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6. Spine MCQs

Practice Set 286 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 5701

Topic: 6. Spine
For a patient presenting with new onset radicular pain secondary to a lumbar disc herniation, what is the generally accepted duration of conservative management before considering surgical intervention, in the absence of red flag symptoms?
. 1-2 weeks
. 2-4 weeks
. 4-6 weeks
. 6-12 weeks
. Greater than 6 months

Correct Answer & Explanation

. 6-12 weeks

Explanation

In the absence of progressive neurological deficit or Cauda Equina Syndrome, conservative management for 6-12 weeks (often cited as 6 weeks to 3 months) is typically recommended for lumbar radiculopathy secondary to disc herniation. Many disc herniations resolve spontaneously or improve significantly with conservative care during this period. Surgery is typically reserved for those who fail conservative management or present with severe, progressive neurological deficits or CES.

Question 5702

Topic: 6. Spine
Which of the following is considered an absolute indication for surgical intervention in a patient with a lumbar disc herniation?
. Intractable radicular pain despite 6 weeks of conservative therapy
. Progressive motor weakness in a specific myotome
. Cauda Equina Syndrome
. Positive straight leg raise test at 30 degrees
. Recurrent episodes of acute low back pain

Correct Answer & Explanation

. Cauda Equina Syndrome

Explanation

Cauda Equina Syndrome is an absolute surgical emergency due to the risk of permanent neurological deficits (bowel/bladder dysfunction, saddle anesthesia). Progressive motor weakness is a strong relative indication and often warrants earlier surgical consideration but is not always an "absolute" emergency like CES. Intractable pain and positive SLR are relative indications for surgery after failed conservative care. Recurrent back pain, without radiculopathy, is generally managed conservatively.

Question 5703

Topic: 6. Spine

What is the primary advantage of microdiscectomy over traditional open lumbar discectomy for a standard posterolateral disc herniation?

. Lower risk of dural tear
. Reduced risk of recurrent disc herniation
. Less muscle damage and faster recovery
. Better visualization of the entire lumbar spinal canal
. Elimination of spinal instability

Correct Answer & Explanation

. Less muscle damage and faster recovery

Explanation

Microdiscectomy utilizes a smaller incision and microscopic visualization, leading to less paraspinal muscle dissection and damage compared to traditional open discectomy. This typically results in less postoperative pain, shorter hospital stays, and faster rehabilitation. The risk of dural tear or recurrent herniation is comparable. It provides excellent visualization of the compressed nerve root and herniated disc, but not necessarily the "entire" spinal canal. It does not directly address or eliminate spinal instability.

Question 5704

Topic: 6. Spine

What is the reported incidence of recurrent lumbar disc herniation after a successful primary microdiscectomy?

. <1%
. 2-5%
. 5-15%
. 15-25%
. >25%

Correct Answer & Explanation

. 5-15%

Explanation

The reported incidence of recurrent lumbar disc herniation after a primary microdiscectomy varies, but generally falls in the range of 5-15%. Factors influencing recurrence include residual annulus defect size, patient activity levels, and genetics.

Question 5705

Topic: 6. Spine

A 60-year-old patient presents with neurogenic claudication characterized by bilateral leg pain and numbness that is worse with standing and walking, and relieved by sitting or leaning forward. While a lumbar disc herniation is on the differential, what is the MORE likely diagnosis given the symptoms?

. Piriformis syndrome
. Spinal tumor
. Lumbar spinal stenosis
. Trochanteric bursitis
. Peripheral neuropathy

Correct Answer & Explanation

. Lumbar spinal stenosis

Explanation

The classic symptoms of neurogenic claudication – bilateral leg pain, numbness, and weakness exacerbated by standing/walking and relieved by sitting or leaning forward (which flexes the lumbar spine and opens the canal) – are highly suggestive of lumbar spinal stenosis. Disc herniations typically cause unilateral or radiating pain (radiculopathy), which may or may not be relieved by sitting, but the position-dependent nature with relief in flexion is hallmark for stenosis. Piriformis syndrome causes sciatic-like pain but is not typically associated with claudication. Spinal tumors and peripheral neuropathy can cause leg symptoms but usually have different patterns.

