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6. Spine MCQs

Practice Set 299 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 5961

Topic: 6. Spine

A 58-year-old male with a history of intravenous drug use presents with acute onset severe low back pain, fever, chills, and progressive weakness in both lower extremities. An MRI shows an L3-L4 disc space infection (spondylodiscitis) and a large epidural abscess. What is the most critical initial diagnostic step in managing this patient?

. Administration of broad-spectrum antibiotics.
. Urgent surgical decompression.
. Blood cultures and C-reactive protein (CRP).
. Lumbar puncture.
. Electromyography (EMG).

Correct Answer & Explanation

. Blood cultures and C-reactive protein (CRP).

Explanation

While urgent surgical decompression may be necessary if there are progressive neurological deficits, and antibiotics are crucial, the most criticalinitial diagnosticstep is to identify the causative organism. Blood cultures and measurement of inflammatory markers like CRP are essential to guide specific antibiotic therapy and monitor response. Lumbar puncture is generally avoided in the presence of an epidural abscess due to the risk of spreading the infection. EMG would provide information on nerve function but is not an acute diagnostic step for infection. Therefore, identifying the pathogen to tailor treatment is paramount once the diagnosis is suspected.

Question 5962

Topic: 6. Spine

A 65-year-old male with a T12 burst fracture and complete paraplegia (ASIA A) is undergoing rehabilitation. He reports difficulty with bowel movements and requires manual disimpaction. What is the most appropriate long-term bowel management strategy for this patient?

. Dietary modifications with increased fiber and fluid intake.
. Daily stimulant laxatives.
. Regular scheduled bowel program with suppositories or digital stimulation.
. Surgical colostomy.
. Expectant management as bowel function may return.

Correct Answer & Explanation

. Regular scheduled bowel program with suppositories or digital stimulation.

Explanation

Patients with a complete spinal cord injury at T12, which is typically above the sacral cord, will have an upper motor neuron (spastic) bowel. The most appropriate long-term management is a regular, scheduled bowel program utilizing suppositories and/or digital stimulation. This helps retrain the bowel to empty reflexively and prevents constipation and impaction. While diet and fluids are important adjuncts, they are insufficient alone. Daily stimulant laxatives are not ideal for long-term use. Surgical colostomy is reserved for intractable problems. Expectant management is inappropriate for a complete SCI. This approach aims to achieve predictable and controlled bowel movements, thereby improving quality of life and preventing complications.

Question 5963

Topic: 6. Spine

Which condition is characterized by ossification of the anterior longitudinal ligament of the spine, primarily affecting the thoracic spine, and may be associated with diabetes mellitus?

. Ankylosing spondylitis.
. Diffuse Idiopathic Skeletal Hyperostosis (DISH).
. Osteoarthritis.
. Pott's disease.
. Rheumatoid arthritis.

Correct Answer & Explanation

. Diffuse Idiopathic Skeletal Hyperostosis (DISH).

Explanation

Diffuse Idiopathic Skeletal Hyperostosis (DISH), also known as Forestier's disease, is a non-inflammatory spondyloarthropathy characterized by extensive ossification of the anterior longitudinal ligament, primarily affecting the thoracic spine. It typically spares the sacroiliac and facet joints and is often associated with metabolic disorders like diabetes mellitus and obesity. Ankylosing spondylitis causes a 'bamboo spine' but is an inflammatory condition affecting entheses and posterior elements. Osteoarthritis is degenerative but not diffuse ossification of the ALL. Pott's disease is infectious. Rheumatoid arthritis primarily affects peripheral joints and the cervical spine, but not with ALL ossification.

Question 5964

Topic: 6. Spine

Which of the following interventions is most critical in preventing long-term orthopedic complications in a child born with myelomeningocele?

. Early bracing for spinal deformities.
. Regular monitoring for hip subluxation/dislocation.
. Prompt surgical closure of the spinal defect at birth.
. Early initiation of physical therapy and occupational therapy.
. Management of hydrocephalus with shunting.

Correct Answer & Explanation

. Prompt surgical closure of the spinal defect at birth.

Explanation

While all listed interventions are important in the comprehensive care of a child with myelomeningocele, prompt surgical closure of the spinal defect at birth is critical. This procedure aims to protect the exposed spinal cord/nerves from trauma and infection, which can worsen neurological function. While it cannot reverse existing deficits, it helps prevent further neurological deterioration, which in turn influences the severity of orthopedic complications like hip dislocations, foot deformities, and scoliosis. Without surgical closure, the risk of infection and further neurological damage to the exposed cord is extremely high. The other options are subsequent management strategies that rely on the initial spinal defect closure.

