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6. Spine MCQs

Practice Set 260 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 5181

Topic: 6. Spine

A 42-year-old man presents to the emergency department with severe lower back pain, bilateral sciatica, saddle anesthesia, and urinary incontinence. Which of the following is the most critical next step?

. High-dose intravenous corticosteroids
. Urgent MRI of the lumbar spine followed by surgical decompression
. Lumbar puncture to rule out infection
. Referral to physical therapy
. Administration of broad-spectrum antibiotics

Correct Answer & Explanation

. Urgent MRI of the lumbar spine followed by surgical decompression

Explanation

These classic symptoms represent Cauda Equina Syndrome, a surgical emergency. Urgent MRI is required to confirm the diagnosis, followed immediately by surgical decompression to maximize the chance of neurologic recovery.

Question 5182

Topic: 6. Spine

Which of the following radiographic criteria is definitively diagnostic for Diffuse Idiopathic Skeletal Hyperostosis (DISH)?

. Flowing ossification along the anterolateral aspect of at least four contiguous vertebral bodies
. Syndesmophyte formation with bamboo spine appearance
. Bamboo spine with sacroiliac joint obliteration
. Anterior wedging of at least three consecutive thoracic vertebrae
. Vacuum phenomenon in the intervertebral discs

Correct Answer & Explanation

. Flowing ossification along the anterolateral aspect of at least four contiguous vertebral bodies

Explanation

DISH is characterized by flowing anterolateral ossification of at least four contiguous vertebral bodies, preservation of disc height, and the absence of sacroiliac joint erosion or fusion.

Question 5183

Topic: 6. Spine

During the physical examination of a patient with suspected cervical myelopathy, you perform a rapid flicking of the distal phalanx of the middle finger, which elicits an involuntary flexion of the thumb and index finger. What is the name of this clinical sign?

. Babinski sign
. Lhermitte sign
. Hoffmann sign
. Spurling sign
. Wartenberg sign

Correct Answer & Explanation

. Hoffmann sign

Explanation

The Hoffmann sign is an upper motor neuron reflex indicative of cervical spinal cord compression (myelopathy). It is elicited by flicking the distal phalanx of the middle finger, resulting in flexion of the thumb and index finger.

Question 5184

Topic: 6. Spine

A 65-year-old man presents with neurogenic claudication characterized by bilateral leg pain and heaviness that worsens with walking and improves when leaning forward over a shopping cart. What is the primary anatomical structure responsible for dorsal central canal narrowing in degenerative lumbar spinal stenosis?

. Ossification of the posterior longitudinal ligament
. Hypertrophy of the ligamentum flavum
. Herniation of the nucleus pulposus
. Anterior osteophyte formation
. Fracture of the pars interarticularis

Correct Answer & Explanation

. Hypertrophy of the ligamentum flavum

Explanation

In degenerative lumbar spinal stenosis, narrowing of the central canal is primarily caused dorsally by hypertrophy and buckling of the ligamentum flavum, often combined ventrally with disc bulging and laterally with facet arthropathy.

Question 5185

Topic: 6. Spine

A 60-year-old woman with a 20-year history of rheumatoid arthritis presents for preoperative evaluation before a total knee arthroplasty. Flexion-extension radiographs of the cervical spine reveal an anterior atlantodental interval (ADI) of 6 mm. What is the most appropriate next step?

. Proceed with the knee arthroplasty without restrictions
. Obtain an MRI of the cervical spine to evaluate the spinal cord and space available for the cord
. Perform immediate posterior C1-C2 fusion
. Prescribe a rigid cervical collar for 6 weeks
. Administer epidural steroid injection

Correct Answer & Explanation

. Obtain an MRI of the cervical spine to evaluate the spinal cord and space available for the cord

Explanation

An ADI > 3 mm in an adult suggests transverse ligament instability, and > 5 mm implies higher risk. MRI is required to measure the Space Available for the Cord (SAC); a SAC < 14 mm strongly predicts impending neurologic deficit.

Question 5186

Topic: 6. Spine

Which of the following surgical approaches is generally contraindicated for the treatment of a central, calcified thoracic disc herniation causing myelopathy?

. Transthoracic approach
. Costotransversectomy
. Lateral extracavitary approach
. Transpedicular approach
. Posterior laminectomy

Correct Answer & Explanation

. Posterior laminectomy

Explanation

A posterior laminectomy is contraindicated for central thoracic disc herniations due to the high risk of catastrophic spinal cord injury caused by traction on the cord to access the ventral pathology.

Question 5187

Topic: 6. Spine

A 22-year-old woman is involved in a high-speed motor vehicle collision while wearing a lap belt. She sustains a flexion-distraction injury (Chance fracture) of L1. What concomitant injury must be heavily suspected and evaluated for?

