For AARS present for less than 1 month, conservative management with halter cervical traction, muscle relaxants, and analgesics is the initial treatment of choice. Surgical fusion is indicated only for chronic subluxations (>3 months), intractable pain failing conservative measures, or the presence of a neurologic deficit.

Question 5035

Topic: 6. Spine

A 24-year-old male arrives at the trauma bay after a high-speed motor vehicle collision. He has 0/5 strength in his lower extremities, 0/5 in wrist flexion and finger extension, but 3/5 in bilateral elbow flexion. He is awake, alert, and fully cooperative. Lateral cervical radiographs demonstrate a bilateral C5-C6 facet dislocation. What is the most appropriate next step in his management?

. Immediate closed reduction with cranial tongs under awake serial neurologic monitoring
. Urgent MRI of the cervical spine prior to any reduction attempts
. Anterior cervical discectomy and fusion (ACDF) without prior reduction
. Posterior cervical instrumented fusion in-situ
. Application of a halo vest and subsequent MRI

Correct Answer & Explanation

. Immediate closed reduction with cranial tongs under awake serial neurologic monitoring

Explanation

For an awake, cooperative patient with a cervical facet dislocation and a neurologic deficit, immediate closed reduction with skeletal traction is indicated to decompress the spinal cord as quickly as possible. Time is spine. MRI is indicated before reduction only if the patient is unexaminable (e.g., comatose, heavily intoxicated) to rule out a massive anterior disc herniation that could cause a secondary spinal cord injury during reduction.

Question 5036

Topic: 6. Spine

A 65-year-old male with long-standing ankylosing spondylitis presents to the emergency department after a ground-level fall. He complains of severe neck pain. He is neurologically intact. Initial plain radiographs of the cervical spine are obscured by the shoulders but read by the resident as showing no acute fracture.

What is the most appropriate next step in his management?

. Discharge with a soft cervical collar and outpatient physical therapy
. Flexion-extension radiographs of the cervical spine
. CT scan of the entire cervical spine
. Intravenous methylprednisolone protocol for 24 hours
. Application of a Minerva brace

Correct Answer & Explanation

. CT scan of the entire cervical spine

Explanation

Patients with ankylosing spondylitis (AS) have a highly rigid, osteoporotic spine and are at high risk for highly unstable extension-type fractures even after low-energy trauma (e.g., ground-level falls). Due to altered bone density and distorted anatomy, plain radiographs frequently miss these fractures. A CT scan of the cervical spine is mandatory to rule out a fracture in an AS patient presenting with neck pain after trauma.

Question 5037

Topic: Thoracolumbar Spine & Deformity

A 62-year-old female presents with severe low back pain and difficulty standing upright. She constantly leans forward to walk. Standing full-length scoliosis radiographs show a pelvic incidence (PI) of 65 degrees, lumbar lordosis (LL) of 30 degrees, and a sagittal vertical axis (SVA) of +12 cm. If surgical intervention is planned, which of the following sagittal alignment goals is most critical to achieve optimal clinical outcomes and reduce the risk of adjacent segment disease?

. Correction of the pelvic incidence to less than 50 degrees
. Restoring the lumbar lordosis to match the pelvic incidence within 10 degrees
. Increasing the sagittal vertical axis to +15 cm
. Decreasing pelvic tilt to greater than 30 degrees
. Creating a flat back by performing multiple Smith-Petersen osteotomies

Correct Answer & Explanation

. Restoring the lumbar lordosis to match the pelvic incidence within 10 degrees

Explanation

In adult spinal deformity, restoring sagittal balance is the most critical factor for a good clinical outcome. A key parameter is the mismatch between pelvic incidence (PI) and lumbar lordosis (LL). The goal of surgical correction is to restore the LL to within 10 degrees of the PI (PI - LL < 10 degrees). Pelvic incidence is a fixed morphological parameter and cannot be changed surgically.

Question 5038

Topic: Cervical Spine

An 82-year-old male with a history of severe COPD and ischemic heart disease presents with neck pain after a low-speed motor vehicle collision. CT scan demonstrates a Type II odontoid fracture with 2 mm of posterior displacement. He is neurologically intact. Which of the following is the most appropriate initial management for this patient?

. Halo vest immobilization
. Rigid cervical collar
. Anterior odontoid screw fixation
. Posterior C1-C2 transarticular screw fixation
. Transoral odontoidectomy

Correct Answer & Explanation

. Rigid cervical collar

Explanation

Type II odontoid fractures in the elderly (especially >80 years) present a difficult challenge. Halo vest immobilization is associated with unacceptably high morbidity and mortality (e.g., pneumonia, respiratory failure) and is contraindicated. Anterior screw fixation has a high failure rate in osteoporotic bone. For minimally displaced fractures in a frail elderly patient with severe comorbidities, a rigid cervical collar is increasingly recommended as initial management, accepting a high rate of fibrous nonunion which is generally well-tolerated and avoids perioperative risks.

Question 5039

Topic: 6. Spine

A 65-year-old female presents with a 2-year history of bilateral lower extremity heaviness and cramping that worsens with walking and improves when leaning over a shopping cart. She has failed 6 months of conservative management. MRI reveals severe L4-L5 spinal stenosis with a stable Grade I degenerative spondylolisthesis. According to the Spine Patient Outcomes Research Trial (SPORT), which of the following statements is true regarding her treatment options?

. Nonoperative treatment provides superior long-term functional outcomes compared to surgery
. Surgical decompression and fusion provides significantly greater improvement in pain and function compared to nonoperative treatment
. Surgical decompression alone without fusion is associated with the lowest risk of reoperation
. Patients treated with surgery have a higher mortality rate at 4 years compared to the nonoperative cohort
. Epidural steroid injections provide long-term symptomatic relief equivalent to surgical decompression

Correct Answer & Explanation

. Surgical decompression and fusion provides significantly greater improvement in pain and function compared to nonoperative treatment

Explanation

The SPORT trial for degenerative spondylolisthesis demonstrated that patients treated surgically (decompression and fusion) had significantly greater improvements in pain and function at 4 years (sustained at 8 years) compared to those treated nonoperatively. Historically, decompression alone in the setting of degenerative spondylolisthesis is associated with a higher risk of progressive instability and reoperation compared to decompression with fusion.

Question 5040

Topic: 6. Spine

A 54-year-old male with a history of intravenous drug use presents with severe mid-back pain, fevers, and new-onset lower extremity weakness (motor strength 3/5 bilaterally). His temperature is 38.9°C (102.0°F), ESR is 110 mm/hr, and CRP is 85 mg/L. MRI of the thoracic spine with gadolinium shows a posterior epidural fluid collection at T6-T8 compressing the spinal cord.

What is the most appropriate next step in management?

. CT-guided needle aspiration and initiation of culture-directed IV antibiotics
. Immediate initiation of broad-spectrum IV antibiotics and observation
. Urgent posterior decompressive laminectomy and debridement
. Anterior corpectomy and strut grafting
. Placement of a thoracic epidural drain

Correct Answer & Explanation

. Urgent posterior decompressive laminectomy and debridement

Explanation

This patient presents with a spinal epidural abscess and progressive neurologic deficits (lower extremity weakness). Medical management (IV antibiotics alone) is reserved for neurologically intact patients or those definitively unfit for surgery. In the presence of a progressive neurologic deficit and focal cord compression, urgent surgical decompression (via posterior laminectomy for a posterior abscess) and debridement is the standard of care.

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