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6. Spine MCQs

Practice Set 281 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 5601

Topic: 6. Spine

A 6-year-old boy with short-trunk dwarfism, corneal clouding, and normal intelligence is diagnosed with Morquio syndrome (MPS IV). He is at highest risk for developing which of the following orthopedic conditions?

. Atlantoaxial instability due to odontoid hypoplasia
. Recurrent pathologic fractures due to osteopenia
. Rigid equinovarus foot deformities
. Malignant transformation of osteochondromas
. Severe early-onset osteoarthritis of the hand

Correct Answer & Explanation

. Atlantoaxial instability due to odontoid hypoplasia

Explanation

Morquio syndrome (MPS IV) is caused by an inability to degrade keratan sulfate. Patients are at exceptionally high risk for life-threatening cervical myelopathy secondary to atlantoaxial instability from severe odontoid hypoplasia.

Question 5602

Topic: 6. Spine

A 4-year-old child presents with rhizomelic short stature, a prominent forehead, midface hypoplasia, and a diagnosis of achondroplasia. Genetic testing confirms a mutation in the FGFR3 gene. Which of the following spinal manifestations is most likely to become symptomatic and require surgical intervention in adulthood?

. Atlantoaxial instability
. Thoracolumbar kyphosis
. Cervical kyphosis
. Lumbar spinal stenosis
. Isthmic spondylolisthesis

Correct Answer & Explanation

. Lumbar spinal stenosis

Explanation

In achondroplasia, narrowed interpedicular distances and congenitally short pedicles lead to absolute spinal canal stenosis. Lumbar spinal stenosis is the most common spinal complication requiring surgical decompression in adult patients with this dysplasia.

Question 5603

Topic: 6. Spine

A 14-year-old male presents with painful scoliosis and back spasms. Radiographs demonstrate an expansile lytic lesion in the posterior elements of L3.

If this lesion is responsible for the patient's scoliosis, what is the expected curve pattern?

. The apex of the curve points towards the lesion
. The apex of the curve points away from the lesion
. Sharp angular kyphosis at the level of the lesion
. A long, sweeping, structural C-shaped curve
. A left thoracic structural curve with significant rotation

Correct Answer & Explanation

. The apex of the curve points away from the lesion

Explanation

Painful spinal lesions like osteoblastomas and osteoid osteomas provoke severe asymmetric muscle spasms on the side of the tumor. This causes concavity towards the lesion, meaning the apex of the scoliotic curve points away from it.

Question 5604

Topic: 6. Spine

A 2-year-old boy with achondroplasia presents for a routine orthopedic evaluation. His parents are concerned about his prominent forehead and bowing legs. What is the most common spinal abnormality requiring surgical intervention in adulthood for patients with this condition?

. Atlantoaxial instability
. Severe cervical kyphosis
. Lumbar spinal stenosis
. Thoracolumbar kyphosis
. High-grade isthmic spondylolisthesis

Correct Answer & Explanation

. Lumbar spinal stenosis

Explanation

Lumbar spinal stenosis is the most common reason for spinal surgery in adult achondroplastic patients. It is caused by anatomically short pedicles and a pathognomonic decrease in interpedicular distance from the upper to lower lumbar spine.

Question 5605

Topic: 6. Spine

A 4-year-old boy with Morquio syndrome (Mucopolysaccharidosis Type IV) presents for orthopedic evaluation. Before clearing this patient for general anesthesia for a hernia repair, which critical cervical spine abnormality must be urgently ruled out?

. Klippel-Feil anomaly
. Atlantoaxial instability secondary to odontoid hypoplasia
. Basilar invagination
. Rigid cervical kyphosis from anterior vertebral beaking
. Congenital muscular torticollis

Correct Answer & Explanation

. Atlantoaxial instability secondary to odontoid hypoplasia

Explanation

Morquio syndrome is classically associated with severe odontoid hypoplasia and ligamentous laxity, resulting in life-threatening atlantoaxial instability. Flexion-extension cervical radiographs must be obtained before any procedure requiring intubation.

Question 5606

Topic: 6. Spine

A 13-year-old male presents with a left-sided thoracic scoliotic curve that has rapidly progressed by 15 degrees in the last 6 months. On physical examination, he has absent superficial abdominal reflexes on the left side.

What is the most appropriate next step in evaluation?

. CT scan of the thoracic spine
. MRI of the entire neuroaxis
. Bracing with a Thoracolumbosacral Orthosis (TLSO)
. Immediate posterior spinal fusion
. Observation and repeat radiographs in 3 months

Correct Answer & Explanation

. MRI of the entire neuroaxis

Explanation

Atypical scoliosis features, such as a left thoracic curve, rapid progression, or abnormal neurologic findings (absent abdominal reflexes), strongly suggest an underlying intraspinal anomaly like syringomyelia. An MRI of the entire neuroaxis is mandatory to evaluate for a syrinx or Chiari malformation.

Question 5607

Topic: 6. Spine

Which of the following associated conditions is most commonly identified on imaging in a patient diagnosed with syringomyelia?

