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6. Spine MCQs

Practice Set 310 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 6181

Topic: 6. Spine

A 68-year-old female presents with neurogenic claudication and L4-L5 grade I degenerative spondylolisthesis. She has failed 6 months of conservative treatment. Dynamic radiographs show 4 mm of translation upon flexion. What is the gold standard surgical treatment?

. Laminectomy alone
. Anterior lumbar interbody fusion (ALIF) alone
. Posterior lumbar decompression with instrumented posterolateral fusion
. Interspinous spacer placement
. Total disc arthroplasty

Correct Answer & Explanation

. Laminectomy alone

Explanation

In degenerative spondylolisthesis with mechanical instability and claudication, decompression alone (laminectomy) has a high rate of progressive slip and recurrent symptoms. The SPORT trial supports that the addition of an instrumented posterolateral fusion provides superior long-term clinical outcomes.

Question 6182

Topic: Thoracolumbar Spine & Deformity
A 16-year-old boy presents with an increasingly prominent mid-back curvature and aching pain after prolonged sitting. Lateral radiographs reveal a thoracic kyphosis of 65 degrees. What radiographic finding is necessary to confirm the diagnosis of Scheuermann's disease?
. Spondylolysis at the L5 pars interarticularis
. Anterior wedging of โ‰ฅ5 degrees in 3 consecutive vertebrae
. Decreased interpedicular distance
. Complete absence of the pedicles (winking owl sign)
. Calcification of the anterior longitudinal ligament

Correct Answer & Explanation

. Anterior wedging of โ‰ฅ5 degrees in 3 consecutive vertebrae

Explanation

Sorensen's criteria for the diagnosis of Scheuermann's kyphosis require the presence of structural kyphosis > 45 degrees, and anterior wedging of at least 5 degrees in 3 or more consecutive vertebral bodies.

Question 6183

Topic: 6. Spine

A 60-year-old Japanese male presents with progressive clumsiness of his hands, difficulty walking, and hyperreflexia in both upper and lower extremities. Lateral cervical radiograph reveals dense ossification extending vertically along the posterior aspect of the C3 to C6 vertebral bodies. Which surgical approach is generally preferred if the canal occupying ratio is 60% and cervical alignment is lordotic?

. Anterior cervical corpectomy and fusion
. Posterior laminoplasty
. Laminectomy alone
. Anterior cervical discectomy and fusion
. Occipitocervical fusion

Correct Answer & Explanation

. Anterior cervical corpectomy and fusion

Explanation

For multilevel OPLL (>3 levels) with a high canal occupying ratio in a lordotic spine, a posterior approach such as laminoplasty is typically preferred. Anterior approaches for massive OPLL carry a very high risk of dural tears and spinal cord injury.

Question 6184

Topic: Cervical Spine

A 65-year-old female with long-standing Rheumatoid Arthritis presents with neck pain and occipital headaches. Lateral cervical flexion-extension radiographs show an anterior atlantodental interval (ADI) of 11 mm. What is the most appropriate management?

. Observation and serial radiographs
. Hard cervical collar
. Posterior C1-C2 fusion
. Occipitocervical fusion
. Subaxial cervical decompression

Correct Answer & Explanation

. Observation and serial radiographs

Explanation

In rheumatoid arthritis, anterior atlantoaxial subluxation is an indication for surgery when the ADI is > 9-10 mm. The standard surgical procedure for isolated C1-C2 instability without cranial settling is a posterior C1-C2 fusion.

Question 6185

Topic: 6. Spine

A 60-year-old man on warfarin for atrial fibrillation undergoes a lumbar laminectomy. Six hours postoperatively, he complains of excruciating back pain and develops profound, rapidly progressive bilateral lower extremity weakness and saddle anesthesia. What is the most urgent next step?

. Order an emergent MRI of the lumbar spine
. Administer high-dose IV dexamethasone
. Take the patient immediately back to the operating room for exploration and evacuation
. Reverse the warfarin and observe
. Order an urgent CT myelogram

Correct Answer & Explanation

. Order an emergent MRI of the lumbar spine

Explanation

The clinical presentation is classic for a postoperative spinal epidural hematoma causing cauda equina syndrome. Immediate surgical re-exploration and evacuation of the hematoma are indicated without waiting for advanced imaging, which would unnecessarily delay care.

Question 6186

Topic: 6. Spine

A 65-year-old male undergoes a C3-C6 posterior cervical laminectomy and instrumented fusion for cervical spondylotic myelopathy. On post-operative day 2, he develops isolated, profound weakness of the right deltoid and biceps (Grade 2/5). Sensation is intact, and his lower extremity function is unchanged. Post-operative MRI shows adequate decompression with no epidural hematoma. What is the most likely etiology of this complication?

