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6. Spine MCQs

Practice Set 300 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 5981

Topic: 6. Spine

A 70-year-old male with chronic lumbar radiculopathy due to severe spinal stenosis undergoes a lumbar laminectomy. Postoperatively, he develops a cerebrospinal fluid (CSF) leak from the surgical site. Which of the following is the most appropriate immediate management strategy?

. Conservative management with bed rest, head elevation, and local wound care.
. Immediate surgical exploration and direct repair of the dural defect.
. Placement of a lumbar drain to reduce CSF pressure.
. Prescription of oral antibiotics to prevent meningitis.
. Application of a rigid lumbar orthosis.

Correct Answer & Explanation

. Conservative management with bed rest, head elevation, and local wound care.

Explanation

Small, iatrogenic cerebrospinal fluid (CSF) leaks (durotomies) following lumbar spine surgery are common. Themost appropriate initial managementfor an uncomplicated, small CSF leak without signs of infection or neurological deficit is typically conservative: bed rest (often flat or Trendelenburg to reduce CSF pressure at the leak site), head elevation for other types of leaks, and close observation. Many small leaks seal spontaneously. Surgical exploration is reserved for large leaks, those failing conservative management, or those with significant neurological compromise or persistent wound drainage. A lumbar drain might be used as an adjunct to conservative care or before re-operation but is not always the first step. Antibiotics are not routinely given unless there's an infection. Bracing is generally not specific for CSF leaks.

Question 5982

Topic: 6. Spine

A 60-year-old active male is diagnosed with a small, contained lumbar disc herniation (L4-L5) causing chronic L5 radiculopathy. He has failed extensive conservative management including physical therapy and epidural steroid injections. Which of the following surgical procedures is generally considered the gold standard for treating this condition?

. Lumbar fusion (TLIF/PLIF).
. Total disc replacement.
. Minimally invasive microdiscectomy.
. Laminectomy with facetectomy.
. Percutaneous nucleoplasty.

Correct Answer & Explanation

. Minimally invasive microdiscectomy.

Explanation

For a contained lumbar disc herniation causing radiculopathy that has failed conservative management, minimally invasive microdiscectomy is considered the gold standard. It is a highly effective procedure for decompressing the nerve root, offering high success rates, rapid recovery, and minimal tissue disruption. Lumbar fusion is reserved for instability or severe degenerative conditions. Total disc replacement is for specific cases of discogenic pain without significant facet arthritis. Laminectomy with facetectomy is typically for more extensive stenosis. Percutaneous nucleoplasty has limited indications and less robust efficacy for significant herniations.

Question 5983

Topic: 6. Spine

A 68-year-old male with long-standing rheumatoid arthritis presents with progressive cervical myelopathy and signs of atlantoaxial instability. Which of the following radiological findings is the most critical for surgical planning of cervical fusion?

. Increased signal intensity on T2-weighted MRI of the spinal cord.
. Presence of a pannus behind the odontoid process.
. Measurement of the Atlanatodental Interval (ADI) on flexion/extension views.
. Degenerative changes at the C3-C4 level.
. Presence of a subaxial kyphosis.

Correct Answer & Explanation

. Measurement of the Atlanatodental Interval (ADI) on flexion/extension views.

Explanation

In patients with rheumatoid arthritis and suspected atlantoaxial instability, the Atlanatodental Interval (ADI) on flexion/extension radiographs (or dynamic CT/MRI) is the most critical measurement. An ADI >3 mm (in adults) or >5 mm (in children) indicates instability of the atlantoaxial joint and can necessitate surgical fusion, especially if accompanied by neurological symptoms. While T2 signal changes indicate myelopathy and pannus formation is characteristic of RA, the ADI directly quantifies the instability requiring surgical intervention. Subaxial kyphosis and C3-C4 degeneration are important but not as critical for atlantoaxial instability specifically.

Question 5984

Topic: 6. Spine

What is the primary goal of surgical management for an unstable thoracolumbar burst fracture with neurological deficit?

. Early ambulation.
. Pain relief.
. Decompression of neural elements and stabilization of the spinal column.
. Prevention of kyphosis.
. Minimizing blood loss.

