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6. Spine MCQs

Practice Set 283 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 5641

Topic: 6. Spine

A 13-year-old boy presents with a rapidly progressive, left-sided thoracic scoliosis and associated upper extremity weakness.

Given the underlying pathology seen on the MRI, what is the most appropriate initial management strategy?

. Posterior spinal fusion with instrumentation
. Thoracolumbosacral orthosis (TLSO) bracing
. Neurosurgical decompression of the foramen magnum
. Serial body casting
. Physical therapy focusing on core strengthening

Correct Answer & Explanation

. Neurosurgical decompression of the foramen magnum

Explanation

The MRI shows a syrinx often associated with a Chiari malformation. The initial treatment for syringomyelia-associated scoliosis is neurosurgical decompression of the foramen magnum, which can halt or occasionally reverse curve progression.

Question 5642

Topic: 6. Spine
When evaluating an adolescent for scoliosis, certain atypical features should prompt an entire spine MRI to rule out a neuroaxis abnormality such as syringomyelia. These 'red flag' features include all of the following EXCEPT:
. Left-sided thoracic curve
. Rapid curve progression
. Absence of apical thoracic lordosis
. Neurological signs such as absent abdominal reflexes
. Right-sided thoracic curve

Correct Answer & Explanation

. Right-sided thoracic curve

Explanation

A right-sided thoracic curve is the standard, typical pattern for adolescent idiopathic scoliosis. A left-sided thoracic curve, rapid progression, or an absent apical lordosis are atypical and strongly warrant an MRI screening.

Question 5643

Topic: 6. Spine

A 45-year-old male with a history of a T12 burst fracture treated non-operatively 15 years ago presents with new-onset ascending spasticity, weakness, and sensory changes in his legs.

What is the most likely diagnosis shown on his current imaging?

. Adhesive arachnoiditis
. Spinal canal stenosis from heterotopic ossification
. Post-traumatic syringomyelia
. Ischemic myelomalacia
. Intramedullary ependymoma

Correct Answer & Explanation

. Post-traumatic syringomyelia

Explanation

Post-traumatic syringomyelia can develop months to decades after an initial spinal cord injury. Symptoms typically include ascending myelopathy due to the progressive rostral extension of the fluid-filled syrinx.

Question 5644

Topic: 6. Spine

A 45-year-old man presents with progressive, painless swelling and instability of his right shoulder over 6 months. Exam reveals loss of pain and temperature sensation in a cape-like distribution. X-rays show severe glenohumeral destruction with osseous debris. MRI of the spine will most likely show:

. Ependymoma
. Central cord cavitation
. Dural arteriovenous fistula
. Cervical spondylotic myelopathy
. Epidural abscess

Correct Answer & Explanation

. Ependymoma

Explanation

Neuropathic (Charcot) arthropathy of the upper extremity, especially the shoulder, is highly associated with syringomyelia (central cord cavitation). The syrinx expands to compress the spinothalamic tracts, leading to dissociated sensory loss in a cape-like distribution.

Question 5645

Topic: 6. Spine

In a 12-year-old patient with long-standing, poorly controlled polyarticular Juvenile Idiopathic Arthritis (JIA), what is the most common pattern of cervical spine involvement?

. Atlantoaxial subluxation
. Basilar invagination
. Subaxial ankylosis with facet fusion
. Atlanto-occipital dislocation
. Odontoid fracture

Correct Answer & Explanation

. Subaxial ankylosis with facet fusion

Explanation

While atlantoaxial subluxation can occur, the most characteristic and common cervical spine manifestation in JIA is subaxial ankylosis (fusion of the facet joints). This can lead to altered growth, a hypoplastic cervical spine, and limited neck extension.

Question 5646

Topic: Thoracolumbar Spine & Deformity

A 30-year-old female presents with atypical scoliosis and weakness in her intrinsic hand muscles. Neurological exam demonstrates diminished pinprick sensation over her shoulders. Imaging confirms a cervical syrinx. What cranial anomaly is most frequently associated with this condition?

. Dandy-Walker malformation
. Chiari I malformation
. Encephalocele
. Arachnoid cyst
. Craniosynostosis

Correct Answer & Explanation

. Chiari I malformation

Explanation

Syringomyelia is strongly associated with Chiari I malformations. Herniation of the cerebellar tonsils through the foramen magnum disrupts normal cerebrospinal fluid flow, leading to central cord cavitation.

Question 5647

Topic: 6. Spine

A 12-year-old girl is evaluated for scoliosis. She has an atypical left thoracic curve and absent abdominal reflexes. An MRI reveals a large syrinx in the thoracic spinal cord. What is the recommended sequence of treatment for her condition?

. Immediate posterior spinal fusion and instrumentation
. Neurosurgical decompression of the syrinx prior to any corrective scoliosis surgery
. Thoracolumbosacral orthosis (TLSO) bracing for 6 months prior to surgery
. Observation with serial MRIs until skeletal maturity
. Anterior spinal tethering followed by syrinx shunting

Correct Answer & Explanation

. Neurosurgical decompression of the syrinx prior to any corrective scoliosis surgery

Explanation

In patients with a syrinx and progressive scoliosis requiring surgery, neurosurgical decompression (e.g., foramen magnum decompression for a Chiari malformation) must be performed first. This significantly reduces the risk of neurologic injury during subsequent spinal deformity correction.

