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6. Spine MCQs

Practice Set 313 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 6241

Topic: 6. Spine

A 32-year-old male sustains a traumatic spondylolisthesis of the axis (Hangman's fracture). Radiographs demonstrate an oblique fracture through the pars interarticularis with severe angulation and minimal translation. The C2-C3 disc space is widened posteriorly. According to the Levine-Edwards classification (Type IIA), which of the following is the most appropriate initial non-operative management?

. Immediate cervical traction with 15 lbs of weight
. Application of a halo vest in slight extension and compression
. Application of a halo vest in slight flexion and distraction
. Rigid cervical collar for 6 weeks
. Minerva cast in neutral alignment

Correct Answer & Explanation

. Immediate cervical traction with 15 lbs of weight

Explanation

Levine-Edwards Type IIA Hangman's fractures show significant angulation with minimal translation and denote a flexion-distraction injury with an incompetent C2-C3 disc. Cervical traction is strictly contraindicated as it will worsen the deformity and cause over-distraction. The treatment is reduction under fluoroscopy with gentle extension and compression, followed by application of a halo vest.

Question 6242

Topic: 6. Spine

A 68-year-old male complains of bilateral leg and buttock pain that worsens with walking and prolonged standing. Which of the following clinical findings most strongly suggests neurogenic claudication secondary to lumbar spinal stenosis rather than vascular claudication?

. Pain is rapidly relieved by standing perfectly still in an upright position
. Pain classically radiates from a distal to a proximal direction
. Pain relief occurs when leaning forward on a shopping cart or walking uphill
. Diminished posterior tibial and dorsalis pedis pulses
. Skin atrophy, pallor, and hair loss on the lower extremities

Correct Answer & Explanation

. Pain is rapidly relieved by standing perfectly still in an upright position

Explanation

Neurogenic claudication is exacerbated by lumbar extension (which decreases canal volume) and relieved by lumbar flexion (which increases canal volume). The 'shopping cart sign' (relief upon leaning forward) and better tolerance of walking uphill compared to downhill are classic for neurogenic claudication. Vascular claudication is typically relieved simply by stopping and standing still, radiates distal to proximal, and is associated with diminished pulses and skin changes.

Question 6243

Topic: 6. Spine

A 55-year-old patient of Japanese descent presents with progressive clumsiness of the hands and broad-based gait. Cervical imaging confirms ossification of the posterior longitudinal ligament (OPLL). The 'K-line' is determined to be negative. Which of the following surgical approaches is most appropriate for this patient?

. Cervical laminectomy without fusion
. Cervical laminoplasty
. Posterior cervical laminectomy and instrumented fusion
. Anterior cervical corpectomy and fusion
. Cervical foraminotomy

Correct Answer & Explanation

. Cervical laminectomy without fusion

Explanation

The K-line is a line drawn from the mid-point of the spinal canal at C2 to the mid-point of the spinal canal at C7 on a lateral radiograph. A "K-line negative" cervical spine means the OPLL mass crosses (extends posterior to) this line, typically due to a massive OPLL or cervical kyphosis. In a K-line negative spine, posterior decompression (laminectomy or laminoplasty) will fail because the spinal cord remains draped over the anterior pathology and cannot adequately shift posteriorly. Therefore, an anterior approach (such as corpectomy and fusion) or a combined anterior-posterior approach is required.

Question 6244

Topic: 6. Spine

A 6-year-old child with a known diagnosis of Morquio syndrome (Mucopolysaccharidosis type IV) presents for orthopedic evaluation prior to tonsillectomy. Which of the following cervical spine abnormalities is the most critical to evaluate with flexion-extension radiographs in this patient?

. Congenital fusion of C2 and C3 (Klippel-Feil variant)
. Odontoid hypoplasia causing atlantoaxial instability
. Cervical kyphosis secondary to anterior vertebral body wedging
. Subaxial facet dislocation
. Basilar invagination leading to brainstem compression

Correct Answer & Explanation

. Congenital fusion of C2 and C3 (Klippel-Feil variant)

Explanation

Morquio syndrome (MPS IV) is caused by a deficiency in N-acetylgalactosamine-6-sulfatase. Patients have severe skeletal dysplasia but normal intelligence. The most lethal orthopedic manifestation is atlantoaxial instability secondary to odontoid hypoplasia (and ligamentous laxity). They are at high risk of sudden myelopathy or death, particularly during intubation/anesthesia, making preoperative flexion-extension radiographs and potential prophylactic fusion critical.

Question 6245

Topic: 6. Spine

A patient with Marfan syndrome presents with severe back pain and progressive deformity. This condition is caused by a mutation in the FBN1 gene. Which of the following spinal or pelvic conditions is most uniquely characteristic of this specific connective tissue disorder?