Question 5965

Topic: 6. Spine

A patient with a traumatic T4 spinal cord injury develops new-onset fever, increased spasticity, and a worsening sacral pressure ulcer. What is the most concerning urological complication that could be contributing to these systemic symptoms?

. Stress incontinence.
. Neurogenic bladder with recurrent urinary tract infections.
. Bladder stones.
. Renal insufficiency.
. Autonomic dysreflexia.

Correct Answer & Explanation

. Neurogenic bladder with recurrent urinary tract infections.

Explanation

In a patient with SCI, a neurogenic bladder predisposes to recurrent urinary tract infections (UTIs) due to incomplete emptying, catheterization, and stasis. UTIs can manifest with systemic symptoms like fever, increased spasticity (a common sign of infection in SCI patients), and can complicate wound healing (like pressure ulcers) or even lead to sepsis. While bladder stones and renal insufficiency are possible long-term complications of neurogenic bladder, recurrent UTIs are the most direct and common cause of acute systemic symptoms in this scenario. Stress incontinence is a symptom, not a systemic complication. Autonomic dysreflexia is a sympathetic hyperreflexia, typically triggered by noxious stimuli, and while it can cause fever, the overall clinical picture with worsening pressure ulcer makes UTI a primary suspect.

Question 5966

Topic: 6. Spine

A 70-year-old male with severe osteoporotic vertebral compression fractures in the thoracic spine develops persistent, severe back pain despite conservative measures. What is a key consideration when deciding on surgical intervention (e.g., kyphoplasty/vertebroplasty) in an elderly patient with significant comorbidities?

. The age of the patient is the most important determinant.
. The degree of kyphosis correction is the primary goal.
. Maintaining pulmonary function post-procedure.
. The presence of neurological deficit is an absolute indication for surgery.
. The potential for cement extravasation into the thoracic cavity.

Correct Answer & Explanation

. The potential for cement extravasation into the thoracic cavity.

Explanation

While age, kyphosis correction, and pulmonary function are all considerations, a critical and unique risk specific to kyphoplasty/vertebroplasty in the thoracic spine is the potential for cement extravasation into the thoracic cavity (pleural space, lung parenchyma, or mediastinum). This can lead to serious complications such as pneumothorax, pulmonary embolism (cement embolization), or injury to vital structures. Neurological deficit is an indication for surgery, but the question asks for a key considerationwhen deciding on surgical interventionspecifically in this context, highlighting a unique risk of the procedure itself. The risk of cement extravasation into the thoracic cavity mandates careful technique and imaging guidance.

Question 5967

Topic: 6. Spine

Which of the following is the most effective approach for assessing the respiratory status and identifying complications in a patient with a T2 complete spinal cord injury in the acute setting?

. Spirometry and full pulmonary function tests (PFTs).
. Daily chest X-rays.
. Serial arterial blood gas (ABG) analysis and clinical observation for signs of respiratory distress.
. Auscultation of breath sounds and percussion for consolidation.
. Pulse oximetry and capnography.

Correct Answer & Explanation

. Serial arterial blood gas (ABG) analysis and clinical observation for signs of respiratory distress.

Explanation

A T2 complete SCI affects all intercostal muscles, leaving only the diaphragm (phrenic nerve C3-C5) and accessory neck muscles for respiration. This significantly compromises ventilatory capacity and cough effectiveness. In the acute setting, serial arterial blood gas (ABG) analysis provides crucial information on oxygenation and ventilation (pH, PaCO2, PaO2). Combined with rigorous clinical observation for signs of respiratory distress (e.g., increased work of breathing, accessory muscle use), it offers the most effective and real-time assessment of respiratory status and helps identify complications like hypoventilation or respiratory failure. Spirometry/PFTs are typically for stable patients. Daily chest X-rays are not always necessary. Auscultation/percussion and pulse oximetry are important but less comprehensive than ABG for a critical T2 SCI. Capnography is useful but primarily for CO2 monitoring, and ABG offers a broader picture.

Question 5968

Topic: 6. Spine

What is the most common cause of a spontaneous psoas abscess that may mimic or cause spinal symptoms?

. Tuberculosis of the spine.
. Crohn's disease with fistulizing complications.
. Diverticulitis.
. Urinary tract infection.
. Appendicitis.

Correct Answer & Explanation

. Urinary tract infection.

