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6. Spine MCQs

Practice Set 265 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 5281

Topic: 6. Spine

A 35-year-old man presents after a motor vehicle collision with severe neck pain and right-sided C6 radiculopathy. CT imaging demonstrates a right unilateral C5-C6 facet dislocation. MRI reveals a large, extruded disc herniation posterior to the C5-C6 interspace, severely compressing the thecal sac. What is the most appropriate next step in management?

. Awake closed reduction using cranial traction
. Posterior cervical open reduction and fusion
. Anterior cervical discectomy, open reduction, and fusion
. Posterior cervical laminectomy and lateral mass fixation
. Immobilization in a halo vest

Correct Answer & Explanation

. Anterior cervical discectomy, open reduction, and fusion

Explanation

In the presence of a cervical facet dislocation with a large, extruded disc herniation on MRI, closed reduction or a primary posterior approach carries a high risk of retropulsing the disc into the spinal cord. An anterior cervical discectomy must be performed first to decompress the cord, followed by open reduction and anterior fusion.

Question 5282

Topic: 6. Spine

A 68-year-old woman undergoes posterior spinal instrumentation and fusion from the lower thoracic spine to the pelvis for adult degenerative scoliosis. Postoperatively, she is at risk for developing proximal junctional kyphosis (PJK). Which of the following factors is most strongly associated with an increased risk of PJK?

. Termination of the uppermost instrumented vertebra (UIV) at the thoracolumbar junction (T9-T11)
. Use of transverse process hooks instead of pedicle screws at the UIV
. Preservation of the supraspinous and interspinous ligaments at the UIV
. Extension of the proximal construct to the upper thoracic spine (T2-T4)
. Use of a combined anterior-posterior surgical approach

Correct Answer & Explanation

. Termination of the uppermost instrumented vertebra (UIV) at the thoracolumbar junction (T9-T11)

Explanation

Termination of a long fusion construct at the thoracolumbar junction (T9-T11) is a major risk factor for proximal junctional kyphosis (PJK) due to the abrupt transition from the rigid thoracic spine to the mobile lumbar spine. Preserving the posterior ligamentous complex and using softer anchors like hooks at the UIV can actually help reduce this risk.

Question 5283

Topic: 6. Spine

A 62-year-old man presents with progressive hand clumsiness and an unsteady gait. Physical examination reveals lower extremity hyperreflexia, a positive Hoffmann sign bilaterally, and a positive inverted brachioradialis reflex. When the brachioradialis tendon is tapped, there is a diminished radial reflex but spontaneous, brisk flexion of the fingers. At which of the following cervical intervertebral levels is the spinal cord compression most likely located?

. C3-C4
. C4-C5
. C5-C6
. C6-C7
. C7-T1

Correct Answer & Explanation

. C5-C6

Explanation

The inverted brachioradialis reflex is a reliable localizing sign for cervical spondylotic myelopathy at the C5-C6 level. It indicates a lower motor neuron lesion at C6 causing an absent brachioradialis reflex, combined with upper motor neuron hyperreflexia below the lesion causing brisk finger flexion (C8).

Question 5284

Topic: 6. Spine

A 45-year-old man presents to the emergency department with acute urinary retention, saddle anesthesia, and severe bilateral leg pain. MRI reveals a massive central disc herniation at L4-L5. Regarding the timing of surgical intervention, which of the following statements is most accurate?

. Surgery performed after 48 hours yields identical bladder recovery outcomes as surgery performed within 24 hours.
. Decompression performed within 48 hours is associated with significantly better bladder and motor recovery than delayed surgery.
. Surgical decompression must be performed within 6 hours of symptom onset to avoid permanent deficits.
. High-dose intravenous corticosteroids should be administered for 24 hours prior to surgical intervention.
. Cauda equina syndrome is primarily an upper motor neuron injury, dictating a delayed surgical approach.

Correct Answer & Explanation

. Decompression performed within 48 hours is associated with significantly better bladder and motor recovery than delayed surgery.

Explanation

Cauda equina syndrome is a surgical emergency. Decompression within 24 to 48 hours of symptom onset is associated with significantly improved outcomes for bladder, bowel, and motor function compared to surgery performed after 48 hours.

Question 5285

Topic: 6. Spine

A 60-year-old man undergoes a C3-C6 posterior laminectomy and fusion for cervical spondylotic myelopathy. On postoperative day 1, he demonstrates profound weakness in his right deltoid and biceps (0/5) but has preserved hand grip and normal sensation. What is the most likely etiology of this new deficit?