Question 5706

Topic: 6. Spine

Which medication class is generally considered first-line pharmacological treatment for acute radicular pain due to lumbar disc herniation, assuming no contraindications?

. Opioid analgesics
. Benzodiazepines
. NSAIDs
. Muscle relaxants
. Antidepressants

Correct Answer & Explanation

. NSAIDs

Explanation

Non-steroidal anti-inflammatory drugs (NSAIDs) are typically the first-line pharmacological treatment for acute radicular pain due to their anti-inflammatory and analgesic properties. While muscle relaxants can be used as an adjunct, and opioids for severe short-term pain, NSAIDs are preferred for initial management. Benzodiazepines are not indicated for radicular pain. Antidepressants, particularly tricyclic antidepressants or SNRIs, are used for chronic neuropathic pain, not typically first-line for acute radiculopathy.

Question 5707

Topic: 6. Spine

A patient undergoes successful lumbar microdiscectomy for L5 radiculopathy. Six months post-operatively, he develops new onset worsening leg pain. If a recurrent disc herniation is suspected, what is the MOST appropriate imaging study to differentiate it from postoperative scarring (fibrosis)?

. Plain radiographs
. CT scan with contrast
. MRI with gadolinium contrast
. Myelography
. Ultrasound

Correct Answer & Explanation

. MRI with gadolinium contrast

Explanation

MRI with gadolinium contrast is the gold standard for differentiating recurrent disc herniation from postoperative scar tissue (fibrosis). Scar tissue typically enhances with gadolinium, whereas a recurrent disc herniation, being avascular, usually does not. Plain radiographs and CT scans are less effective for this differentiation. Myelography is an older, invasive technique rarely used for this specific purpose when MRI is available.

Question 5708

Topic: 6. Spine

A 50-year-old male presents with severe left leg pain and weakness. Physical exam reveals weakness of left hip flexion (iliopsoas) and absent left patellar reflex. Sensation is diminished over the anterior thigh. A standard posterolateral disc herniation is suspected at L3-L4. However, considering the isolated L3 deficits, what type of herniation should also be strongly considered?

. Central disc herniation
. Subligamentous disc herniation
. Intradural disc herniation
. Far lateral (foraminal/extraforaminal) disc herniation
. Migrated disc herniation

Correct Answer & Explanation

. Far lateral (foraminal/extraforaminal) disc herniation

Explanation

A standard posterolateral L3-L4 disc herniation would typically affect the L4 nerve root. However, isolated L3 radiculopathy (weakness in hip flexion, diminished patellar reflex, anterior thigh numbness) in the setting of an L3-L4 pathology suggests a far lateral (foraminal or extraforaminal) disc herniation. These herniations directly compress the exiting nerve root at that level (L3), rather than the traversing root (L4) which is compressed in posterolateral herniations.

Question 5709

Topic: 6. Spine

During a posterior lumbar microdiscectomy, which ligament is typically resected or retracted to gain access to the interlaminar space and subsequently the disc?

. Anterior longitudinal ligament
. Posterior longitudinal ligament
. Ligamentum flavum
. Supraspinous ligament
. Interspinous ligament

Correct Answer & Explanation

. Ligamentum flavum

Explanation

The ligamentum flavum (yellow ligament) connects the laminae of adjacent vertebrae and forms the posterior border of the spinal canal. During a posterior microdiscectomy, a portion of the ligamentum flavum is typically resected or incised to access the epidural space and the herniated disc. The anterior and posterior longitudinal ligaments are anterior to the spinal canal or directly posterior to the vertebral bodies/discs. The supraspinous and interspinous ligaments are superficial to the lamina and protect the posterior elements.

Question 5710

Topic: 6. Spine

What percentage of symptomatic lumbar disc herniations are estimated to resolve spontaneously or significantly improve with conservative management within 3 months?