Explanation

A primary psoas abscess, while less common than secondary, can arise from hematogenous spread without an obvious local source. However, secondary psoas abscesses, which are far more common, usually originate from infections of adjacent structures. Among the choices provided, urinary tract infections (UTIs) are a relatively common source of infection that can spread to the psoas muscle, particularly in immunocompromised individuals or those with anatomical abnormalities. Tuberculosis of the spine (Pott's disease) is a classic cause of psoas abscess but is less common in developed countries compared to other sources. Crohn's disease, diverticulitis, and appendicitis are also causes of secondary psoas abscess by direct extension, but UTIs can be a more insidious and widespread source via hematogenous or lymphatic routes. In many contexts, urogenital and gastrointestinal sources are both major contributors to secondary psoas abscesses.

Question 5969

Topic: 6. Spine

Which of the following is an expected neurogenic bladder pattern in a patient with a complete T10 spinal cord injury (UMN bladder)?

. Flaccid, areflexic bladder with continuous dribbling.
. Acontractile bladder requiring manual expression.
. Spastic, hyperreflexic bladder with detrusor-sphincter dyssynergia.
. Normal bladder sensation and function.
. Bladder dysfunction solely due to psychological factors.

Correct Answer & Explanation

. Spastic, hyperreflexic bladder with detrusor-sphincter dyssynergia.

Explanation

A complete T10 spinal cord injury is above the sacral micturition center (S2-S4). This results in an upper motor neuron (UMN) or spastic/reflexic bladder. Key characteristics of a UMN bladder include hyperreflexia of the detrusor muscle, leading to involuntary contractions and poor coordination with the external urethral sphincter (detrusor-sphincter dyssynergia, DSD). This results in high intravesical pressures and incomplete emptying, increasing the risk of UTIs and renal damage. A flaccid, areflexic bladder is characteristic of lower motor neuron lesions (e.g., cauda equina injury or sacral level SCI). Normal function is not expected, and bladder dysfunction is neurological, not psychological.

Question 5970

Topic: 6. Spine

A 20-year-old male presents after a high-energy fall, resulting in a T11 burst fracture with an incomplete spinal cord injury (ASIA D). He is able to void spontaneously but reports a sensation of incomplete bladder emptying. Which of the following studies is most appropriate for further evaluation of his bladder function?

. Intravenous pyelogram (IVP).
. Cystoscopy.
. Urodynamic studies.
. Retrograde urethrogram (RUG).
. Abdominal ultrasound for renal size.

Correct Answer & Explanation

. Urodynamic studies.

Explanation

Given the patient's incomplete SCI and symptoms of incomplete bladder emptying, urodynamic studies are the most appropriate investigation. Urodynamics provide a comprehensive assessment of bladder storage (compliance, sensation, capacity) and emptying (detrusor contractility, detrusor-sphincter synergy/dyssynergia, post-void residual volume). This information is crucial for guiding specific treatment to prevent long-term complications like UTIs and renal damage. IVP and renal ultrasound assess upper tract anatomy but not bladder function. Cystoscopy allows direct visualization of the bladder but not its function. RUG evaluates the urethra, not primary bladder function. The patient's ability to void spontaneously indicates a need to understand the mechanics of his voiding, not just anatomy.

Question 5971

Topic: 6. Spine

Which of the following is the most likely long-term complication of a severely rigid and uncorrected adult kyphoscoliosis?

. Recurrent lumbar disc herniation.
. Facet joint arthritis.
. Progressive restrictive lung disease leading to cor pulmonale.
. Persistent radicular pain.
. Increased risk of spontaneous fractures.

Correct Answer & Explanation

. Progressive restrictive lung disease leading to cor pulmonale.

Explanation

A severely rigid and uncorrected adult kyphoscoliosis, especially with significant thoracic curvature, can lead to severe restriction of lung volumes. Over time, this chronic restrictive lung disease causes increased pulmonary vascular resistance, eventually leading to pulmonary hypertension and right-sided heart failure (cor pulmonale). This is a major cause of morbidity and mortality in patients with severe, untreated spinal deformities. The other options are orthopedic complications that can occur with spinal deformities but are not the most significant long-term, life-threatening complication associated with severe, uncorrected kyphoscoliosis specifically impacting overall health.

Question 5972

Topic: 6. Spine

What is the primary goal of surgical management for an unstable thoracolumbar burst fracture in a neurologically intact patient?

. Immediate return to full activity.
. Prevention of future neurological deficit and restoration of spinal alignment.
. Complete pain relief.
. Minimizing surgical time at all costs.
. Fusion of as many levels as possible.