. Intraoperative contusion of the spinal cord
. Tethering of the nerve root due to posterior spinal cord shift
. Unrecognized anterior C4-C5 paracentral disc herniation
. Direct mechanical injury from C5 pedicle screw malposition
. Exacerbation of myelopathy due to reperfusion injury

Correct Answer & Explanation

. Intraoperative contusion of the spinal cord

Explanation

Post-operative C5 palsy is a well-documented complication occurring in about 5-10% of patients undergoing cervical decompression (particularly multi-level posterior laminectomies). The most widely accepted mechanism is the 'tethering effect': as the spinal cord shifts posteriorly following decompression, tension is placed on the relatively short and horizontally oriented C5 nerve roots, leading to ischemic or traction neurapraxia. Most cases resolve spontaneously over months with conservative management.

Question 6187

Topic: 6. Spine

A 55-year-old male with a long-standing history of ankylosing spondylitis presents to the emergency department with severe back pain after a ground-level fall.

A CT scan demonstrates a fracture through the T8-T9 intervertebral disc space extending into the posterior elements. He is neurologically intact. What is the most appropriate management?

. Rigid TLSO bracing for 12 weeks with gradual mobilization
. Anterior-only instrumentation and fusion
. Percutaneous balloon kyphoplasty
. Posterior instrumentation and fusion at least 3 levels above and below the fracture
. Laminectomy alone to decompress the spinal canal proactively

Correct Answer & Explanation

. Rigid TLSO bracing for 12 weeks with gradual mobilization

Explanation

Spinal fractures in patients with ankylosing spondylitis are highly unstable because the spine acts as a long, rigid lever arm. These fractures are considered pan-column injuries (often shear or extension mechanism) and have a high risk of displacement, epidural hematoma, and catastrophic neurological decline. Rigid posterior fixation with long constructs (typically 3 levels above and 3 levels below the injury) is the gold standard of care.

Question 6188

Topic: Thoracolumbar Spine & Deformity

In evaluating a patient for adult spinal deformity correction, which of the following spinopelvic parameters is morphological, established at skeletal maturity, and remains fixed regardless of patient positioning or pelvic retroversion?

. Pelvic Tilt (PT)
. Sacral Slope (SS)
. Pelvic Incidence (PI)
. Lumbar Lordosis (LL)
. Sagittal Vertical Axis (SVA)

Correct Answer & Explanation

. Pelvic Tilt (PT)

Explanation

Pelvic Incidence (PI) is a morphological parameter that describes the anatomical relationship between the sacrum and the pelvis. It is calculated as the sum of Pelvic Tilt (PT) and Sacral Slope (SS). Because the sacroiliac joint is essentially immobile, PI becomes fixed at skeletal maturity and does not change with posture, making it the fundamental baseline measurement when calculating target lumbar lordosis (LL) during deformity correction (goal PI-LL mismatch < 10 degrees).

Question 6189

Topic: 6. Spine

A 45-year-old male presents with severe right anterior thigh pain and weakness in knee extension. An MRI of the lumbar spine reveals a far lateral (extraforaminal) disc herniation at the L3-L4 level on the right. Which nerve root is most likely compressed by this specific herniation?

. L2
. L3
. L4
. L5
. S1

Correct Answer & Explanation

. L2

Explanation

In the lumbar spine, far lateral (extraforaminal) disc herniations compress the exiting nerve root at that level. At L3-L4, the L3 nerve root exits the foramen and is thus compressed by a far lateral disc herniation. Conversely, a typical paracentral disc herniation at L3-L4 would compress the traversing L4 nerve root.

Question 6190

Topic: 6. Spine
A 25-year-old male suffers a stab wound to the thoracic spine. Neurological examination reveals loss of motor function and proprioception in the right lower extremity, and loss of pain and temperature sensation in the left lower extremity. This presentation implies injury to which of the following combinations of spinal cord tracts?
. Right spinothalamic and left corticospinal tracts
. Right corticospinal, right dorsal columns, and right spinothalamic tracts
. Left corticospinal, left dorsal columns, and right spinothalamic tracts
. Central gray matter and anterior white commissure
. Bilateral anterior corticospinal tracts

Correct Answer & Explanation

. Right corticospinal, right dorsal columns, and right spinothalamic tracts

Explanation

This describes Brown-Sรฉquard syndrome, caused by a hemisection of the spinal cord (in this case, on the right side). Injury to the right corticospinal tract causes ipsilateral (right) motor loss. Injury to the right dorsal columns causes ipsilateral (right) loss of proprioception and vibration. Injury to the right spinothalamic tract causes contralateral (left) loss of pain and temperature, because the spinothalamic fibers cross the midline near their entry level in the spinal cord.