Correct Answer & Explanation

. Decompression of neural elements and stabilization of the spinal column.

Explanation

For an unstable thoracolumbar burst fracture with neurological deficit, the primary surgical goals are to decompress the neural elements (spinal cord or cauda equina) that are compromised by retropulsed bone fragments or disc material, and to stabilize the spinal column to prevent further injury and allow for neurological recovery. While early ambulation, pain relief, and prevention of kyphosis are important secondary goals, and minimizing blood loss is a surgical principle, they are not the primary aims of the surgery itself in this specific context of instability and neurological compromise.

Question 5985

Topic: Thoracolumbar Spine & Deformity

Which type of scoliosis typically presents in adolescence, has no identifiable cause, and is the most common form?

. Congenital scoliosis.
. Neuromuscular scoliosis.
. Syndromic scoliosis.
. Adolescent idiopathic scoliosis.
. Degenerative scoliosis.

Correct Answer & Explanation

. Adolescent idiopathic scoliosis.

Explanation

Adolescent idiopathic scoliosis (AIS) is the most common type of scoliosis, affecting approximately 2-3% of adolescents. It typically presents in children aged 10-18 years, progresses during growth spurts, and has no identifiable underlying cause. Congenital scoliosis is due to vertebral anomalies. Neuromuscular scoliosis is associated with neurological conditions (e.g., cerebral palsy). Syndromic scoliosis is associated with specific syndromes. Degenerative scoliosis occurs in older adults due to spinal degeneration.

Question 5986

Topic: 6. Spine

A 60-year-old male with chronic low back pain and bilateral leg pain, worse with standing and walking, and relieved by sitting or leaning forward (shopping cart sign), most likely has which of the following conditions?

. Lumbar disc herniation.
. Spondylolisthesis.
. Lumbar spinal stenosis.
. Sacroiliac joint dysfunction.
. Piriformis syndrome.

Correct Answer & Explanation

. Lumbar spinal stenosis.

Explanation

The classic symptoms of neurogenic claudication, including bilateral leg pain worse with standing and walking, and relieved by sitting or leaning forward (the 'shopping cart sign'), are highly suggestive of lumbar spinal stenosis. This condition involves narrowing of the spinal canal, compressing the cauda equina. Lumbar disc herniation typically causes more acute radicular pain, often unilateral. Spondylolisthesis can cause back and leg pain but the claudication pattern is distinct to stenosis. Sacroiliac joint dysfunction causes localized buttock pain. Piriformis syndrome causes sciatic-like pain but usually without the classic claudication pattern.

Question 5987

Topic: 6. Spine

What is the primary indication for surgical intervention in patients with a herniated lumbar disc?

. Chronic low back pain lasting more than 6 months.
. Failed conservative management for at least 6 weeks.
. Radiographic evidence of disc herniation, regardless of symptoms.
. Progressive neurological deficit (e.g., motor weakness, cauda equina syndrome).
. Patients requesting immediate pain relief.

Correct Answer & Explanation

. Progressive neurological deficit (e.g., motor weakness, cauda equina syndrome).

Explanation

The primary indication for urgent surgical intervention in patients with a herniated lumbar disc is the presence of a progressive neurological deficit, especially cauda equina syndrome (bowel/bladder dysfunction, saddle anesthesia, bilateral leg weakness). While failed conservative management (typically 6-12 weeks) is a common indication for elective surgery, it is not the most urgent. Chronic back pain alone is not a surgical indication for disc herniation. Radiographic evidence without correlating symptoms is insufficient.

Question 5988

Topic: 6. Spine

Which of the following is a contraindication for an MRI in a patient with suspected spinal cord injury?

. Pregnancy.
. Presence of a pacemaker or certain metallic implants.
. Claustrophobia.
. Renal insufficiency.
. Obesity.

Correct Answer & Explanation

. Presence of a pacemaker or certain metallic implants.