. 10-20%
. 30-40%
. 50-70%
. 80-90%
. Virtually all

Correct Answer & Explanation

. 50-70%

Explanation

A significant proportion of symptomatic lumbar disc herniations, estimated to be between 50-70% (and some studies suggesting even higher), resolve spontaneously or improve significantly with conservative management within 3 months. This is often attributed to resorption of disc material and reduction of inflammation. This high rate of spontaneous resolution supports initial conservative management for most patients.

Question 5711

Topic: 6. Spine

A physical therapist is treating a patient with acute lumbar radiculopathy using the McKenzie method. What is the primary principle behind this approach for discogenic pain?

. Strengthening core muscles in flexion
. Improving spinal mobility through rotation
. Centralization of pain with specific extension exercises
. Pelvic floor muscle training
. Total bed rest

Correct Answer & Explanation

. Centralization of pain with specific extension exercises

Explanation

The McKenzie method (Mechanical Diagnosis and Therapy) for discogenic pain primarily focuses on centralization of pain, where radiating symptoms move from the periphery towards the spine, often achieved through repeated lumbar extension exercises. This is thought to help reduce the disc bulge or herniation away from the nerve root. It is not primarily about strengthening in flexion, rotation, or bed rest.

Question 5712

Topic: 6. Spine

What is the primary mechanism of action of epidural steroid injections for lumbar radiculopathy secondary to disc herniation?

. Direct mechanical reduction of the disc herniation
. Neurolysis of the affected nerve root
. Reducing inflammation around the compressed nerve root
. Strengthening the posterior longitudinal ligament
. Improving disc hydration

Correct Answer & Explanation

. Reducing inflammation around the compressed nerve root

Explanation

Epidural steroid injections primarily work by delivering potent anti-inflammatory medication (corticosteroids) directly to the epidural space, reducing inflammation and edema around the compressed and irritated nerve root. They do not mechanically reduce the disc, cause neurolysis, strengthen ligaments, or improve disc hydration.

Question 5713

Topic: 6. Spine

Which of the following is a common cause of Failed Back Surgery Syndrome (FBSS) following lumbar discectomy?

. Surgical site infection
. New onset Cauda Equina Syndrome
. Recurrent disc herniation
. Systemic inflammatory disease
. Acute kidney injury

Correct Answer & Explanation

. Recurrent disc herniation

Explanation

Recurrent disc herniation is one of the most common causes of Failed Back Surgery Syndrome (FBSS) after a primary lumbar discectomy. Other common causes include epidural fibrosis, inadequate decompression, spinal instability, facet joint pain, and psychological factors. Surgical site infection is a complication, but not the most common cause of persistent pain in FBSS.

Question 5714

Topic: 6. Spine

A patient presents with classic L4 radiculopathy symptoms (weak quadriceps, diminished patellar reflex, medial thigh/shin numbness). On MRI, a significant disc herniation is identified at the L3-L4 level. However, the herniation appears to be primarily central and subarticular, not obviously foraminal. Which anatomical structure is most likely being compressed by this herniation pattern to cause L4 symptoms?

. L3 nerve root in the foramen
. L4 nerve root exiting at L4-L5
. L4 nerve root traversing the L3-L4 level
. S1 nerve root
. Lumbar sympathetic chain

Correct Answer & Explanation

. L4 nerve root traversing the L3-L4 level

Explanation

A standard posterolateral or subarticular disc herniation at the L3-L4 level will compress the traversing nerve root, which is the L4 nerve root, before it exits at the L4-L5 foramen. The L3 nerve root exits at the L3-L4 foramen and is typically spared in a standard posterolateral herniation at this level.

Question 5715

Topic: 6. Spine

In the context of lumbar disc herniation, what does a high signal intensity on T2-weighted MRI images within the disc material typically indicate?

. Degenerative changes
. Annular tear
. High water content and healthy nucleus pulposus
. Inflammation or acute injury
. Calcification

Correct Answer & Explanation

. High water content and healthy nucleus pulposus

Explanation

On T2-weighted MRI, a high signal intensity within the nucleus pulposus indicates high water content, which is characteristic of a healthy, non-degenerated disc. Loss of T2 signal (darkening) is indicative of dehydration and degenerative changes. While inflammation can be bright on T2, in the context of disc material itself, high signal is healthy. Annular tears or calcification have different appearances.