Question 6191

Topic: Thoracolumbar Spine & Deformity

A 14-year-old gymnast presents with chronic low back pain. Conservative management for 6 months has failed.

Radiographs demonstrate a Grade II isthmic spondylolisthesis at L5-S1. What is the recommended surgical treatment?

. L5-S1 anterior lumbar interbody fusion without posterior fixation
. L5-S1 laminectomy and bilateral foraminal decompression alone
. Direct pars interarticularis repair (e.g., Buck's or Scott wiring)
. L5-S1 posterior instrumented fusion
. L4-S1 posterior instrumented fusion to ensure adequate stabilization

Correct Answer & Explanation

. L5-S1 anterior lumbar interbody fusion without posterior fixation

Explanation

For pediatric or adolescent patients with a symptomatic Grade I or II isthmic spondylolisthesis failing conservative management, the gold standard treatment is an in-situ or partially reduced L5-S1 posterior instrumented fusion (with or without interbody support). Direct pars repairs are generally reserved for L1-L4 defects or very early-stage L5 defects with minimal to no slip, not for a Grade II slip. Laminectomy alone would further destabilize the spine.

Question 6192

Topic: 6. Spine

A 55-year-old diabetic male presents with 2 weeks of worsening back pain and low-grade fever. MRI reveals a ventral epidural abscess from L2 to L4. He has full motor strength, intact sensation, normal bowel/bladder function, and no mechanical instability. Blood cultures rapidly grow methicillin-sensitive Staphylococcus aureus (MSSA). What is the most appropriate initial management?

. Immediate L2-L4 laminectomy and washout
. Intravenous antibiotics alone with close neurological monitoring
. CT-guided percutaneous aspiration of the epidural space
. L2-L4 anterior corpectomy and strut grafting
. Posterior instrumented fusion L1-L5 without decompression

Correct Answer & Explanation

. Immediate L2-L4 laminectomy and washout

Explanation

Spinal epidural abscesses (SEA) can be managed non-operatively with intravenous antibiotics if the patient is neurologically intact, the causative organism is known (from blood cultures or distant source), and there is no spinal instability or severe deformity. This is particularly relevant for ventral abscesses, which are difficult to safely access via a standard posterior approach without neural retraction.

Question 6193

Topic: Thoracolumbar Spine & Deformity

A 19-year-old female is involved in a high-speed motor vehicle collision wearing only a lap belt. Radiographs show a transverse fracture through the spinous process, pedicles, and vertebral body of L2. Based on the mechanism of injury, what is the most commonly associated concomitant pathology?

. Traumatic aortic transection
. Intra-abdominal hollow viscus injury
. Diaphragmatic rupture
. Pneumothorax
. Closed head injury

Correct Answer & Explanation

. Traumatic aortic transection

Explanation

The patient has a Chance fracture, which is a flexion-distraction injury classically associated with lap-belt use in motor vehicle collisions. These injuries are highly associated with concurrent intra-abdominal pathology (up to 40-50% of cases), particularly traumatic rupture or ischemia of hollow viscera (e.g., small bowel). A high index of suspicion and general surgery evaluation is critical.

Question 6194

Topic: Thoracolumbar Spine & Deformity

According to the Thoracolumbar Injury Classification and Severity Score (TLICS), which of the following cumulative scores serves as a definitive indication for operative management?

. A score of 2
. A score of 3
. A score of 4
. A score of 5 or greater
. TLICS relies solely on neurological status, not a cumulative score

Correct Answer & Explanation

. A score of 2

Explanation

The TLICS system guides treatment of thoracolumbar trauma based on morphology, neurological status, and the integrity of the posterior ligamentous complex (PLC). A score of 3 or less is typically treated non-operatively. A score of 4 is indeterminate and depends on surgeon preference/patient factors. A score of 5 or greater is a strong indication for operative stabilization.

Question 6195

Topic: 6. Spine

A 42-year-old male presents to the emergency department with acute onset of severe low back pain, bilateral sciatica, and subjective perineal numbness. Which of the following clinical evaluations is considered the most sensitive indicator for objective urinary retention in the setting of suspected cauda equina syndrome?

. Loss of the bulbocavernosus reflex
. Decreased anal sphincter tone on digital rectal examination
. Post-void residual volume assessment
. Inability to voluntarily initiate a urinary stream
. Bilateral absent Achilles reflexes

Correct Answer & Explanation

. Loss of the bulbocavernosus reflex

Explanation

Post-void residual (PVR) volume evaluation (via bladder ultrasound or straight catheterization) is highly sensitive for urinary retention, which is a hallmark of incomplete or complete cauda equina syndrome. A PVR of less than 100-200 mL has a high negative predictive value and makes the diagnosis of established cauda equina syndrome highly unlikely.

