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6. Spine MCQs

Practice Set 307 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 6121

Topic: 6. Spine

A 60-year-old male with severe cervical spinal stenosis exhibits a positive Lhermitte's sign during a physical examination. What specific pathophysiological process does this clinical sign indicate?

. Compression of the anterior horn cells causing lower motor neuron signs.
. Demyelination or irritation of the posterior columns of the spinal cord upon neck flexion.
. Foraminal stenosis causing acute compression of the exiting C6 nerve root.
. Tethering of the C5 nerve root secondary to severe cervical kyphosis.
. Ischemia to the lateral spinothalamic tract resulting in contralateral pain and temperature loss.

Correct Answer & Explanation

. Compression of the anterior horn cells causing lower motor neuron signs.

Explanation

Lhermitte's sign is described as an electric shock-like sensation radiating down the spine or into the extremities, classically triggered by active or passive forward flexion of the neck. It is a sign of cervical myelopathy (or multiple sclerosis) and specifically indicates mechanical irritation or demyelination of the posterior columns (dorsal columns) of the spinal cord, which carry proprioception and vibratory sensation. It is not a sign of radiculopathy (which would present with dermatomal pain, e.g., Spurling's test) or anterior horn cell compression.

Question 6122

Topic: 6. Spine

What was the primary finding of the Spine Patient Outcomes Research Trial (SPORT) regarding degenerative spondylolisthesis treated surgically versus non-surgically?

. Surgery had higher complication rates with no functional difference at 4 years
. Surgery showed significantly improved clinical outcomes and quality of life at 4 years compared to non-operative treatment
. Non-operative treatment was statistically superior to surgical intervention at all time points
. Decompression alone was overwhelmingly superior to decompression with instrumented fusion
. There was no significant difference in outcomes due to a 90% crossover rate between groups

Correct Answer & Explanation

. Surgery had higher complication rates with no functional difference at 4 years

Explanation

The SPORT trial demonstrated that surgical intervention (decompression and fusion) for degenerative spondylolisthesis provided significantly better outcomes in pain and function at 4 years compared to non-operative treatment, despite substantial crossover.

Question 6123

Topic: Cervical Spine

An 82-year-old male sustains a Type II odontoid fracture with 2 mm of posterior displacement after a ground-level fall. He is neurologically intact. Which of the following treatments is associated with the highest survival rate for this specific patient demographic?

. Halo vest immobilization
. Posterior C1-C2 instrumented fusion
. Rigid cervical collar
. Anterior odontoid screw fixation
. Occipitocervical fusion

Correct Answer & Explanation

. Halo vest immobilization

Explanation

In elderly patients (typically over 80 years) with Type II odontoid fractures, rigid cervical collar immobilization is favored as it has the lowest morbidity and highest survival rates. Halo vest immobilization in this age group carries a high risk of respiratory complications and mortality.

Question 6124

Topic: 6. Spine

A 25-year-old male presents with incomplete quadriplegia following a diving accident. Radiographs reveal a C5-C6 bilateral facet dislocation. The patient is awake, alert, and fully cooperative. What is the most appropriate next step in management?

. Immediate MRI of the cervical spine
. Closed reduction with cranial traction
. Open reduction and posterior fusion
. Anterior cervical discectomy and fusion
. Administration of high-dose methylprednisolone

Correct Answer & Explanation

. Immediate MRI of the cervical spine

Explanation

For an awake, alert, and cooperative patient with a cervical facet dislocation and an acute incomplete spinal cord injury, emergent closed reduction with cranial traction is indicated. An MRI should not delay closed reduction in an examinable patient.

Question 6125

Topic: 6. Spine

A 35-year-old male presents with acute back pain radiating to the dorsum of his left foot. Motor testing reveals 4/5 strength in extensor hallucis longus. A central and paracentral disc herniation at L4-L5 is suspected. Which nerve root is most likely affected by this paracentral herniation?