Correct Answer & Explanation

. Prevention of future neurological deficit and restoration of spinal alignment.

Explanation

For an unstable thoracolumbar burst fracture in a neurologically intact patient, the primary goal of surgical management is to prevent future neurological deterioration by stabilizing the spinal column and decompressing the spinal canal, while also restoring sagittal alignment (preventing progressive kyphosis). While complete pain relief and immediate return to activity are desirable, they are secondary goals. Minimizing surgical time is important but not the primary goal. Fusion of as many levels as possible is generally avoided to preserve spinal mobility if stability can be achieved with shorter constructs.

Question 5973

Topic: 6. Spine

A 40-year-old male with a history of recurrent urinary tract infections presents with severe, acute low back pain, fever, and new-onset weakness in his right leg. MRI shows an L4-L5 epidural abscess with significant cord compression. What is the most appropriate initial management?

. Oral antibiotics and rest.
. Lumbar epidural steroid injection.
. Urgent surgical decompression and intravenous antibiotics.
. Percutaneous drainage of the abscess.
. Brace immobilization and close observation.

Correct Answer & Explanation

. Urgent surgical decompression and intravenous antibiotics.

Explanation

The patient's presentation with severe back pain, fever, new-onset focal neurological deficit (right leg weakness), and MRI evidence of an epidural abscess with significant cord compression constitutes a surgical emergency. Urgent surgical decompression is required to relieve pressure on the spinal cord and prevent irreversible neurological damage. This must be combined with intravenous antibiotics to treat the infection. Oral antibiotics are insufficient. Epidural steroid injections are contraindicated in infection. Percutaneous drainage may be considered for small, non-compressive abscesses without neurological deficits, but not in this scenario. Brace immobilization and observation are inappropriate for acute neurological compromise.

Question 5974

Topic: 6. Spine

A 68-year-old male presents with a 6-month history of bilateral lower extremity pain, numbness, and weakness, exacerbated by walking and relieved by sitting or leaning forward. His MRI shows severe lumbar canal stenosis at L4-L5 with degenerative spondylolisthesis. Neurological examination reveals mild weakness in bilateral quadriceps (4/5) and diminished patellar reflexes. Which of the following is the most appropriate initial management strategy?

. Urgent surgical decompression and fusion
. Epidural steroid injections and physical therapy
. Gabapentin and non-steroidal anti-inflammatory drugs (NSAIDs)
. Bracing and activity modification
. Myelogram for definitive diagnosis

Correct Answer & Explanation

. Epidural steroid injections and physical therapy

Explanation

The patient exhibits classic symptoms of lumbar spinal stenosis with neurogenic claudication. While surgical intervention (decompression, often with fusion for instability like degenerative spondylolisthesis) is definitive for severe, refractory symptoms, conservative management is typically the first line. This includes physical therapy (flexion-based exercises often helpful), epidural steroid injections (for short-term pain relief), NSAIDs, and neuropathic pain medications like gabapentin. Urgent surgery is reserved for progressive neurological deficit or cauda equina syndrome. Myelogram is largely supplanted by MRI for diagnosis.

Question 5975

Topic: Thoracolumbar Spine & Deformity

In evaluating a patient with scoliosis, which of the following Cobb angle measurements typically warrants surgical intervention in an adolescent with progressive idiopathic scoliosis?

. 10-20 degrees
. 20-30 degrees
. 30-40 degrees
. 40-50 degrees
. Greater than 50 degrees

Correct Answer & Explanation

. Greater than 50 degrees

Explanation

For progressive idiopathic scoliosis in adolescents, surgical correction is generally recommended for curves greater than 45-50 degrees to prevent further progression and mitigate potential pulmonary compromise. Curves 20-40 degrees often warrant bracing, especially if progressive in a growing child. Curves less than 20 degrees are typically observed. The threshold for surgery can vary slightly based on skeletal maturity, curve pattern, and patient symptoms, but >50 degrees is a common general guideline.

Question 5976

Topic: 6. Spine

A patient with a chronic history of rheumatoid arthritis develops sudden onset of neck pain, occipital headache, and myelopathic symptoms. Imaging reveals atlantoaxial instability with C1-C2 subluxation. What is the most appropriate initial management?