. Iatrogenic spinal cord injury
. Postoperative epidural hematoma
. C5 nerve root palsy
. Vertebral artery injury
. Incorrect lateral mass screw placement at C6

Correct Answer & Explanation

. C5 nerve root palsy

Explanation

Postoperative C5 palsy is a known complication following cervical decompression (especially posterior laminectomy), presenting as deltoid and biceps weakness. It is thought to be caused by posterior shifting of the spinal cord resulting in traction on the short, tethered C5 nerve roots.

Question 5286

Topic: 6. Spine

A 55-year-old woman with a 20-year history of rheumatoid arthritis presents with progressive neck pain and hyperreflexia in her lower extremities. Flexion-extension radiographs demonstrate an Atlanto-Dental Interval (ADI) of 9 mm. There is no evidence of cranial settling. What is the most appropriate management?

. Immobilization in a rigid cervical collar
. C1-C2 posterior instrumented fusion
. Occipitocervical fusion
. Transoral odontoidectomy
. Anterior cervical discectomy and fusion

Correct Answer & Explanation

. C1-C2 posterior instrumented fusion

Explanation

In rheumatoid arthritis, an ADI greater than 8-9 mm or the presence of neurologic symptoms (myelopathy) is an indication for C1-C2 posterior fusion. Occipitocervical fusion would be indicated if there were concurrent cranial settling (vertical subluxation).

Question 5287

Topic: Thoracolumbar Spine & Deformity

A 35-year-old woman falls from a horse and sustains a T12 burst fracture. She is neurologically intact. MRI demonstrates that the posterior ligamentous complex (PLC) is intact. Loss of vertebral body height is 30%, and local kyphosis is 15 degrees. Based on the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the most appropriate management?

. Anterior corpectomy and fusion
. Posterior short-segment pedicle screw fixation
. Thoracolumbosacral orthosis (TLSO) brace
. Kyphoplasty
. Posterior laminectomy alone

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) brace

Explanation

The patient's TLICS score is 2 (2 points for burst morphology, 0 for intact neurology, 0 for intact PLC). A TLICS score less than 4 is an indication for non-operative management, typically with a TLSO brace.

Question 5288

Topic: 6. Spine

A 45-year-old man presents with severe right anterior thigh pain, weakness in right knee extension, and a diminished right patellar reflex. MRI of the lumbar spine reveals a far lateral (extraforaminal) disc herniation at the L3-L4 level on the right. Which nerve root is most likely being compressed?

. L2
. L3
. L4
. L5
. S1

Correct Answer & Explanation

. L2

Explanation

In the lumbar spine, a far lateral (extraforaminal) disc herniation compresses the exiting nerve root at that level. Therefore, an L3-L4 far lateral disc compresses the L3 nerve root, while a paracentral disc at the same level would compress the traversing L4 root.

Question 5289

Topic: Cervical Spine

A 50-year-old woman undergoes a C5-C6 anterior cervical discectomy and fusion via a right-sided approach. Postoperatively, she has a hoarse voice, and direct laryngoscopy confirms unilateral vocal cord paralysis. The nerve most likely injured in this approach courses between which two anatomic structures?

. Trachea and esophagus
. Carotid artery and internal jugular vein
. Thyroid gland and strap muscles
. Esophagus and prevertebral fascia
. Cricoid cartilage and thyroid cartilage

Correct Answer & Explanation

. Trachea and esophagus

Explanation

The recurrent laryngeal nerve is vulnerable during anterior cervical approaches, particularly on the right side where its course is more variable. It normally ascends in the tracheoesophageal groove between the trachea and esophagus.

Question 5290

Topic: 6. Spine

A 65-year-old man with known cervical spondylosis is involved in a rear-end motor vehicle collision. He presents with severe bilateral upper extremity weakness (motor strength 2/5) but relatively preserved lower extremity strength (motor strength 4/5) and patchy sensory loss. Which of the following represents the typical expected recovery pattern for his neurologic condition?

. Lower extremities recover first, followed by bowel/bladder, then proximal upper extremities, and hands last.
. Fine motor skills of the hand recover first, followed by proximal upper extremities and then lower extremities.
. Complete permanent paralysis below the level of injury is the most common outcome.
. Bowel and bladder function rarely recover, even if motor function normalizes.
. Sensory function recovery invariably lags behind complete motor recovery.

Correct Answer & Explanation

. Lower extremities recover first, followed by bowel/bladder, then proximal upper extremities, and hands last.