. Traversing L4 root
. Exiting L4 root
. Traversing L5 root
. Exiting L5 root
. Traversing S1 root

Correct Answer & Explanation

. Traversing L4 root

Explanation

In the lumbar spine, a typical paracentral disc herniation compresses the traversing nerve root, which corresponds to the lower vertebral level. Therefore, an L4-L5 paracentral disc herniation affects the traversing L5 root.

Question 6126

Topic: 6. Spine

A 65-year-old male with long-standing ankylosing spondylitis presents with severe neck pain following a minor low-speed motor vehicle collision. Computed tomography reveals a displaced fracture through the C6-C7 disc space. What is the most common associated complication in this patient population that requires urgent evaluation?

. Vertebral artery dissection
. Epidural hematoma
. Esophageal perforation
. Central cord syndrome
. Post-traumatic syringomyelia

Correct Answer & Explanation

. Vertebral artery dissection

Explanation

Patients with ankylosing spondylitis are highly prone to unstable spine fractures even after minor trauma. They have a notably high incidence of associated spinal epidural hematomas, necessitating prompt MRI evaluation.

Question 6127

Topic: 6. Spine

A 4-year-old child presents to the emergency department after a fall. Lateral cervical spine radiographs demonstrate 3 mm of anterior displacement of C2 on C3. Which of the following radiographic lines is most useful to differentiate physiological pseudosubluxation from true traumatic instability?

. Wackenheim clivus line
. McGregor line
. Chamberlain line
. Swischuk line
. Harris ring

Correct Answer & Explanation

. Wackenheim clivus line

Explanation

The Swischuk line (posterior cervical line) is drawn from the anterior aspect of the C1 spinous process to the anterior aspect of the C3 spinous process. If the anterior aspect of the C2 spinous process misses this line by 2 mm or more, it indicates true traumatic instability rather than physiological pseudosubluxation.

Question 6128

Topic: 6. Spine

A 40-year-old female presents with severe low back pain, bilateral lower extremity radicular pain, and altered perineal sensation. Which of the following clinical findings has the highest sensitivity for diagnosing cauda equina syndrome in this setting?

. Decreased anal sphincter tone
. Bilateral absent Achilles reflexes
. Urinary retention
. Fecal incontinence
. Saddle anesthesia

Correct Answer & Explanation

. Decreased anal sphincter tone

Explanation

Urinary retention (often evaluated by a post-void residual volume > 100-200 cc) is the most consistent and sensitive early clinical finding in cauda equina syndrome. Its absence effectively makes cauda equina syndrome highly unlikely.

Question 6129

Topic: 6. Spine
The Spinal Instability Neoplastic Score (SINS) is used to guide the need for surgical stabilization in metastatic spine disease. Which of the following criteria contributes points indicating a higher risk of instability within the SINS scoring system?
. Blastic lesion
. Location in the rigid upper thoracic spine (T3-T10)
. Lytic lesion
. Absence of pain with movement
. Intact posterolateral spinal elements

Correct Answer & Explanation

. Lytic lesion

Explanation

In the SINS classification, lytic lesions (2 points) contribute more to instability than blastic lesions (0 points). Higher scores indicate impending or actual instability, prompting surgical stabilization.

Question 6130

Topic: 6. Spine

A 14-year-old female undergoes surgical treatment for a high-grade dysplastic L5-S1 spondylolisthesis. The surgeon decides to perform an instrumented reduction of the slip prior to fusion. Which nerve root is at the highest risk of iatrogenic injury during the reduction maneuver?

. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L3

Explanation

Reduction of a high-grade L5-S1 spondylolisthesis places the exiting L5 nerve root under significant tension. Iatrogenic L5 radiculopathy is the most common neurologic complication associated with this specific reduction maneuver.

Question 6131

Topic: 6. Spine

A 55-year-old Asian male presents with progressive fine motor clumsiness and an unsteady gait. Imaging reveals continuous ossification of the posterior longitudinal ligament (OPLL) from C3 to C6, with a rigid kyphotic cervical alignment (K-line negative). Which surgical approach is most appropriate?