Question 5648

Topic: 6. Spine

A 12-year-old boy presents with a left-sided thoracic scoliosis. Neurological examination reveals absent superficial abdominal reflexes and diminished pain and temperature sensation in both upper extremities. Which of the following is the most appropriate next step in evaluation?

. Immediate application of a thoracolumbosacral orthosis (TLSO)
. Total spine magnetic resonance imaging (MRI)
. Computed tomography (CT) of the thoracic spine
. Electromyography and nerve conduction studies
. Immediate posterior spinal fusion

Correct Answer & Explanation

. Total spine magnetic resonance imaging (MRI)

Explanation

A left thoracic curve, absent abdominal reflexes, and sensory dissociation (loss of pain/temperature with preserved light touch) strongly suggest an intraspinal anomaly like syringomyelia. A total spine MRI is mandatory to evaluate for a syrinx or Chiari malformation before any scoliosis treatment.

Question 5649

Topic: 6. Spine

A 9-year-old girl with severe polyarticular JIA is scheduled for bilateral total hip arthroplasty due to debilitating pain and contractures. Prior to general anesthesia, which of the following imaging studies is absolutely mandatory?

. Pelvis inlet and outlet views
. Cervical spine flexion and extension radiographs
. Anteroposterior (AP) and lateral chest radiographs
. Bilateral standing knee radiographs
. Thoracic spine MRI

Correct Answer & Explanation

. Cervical spine flexion and extension radiographs

Explanation

Patients with polyarticular JIA frequently develop cervical spine involvement, particularly C1-C2 instability or ankylosis. Flexion/extension cervical spine radiographs are essential to assess instability and prevent catastrophic spinal cord injury during intubation.

Question 5650

Topic: 6. Spine

A 14-year-old girl presents with a rapidly progressive right thoracic scoliosis. MRI reveals a large fluid-filled cavity within the central spinal cord extending from C4 to T8. Which of the following cranial abnormalities is most commonly associated with this specific spinal finding?

. Dandy-Walker malformation
. Arnold-Chiari type I malformation
. Tethered cord syndrome
. Diastematomyelia
. Arachnoid cyst

Correct Answer & Explanation

. Arnold-Chiari type I malformation

Explanation

Syringomyelia is a fluid-filled cyst within the spinal cord that is most frequently associated with an Arnold-Chiari type I malformation (tonsillar herniation). Treatment often involves suboccipital decompression.

Question 5651

Topic: 6. Spine

The pathogenesis of scoliosis in patients with syringomyelia is best explained by which of the following mechanisms?

. Asymmetric paralysis of the paraspinal muscles secondary to anterior horn cell damage
. Disruption of proprioceptive ascending pathways within the posterior columns
. Direct mechanical pressure of the syrinx on the adjacent vertebral bodies
. Increased sympathetic tone causing unilateral ischemia of the growth plates
. Primary tethering of the filum terminale pulling asymmetrically on the sacrum

Correct Answer & Explanation

. Asymmetric paralysis of the paraspinal muscles secondary to anterior horn cell damage

Explanation

Scoliosis in syringomyelia is believed to result from asymmetric expansion of the syrinx compressing the anterior horn cells. This leads to subtle, asymmetric weakness or paralysis of the paraspinal musculature, causing the spine to curve.

Question 5652

Topic: 6. Spine

A 12-year-old boy presents with an atypical, rapidly progressive left thoracic scoliotic curve. He also reports frequent occipital headaches and upper extremity clumsiness. An MRI confirms a syrinx.

What is the most appropriate initial management for his spinal deformity?

. Immediate posterior spinal fusion
. Thoracolumbosacral orthosis (TLSO) bracing
. Neurosurgical decompression of the syrinx
. Observation with serial radiographs
. Anterior spinal tethering

Correct Answer & Explanation

. Neurosurgical decompression of the syrinx

Explanation

Atypical scoliosis (e.g., left thoracic curve) driven by a syrinx should be addressed by neurosurgical decompression first. Addressing the underlying syrinx may halt or even reverse the curve progression in younger children.

Question 5653

Topic: 6. Spine

A 14-year-old girl with severe, long-standing polyarticular JIA complains of neck pain, myelopathic symptoms, and a "clunking" sensation when nodding. Which of the following radiographic findings is most critical to evaluate before planning any elective surgical procedures requiring intubation?

. Basilar invagination
. Atlantoaxial subluxation
. Subaxial step-off
. Ossification of the posterior longitudinal ligament
. C1 ring fracture

Correct Answer & Explanation

. Atlantoaxial subluxation

Explanation

Cervical spine involvement in JIA often leads to atlantoaxial subluxation due to ligamentous laxity and pannus formation. This must be evaluated with flexion/extension radiographs prior to intubation to prevent catastrophic spinal cord injury.

Question 5654

Topic: 6. Spine

In a patient with early syringomyelia

experiencing isolated loss of pain and temperature sensation in the upper extremities, which specific spinal cord structure is primarily compressed by the expanding syrinx?

