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6. Spine MCQs

Practice Set 30 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 581

Topic: Cervical Spine

An 82-year-old male sustains a Type II odontoid fracture with 3 mm of posterior displacement following a ground-level fall. He has severe medical comorbidities. What is the most appropriate management?

. Halo vest immobilization for 12 weeks
. Rigid cervical collar for 8 to 12 weeks
. Anterior odontoid screw fixation
. Posterior C1-C2 transarticular screw fixation
. Posterior C1-C2 Harms technique fusion

Correct Answer & Explanation

. Rigid cervical collar for 8 to 12 weeks

Explanation

In elderly patients with severe medical comorbidities, a rigid cervical collar is often preferred despite a higher nonunion rate, as halo vest immobilization carries a high mortality risk in this population. Surgery is reserved for patients who fail conservative management or can tolerate the procedure.

Question 582

Topic: 6. Spine

A traumatic spondylolisthesis of the axis (Hangman's fracture) primarily involves bilateral fractures of which of the following anatomic structures?

. Dens
. Lateral masses of C1
. Pars interarticularis of C2
. Pedicles of C3
. Spinous process of C2

Correct Answer & Explanation

. Pars interarticularis of C2

Explanation

A Hangman's fracture is defined as bilateral fractures through the pars interarticularis of C2 (the axis). It is typically caused by hyperextension and axial loading mechanisms.

Question 583

Topic: 6. Spine

A 30-year-old male presents with a unilateral facet dislocation at C5-C6 and is neurologically intact. He is alert and cooperative. What is the most accepted next step in management?

. Obtain a screening MRI of the cervical spine before attempting reduction
. Attempt closed reduction with awake serial cranial traction
. Proceed directly to posterior open reduction and fusion
. Proceed directly to anterior open reduction and fusion
. Apply a halo vest in the current position

Correct Answer & Explanation

. Attempt closed reduction with awake serial cranial traction

Explanation

In an awake, cooperative, and neurologically intact patient with a cervical facet dislocation, closed reduction with cranial traction can be performed safely prior to MRI. Frequent clinical neurologic exams must be performed during the serial weight additions.

Question 584

Topic: 6. Spine

Which of the following radiographic findings on an open-mouth odontoid view suggests disruption of the transverse atlantal ligament in a patient with a Jefferson burst fracture?

. Combined lateral mass overhang greater than 6.9 mm
. Anterior atlantodental interval of 2 mm
. Asymmetry of the C1-C2 facet joints
. Fracture through the base of the dens
. Prevertebral soft tissue swelling of 5 mm

Correct Answer & Explanation

. Combined lateral mass overhang greater than 6.9 mm

Explanation

Spence's rule states that if the combined overhang of the C1 lateral masses on C2 is 6.9 mm or greater on an open-mouth AP radiograph, it indicates an incompetent transverse atlantal ligament, rendering the fracture highly unstable.

Question 585

Topic: 6. Spine

A 25-year-old male arrives at the trauma bay completely tetraplegic after a diving accident. His heart rate is 55 bpm, and blood pressure is 85/50 mmHg. The bulbocavernosus reflex is absent. Which of the following states best describes his condition?

. Hypovolemic shock
. Cardiogenic shock
. Spinal shock and neurogenic shock
. Autonomic dysreflexia
. Brown-Sequard syndrome

Correct Answer & Explanation

. Spinal shock and neurogenic shock

Explanation

The absence of the bulbocavernosus reflex indicates spinal shock (loss of all reflex activity below the injury). The triad of hypotension, bradycardia, and peripheral vasodilation simultaneously defines neurogenic shock, caused by a loss of sympathetic tone.

Question 586

Topic: 6. Spine

A patient suffers a severe flexion injury of the cervical spine resulting in an anterior spinal cord syndrome. Which of the following neurologic functions is typically preserved?

. Motor function below the level of injury
. Pain and temperature sensation
. Proprioception and vibratory sense
. Bowel and bladder control
. Deep tendon reflexes

Correct Answer & Explanation

. Proprioception and vibratory sense

Explanation

Anterior cord syndrome involves injury to the anterior two-thirds of the spinal cord, causing a loss of motor function and pain/temperature sensation. The posterior columns are spared, preserving proprioception and vibratory sense.

Question 587

Topic: Cervical Spine

When planning intubation for a patient with severe rheumatoid arthritis, the anesthesiologist should be particularly cautious of atlantoaxial instability. Which ligament's laxity or destruction is the primary cause of this instability?