. Aortic transection
. Intra-abdominal visceral injury
. Cervical spine fracture
. Pelvic ring disruption
. Traumatic brain injury

Correct Answer & Explanation

. Intra-abdominal visceral injury

Explanation

Chance fractures are highly associated with seatbelt injuries. There is a very high incidence (up to 50%) of concurrent intra-abdominal hollow viscus injuries, such as bowel or mesenteric lacerations, which must be ruled out.

Question 5188

Topic: 6. Spine

A 55-year-old woman presents with neurogenic claudication and lower back pain. Radiographs reveal a grade 1 degenerative spondylolisthesis at L4-L5. She has failed six months of physical therapy and injections. Which of the following is the most appropriate surgical intervention based on major clinical trials?

. Laminectomy alone without fusion
. Decompression and posterolateral instrumented fusion
. Anterior lumbar interbody fusion alone
. Total disc replacement
. Intradiscal electrothermal therapy

Correct Answer & Explanation

. Decompression and posterolateral instrumented fusion

Explanation

The SPORT trial demonstrated that surgical decompression combined with instrumented fusion provides superior clinical outcomes compared to laminectomy alone for patients with symptomatic degenerative spondylolisthesis.

Question 5189

Topic: 6. Spine

A 65-year-old man presents with acute bilateral leg pain, urinary retention, and saddle anesthesia. Post-void residual (PVR) ultrasound is 400 mL. Which of the following urodynamic findings is most consistent with the underlying pathophysiology of this syndrome?

. Detrusor hyperreflexia
. Decreased bladder compliance
. Areflexic detrusor with overflow incontinence
. Detrusor sphincter dyssynergia
. Normal cystometrogram

Correct Answer & Explanation

. Areflexic detrusor with overflow incontinence

Explanation

Cauda equina syndrome causes a lower motor neuron lesion affecting the S2-S4 nerve roots. This results in an areflexic (flaccid) bladder and overflow incontinence, commonly detected by a post-void residual greater than 100-200 mL.

Question 5190

Topic: 6. Spine

A 45-year-old man presents with severe radicular leg pain. MRI demonstrates a far-lateral disc herniation at the L4-L5 level. Which of the following physical examination findings is most likely to be present?

. Weakness of the extensor hallucis longus
. Depressed Achilles reflex
. Weakness of ankle plantar flexion
. Depressed patellar reflex and quadriceps weakness
. Numbness in the first dorsal web space

Correct Answer & Explanation

. Depressed patellar reflex and quadriceps weakness

Explanation

A far-lateral disc herniation at L4-L5 compresses the exiting L4 nerve root, unlike a paracentral herniation which affects the traversing L5 root. L4 radiculopathy is characterized by weakness in knee extension, numbness over the medial lower leg, and a depressed patellar reflex.

Question 5191

Topic: 6. Spine

A 72-year-old woman sustains a hyperextension injury to her cervical spine. She presents with significant weakness in her upper extremities, but her lower extremities have 4/5 motor strength. Which function is typically the last to recover in this specific spinal cord syndrome?

. Lower extremity motor function
. Bowel and bladder function
. Proximal upper extremity motor function
. Distal upper extremity fine motor function
. Proprioception of the lower extremities

Correct Answer & Explanation

. Lower extremity motor function

Explanation

Central cord syndrome classically presents with upper extremity weakness greater than lower extremity weakness. The typical sequence of neurological recovery is lower extremity function first, followed by bowel/bladder, proximal upper extremity, and finally fine motor function of the hand.

Question 5192

Topic: 6. Spine

A 55-year-old man presents with progressive gait difficulty and hand clumsiness. Examination reveals hyperreflexia, a positive Hoffman's sign, and difficulty buttoning his shirt. Which of the following tests best differentiates cervical myelopathy from a central nervous system pathology above the foramen magnum?

. Babinski sign
. Lhermitte's sign
. Jaw jerk reflex
. Clonus testing
. Romberg test

Correct Answer & Explanation

. Jaw jerk reflex

Explanation

The jaw jerk reflex tests the trigeminal nerve (cranial nerve V). A hyperactive jaw jerk reflex suggests a pathologic upper motor neuron lesion above the foramen magnum, distinguishing cranial pathology from cervical myelopathy.

Question 5193

Topic: Cervical Spine

An 82-year-old man presents with neck pain following a ground-level fall. CT scan reveals a Type II odontoid fracture with 2 mm of displacement. He has a history of severe COPD, congestive heart failure, and diabetes. What is the most appropriate definitive management?

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

Correct Answer & Explanation

. Rigid cervical collar immobilization

Explanation

While surgical fixation is often favored for Type II odontoid fractures in healthy adults, this patient's severe comorbidities and age make surgery high risk. Halo immobilization is strictly contraindicated in the elderly due to severe respiratory complications, making a rigid collar the safest choice despite nonunion risks.

Question 5194

Topic: Thoracolumbar Spine & Deformity

A

35-year-old man is diagnosed with an unstable T12 thoracolumbar burst fracture with MRI-confirmed posterior ligamentous complex (PLC) disruption. He is neurologically intact. Based on the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his point value and the recommended treatment?