. Cervical laminoplasty
. Cervical laminectomy alone
. Anterior cervical decompression and fusion
. Posterior cervical fusion without decompression
. Interspinous process distraction

Correct Answer & Explanation

. Cervical laminoplasty

Explanation

In patients with OPLL and a K-line negative (kyphotic) cervical spine, posterior decompression (laminoplasty or laminectomy) is insufficient because the spinal cord remains draped over the anterior pathology. Anterior decompression and fusion, or a combined anterior-posterior approach, is required.

Question 6132

Topic: Thoracolumbar Spine & Deformity

A 30-year-old male sustains a T12 burst fracture in a fall. He is neurologically intact. Imaging shows a 25% loss of vertebral body height, 15 degrees of local kyphosis, and an intact posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his total score?

. TLICS 2
. TLICS 3
. TLICS 4
. TLICS 5
. TLICS 7

Correct Answer & Explanation

. TLICS 2

Explanation

The TLICS score assigns points for morphology (Burst = 2), neurologic status (Intact = 0), and PLC integrity (Intact = 0). A total score of 2 generally warrants non-operative management.

Question 6133

Topic: Thoracolumbar Spine & Deformity

A 15-year-old male presents with thoracic back pain and a prominent, rigid thoracic kyphosis. Radiographs are obtained to evaluate for Scheuermann's disease. According to Sorensen's criteria, the radiographic diagnosis requires anterior wedging of at least how many degrees in how many consecutive vertebrae?

. 3 degrees in 2 consecutive vertebrae
. 5 degrees in 2 consecutive vertebrae
. 5 degrees in 3 consecutive vertebrae
. 10 degrees in 2 consecutive vertebrae
. 10 degrees in 3 consecutive vertebrae

Correct Answer & Explanation

. 3 degrees in 2 consecutive vertebrae

Explanation

Sorensen's criteria define classical Scheuermann's kyphosis as structural anterior wedging of 5 degrees or more in at least 3 consecutive thoracic vertebrae.

Question 6134

Topic: 6. Spine

A 6-year-old girl is diagnosed with Klippel-Feil syndrome based on a short neck, low posterior hairline, and limited cervical range of motion. Due to known syndromic associations, which of the following screening tests should be routinely ordered?

. Echocardiogram and Renal Ultrasound
. Pulmonary function tests
. Ophthalmologic slit-lamp exam
. Audiogram alone
. Dual-energy X-ray absorptiometry (DEXA)

Correct Answer & Explanation

. Echocardiogram and Renal Ultrasound

Explanation

Klippel-Feil syndrome is caused by a failure of segmentation of the cervical spine and is highly associated with congenital renal anomalies (over 30% of cases) and cardiac defects. Therefore, renal ultrasound and echocardiography are mandatory screening tests.

Question 6135

Topic: 6. Spine

A 50-year-old male with a history of intravenous drug use presents with severe back pain, fever, and progressive lower extremity weakness over 48 hours. MRI reveals an extensive lumbar epidural abscess. What is the most common route of bacterial seeding to the epidural space in this adult demographic?

. Direct extension from a psoas abscess
. Hematogenous spread via arterial microcirculation
. Hematogenous spread via Batson's venous plexus
. Lymphatic spread from pelvic infections
. Ascending spread via the cerebrospinal fluid

Correct Answer & Explanation

. Direct extension from a psoas abscess

Explanation

In adults, spinal epidural abscesses and discitis/osteomyelitis most commonly result from hematogenous spread via the valveless Batson's venous plexus. In contrast, pediatric discitis often spreads via arterial end-vessels.

Question 6136

Topic: 6. Spine

A 55-year-old male presents with severe mechanical back pain and a known history of renal cell carcinoma. Imaging reveals a lytic lesion in the L3 vertebral body. According to the Spinal Instability Neoplastic Score (SINS), what total score range defines a "potentially unstable" spine that warrants surgical consultation?