Question 6196

Topic: 6. Spine

Which of the following radiographic findings is most characteristic of early spinal tuberculosis (Pott's disease) when compared to pyogenic spondylodiscitis?

. Rapid and early destruction of the intervertebral disc space
. Extensive sclerosis and prominent marginal osteophyte formation
. Relative preservation of the intervertebral disc with subligamentous spread
. Isolated destruction of the posterior elements (pedicles and lamina)
. Bony ankylosis occurring within 4-6 weeks of symptom onset

Correct Answer & Explanation

. Rapid and early destruction of the intervertebral disc space

Explanation

A classic differentiating feature of spinal tuberculosis (Pott's disease) compared to pyogenic infections is the relative preservation of the intervertebral disc space until late in the disease process. Mycobacterium tuberculosis lacks the proteolytic enzymes that staphylococcal species possess, which rapidly degrade disc cartilage. Instead, TB spreads subligamentously (anterior longitudinal ligament), leading to anterior vertebral body destruction and severe angular kyphosis.

Question 6197

Topic: 6. Spine

During the physical examination of a patient with suspected cervical spondylotic myelopathy, the examiner firmly flicks the distal phalanx of the middle finger into flexion. A positive response consists of reflexive flexion of the interphalangeal joint of the thumb and index finger. What is the name of this clinical sign?

. Babinski sign
. Lhermitte's sign
. Wartenberg's sign
. Hoffmann's sign
. Spurling's test

Correct Answer & Explanation

. Babinski sign

Explanation

Hoffmann's sign is an upper motor neuron (UMN) physical examination finding indicating cervical cord compression/myelopathy above the C5/C6 level. Lhermitte's sign refers to electrical shock-like sensations down the spine with neck flexion. Wartenberg's sign is the involuntary abduction of the fifth digit (ulnar nerve or myelopathy). Spurling's test assesses for cervical radiculopathy.

Question 6198

Topic: 6. Spine

A 60-year-old male of East Asian descent presents with progressive clumsiness in his hands and an unsteady gait.

Lateral cervical radiographs reveal a continuous, dense radiopaque stripe immediately posterior to the vertebral bodies from C3 to C6. What is the most likely diagnosis?

. Ankylosing spondylitis
. Diffuse idiopathic skeletal hyperostosis (DISH)
. Ossification of the posterior longitudinal ligament (OPLL)
. Cervical spondylosis with bridging osteophytes
. Rheumatoid arthritis

Correct Answer & Explanation

. Ankylosing spondylitis

Explanation

The patient's demographics (East Asian descent), clinical presentation (myelopathy), and distinct radiographic finding (a dense ossified band along the posterior aspect of the vertebral bodies) are pathognomonic for Ossification of the Posterior Longitudinal Ligament (OPLL). This condition severely reduces canal diameter, leading to compressive myelopathy.

Question 6199

Topic: 6. Spine

Which of the following is an essential radiographic criterion for the diagnosis of Diffuse Idiopathic Skeletal Hyperostosis (DISH) according to Resnick and Niwayama?

. Flowing ossification along the anterolateral aspect of at least four contiguous vertebral bodies
. Complete fusion of the bilateral sacroiliac joints
. Extensive erosion and collapse of the intervertebral disc spaces
. Ankylosis of the apophyseal (facet) joints
. Marginal syndesmophytes predominantly involving the lumbar spine

Correct Answer & Explanation

. Flowing ossification along the anterolateral aspect of at least four contiguous vertebral bodies

Explanation

Resnick criteria for DISH include: 1) Flowing calcification/ossification along the anterolateral aspect of at least four contiguous vertebral bodies; 2) Relative preservation of disc height; and 3) Absence of apophyseal joint ankylosis and absence of sacroiliac joint erosion/fusion. The latter helps strongly differentiate DISH from ankylosing spondylitis.

Question 6200

Topic: Thoracolumbar Spine & Deformity

A 35-year-old man falls from a 10-foot ladder. Imaging reveals an L1 burst fracture with widening of the interspinous distance, indicating a definite posterior ligamentous complex (PLC) disruption. He is neurologically intact. According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the score and appropriate management?

. TLICS is 2; conservative management
. TLICS is 3; conservative management
. TLICS is 5; operative management
. TLICS is 7; operative management
. TLICS is 1; conservative management

Correct Answer & Explanation

. TLICS is 2; conservative management

Explanation

The TLICS score is calculated as follows: Burst fracture morphology (2 points) + definite PLC injury (3 points) + neurologically intact (0 points) = 5 points. A score of 5 or greater is an indication for operative management.

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