Explanation

The presence of a pacemaker or certain ferrous metallic implants (e.g., older aneurysm clips, some shrapnel) is an absolute contraindication to MRI due to the strong magnetic field, which can interfere with device function or cause movement/heating of the metallic object. While pregnancy, claustrophobia, renal insufficiency (relevant for contrast), and obesity can be challenges, they are not absolute contraindications that preclude the MRI if critically indicated for spinal cord injury.

Question 5989

Topic: Cervical Spine
What is the most appropriate initial management for a stable type I odontoid fracture?
. Emergent surgical fixation.
. Halo vest immobilization.
. Soft cervical collar for 6 weeks.
. Traction.
. Atlantoaxial fusion.

Correct Answer & Explanation

. Soft cervical collar for 6 weeks.

Explanation

A Type I odontoid fracture is an oblique fracture of the odontoid tip, which is typically stable. It usually heals well with non-operative management, often with a rigid cervical collar (like a Miami J or Philadelphia collar) for 6-12 weeks. Halo vest immobilization or surgical fixation are generally reserved for more unstable Type II or Type III odontoid fractures. Traction is not indicated, and atlantoaxial fusion is a definitive surgical treatment for instability, not initial management for a stable Type I.

Question 5990

Topic: 6. Spine
In the context of spinal cord injury, what is Brown-Séquard syndrome characterized by?
. Complete loss of motor and sensory function below the level of injury.
. Loss of motor function with preservation of sensation.
. Loss of proprioception and vibratory sense ipsilaterally, with loss of pain and temperature contralaterally.
. Loss of pain and temperature below the level of injury, with preservation of proprioception and motor function.
. Flaccid paralysis and areflexia below the level of injury.

Correct Answer & Explanation

. Loss of proprioception and vibratory sense ipsilaterally, with loss of pain and temperature contralaterally.

Explanation

Brown-Séquard syndrome results from hemisection of the spinal cord (e.g., due to penetrating trauma). It is characterized by ipsilateral loss of motor function, proprioception, and vibratory sense (due to corticospinal and dorsal column pathway damage), and contralateral loss of pain and temperature sensation (due to spinothalamic tract damage), typically 1-2 levels below the lesion. Complete loss of function is complete cord injury. Loss of motor with preserved sensation is anterior cord syndrome. Flaccid paralysis is spinal shock or cauda equina. Loss of pain/temp with preserved motor/proprioception can be central cord syndrome if only crossing fibers are affected or pure spinothalamic lesion.

Question 5991

Topic: 6. Spine

A patient presents with persistent symptoms of cervical radiculopathy (C6 distribution) despite 8 weeks of conservative management including physical therapy, NSAIDs, and epidural steroid injections. MRI shows a large C5-C6 soft disc herniation. Which surgical procedure is typically considered the gold standard for this condition?

. Posterior cervical laminectomy.
. Anterior cervical discectomy and fusion (ACDF).
. Cervical laminoplasty.
. Posterior cervical foraminotomy.
. Artificial disc replacement.

Correct Answer & Explanation

. Anterior cervical discectomy and fusion (ACDF).

Explanation

For cervical radiculopathy caused by a soft disc herniation that has failed conservative management, anterior cervical discectomy and fusion (ACDF) is widely considered the gold standard. It involves removing the herniated disc and fusing the vertebrae, providing excellent decompression and stability. Posterior laminectomy is more for myelopathy or diffuse stenosis. Laminoplasty is for multi-level stenosis. Posterior foraminotomy is for lateral foraminal stenosis. Artificial disc replacement is an alternative to fusion for select cases, but ACDF remains the most common and established approach.

Question 5992

Topic: 6. Spine
In the context of the spine, what is the 'Hangman's fracture'?
. A fracture of the odontoid process.
. A bilateral pedicle fracture of C2.
. A burst fracture of C1.
. A fracture of the body of C7.
. An avulsion fracture of the spinous process of C6.

Correct Answer & Explanation

. A bilateral pedicle fracture of C2.

Explanation

A 'Hangman's fracture' is a traumatic spondylolisthesis of the axis (C2), specifically a bilateral fracture of the C2 pars interarticularis (pedicles). It typically occurs from hyperextension and distraction injuries. Odontoid fractures are Type I, II, or III. A burst fracture of C1 is a Jefferson fracture. The other options describe different, less specific cervical spine injuries.