Explanation

The patient has central cord syndrome, classically caused by a hyperextension injury in a stenotic cervical spine. Recovery typically occurs in a predictable sequence: lower extremities first, followed by bowel/bladder function, then proximal upper extremities, and finally distal upper extremity fine motor function.

Question 5291

Topic: 6. Spine

A 55-year-old intravenous drug user presents with severe midthoracic back pain, fevers, and rapidly progressive bilateral leg weakness over the past 24 hours. MRI demonstrates a dorsal epidural fluid collection at T8-T10 causing severe spinal cord compression. What is the most appropriate definitive management?

. CT-guided needle aspiration and 6 weeks of intravenous antibiotics
. Intravenous antibiotics alone for 6 to 8 weeks
. Urgent surgical decompression and debridement
. High-dose intravenous corticosteroids followed by bracing
. Anterior corpectomy and instrumented fusion

Correct Answer & Explanation

. Urgent surgical decompression and debridement

Explanation

A spinal epidural abscess presenting with an acute or progressive neurologic deficit is an absolute indication for urgent surgical decompression. A posterior approach (laminectomy) is typically used for dorsal collections.

Question 5292

Topic: 6. Spine

A 65-year-old woman presents with neurogenic claudication and localized low back pain. Radiographs demonstrate a Grade 1 degenerative spondylolisthesis at L4-L5 with dynamic instability on flexion-extension views. She has failed 6 months of non-operative management. According to long-term outcome studies, which surgical intervention provides the most durable outcome for this patient?

. Lumbar laminectomy alone
. Placement of an interspinous process spacer
. Laminectomy and instrumented posterolateral fusion
. Microscopic discectomy
. Anterior lumbar interbody fusion without posterior instrumentation

Correct Answer & Explanation

. Laminectomy and instrumented posterolateral fusion

Explanation

For degenerative spondylolisthesis with dynamic instability and neurogenic claudication, decompression with instrumented fusion yields better long-term clinical outcomes and lower reoperation rates compared to decompression alone.

Question 5293

Topic: Cervical Spine

A 55-year-old man undergoes a straightforward C3-C6 anterior cervical discectomy and fusion (ACDF). Three hours postoperatively in the PACU, he develops rapidly progressive quadriparesis and difficulty breathing. His drain output is minimal, but his neck is visibly swollen. What is the most appropriate next step in management?

. Immediate stat MRI of the cervical spine
. Open the neck incision at the bedside
. Administer high-dose IV dexamethasone
. STAT CT scan of the neck with contrast
. Re-intubate and transfer to the ICU for observation

Correct Answer & Explanation

. Open the neck incision at the bedside

Explanation

Postoperative retropharyngeal hematoma can cause rapid airway compromise and neurologic deficit. Immediate bedside opening of the wound to evacuate the hematoma is the lifesaving next step before returning to the OR.

Question 5294

Topic: 6. Spine

A 65-year-old man with a long-standing history of ankylosing spondylitis presents to the emergency department after a ground-level fall. He complains of severe lower neck pain but has no neurologic deficits. Plain radiographs of the cervical spine are obscured by the shoulders and appear unremarkable. What is the most appropriate next step in management?

. Discharge with a soft cervical collar and outpatient follow-up
. Discharge with a rigid cervical collar and outpatient follow-up
. Perform flexion-extension cervical radiographs
. Obtain a CT scan of the entire cervical and upper thoracic spine
. Reassurance and physical therapy

Correct Answer & Explanation

. Obtain a CT scan of the entire cervical and upper thoracic spine

Explanation

Patients with AS are highly susceptible to unstable fractures from low-energy trauma. Due to altered anatomy and osteopenia, radiographs are often inadequate; a CT scan is mandatory to rule out a highly unstable occult fracture.

Question 5295

Topic: Cervical Spine

An 82-year-old woman sustains a Type II odontoid fracture after a fall. She is neurologically intact. Her past medical history is significant for severe COPD and congestive heart failure. Which of the following treatments is associated with the lowest morbidity and mortality for this patient?

. Halo vest immobilization
. Rigid cervical collar immobilization
. Anterior odontoid screw fixation
. Posterior C1-C2 transarticular screw fixation
. Posterior C1-C2 Harms construct (screw-rod)

Correct Answer & Explanation

. Rigid cervical collar immobilization

Explanation

In elderly patients with significant comorbidities, surgical fixation and halo vest immobilization carry a high risk of morbidity and mortality. Rigid cervical collar immobilization is the safest initial treatment, accepting a higher rate of nonunion which is often asymptomatic.

