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6. Spine MCQs

Practice Set 301 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 6001

Topic: 6. Spine

In the context of the cervical spine, which of the following is a classic finding of C5 radiculopathy?

. Weakness in wrist extension and paresthesias in the middle finger.
. Weakness in shoulder abduction and external rotation, with sensory loss over the deltoid region.
. Weakness in elbow flexion and wrist pronation, with sensory loss over the thumb.
. Weakness in triceps extension, with sensory loss over the little finger.
. Weakness in hand intrinsics and sensory loss over the medial forearm.

Correct Answer & Explanation

. Weakness in shoulder abduction and external rotation, with sensory loss over the deltoid region.

Explanation

C5 radiculopathy typically affects the deltoid and biceps muscles. Therefore, weakness in shoulder abduction (deltoid) and external rotation (infraspinatus, teres minor) is common. Sensory loss is typically over the lateral shoulder/deltoid region. C6 radiculopathy involves wrist extension, biceps, and sensation in the thumb/index finger. C7 involves triceps, wrist flexion, and sensation in the middle finger. C8 involves finger flexion and hand intrinsics, with sensation in the little finger. T1 involves hand intrinsics and sensation in the medial forearm.

Question 6002

Topic: 6. Spine

In the surgical management of adolescent idiopathic scoliosis, which of the following is considered the most important factor for achieving a balanced spine in the coronal plane?

. Achieving maximum correction of the primary curve.
. Balancing the upper instrumented vertebra (UIV) with the lower instrumented vertebra (LIV).
. Selecting the appropriate length of fusion.
. Correcting the rib hump deformity.
. Restoring sagittal balance.

Correct Answer & Explanation

. Balancing the upper instrumented vertebra (UIV) with the lower instrumented vertebra (LIV).

Explanation

In adolescent idiopathic scoliosis, achieving a balanced spine in the coronal plane critically depends on balancing the upper instrumented vertebra (UIV) and the lower instrumented vertebra (LIV). The UIV should be centered over the sacrum, and the LIV should be stable and neutral. While maximizing correction is a goal, overcorrection can lead to imbalance. Selecting the appropriate length of fusion is intertwined with UIV/LIV selection. Correcting the rib hump is a cosmetic goal, and restoring sagittal balance is another critical, but distinct, aspect of spinal deformity correction. Proper UIV/LIV selection ensures the spine remains centered over the pelvis, preventing truncal shift.

Question 6003

Topic: 6. Spine

A 40-year-old male with chronic low back pain reports worsening symptoms with prolonged standing and walking, associated with a burning sensation in his calves. He states he gets relief when he sits down or leans forward over a shopping cart. Neurological examination is unremarkable. Which diagnostic imaging study is most appropriate for initial evaluation?

. Plain radiographs of the lumbar spine
. MRI of the lumbar spine
. CT scan of the lumbar spine
. Electromyography (EMG) and nerve conduction studies (NCS)
. Bone scan

Correct Answer & Explanation

. MRI of the lumbar spine

Explanation

The patient's symptoms are highly classic for neurogenic claudication, characteristic of lumbar spinal stenosis. While plain radiographs can show degenerative changes, an MRI of the lumbar spine is the gold standard for visualizing soft tissue structures, including the intervertebral discs, ligaments, and neural elements within the spinal canal, which are crucial for diagnosing spinal stenosis. A CT scan is excellent for bone detail but less so for soft tissue. EMG/NCS evaluates nerve function but is not the primary imaging for stenosis diagnosis. A bone scan would be more appropriate for infection, tumor, or stress fracture.

Question 6004

Topic: Thoracolumbar Spine & Deformity

Regarding idiopathic scoliosis, which finding on physical examination warrants the most concern for a non-idiopathic (e.g., congenital or neurological) etiology?

. Left thoracic curve
. Rib hump on forward bend test
. Progressive curve magnitude
. Normal neurological exam
. Associated leg length discrepancy

Correct Answer & Explanation

. Left thoracic curve

Explanation

A left thoracic curve is highly atypical for idiopathic scoliosis, which is overwhelmingly characterized by right thoracic curves. A left thoracic curve should prompt a thorough workup to rule out an underlying neurological (e.g., syrinx, tethered cord) or congenital cause. A rib hump is a common finding in idiopathic scoliosis. Progressive curve magnitude is a feature, not a differentiator from idiopathic. A normal neurological exam supports idiopathic. Leg length discrepancy can cause compensatory scoliosis, but the curve morphology (left thoracic) is a stronger indicator of non-idiopathic origin.