. Chiari I malformation
. Tethered cord syndrome
. Diastematomyelia
. Klippel-Feil syndrome
. Neurofibromatosis type 1

Correct Answer & Explanation

. Chiari I malformation

Explanation

Syringomyelia is most commonly associated with a Chiari I malformation, which involves the downward herniation of the cerebellar tonsils through the foramen magnum. This alters CSF flow dynamics, leading to the formation of the syrinx in the spinal cord.

Question 5608

Topic: 6. Spine

A 24-year-old female with long-standing polyarticular Juvenile Idiopathic Arthritis (JIA) is scheduled for a bilateral total hip arthroplasty due to severe secondary osteoarthritis. Which of the following preoperative assessments is most critical for preventing a catastrophic intraoperative complication?

. Bone mineral density (DEXA) scan
. Flexion-extension radiographs of the cervical spine
. Erythrocyte sedimentation rate and CRP
. Echocardiogram
. Pulmonary function tests

Correct Answer & Explanation

. Flexion-extension radiographs of the cervical spine

Explanation

Patients with JIA frequently develop cervical spine involvement, most notably atlantoaxial subluxation and basilar invagination. Preoperative flexion-extension radiographs are essential to assess stability and guide safe endotracheal intubation, preventing fatal spinal cord compression.

Question 5609

Topic: 6. Spine

A patient with systemic Juvenile Idiopathic Arthritis is scheduled for cervical spine fusion due to basilar invagination. Which of the following airway complications is most frequently anticipated in this specific patient population by the anesthesia team?

. Tracheomalacia
. Severe micrognathia and temporomandibular joint ankylosis
. Subglottic stenosis
. Vocal cord paralysis
. Macroglossia

Correct Answer & Explanation

. Severe micrognathia and temporomandibular joint ankylosis

Explanation

Patients with severe JIA often develop growth disturbances of the mandible leading to severe micrognathia (bird-face deformity) and restricted mouth opening due to TMJ ankylosis. This makes intubation exceptionally difficult, often requiring fiberoptic awake intubation.

Question 5610

Topic: 6. Spine

In the pathogenesis of the neurological deficits seen in the patient from the previous question, which spinal cord structure is initially affected by the expanding central cystic cavity?

. Dorsal columns
. Spinocerebellar tract
. Anterior white commissure
. Corticospinal tract
. Rubrospinal tract

Correct Answer & Explanation

. Anterior white commissure

Explanation

Syringomyelia typically begins in the central canal of the spinal cord. It first compresses the anterior white commissure, disrupting the decussating fibers of the spinothalamic tract and causing a bilateral loss of pain and temperature sensation.

Question 5611

Topic: 6. Spine

A 12-year-old girl with long-standing systemic juvenile idiopathic arthritis presents with neck stiffness. Radiographs of the cervical spine are obtained. Which of the following is the most characteristic cervical spine radiographic finding in this condition?

. Atlantoaxial rotatory subluxation
. Ankylosis of the apophyseal (facet) joints, most commonly at C2-C3
. Basilar invagination
. Ossification of the posterior longitudinal ligament (OPLL)
. Severe disc space narrowing without facet involvement

Correct Answer & Explanation

. Ankylosis of the apophyseal (facet) joints, most commonly at C2-C3

Explanation

The hallmark of cervical spine involvement in juvenile idiopathic arthritis is ankylosis of the apophyseal (facet) joints. This most frequently occurs at the C2-C3 level.

Question 5612

Topic: 6. Spine

A 14-year-old female presents for evaluation of a newly noted left thoracic scoliosis. Neurological examination reveals absent abdominal reflexes. What is the most appropriate next step in management?

. Observation and follow-up in 6 months
. Prescription of a TLSO brace
. Right-bending radiographs to assess curve flexibility
. MRI of the entire neural axis
. Immediate posterior spinal fusion

Correct Answer & Explanation

. MRI of the entire neural axis

Explanation

A left-sided thoracic scoliosis and absent abdominal reflexes are significant 'red flags' for an intraspinal anomaly, such as syringomyelia or a tethered cord. An MRI of the entire spine and brainstem is indicated before any orthopaedic intervention.

Question 5613

Topic: 6. Spine

A 13-year-old patient with a rapidly progressing 45-degree scoliosis curve is found to have a Chiari I malformation and a large cervicothoracic syrinx on MRI. What is the recommended sequence of surgical management?

. Spinal deformity correction followed immediately by neurosurgical decompression
. Neurosurgical decompression of the syrinx/Chiari, followed by observation or delayed deformity correction
. Simultaneous neurosurgical decompression and spinal fusion
. Spinal deformity correction alone, as the syrinx will resolve spontaneously
. Rigid bracing is preferred over surgery for syrinx-associated scoliosis

Correct Answer & Explanation

. Neurosurgical decompression of the syrinx/Chiari, followed by observation or delayed deformity correction

Explanation

In patients with scoliosis secondary to syringomyelia/Chiari malformation, the neurosurgical decompression should be performed first. In a significant percentage of patients, the curve may stabilize or even improve after syrinx decompression, delaying or preventing the need for spinal fusion.

Question 5614

Topic: 6. Spine

A 40-year-old presents with a Charcot shoulder joint.