Question 5993

Topic: 6. Spine

An orthopedic patient who recently underwent spine surgery is found to have a small Richter hernia at a trocar site. What is the orthopedic surgeon's primary role in managing this acute abdominal issue?

. Manage the patient's pain until a general surgeon is available.
. Perform a bedside reduction of the hernia.
. Order imaging to confirm the diagnosis and assess viability.
. Facilitate urgent consultation with a general surgeon and assist in coordinating care.
. Advise the patient to monitor symptoms closely.

Correct Answer & Explanation

. Facilitate urgent consultation with a general surgeon and assist in coordinating care.

Explanation

The orthopedic surgeon's primary role in managing this acute abdominal issue is to facilitate urgent consultation with a general surgeon and assist in coordinating care. While managing pain and ordering imaging might be initial steps, the ultimate definitive management (diagnosis confirmation, assessment of viability, and surgical repair) falls within the expertise of a general surgeon for a Richter hernia. The orthopedic surgeon's role is to promptly recognize the potential surgical emergency and ensure the patient receives appropriate specialized care without delay, while also integrating this into the overall orthopedic recovery plan.

Question 5994

Topic: 6. Spine

What is the most common site of metastatic bone disease in the spine?

. Cervical spine
. Thoracic spine
. Lumbar spine
. Sacrum
. Coccyx

Correct Answer & Explanation

. Thoracic spine

Explanation

The thoracic spine is the most common site for metastatic bone disease in the spine, accounting for about 60-70% of spinal metastases. This is followed by the lumbar spine (20-25%) and then the cervical spine (10-15%). The rich vascularity of the thoracic vertebral bodies and their proximity to the venous plexus of Batson contribute to this predilection.

Question 5995

Topic: 6. Spine

What is the appropriate management for a stable burst fracture of the thoracolumbar spine with no neurological deficit?

. Emergent surgical decompression and fusion
. Posterior instrumentation and fusion
. Anterior corpectomy and fusion
. Non-operative management with brace immobilization
. Vertebroplasty or kyphoplasty

Correct Answer & Explanation

. Non-operative management with brace immobilization

Explanation

For a stable burst fracture of the thoracolumbar spine without neurological deficit, non-operative management with brace immobilization (e.g., thoracolumbosacral orthosis, TLSO) is often the preferred treatment. Surgical intervention is typically reserved for unstable fractures, those with neurological deficits, or significant kyphosis. Vertebroplasty or kyphoplasty are mainly used for osteoporotic compression fractures, not acute traumatic burst fractures. Emergent surgical decompression and fusion are for unstable fractures with neurological compromise.

Question 5996

Topic: 6. Spine

Which of the following conditions is most commonly associated with a 'double bubble' sign on prenatal ultrasound?

. VATER syndrome
. Duodenal atresia
. Hirschsprung's disease
. Meckel's diverticulum
. Pyloric stenosis

Correct Answer & Explanation

. Duodenal atresia

Explanation

The 'double bubble' sign on prenatal ultrasound is pathognomonic for duodenal atresia, representing a dilated stomach and a dilated proximal duodenum separated by the pylorus. While duodenal atresia can be associated with Down syndrome (Trisomy 21), it is the direct cause of the radiological sign. VATER syndrome is a broader association of anomalies. Hirschsprung's disease affects the large intestine. Meckel's diverticulum is a congenital anomaly of the small intestine that does not typically present with this sign. Pyloric stenosis is an acquired condition of infancy, not typically a prenatal finding, and causes gastric outlet obstruction but not a 'double bubble' sign.

Question 5997

Topic: 6. Spine

Which of the following best describes a typical presentation of a patient with spinal stenosis due to degenerative changes?

. Acute, severe radicular pain exacerbated by rest and relieved by activity.
. Gradual onset of bilateral leg pain, numbness, and weakness, worsened by standing and walking, relieved by sitting or leaning forward.
. Sudden onset of unilateral leg weakness, foot drop, and bowel/bladder incontinence.
. Localized back pain with morning stiffness, improving with activity.
. Severe back pain radiating to the buttock, relieved by lying flat.