Question 6005

Topic: Cervical Spine

In a patient with a stable C2 odontoid type II fracture, which of the following treatment options is generally preferred in a younger, active patient?

. Halo vest immobilization
. Transarticular screw fixation (C1-C2)
. Anterior odontoid screw fixation
. Posterior C1-C2 fusion
. Soft cervical collar

Correct Answer & Explanation

. Anterior odontoid screw fixation

Explanation

For a stable C2 odontoid type II fracture, anterior odontoid screw fixation is often preferred in a younger, active patient. It allows for direct fixation of the fracture, preserves C1-C2 rotation, and avoids the need for prolonged external immobilization (halo vest), which can be uncomfortable and associated with complications. Halo vest immobilization has a higher nonunion rate and often prolonged discomfort. Transarticular screw fixation or posterior C1-C2 fusion are options, but they sacrifice C1-C2 rotation, which anterior odontoid screw fixation preserves. A soft cervical collar is inadequate for an odontoid fracture.

Question 6006

Topic: 6. Spine

A 30-year-old male is brought to the trauma center after a diving accident. He is intubated, sedated, and paralyzed on arrival. Lateral cervical radiographs reveal a bilateral facet dislocation at C5-C6 with 50% anterior subluxation. His hemodynamic status is stable. What is the most appropriate next step in the management of his cervical spine injury?

. Awake closed traction reduction using Gardner-Wells tongs
. Magnetic Resonance Imaging (MRI) of the cervical spine
. Immediate anterior cervical discectomy and fusion (ACDF)
. Immediate posterior cervical instrumented fusion
. Computed Tomography (CT) myelogram

Correct Answer & Explanation

. Magnetic Resonance Imaging (MRI) of the cervical spine

Explanation

In a patient with a cervical facet dislocation who cannot participate in a reliable neurologic examination (e.g., intubated, comatose, or paralyzed), an MRI of the cervical spine must be obtained before any reduction attempts (closed or open). This is to evaluate for a concurrent cervical disc herniation, which occurs in up to 50% of facet dislocations. Reducing the spine without removing a herniated disc can draw the disc material into the spinal canal, leading to an iatrogenic spinal cord injury. If the patient were awake and cooperative, an awake closed traction reduction with serial neurologic exams would be indicated.

Question 6007

Topic: 6. Spine

A 35-year-old male is brought in following a severe motor vehicle collision. He is intubated, sedated, and obtunded upon arrival. Radiographs and CT of the cervical spine reveal a bilateral facet dislocation at C5-C6. What is the most appropriate next step in the management of his cervical spine injury prior to attempted reduction?

. Immediate placement of cranial tongs and awake traction
. Closed cranial traction reduction under general anesthesia
. Immediate anterior cervical discectomy and fusion (ACDF) without prior imaging
. Magnetic Resonance Imaging (MRI) of the cervical spine
. Immediate posterior spinal fusion

Correct Answer & Explanation

. Magnetic Resonance Imaging (MRI) of the cervical spine

Explanation

In an obtunded or unexaminable patient with a cervical facet dislocation, an MRI of the cervical spine is mandatory prior to any reduction maneuvers (closed or open). This is to evaluate for a herniated cervical disc, which could be drawn into the spinal canal during reduction, leading to catastrophic spinal cord transection. Awake, neurologically intact patients can undergo closed traction reduction prior to MRI.

Question 6008

Topic: 6. Spine
A 25-year-old male is evaluated in the trauma bay after a high-speed rollover collision. Lateral cervical spine radiography reveals a Basion-Dental Interval (BDI) of 14 mm. Based on this diagnosis, which of the following interventions is strictly CONTRAINDICATED in the immediate management of this patient?
. Placement of a rigid cervical collar
. Cervical traction
. Intubation using manual in-line stabilization
. Administration of high-dose steroids
. Magnetic Resonance Imaging (MRI)

Correct Answer & Explanation

. Cervical traction

Explanation

A Basion-Dental Interval (BDI) > 12 mm is diagnostic of occipitocervical dissociation (craniocervical dissociation), a highly unstable injury disrupting the tectorial membrane and alar ligaments. Cervical traction is absolutely contraindicated as it can cause fatal over-distraction, leading to severe brainstem and spinal cord stretch injuries. Initial management includes rigid cervical collar immobilization followed by definitive occipitocervical fusion.

Question 6009

Topic: 6. Spine

Which of the following physical examination findings is a manifestation of upper motor neuron involvement, commonly seen in cervical spondylotic myelopathy?