. 0 to 6
. 7 to 12
. 13 to 18
. 19 to 24
. Greater than 24

Correct Answer & Explanation

. 0 to 6

Explanation

A SINS score of 0-6 denotes stability, 7-12 is potentially unstable and warrants surgical consultation, and 13-18 is considered highly unstable. Thus, 7 is the threshold prompting surgical referral.

Question 6137

Topic: 6. Spine

A 60-year-old male with progressive clumsiness in his hands and hyperreflexia undergoes an MRI of the cervical spine. The imaging demonstrates significant cervical stenosis with focal T2 hyperintensity and corresponding T1 hypointensity within the spinal cord at C4-C5. What is the prognostic significance of these MRI findings?

. Excellent prognosis for neurologic recovery post-decompression
. Poor prognosis for neurologic recovery post-decompression
. Indicates acute, reversible spinal cord edema
. Suggests the presence of a concomitant syrinx
. Indicates an active demyelinating disease rather than mechanical compression

Correct Answer & Explanation

. Excellent prognosis for neurologic recovery post-decompression

Explanation

Focal T1 hypointensity combined with T2 hyperintensity within the spinal cord indicates myelomalacia (irreversible cord damage). This finding is a strong, reliable predictor of poor neurologic recovery following surgical decompression for cervical spondylotic myelopathy.

Question 6138

Topic: Thoracolumbar Spine & Deformity

In surgical planning for adult spinal deformity, achieving specific spinopelvic parameters is highly correlated with improved Health-Related Quality of Life (HRQOL) outcomes. According to the SRS-Schwab classification, which of the following represents an optimal alignment goal?

. Sagittal Vertical Axis (SVA) < 10 cm
. Pelvic Tilt (PT) > 25 degrees
. Pelvic Incidence minus Lumbar Lordosis (PI-LL) < 10 degrees
. Thoracic kyphosis < 20 degrees
. Sacral slope < 10 degrees

Correct Answer & Explanation

. Sagittal Vertical Axis (SVA) < 10 cm

Explanation

The SRS-Schwab criteria for optimal HRQOL outcomes in adult spinal deformity recommend a Sagittal Vertical Axis (SVA) < 5 cm, Pelvic Tilt (PT) < 20 degrees, and a PI-LL mismatch of less than 10 degrees.

Question 6139

Topic: Cervical Spine

A 25-year-old male presents with a C5-C6 bilateral facet dislocation after a motor vehicle accident. He is awake, alert, cooperative, and has no neurological deficits. What is the most appropriate next step in management?

. Immediate MRI to assess the intervertebral disc status
. Immediate closed reduction with cranial traction under fluoroscopy
. Emergent open posterior reduction and instrumented fusion
. Emergent open anterior reduction and ACDF
. Application of a hard collar and delayed MRI in 24 hours

Correct Answer & Explanation

. Immediate MRI to assess the intervertebral disc status

Explanation

In an awake, alert, and cooperative patient with a cervical facet dislocation, immediate closed reduction with cranial traction is indicated without waiting for an MRI. Pre-reduction MRI is reserved for patients who are obtunded or fail closed reduction.

Question 6140

Topic: Thoracolumbar Spine & Deformity

A 30-year-old male falls from a height of 10 feet. CT demonstrates an L1 burst fracture. His neurological examination is completely normal. MRI confirms that the posterior ligamentous complex (PLC) is intact. What is his Thoracolumbar Injury Classification and Severity (TLICS) score, and what is the recommended treatment?

. TLICS Score 2, recommend non-operative management
. TLICS Score 4, recommend operative management
. TLICS Score 5, recommend operative management
. TLICS Score 2, recommend operative management
. TLICS Score 4, recommend non-operative management

Correct Answer & Explanation

. TLICS Score 2, recommend non-operative management

Explanation

The TLICS score is 2 (Burst fracture morphology = 2, intact PLC = 0, neurologically intact = 0). A TLICS score of 3 or less is generally an indication for non-operative management.

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