. Physical therapy and cervical strengthening exercises
. Immediate surgical stabilization of C1-C2
. Oral corticosteroids and NSAIDs
. Cervical traction
. Observe with regular follow-up

Correct Answer & Explanation

. Immediate surgical stabilization of C1-C2

Explanation

Atlantoaxial instability with myelopathic symptoms in a rheumatoid arthritis patient is an urgent condition. The presence of neurological deficits due to spinal cord compression necessitates immediate surgical stabilization (C1-C2 fusion) to prevent irreversible neurological damage. Conservative measures like physical therapy, medication, or observation are inappropriate and potentially dangerous in this setting. Cervical traction might be used acutely but is not definitive management.

Question 5977

Topic: 6. Spine

A patient undergoing an anterior cervical discectomy and fusion (ACDF) develops hoarseness post-operatively. Which nerve is most likely injured?

. Phrenic nerve
. Recurrent laryngeal nerve
. Vagus nerve (main trunk)
. Brachial plexus
. Spinal accessory nerve

Correct Answer & Explanation

. Recurrent laryngeal nerve

Explanation

Hoarseness after anterior cervical spine surgery (like ACDF) is a well-known complication due to injury or irritation of the recurrent laryngeal nerve. This nerve, a branch of the vagus nerve, innervates most of the intrinsic muscles of the larynx. Injury can occur during retraction or direct trauma. The phrenic nerve supplies the diaphragm, and its injury would cause breathing difficulties. Vagus nerve injury can cause broader issues, but hoarseness points specifically to the recurrent laryngeal branch. Brachial plexus injury would cause upper limb neurological deficits.

Question 5978

Topic: 6. Spine

A 60-year-old male with a history of IV drug use presents with acute onset back pain, fever, and new neurological deficits. An MRI confirms epidural abscess. He is hemodynamically unstable. What is the most important component of source control for this patient?

. Administration of empiric broad-spectrum antibiotics immediately
. Surgical drainage of the epidural abscess
. Optimization of blood pressure with fluids and vasopressors
. Pain management with opioid analgesics
. Physical therapy to prevent neurological deterioration

Correct Answer & Explanation

. Surgical drainage of the epidural abscess

Explanation

In this scenario, the epidural abscess is the clear source of infection. Surgical drainage of the abscess is the most critical and definitive aspect of source control, as antibiotics alone often cannot penetrate adequately or resolve a contained purulent collection. While antibiotics, hemodynamic support, and pain management are vital, they are adjunctive to the definitive source control.

Question 5979

Topic: 6. Spine

A 60-year-old male presents with acute onset of severe low back pain radiating down both legs, associated with bilateral leg weakness and urinary retention following a minor fall. Physical exam reveals saddle anesthesia. Which of the following orthopedic diagnoses is most likely, and what is its typical management priority?

. Lumbar disc herniation; initial management with physiotherapy and NSAIDs.
. Spinal stenosis; managed with epidural steroid injections and physical therapy.
. Cauda Equina Syndrome; requiring urgent surgical decompression.
. Vertebral compression fracture; managed with bracing and pain control.
. Spondylolisthesis; usually managed conservatively unless severe instability.

Correct Answer & Explanation

. Cauda Equina Syndrome; requiring urgent surgical decompression.

Explanation

The patient's symptoms (bilateral leg weakness, urinary retention, saddle anesthesia) are classic for Cauda Equina Syndrome (CES), a surgical emergency. This condition results from compression of the cauda equina nerve roots, typically by a large disc herniation, tumor, or trauma. Urgent surgical decompression is required to prevent permanent neurological deficits, especially bladder and bowel dysfunction. The other options describe conditions with less acute or less severe neurological deficits and typically have different management algorithms.

Question 5980

Topic: 6. Spine

A 45-year-old patient with rheumatoid arthritis undergoes a cervical spine fusion. Postoperatively, she develops acute onset of difficulty swallowing (dysphagia) and a hoarse voice (dysphonia). Which of the following is the most likely cause?

. Esophageal perforation during surgery.
. Recurrent laryngeal nerve palsy due to intubation trauma.
. Pharyngeal edema due to prolonged retraction.
. Spinal cord injury leading to bulbar dysfunction.
. Pneumonia due to aspiration.

Correct Answer & Explanation

. Pharyngeal edema due to prolonged retraction.

Explanation

Dysphagia and dysphonia following anterior cervical spine surgery are relatively common complications, most frequently caused by pharyngeal/esophageal edema and/or recurrent laryngeal nerve neuropraxia due to prolonged retraction of soft tissues during the approach. While esophageal perforation is a serious but rare complication, and recurrent laryngeal nerve palsy can occur, edema from retraction is the most common cause of these symptoms. Spinal cord injury would present with more profound neurological deficits. Aspiration pneumonia is a consequence, not a primary cause of the dysphagia/dysphonia itself.

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