. Atrophy of the intrinsic hand muscles
. Decreased biceps reflex
. Positive Lhermitte's sign
. Positive Hoffmann's sign
. Fasciculations in the deltoid muscle

Correct Answer & Explanation

. Positive Hoffmann's sign

Explanation

Hoffmann's sign is a classic upper motor neuron (UMN) sign indicating cervical cord compression (myelopathy). Lhermitte's sign indicates dorsal column irritation. Atrophy, hyporeflexia, and fasciculations are signs of lower motor neuron (LMN) or nerve root involvement.

Question 6010

Topic: 6. Spine

A 28-year-old male sustains a severe cervical spine fracture with complete cord transection at C5. In the trauma bay, he is hypotensive (80/50 mmHg) and bradycardic (48 bpm). Which of the following best explains this physiologic state?

. Hemorrhagic shock due to concomitant visceral organ injury
. Loss of sympathetic vascular tone resulting in neurogenic shock
. Transient physiological cord dysfunction known as spinal shock
. Cardiogenic shock secondary to unrecognized blunt cardiac injury
. Vagal nerve transection leading to unopposed parasympathetic tone

Correct Answer & Explanation

. Loss of sympathetic vascular tone resulting in neurogenic shock

Explanation

Neurogenic shock occurs due to the loss of sympathetic outflow in spinal cord lesions above T6. This results in unopposed parasympathetic tone, characteristically manifesting as hypotension paired with bradycardia.

Question 6011

Topic: 6. Spine

A trauma patient arrives with a cervical spine fracture. He is hypotensive, bradycardic, and has warm, flushed extremities. Which of the following is the most likely diagnosis?

. Hypovolemic shock
. Cardiogenic shock
. Spinal shock
. Neurogenic shock
. Septic shock

Correct Answer & Explanation

. Neurogenic shock

Explanation

Neurogenic shock is characterized by hypotension and bradycardia due to the loss of sympathetic tone following a high spinal cord injury. This differs from spinal shock, which refers to the temporary areflexia and flaccidity below the level of injury.

Question 6012

Topic: 6. Spine

A 45-year-old male is undergoing a posterolateral lumbar fusion at L4-L5. During the exposure, the surgeon identifies the mamillo-accessory ligament. Which of the following neural structures passes beneath this ligament and is at risk of iatrogenic injury during local dissection?

. The ventral ramus of the spinal nerve
. The dorsal root ganglion
. The medial branch of the dorsal primary ramus
. The recurrent meningeal nerve (sinuvertebral nerve)
. The lateral branch of the ventral primary ramus

Correct Answer & Explanation

. The medial branch of the dorsal primary ramus

Explanation

The medial branch of the dorsal primary ramus provides vital innervation to the facet joints and the deep multifidus muscles. At the lumbar spine level, this nerve travels through an osseo-fibrous tunnel formed by the mamillo-accessory ligament (running between the mamillary process and the accessory process). Knowledge of this anatomy is critical for surgical exposure and radiofrequency ablation procedures.

Question 6013

Topic: 6. Spine

A 50-year-old male presents with severe lower back pain radiating down both legs. Which of the following clinical findings is considered the most sensitive for the diagnosis of cauda equina syndrome?

. Saddle anesthesia
. Decreased anal sphincter tone
. Urinary retention
. Bilateral foot drop
. Loss of the Achilles reflex

Correct Answer & Explanation

. Urinary retention

Explanation

Urinary retention is the most sensitive symptom (sensitivity of ~90%) for the diagnosis of cauda equina syndrome. If a patient does not have urinary retention (which leads to overflow incontinence), the diagnosis of complete cauda equina syndrome is highly unlikely. A post-void residual > 100-200 mL is often used as a clinical threshold to assess for this finding.

Question 6014

Topic: 6. Spine

A patient with acute spinal cord injury presents with flaccid paralysis, absent reflexes, and no autonomic tone below the level of the injury. The definitive clinical indicator that the patient has emerged from the phase of 'spinal shock' is the return of which of the following?

. Normal blood pressure and heart rate.
. Deep tendon reflexes in the lower extremities.
. The bulbocavernosus reflex.
. Voluntary anal sphincter contraction.
. Pain and temperature sensation below the injury level.

Correct Answer & Explanation

. The bulbocavernosus reflex.

Explanation

Spinal shock is a temporary physiological state characterized by flaccidity and loss of reflexes below the level of a spinal cord injury. The hallmark of the end of spinal shock is the return of the bulbocavernosus reflex. Until this reflex returns, a true assessment of the completeness of the spinal cord injury cannot be fully determined.