Question 5716

Topic: 6. Spine

When is electrodiagnostic testing (EMG/NCS) MOST helpful in the diagnostic workup of lumbar radiculopathy?

. As a first-line diagnostic test for acute radicular pain
. To differentiate radiculopathy from peripheral neuropathy or plexopathy
. To quantify the size of a disc herniation
. To predict surgical outcome
. To assess for Cauda Equina Syndrome

Correct Answer & Explanation

. To differentiate radiculopathy from peripheral neuropathy or plexopathy

Explanation

EMG/NCS is most helpful in differentiating true radiculopathy from other neuropathic conditions like peripheral neuropathy, plexopathy, or myopathy, especially when clinical findings are equivocal or to confirm the level of nerve root involvement. It is not a first-line test for acute radicular pain, nor does it quantify disc size or predict surgical outcome. It has a limited role in diagnosing acute Cauda Equina Syndrome, where urgent MRI is paramount.

Question 5717

Topic: 6. Spine
Which type of lumbar disc herniation has the highest probability of spontaneous regression and resorption?
. Disc protrusion
. Contained disc herniation
. Disc extrusion
. Disc bulge
. Far lateral disc herniation

Correct Answer & Explanation

. Disc extrusion

Explanation

Disc extrusions, particularly those that are sequestered (free fragments), have the highest reported rates of spontaneous regression and resorption. This is thought to be due to their exposure to the epidural vascular supply and immune system, facilitating phagocytosis. Protrusions, being contained, have lower rates of regression.

Question 5718

Topic: 6. Spine

For a true far lateral (foraminal or extraforaminal) lumbar disc herniation causing severe radiculopathy, which surgical approach is often preferred to directly access the pathology?

. Transforaminal lumbar interbody fusion (TLIF)
. Posterior lumbar interbody fusion (PLIF)
. Minimally invasive microdiscectomy via interlaminar approach
. Open paramedian muscle-splitting approach (e.g., Wiltse approach)
. Anterior lumbar interbody fusion (ALIF)

Correct Answer & Explanation

. Open paramedian muscle-splitting approach (e.g., Wiltse approach)

Explanation

A far lateral disc herniation is often best approached via a paramedian muscle-splitting approach (like the Wiltse approach), which allows direct access to the neural foramen and extraforaminal space without requiring extensive facetectomy or laminectomy, thereby preserving spinal stability. Standard interlaminar microdiscectomy can be difficult to access far lateral lesions. TLIF, PLIF, and ALIF are fusion procedures not typically indicated for isolated far lateral disc herniation unless instability is present.

Question 5719

Topic: 6. Spine

Which of the following is the MOST significant modifiable risk factor for lumbar disc herniation?

. Age
. Gender
. Genetic predisposition
. Obesity
. Tall stature

Correct Answer & Explanation

. Obesity

Explanation

While age and genetic predisposition are significant risk factors, they are non-modifiable. Obesity (and its associated factors like sedentary lifestyle and poor core strength) is considered a major modifiable risk factor for lumbar disc herniation due to increased mechanical stress on the spine. Gender and tall stature are generally considered non-modifiable or less significant modifiable factors.

Question 5720

Topic: 6. Spine
During a lumbar microdiscectomy, a dural tear occurs. What is the most common early postoperative complication associated with an unrecognized or inadequately repaired dural tear?
. Deep vein thrombosis
. Wound infection
. Post-dural puncture headache (PDPH)
. Nerve root palsy
. Spinal epidural hematoma

Correct Answer & Explanation

. Post-dural puncture headache (PDPH)

Explanation

The most common early postoperative complication of an unrecognized or inadequately repaired dural tear is a post-dural puncture headache (PDPH), resulting from cerebrospinal fluid (CSF) leakage and intracranial hypotension. Other potential complications include CSF fistula, pseudomeningocele, and meningitis, but headache is the most frequent symptom.

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