. Multiple cervical neurofibromas
. Hypertrophic posterior longitudinal ligament
. Dural ectasia and protrusio acetabuli
. Sacral agenesis
. Odontoid hypoplasia with atlantoaxial instability

Correct Answer & Explanation

. Multiple cervical neurofibromas

Explanation

Marfan syndrome is an autosomal dominant disorder caused by mutations in the fibrillin-1 (FBN1) gene. Classic orthopedic manifestations include arachnodactyly, scoliosis, protrusio acetabuli, and dural ectasia. Dural ectasia (widening of the dural sac, often causing scalloping of the posterior vertebral bodies in the lumbosacral spine) is highly characteristic of Marfan syndrome and is included in the Ghent criteria for its diagnosis.

Question 6246

Topic: 6. Spine
A 25-year-old patient falls from a height and sustains a vertical sacral fracture. The fracture line passes medial to the sacral foramina, directly involving the central sacral canal. According to the Denis classification, what is the anatomical zone and the corresponding risk of neurologic deficit?
. Zone I; 5% risk of nerve root injury
. Zone II; 28% risk of radiculopathy
. Zone III; highest risk (>50%) of bowel and bladder dysfunction
. Zone I; 90% risk of cauda equina syndrome
. Zone III; 5% risk of any neurological injury

Correct Answer & Explanation

. Zone III; highest risk (>50%) of bowel and bladder dysfunction

Explanation

The Denis classification of sacral fractures divides them into three zones. Zone I is lateral to the foramina (alar), with the lowest risk of neuro deficit (~5%, typically L5 nerve root). Zone II involves the neural foramina, with an intermediate risk (~28%, typically sciatica/radiculopathy). Zone III involves the central sacral canal (medial to the foramina); these fractures have the highest risk of neurologic deficit (>50%), frequently involving the cauda equina and resulting in bowel, bladder, and sexual dysfunction.

Question 6247

Topic: 6. Spine

A 42-year-old male presents with acute, severe, unremitting right shoulder pain that awakened him from sleep, lasting for 5 days before resolving. He subsequently developed profound weakness in shoulder abduction and external rotation. Cervical spine MRI is unremarkable. Which of the following is the most likely diagnosis?

. C5 radiculopathy
. Parsonage-Turner syndrome (Neuralgic Amyotrophy)
. Massive rotator cuff tear
. Adhesive capsulitis
. Quadrilateral space syndrome

Correct Answer & Explanation

. C5 radiculopathy

Explanation

Parsonage-Turner syndrome (neuralgic amyotrophy) is an acute idiopathic brachial neuritis. The classic presentation involves sudden, severe, non-traumatic shoulder or upper extremity pain lasting days to weeks, followed by patchy lower motor neuron weakness (commonly affecting the suprascapular nerve, axillary nerve, or anterior interosseous nerve) and muscle atrophy as the pain subsides.

Question 6248

Topic: 6. Spine

An obtunded polytrauma patient (GCS 6) has a high-quality, multi-detector CT scan of the cervical spine with multiplanar reconstructions that is completely normal. According to current Eastern Association for the Surgery of Trauma (EAST) guidelines, what is the most appropriate next step regarding the patient's cervical spine precautions?

. Maintain the cervical collar until an MRI can be obtained to rule out ligamentous injury
. Maintain the cervical collar until the patient can be extubated and is alert for a clinical exam
. Remove the cervical collar based solely on the normal high-quality CT scan
. Perform dynamic flexion-extension fluoroscopy in the intensive care unit
. Transition from a rigid collar to a soft collar for 6 weeks

Correct Answer & Explanation

. Maintain the cervical collar until an MRI can be obtained to rule out ligamentous injury

Explanation

Current EAST guidelines state that in an obtunded trauma patient, a normal, high-quality multi-detector CT scan is sufficient to clear the cervical spine. The incidence of clinically significant ligamentous injuries missed by a modern high-quality CT scan is exceedingly low. Prolonged use of cervical collars in obtunded patients leads to significant morbidity, including pressure ulcers, increased intracranial pressure, and impaired venous return. Therefore, collar removal without an MRI is recommended.

Question 6249

Topic: Cervical Spine

An 82-year-old male with severe chronic obstructive pulmonary disease and heart failure presents after a mechanical fall from a standing height. He reports significant neck pain. Neurologic examination is unremarkable.

Imaging demonstrates a displaced Type II odontoid fracture. What is the most appropriate management for this patient?