Question 6015

Topic: 6. Spine

In patients with cervical spondylotic myelopathy (CSM), direct compression and subsequent ischemia contribute to progressive spinal cord dysfunction. Which vascular structure is most susceptible to direct compression from anterior disc osteophyte complexes, leading to ischemia of the lateral corticospinal tracts?

. Posterior spinal arteries
. Anterior spinal artery
. Artery of Adamkiewicz
. Radicular arteries in the neural foramen
. Pial plexus

Correct Answer & Explanation

. Anterior spinal artery

Explanation

The anterior spinal artery supplies the anterior two-thirds of the spinal cord, including the lateral corticospinal tracts and anterior horn cells. In CSM, anterior compression from disc osteophyte complexes directly impinges upon this artery, causing focal ischemia that contributes heavily to myelopathic symptoms.

Question 6016

Topic: 6. Spine

A 24-year-old male sustains a burst fracture of C5. On examination, he has no voluntary motor function below the C5 level. However, he has preserved pinprick and light touch sensation in the S4-S5 dermatomes, as well as deep anal pressure. What is his ASIA Impairment Scale (AIS) grade?

. ASIA A
. ASIA B
. ASIA C
. ASIA D
. ASIA E

Correct Answer & Explanation

. ASIA B

Explanation

ASIA B describes a sensory incomplete spinal cord injury where sensory function (but not motor function) is preserved below the neurological level and must include the sacral segments S4-S5. ASIA A is a complete injury. ASIA C and D are motor incomplete injuries differentiated by muscle strength.

Question 6017

Topic: 6. Spine

A 68-year-old male with pre-existing cervical spondylosis presents after a hyperextension injury. He exhibits significant weakness in his bilateral hands and arms, with relative sparing of his lower extremities. Sensation is variably diminished. This clinical presentation is best explained by injury to which aspect of the spinal cord?

. Anterior horn cells at the lumbar level
. Central grey matter and medial aspects of the corticospinal tracts
. Posterior columns exclusively
. Spinothalamic tracts in the lateral funiculus
. Complete transverse section of the cord

Correct Answer & Explanation

. Central grey matter and medial aspects of the corticospinal tracts

Explanation

This is Central Cord Syndrome, the most common incomplete spinal cord injury pattern. It typically occurs in older patients with spondylosis who suffer a hyperextension injury. Damage to the central grey matter and the medial aspect of the corticospinal tracts (which carry cervical motor fibers) leads to upper extremity weakness being far greater than lower extremity weakness.

Question 6018

Topic: 6. Spine

During the physical examination of a 62-year-old male with suspected cervical spondylotic myelopathy, you sharply flick the distal phalanx of the middle finger into flexion. In response, you observe reflex flexion of the patient's thumb and index finger. What is the name of this pathologic reflex?

. Babinski sign
. Oppenheim reflex
. Hoffmann sign
. Wartenberg sign
. Lhermitte's sign

Correct Answer & Explanation

. Hoffmann sign

Explanation

The Hoffmann sign is elicited by flicking the distal phalanx of the middle finger, resulting in reflex flexion of the thumb and index finger. It indicates upper motor neuron dysfunction and is a classic finding in cervical myelopathy.

Question 6019

Topic: 6. Spine

A 65-year-old man presents with progressive clumsiness in his hands, difficulty buttoning his shirt, and a wide-based gait. Physical examination reveals a positive Hoffmann sign and hyperreflexia in both lower extremities. What is the most sensitive early clinical symptom of this condition?

. Bowel or bladder incontinence
. Loss of fine motor skills and hand clumsiness
. Severe neck pain radiating to the occiput
. Flaccid paralysis of the upper extremities
. Loss of pain and temperature sensation in a cape-like distribution

Correct Answer & Explanation

. Loss of fine motor skills and hand clumsiness

Explanation

The patient has cervical spondylotic myelopathy (CSM). The most sensitive and earliest clinical symptom of CSM is a loss of fine motor skills, often described by patients as clumsiness in their hands or difficulty with tasks like buttoning a shirt or writing.

Question 6020

Topic: 6. Spine

A 35-year-old man is involved in a high-speed motor vehicle collision resulting in a hyperextension-axial loading injury to his cervical spine. Radiographs show bilateral fractures through the pars interarticularis of C2. This injury is best described as which of the following?

. Jefferson fracture
. Hangman's fracture
. Odontoid type II fracture
. Clay shoveler's fracture
. Flexion teardrop fracture

Correct Answer & Explanation

. Hangman's fracture

Explanation

A Hangman's fracture is a traumatic spondylolisthesis of the axis (C2), characterized by bilateral fractures through the pars interarticularis. It is classically caused by a hyperextension and axial loading mechanism.

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