Correct Answer & Explanation

. Gradual onset of bilateral leg pain, numbness, and weakness, worsened by standing and walking, relieved by sitting or leaning forward.

Explanation

Spinal stenosis typically presents with neurogenic claudication: bilateral leg pain, numbness, and weakness that is worsened by extension of the spine (standing, walking) and relieved by flexion (sitting, leaning forward, bicycling). This is often described as the 'shopping cart' sign. Acute radicular pain, especially worse at rest, is more indicative of disc herniation. Cauda equina syndrome involves acute bilateral neurological deficits and bowel/bladder dysfunction. Morning stiffness relieved by activity points towards inflammatory arthritis. Sciatica relieved by lying flat is common in disc herniations but not specific to stenosis.

Question 5998

Topic: 6. Spine
A 6-year-old boy presents with painless scoliosis. On examination, a café-au-lait spot is noted on his back, and axillary freckling is present. Which of the following conditions should be strongly suspected?
. Adolescent idiopathic scoliosis
. Congenital scoliosis
. Marfan syndrome
. Neurofibromatosis type 1 (NF1)
. Spinal muscular atrophy

Correct Answer & Explanation

. Neurofibromatosis type 1 (NF1)

Explanation

The presence of café-au-lait spots and axillary freckling (Crowe's sign) in a child with scoliosis is pathognomonic for Neurofibromatosis type 1 (NF1). The scoliosis associated with NF1 can be dystrophic (short-segment, sharply angulated) or non-dystrophic. Adolescent idiopathic scoliosis usually presents later and without these skin stigmata. Congenital scoliosis is due to vertebral anomalies and may have other associated findings but not typically NF1 skin signs. Marfan syndrome has a different phenotype (tall stature, arachnodactyly, lens subluxation, aortic root dilation). Spinal muscular atrophy is a neuromuscular condition causing muscle weakness and often scoliosis, but without the specific skin findings of NF1.

Question 5999

Topic: 6. Spine

A 55-year-old construction worker presents with chronic low back pain radiating into his right buttock and posterior thigh. He denies motor weakness or bowel/bladder dysfunction. His symptoms are worse with prolonged sitting and lifting. Physical examination reveals tenderness over the right sacroiliac joint and a positive Gaenslen's test. What is the most likely diagnosis?

. Lumbar disc herniation
. Piriformis syndrome
. Sacroiliac joint dysfunction
. Facet arthropathy
. Lumbar spinal stenosis

Correct Answer & Explanation

. Sacroiliac joint dysfunction

Explanation

The patient's symptoms (chronic low back pain radiating to the buttock/thigh, worse with prolonged sitting/lifting) and physical exam findings (tenderness over the SI joint, positive Gaenslen's test) are highly suggestive of sacroiliac joint dysfunction. Lumbar disc herniation typically presents with more distinct radicular pain down the leg, often with neurological deficits, and positive straight leg raise. Piriformis syndrome causes sciatic-like pain but is due to sciatic nerve compression by the piriformis muscle. Facet arthropathy causes localized back pain, sometimes with referred pain, but usually without specific SI joint findings. Lumbar spinal stenosis causes neurogenic claudication worsened by standing/walking.

Question 6000

Topic: Thoracolumbar Spine & Deformity

Regarding adult spondylolisthesis, which type is most commonly observed in patients over 50 years old?

. Dysplastic (congenital)
. Isthmic (spondylolytic)
. Degenerative
. Traumatic
. Pathologic

Correct Answer & Explanation

. Degenerative

Explanation

Degenerative spondylolisthesis is the most common type observed in patients over 50 years old. It results from chronic degenerative changes in the facet joints and intervertebral disc, leading to segmental instability and anterior slippage of one vertebra over another, most commonly at L4-L5. Isthmic spondylolisthesis, caused by a defect in the pars interarticularis (spondylolysis), is more common in younger individuals and athletes. Dysplastic is congenital, traumatic is due to acute injury, and pathologic is associated with tumors or metabolic bone disease.

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