An MRI of the cervical spine and craniocervical junction is performed, showing a syrinx. Which cranial malformation is most frequently associated with this pathology?

. Chiari I malformation (tonsillar herniation >5mm)
. Chiari II malformation (myelomeningocele association)
. Dandy-Walker malformation
. Tethered spinal cord
. Diastematomyelia

Correct Answer & Explanation

. Chiari I malformation (tonsillar herniation >5mm)

Explanation

Syringomyelia in adults is most commonly associated with a Chiari I malformation, which is defined by cerebellar tonsillar herniation of more than 5 mm below the foramen magnum. This alters CSF flow, leading to syrinx formation.

Question 5615

Topic: 6. Spine

A 35-year-old male presents with painless burn scars on his hands. Neurological examination reveals loss of pain and temperature sensation in a 'cape-like' distribution over his shoulders and arms, but intact proprioception and vibratory sense.

What is the most likely diagnosis?

. Amyotrophic lateral sclerosis
. Brown-Sequard syndrome
. Syringomyelia
. Cervical spondylotic myelopathy
. Multiple sclerosis

Correct Answer & Explanation

. Syringomyelia

Explanation

Syringomyelia typically presents with dissociated sensory loss (loss of pain and temperature with preserved dorsal column function) in a cape-like distribution. This is due to the expansion of the central syrinx disrupting the decussating spinothalamic fibers.

Question 5616

Topic: 6. Spine

A 10-year-old boy with polyarticular JIA is scheduled for elective bilateral total hip arthroplasty due to severe joint destruction. During the preoperative assessment, which of the following cervical spine abnormalities must be carefully ruled out before administering general anesthesia?

. Basilar invagination
. Atlantoaxial instability
. Subaxial spondylolisthesis
. Cervical stenosis with myelopathy
. Odontoid fracture

Correct Answer & Explanation

. Atlantoaxial instability

Explanation

Patients with polyarticular JIA frequently develop cervical spine involvement, most notably atlantoaxial instability and apophyseal joint ankylosis. Flexion-extension cervical spine radiographs are mandatory prior to intubation to prevent catastrophic spinal cord injury.

Question 5617

Topic: 6. Spine

A 30-year-old female undergoes an MRI of the cervical spine due to progressive bilateral upper extremity weakness and sensory loss. The MRI reveals a large cervical syrinx. What is the most common congenital malformation associated with this finding?

. Tethered cord syndrome
. Dandy-Walker malformation
. Chiari type I malformation
. Diastematomyelia
. Spina bifida occulta

Correct Answer & Explanation

. Chiari type I malformation

Explanation

Syringomyelia is highly associated with Chiari type I malformations, characterized by downward displacement (herniation) of the cerebellar tonsils through the foramen magnum. This disrupts normal CSF flow dynamics, promoting syrinx formation.

Question 5618

Topic: 6. Spine

A 12-year-old girl with long-standing polyarticular Juvenile Idiopathic Arthritis (JIA) presents with new-onset clumsiness in her hands and hyperreflexia in her lower extremities. Which of the following is the most likely cervical spine radiographic finding?

. Ossification of the posterior longitudinal ligament
. Anterior atlantoaxial subluxation
. Subaxial subluxation
. Klippel-Feil anomaly
. Atlantoaxial impaction (cranial settling)

Correct Answer & Explanation

. Anterior atlantoaxial subluxation

Explanation

Anterior atlantoaxial subluxation is the most common cervical spine manifestation in JIA. Neurologic symptoms like clumsiness and hyperreflexia indicate cervical myelopathy, necessitating urgent MRI and possible fusion.

Question 5619

Topic: 6. Spine

A 13-year-old boy presents with a rapidly progressive left-sided thoracic scoliosis and absent abdominal reflexes. MRI of the spine reveals a large syrinx extending from C5 to T8.

What is the most appropriate sequencing of treatment?

. Immediate posterior spinal fusion followed by syrinx shunting
. Neurosurgical decompression of the syrinx prior to scoliosis surgery
. Simultaneous syrinx decompression and posterior spinal fusion
. Bracing until skeletal maturity followed by syrinx observation
. Anterior spinal tethering with continuous neuromonitoring

Correct Answer & Explanation

. Neurosurgical decompression of the syrinx prior to scoliosis surgery

Explanation

In a patient with scoliosis secondary to syringomyelia, neurosurgical decompression of the syrinx (or addressing the underlying Chiari malformation) must be performed first. Scoliosis may stabilize or improve post-decompression, and proceeding directly to deformity correction risks severe neurologic injury.

Question 5620

Topic: 6. Spine

Which of the following is the most common etiology of syringomyelia in the pediatric population?

. Post-traumatic spinal cord tethering
. Chiari type I malformation
. Spinal cord ependymoma
. Meningomyelocele
. Arachnoiditis

Correct Answer & Explanation

. Chiari type I malformation

Explanation

Chiari I malformation, characterized by caudal displacement of the cerebellar tonsils through the foramen magnum, is the most common cause of syringomyelia. Altered CSF flow dynamics at the craniocervical junction lead to syrinx formation.

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