. Alar ligament
. Apical ligament
. Transverse ligament
. Posterior longitudinal ligament
. Ligamentum flavum

Correct Answer & Explanation

. Transverse ligament

Explanation

The transverse ligament is the primary stabilizer of the atlantoaxial joint. Pannus formation in rheumatoid arthritis often leads to the destruction of this ligament, causing anterior atlantoaxial subluxation.

Question 588

Topic: 6. Spine

Which of the following demographic groups has the highest incidence of Ossification of the Posterior Longitudinal Ligament (OPLL), leading to cervical myelopathy?

. Caucasian females
. African American males
. Hispanic females
. Asian males
. Middle Eastern females

Correct Answer & Explanation

. Asian males

Explanation

OPLL is most prevalent in the Asian population, particularly among Japanese men. It is a major cause of cervical myelopathy in this demographic, often requiring surgical decompression via laminoplasty or laminectomy.

Question 589

Topic: 6. Spine

A patient presents with neck pain radiating down the arm. The examiner performs the Spurling test by extending and laterally bending the patient's neck to the affected side while applying axial compression. What does a positive test indicate?

. Cervical myelopathy
. Thoracic outlet syndrome
. Cervical nerve root compression
. Brachial plexus traction injury
. Vertebrobasilar insufficiency

Correct Answer & Explanation

. Cervical nerve root compression

Explanation

The Spurling test actively narrows the neural foramen. Reproduction of radicular arm pain indicates a positive test and is highly specific for cervical nerve root compression (radiculopathy).

Question 590

Topic: 6. Spine

A 45-year-old female presents with neck pain following a rear-end motor vehicle collision. Radiographs show a loss of the normal cervical lordosis but no fractures or dislocations. Neurologic exam is normal. What is the most appropriate initial management?

. Immediate MRI of the cervical spine
. Rigid cervical collar for 4 weeks
. Early mobilization and physical therapy
. Epidural steroid injection
. Diagnostic facet blocks

Correct Answer & Explanation

. Early mobilization and physical therapy

Explanation

For a simple whiplash injury (cervical sprain/strain) without neurologic deficits or fractures, early mobilization, NSAIDs, and physical therapy are the standard of care. Prolonged immobilization can delay recovery and is not recommended.

Question 591

Topic: Cervical Spine

A patient undergoes an anterior cervical discectomy and fusion at C7-T1. Postoperatively, the patient demonstrates a new sensory deficit. If the C8 nerve root is iatrogenically injured, sensation is most likely lost over which of the following areas?

. Lateral aspect of the forearm
. Medial aspect of the forearm and ulnar two digits
. Medial aspect of the arm
. Dorsum of the thumb and index finger
. Volar aspect of the thumb

Correct Answer & Explanation

. Medial aspect of the forearm and ulnar two digits

Explanation

The C8 nerve root provides sensory innervation to the medial aspect of the forearm and the ulnar two digits (ring and little fingers). The lateral forearm is C6, medial arm is T1, and the thumb/index finger typically fall under C6 territory.

Question 592

Topic: 6. Spine

Following a multilevel posterior cervical laminectomy and fusion for cervical spondylotic myelopathy, a patient develops profound weakness in shoulder abduction and elbow flexion on postoperative day 3, without any new sensory deficits. What is the most likely diagnosis?

. Epidural hematoma
. Postoperative C5 palsy
. Recurrent laryngeal nerve injury
. Inadequate decompression at C6
. Iatrogenic spinal cord injury

Correct Answer & Explanation

. Postoperative C5 palsy

Explanation

Postoperative C5 palsy is a known complication of cervical decompression, occurring in up to 5-10% of cases. It presents as isolated deltoid and biceps weakness, typically a few days postoperatively, likely due to nerve root tethering or reperfusion injury.

Question 593

Topic: 6. Spine

During an anterior approach to the lower cervical spine, dissection lateral to the longus colli muscle places a specific nervous structure at risk. Injury to this structure results in which of the following clinical findings?

. Hoarseness and vocal cord paralysis
. Ipsilateral ptosis, miosis, and anhidrosis
. Loss of pain and temperature in the contralateral arm
. Weakness in wrist extension
. Diaphragmatic paralysis

Correct Answer & Explanation

. Ipsilateral ptosis, miosis, and anhidrosis

Explanation

Dissection lateral to the longus colli muscle risks injury to the sympathetic chain and stellate ganglion, leading to Horner's syndrome. This manifests classically as ipsilateral ptosis, miosis, and anhidrosis.

Question 594

Topic: 6. Spine

An elderly patient with pre-existing cervical stenosis sustains a hyperextension injury. Examination reveals motor weakness that is more pronounced in the hands and upper extremities than in the lower extremities. Which spinal cord tract injury best explains the upper extremity motor deficit?