. 3 points, non-operative
. 4 points, operative or non-operative
. 5 points, operative
. 6 points, operative
. 7 points, operative

Correct Answer & Explanation

. 5 points, operative

Explanation

The TLICS score is 5: burst fracture morphology (2 points), posterior ligamentous complex injury (3 points), and intact neurology (0 points). A score of 5 or higher is a definitive indication for operative management.

Question 5195

Topic: 6. Spine

In a patient with adolescent idiopathic scoliosis, which of the following best describes the structural relationship between the apical vertebra and the rib hump?

. The apical vertebra rotates toward the convexity of the curve, causing the ribs on the convex side to be pushed posteriorly.
. The apical vertebra rotates toward the concavity of the curve, causing the ribs on the concave side to be pushed posteriorly.
. The spinous process of the apical vertebra rotates toward the convexity of the curve.
. The rib hump is caused primarily by lateral translation rather than axial rotation.
. The pedicles on the convex side become anatomically shorter than those on the concave side.

Correct Answer & Explanation

. The apical vertebra rotates toward the convexity of the curve, causing the ribs on the convex side to be pushed posteriorly.

Explanation

In adolescent idiopathic scoliosis, the vertebral body rotates toward the convexity of the curve while the spinous processes rotate toward the concavity. This axial rotation pushes the ribs on the convex side posteriorly, creating the classic rib hump seen on the Adams forward bend test.

Question 5196

Topic: Thoracolumbar Spine & Deformity

A 16-year-old male gymnast complains of chronic lower back pain. Radiographs show a grade I spondylolisthesis at L5-S1. What radiographic spinopelvic parameter is most strongly correlated with the risk of progression in isthmic spondylolisthesis?

. Lumbar lordosis
. Sacral slope
. Pelvic tilt
. Pelvic incidence
. Sacrofemoral angle

Correct Answer & Explanation

. Pelvic incidence

Explanation

Pelvic incidence (PI) is a fixed morphologic parameter determined by the sum of Pelvic Tilt and Sacral Slope. A high pelvic incidence strongly correlates with an increased risk of progression in isthmic spondylolisthesis due to elevated shear forces at the lumbosacral junction.

Question 5197

Topic: 6. Spine

A 50-year-old man presents with severe neck pain radiating down his right arm. Neurologic examination reveals weakness in triceps extension and wrist flexion, along with a diminished triceps reflex. He also has numbness over his middle finger. Which of the following nerve roots is most likely compressed?

. C5
. C6
. C7
. C8
. T1

Correct Answer & Explanation

. C7

Explanation

This classic presentation describes a C7 radiculopathy, which typically causes weakness in the triceps and wrist flexors. It is associated with a diminished triceps reflex and sensory loss in the middle finger.

Question 5198

Topic: Cervical Spine

A 78-year-old man with severe chronic obstructive pulmonary disease and congestive heart failure sustains a displaced Type II odontoid fracture after a low-energy fall. He is deemed a high-risk surgical candidate. What is the most appropriate initial management?

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

Correct Answer & Explanation

. Hard cervical collar

Explanation

In elderly patients who are poor surgical candidates, a hard cervical collar is the preferred initial treatment for Type II odontoid fractures. Halo vest immobilization is contraindicated in this demographic due to high rates of morbidity and mortality.

Question 5199

Topic: 6. Spine

A 60-year-old diabetic male presents with worsening back pain, fever, and progressive lower extremity weakness. MRI demonstrates a large ventral epidural abscess spanning L2 to L4 with cord compression. What is the most appropriate definitive surgical management?

. CT-guided aspiration and intravenous antibiotics
. Posterior laminectomy and dorsal decompression
. Anterior corpectomy, debridement, and stabilization
. Translaminar drainage without fusion
. Intravenous antibiotics alone for 6 weeks

Correct Answer & Explanation

. Anterior corpectomy, debridement, and stabilization

Explanation

Ventral epidural abscesses causing neurologic deficits require anterior decompression via corpectomy and debridement. Posterior laminectomy is inadequate for ventral clearance and may cause iatrogenic spinal instability.

Question 5200

Topic: 6. Spine

A 14-year-old gymnast presents with persistent lower back pain exacerbated by extension. Radiographs confirm a Grade 1 isthmic spondylolisthesis at L5-S1. If this patient were to develop a radicular neurologic deficit, which nerve root is most commonly affected?

. L4 radiculopathy
. L5 radiculopathy
. S1 radiculopathy
. S2 radiculopathy
. S3 radiculopathy

Correct Answer & Explanation

. L5 radiculopathy

Explanation

Isthmic spondylolisthesis at L5-S1 typically causes compression of the exiting L5 nerve root in the neural foramen. This is due to the hypertrophic fibrocartilaginous tissue that forms at the pars interarticularis defect.

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