Question 5296

Topic: 6. Spine

A 60-year-old man with severe cervical myelopathy undergoes a C3-C6 posterior laminectomy and fusion. Postoperatively, he has marked improvement in his lower extremity spasticity, but on postoperative day 2, he develops isolated profound weakness in right shoulder abduction and elbow flexion. There is no sensory loss. What is the most likely etiology of this new deficit?

. Iatrogenic intraoperative spinal cord injury
. Postoperative epidural hematoma
. Inadequate decompression of the C5 foramen
. Tethering of the C5 nerve root due to posterior spinal cord drift
. Intraoperative positioning injury to the brachial plexus

Correct Answer & Explanation

. Tethering of the C5 nerve root due to posterior spinal cord drift

Explanation

Postoperative C5 palsy is a known complication of cervical decompression, occurring most commonly due to posterior shift (drift) of the spinal cord and subsequent traction on the relatively short C5 nerve roots. It is typically self-limiting but may take months to recover.

Question 5297

Topic: Thoracolumbar Spine & Deformity

A 35-year-old man falls from a roof and sustains a T12 burst fracture. Neurologic examination reveals normal strength and sensation in the lower extremities (ASIA E). CT and MRI show 40% loss of anterior vertebral height, 15% canal compromise, and an intact posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the recommended treatment?

. Posterior spinal fusion T10-L2
. Anterior corpectomy and fusion T12
. Short segment posterior fixation T11-L1
. Conservative management with a thoracolumbosacral orthosis (TLSO)
. Posterior laminectomy and fusion T11-L1

Correct Answer & Explanation

. Conservative management with a thoracolumbosacral orthosis (TLSO)

Explanation

The TLICS score for this patient is 2 (Morphology: burst = 2, Neurologic status: intact = 0, PLC: intact = 0). A score of 3 or less is an indication for non-operative management, typically with a TLSO.

Question 5298

Topic: 6. Spine

A 62-year-old woman presents with worsening right C6 radiculopathy. Ten years ago, she underwent an uncomplicated C4-C5 anterior cervical discectomy and fusion (ACDF). Imaging now shows a solid fusion at C4-C5 and new, severe right-sided foraminal stenosis at C5-C6. What biomechanical factor most likely contributed to this pathology?

. Decreased segmental motion at C5-C6
. Decreased intradiscal pressure at C5-C6
. Increased biomechanical stress and motion at the adjacent C5-C6 level
. Failure of the C4-C5 fusion mass over time
. Infection at the previous operative site

Correct Answer & Explanation

. Increased biomechanical stress and motion at the adjacent C5-C6 level

Explanation

Adjacent segment disease is thought to result from the natural history of cervical spondylosis coupled with increased biomechanical stress, intradiscal pressure, and compensatory hypermobility at the levels adjacent to a rigid fusion.

Question 5299

Topic: 6. Spine

A 70-year-old man presents with neurogenic claudication. MRI shows severe L4-L5 central canal stenosis with a Grade 1 degenerative spondylolisthesis. Flexion-extension radiographs demonstrate 4 mm of dynamic translation. He has failed 6 months of conservative management. What is the most appropriate surgical intervention?

. L4-L5 laminectomy alone
. L4-L5 laminectomy and posterior spinal fusion with instrumentation
. Interspinous process spacer placement
. Anterior lumbar interbody fusion (ALIF) alone
. Minimally invasive lumbar microdiscectomy

Correct Answer & Explanation

. L4-L5 laminectomy and posterior spinal fusion with instrumentation

Explanation

In the setting of lumbar spinal stenosis with degenerative spondylolisthesis and dynamic instability (translation >3 mm), decompression alone has a high failure rate. Laminectomy combined with instrumented posterolateral fusion yields superior clinical outcomes.

Question 5300

Topic: 6. Spine
A 72-year-old man with pre-existing cervical stenosis experiences a hyperextension injury in a minor motor vehicle collision. He presents with bilateral upper extremity weakness (motor score 2/5 in hands) and relatively preserved lower extremity strength (motor score 4/5). He has hyperreflexia in the lower extremities. What is the most likely diagnosis?
. Anterior cord syndrome
. Brown-Sรฉquard syndrome
. Central cord syndrome
. Posterior cord syndrome
. Conus medullaris syndrome

Correct Answer & Explanation

. Central cord syndrome

Explanation

Central cord syndrome typically occurs after a hyperextension injury in an elderly patient with cervical spondylosis. It is characterized by disproportionately greater motor impairment in the upper extremities compared to the lower extremities.

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