. Lateral corticospinal tract
. Ventral spinothalamic tract
. Dorsal columns
. Spinocerebellar tract
. Rubrospinal tract

Correct Answer & Explanation

. Lateral corticospinal tract

Explanation

This patient has Central Cord Syndrome. The characteristic upper extremity weakness occurs because the cervical motor fibers are located medially within the lateral corticospinal tract, making them more susceptible to central cord injury.

Question 595

Topic: 6. Spine

A patient presents with a paracentral herniated nucleus pulposus at the L4-L5 level. Which of the following physical examination findings is most specific to the expected nerve root compression?

. Weakness in ankle plantarflexion
. Decreased patellar tendon reflex
. Weakness in great toe extension
. Sensory loss over the medial malleolus
. Diminished Achilles tendon reflex

Correct Answer & Explanation

. Weakness in great toe extension

Explanation

A paracentral disc herniation at L4-L5 affects the traversing L5 nerve root. L5 radiculopathy characteristically causes weakness in the extensor hallucis longus (great toe extension) and sensory loss over the dorsum of the foot.

Question 596

Topic: 6. Spine

A 65-year-old male requires surgical decompression for a central T8-T9 calcified disc herniation causing myelopathy. Why is a standard posterior laminectomy strictly contraindicated for this central thoracic disc herniation?

. Inability to mechanically stabilize the thoracic spine
. High risk of iatrogenic spinal cord injury from cord retraction
. Excessive epidural bleeding from Batson's plexus
. High risk of tension pneumothorax
. Unfavorable biomechanics leading to rapid kyphosis

Correct Answer & Explanation

. High risk of iatrogenic spinal cord injury from cord retraction

Explanation

A standard posterior laminectomy for a central thoracic disc requires retraction of the thoracic spinal cord to access the disc, which carries an unacceptably high risk of paraplegia. Anterior or posterolateral (costotransversectomy) approaches are required.

Question 597

Topic: 6. Spine

In a patient with a traumatic spondylolisthesis of the axis (Hangman's fracture), the primary mechanism of injury is most commonly described as:

. Hyperflexion and distraction
. Hyperextension and axial loading
. Lateral bending
. Pure axial loading
. Rotation and shear

Correct Answer & Explanation

. Hyperextension and axial loading

Explanation

A Hangman's fracture involves bilateral pars interarticularis fractures of C2. The classic mechanism of injury in modern trauma (like motor vehicle accidents) is sudden hyperextension combined with axial loading.

Question 598

Topic: Cervical Spine

An open-mouth odontoid radiograph of a trauma patient shows a C1 burst fracture (Jefferson fracture). The sum of the lateral mass overhang of C1 on C2 is measured at 8 mm. According to the Rule of Spence, this finding specifically indicates incompetence of which of the following structures?

. Alar ligament
. Apical ligament
. Transverse ligament
. Posterior longitudinal ligament
. Tectorial membrane

Correct Answer & Explanation

. Transverse ligament

Explanation

The Rule of Spence dictates that if the total overhang of the C1 lateral masses on C2 exceeds 6.9 mm on an AP radiograph, it implies a rupture of the transverse ligament. This indicates an unstable injury requiring rigid immobilization or surgery.

Question 599

Topic: 6. Spine

A patient presenting with neurogenic shock following a severe cervical spine injury will classically exhibit which of the following hemodynamic profiles?

. Hypotension and tachycardia
. Hypertension and bradycardia
. Hypotension and bradycardia
. Hypertension and tachycardia
. Normotension and bradycardia

Correct Answer & Explanation

. Hypotension and bradycardia

Explanation

Neurogenic shock is caused by a loss of sympathetic tone following high spinal cord injury. This results in unopposed vagal tone, classically presenting with hypotension and bradycardia, differentiating it from hypovolemic shock (hypotension/tachycardia).

Question 600

Topic: Cervical Spine

A right-sided anterior cervical approach is utilized for a C6-C7 ACDF. The recurrent laryngeal nerve is at risk. What is the anatomic rationale for the right recurrent laryngeal nerve being more susceptible to injury in the lower neck than the left?

. It loops under the aortic arch
. It loops under the right subclavian artery and ascends more obliquely in the neck
. It is located within the carotid sheath on the right
. It crosses anterior to the thyroid gland
. It runs superficial to the platysma

Correct Answer & Explanation

. It loops under the right subclavian artery and ascends more obliquely in the neck

Explanation

The left recurrent laryngeal nerve loops safely under the aortic arch and ascends vertically in the tracheoesophageal groove. The right nerve loops under the right subclavian artery and ascends more obliquely, making it more variable and susceptible to injury during lower cervical approaches.

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