. Dorsal columns
. Lateral corticospinal tract
. Anterior white commissure
. Anterior horn cells
. Spinocerebellar tract

Correct Answer & Explanation

. Anterior white commissure

Explanation

A central syrinx expands from the central canal outward, initially compressing the crossing spinothalamic fibers located in the anterior white commissure. This results in the classic bilateral loss of pain and temperature sensation.

Question 5655

Topic: 6. Spine

A 40-year-old woman with a history of severe spinal trauma 15 years ago presents with new-onset spasticity in her lower extremities and progressive sensory loss in her hands.

MRI of the cervical and thoracic spine reveals a large cystic cavitation within the spinal cord. What is the most likely diagnosis?

. Myelomalacia
. Post-traumatic syringomyelia
. Ependymoma
. Multiple sclerosis plaque
. Arachnoid cyst

Correct Answer & Explanation

. Post-traumatic syringomyelia

Explanation

Post-traumatic syringomyelia can develop months to years after a spinal cord injury. Fluid accumulates in the spinal cord due to altered CSF dynamics from arachnoid scarring, causing delayed, ascending neurological deficits.

Question 5656

Topic: 6. Spine

A 12-year-old boy with polyarticular JIA complains of progressive neck pain and stiffness. Which of the following cervical spine abnormalities is most characteristic of this disease?

. Atlantoaxial rotatory subluxation
. Congenital block vertebrae at C2-C3
. Basilar invagination with Klippel-Feil syndrome
. Apophyseal joint ankylosis and hypoplasia of the cervical vertebrae
. Degenerative disc disease with large anterior osteophytes

Correct Answer & Explanation

. Apophyseal joint ankylosis and hypoplasia of the cervical vertebrae

Explanation

Cervical spine involvement in JIA typically presents with early apophyseal joint ankylosis, most commonly at C2-C3. This early fusion leads to altered growth, hypoplasia of the involved vertebral bodies, and secondary instability.

Question 5657

Topic: 6. Spine

A 14-year-old girl is evaluated for a left-sided thoracic scoliotic curve of 45 degrees. Neurological exam reveals absent abdominal reflexes. An MRI confirms a cervical syrinx.

What is the most appropriate initial management for her spinal deformity?

. Immediate posterior spinal fusion
. Thoracolumbosacral orthosis (TLSO) bracing
. Neurosurgical decompression of the Chiari malformation/syrinx
. Anterior spinal tethering
. Observation with serial radiographs every 6 months

Correct Answer & Explanation

. Neurosurgical decompression of the Chiari malformation/syrinx

Explanation

In patients with syringomyelia and scoliosis, atypical features like left-thoracic curves or absent abdominal reflexes indicate neural axis pathology. Neurosurgical decompression is the primary initial treatment and may halt or improve the curve progression.

Question 5658

Topic: 6. Spine

A 28-year-old female with rapidly progressive scoliosis and intrinsic hand muscle wasting undergoes whole-spine MRI.

The MRI shows a CSF-filled cavity within the spinal cord. What brain malformation is most frequently associated with this finding?

. Dandy-Walker malformation
. Arnold-Chiari type I malformation
. Arteriovenous malformation of the vein of Galen
. Holoprosencephaly
. Encephalocele

Correct Answer & Explanation

. Arnold-Chiari type I malformation

Explanation

Syringomyelia is a CSF-filled cavitation of the spinal cord, most commonly associated with an Arnold-Chiari type I malformation. The herniation of cerebellar tonsils through the foramen magnum alters normal CSF flow dynamics, leading to syrinx formation.

Question 5659

Topic: 6. Spine

A 10-year-old boy presents with a left-sided thoracic scoliotic curve. Neurological examination reveals a loss of pain and temperature sensation over his bilateral shoulders and upper extremities with preserved light touch. Which of the following is the most appropriate next step in evaluation?

. Reassurance and serial observation
. TLSO bracing
. MRI of the entire spine and brainstem
. CT scan of the thoracic spine
. Electromyography (EMG)

Correct Answer & Explanation

. MRI of the entire spine and brainstem

Explanation

Left-sided thoracic curves and dissociated sensory loss (cape-like distribution) are classic for syringomyelia. MRI of the neuroaxis is required to evaluate for a syrinx and Arnold-Chiari malformation.

Question 5660

Topic: 6. Spine

An MRI of the cervical spine is performed on a 28-year-old female presenting with hand weakness and loss of temperature sensation. It demonstrates a large central intramedullary fluid collection extending from C2 to T1.

Which of the following cranial abnormalities is most commonly associated with this condition?

. Agenesis of the corpus callosum
. Herniation of the cerebellar tonsils through the foramen magnum
. Premature closure of the sagittal suture
. Absent septum pellucidum
. Enlargement of the lateral ventricles without aqueductal stenosis

Correct Answer & Explanation

. Herniation of the cerebellar tonsils through the foramen magnum

Explanation

Syringomyelia is heavily associated with Chiari I malformations. This involves the caudal herniation of the cerebellar tonsils through the foramen magnum, altering CSF dynamics and leading to syrinx formation.

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