. Halo vest immobilization
. Rigid cervical collar immobilization
. Anterior odontoid screw fixation
. Posterior C1-C2 instrumented fusion
. Cervical traction followed by surgical stabilization

Correct Answer & Explanation

. Halo vest immobilization

Explanation

In elderly patients (typically >80 years old) with significant medical comorbidities, nonoperative management with a rigid cervical collar is the treatment of choice for Type II odontoid fractures. While the rate of nonunion is high, stable fibrous nonunions are generally well-tolerated. Halo vest immobilization is contraindicated in this demographic due to an unacceptably high rate of morbidity and mortality, primarily from respiratory complications. Surgery is high-risk in the setting of severe comorbidities.

Question 6250

Topic: 6. Spine

A 65-year-old male presents with progressive clumsiness in his hands, difficulty buttoning his shirt, and a wide-based gait. Physical exam reveals a positive Hoffmann's sign bilaterally.

MRI of the cervical spine demonstrates multilevel degenerative spondylosis with cord compression. Which of the following MRI findings is considered the strongest independent predictor of a poor neurologic recovery following surgical decompression?

. Absence of cerebrospinal fluid (CSF) signal around the cord
. Hyperintensity on T2-weighted images
. Hypointensity on T1-weighted images
. Multilevel anterior osteophyte formation
. Thickening of the posterior longitudinal ligament

Correct Answer & Explanation

. Absence of cerebrospinal fluid (CSF) signal around the cord

Explanation

In cervical spondylotic myelopathy (CSM), T1 hypointensity within the spinal cord indicates cystic necrosis, myelomalacia, or gliosis, and is a strong predictor of irreversible spinal cord injury and poor post-surgical outcome. T2 hyperintensity alone can represent reversible edema or inflammation and is a less reliable prognosticator of permanent deficit than T1 hypointensity.

Question 6251

Topic: 6. Spine

A 55-year-old diabetic male presents with severe mid-thoracic back pain, subjective fevers, and progressive bilateral leg weakness over the past 24 hours. His CRP is 120 mg/L.

An urgent MRI demonstrates a ventral spinal epidural abscess at T8-T10. Which of the following constitutes an absolute indication for urgent surgical decompression?

. Axial back pain that is refractory to opioids
. Positive blood cultures for Staphylococcus aureus
. Presence of a progressive neurologic deficit
. Involvement of three or more consecutive vertebral levels
. Failure of 24 hours of targeted intravenous antibiotics

Correct Answer & Explanation

. Axial back pain that is refractory to opioids

Explanation

The presence of a progressive neurologic deficit is an absolute indication for emergent surgical decompression in the setting of a spinal epidural abscess. While medical management (IV antibiotics) can be attempted in neurologically intact patients or those with prohibitive surgical risk, any sign of cord or nerve root compromise necessitates immediate surgical intervention to maximize the chance of neurologic recovery.

Question 6252

Topic: Thoracolumbar Spine & Deformity

A 35-year-old male construction worker falls 10 feet from scaffolding. He complains of moderate low back pain but has full strength and normal sensation in his lower extremities.

CT imaging shows an L1 burst fracture with 40% loss of anterior vertebral body height and 50% retropulsion into the spinal canal. MRI confirms that the posterior ligamentous complex (PLC) is intact. Based on the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the appropriate score and recommended management?

. 2 points; nonoperative management
. 4 points; surgeon's choice
. 5 points; operative management
. 6 points; operative management
. 7 points; operative management

Correct Answer & Explanation

. 2 points; nonoperative management

Explanation

The TLICS system scores injuries based on three categories: morphology, neurologic status, and integrity of the posterior ligamentous complex (PLC). A burst fracture scores 2 points for morphology. A neurologically intact patient scores 0 points. An intact PLC scores 0 points. The total TLICS score is 2. A score of 3 or less indicates nonoperative management (e.g., bracing/mobilization).

Question 6253

Topic: Thoracolumbar Spine & Deformity

A 16-year-old elite male gymnast complains of chronic low back pain that is distinctly worse with spinal extension. He has failed 6 months of rest, physical therapy, and bracing.

Radiographs demonstrate a Grade II L5-S1 isthmic spondylolisthesis. He remains symptomatic. What is the most appropriate surgical intervention?

. L5-S1 anterior lumbar interbody fusion (ALIF) alone
. L5-S1 posterior instrumented fusion with autograft
. L4-S1 posterolateral in situ fusion without instrumentation
. Laminectomy and bilateral L5 foraminotomies alone
. Direct pars interarticularis repair with pedicle screws and laminar hooks

Correct Answer & Explanation

. L5-S1 anterior lumbar interbody fusion (ALIF) alone

Explanation

In adolescent patients with a symptomatic Grade I or II isthmic spondylolisthesis who fail conservative management, an in situ posterior/posterolateral instrumented fusion with autograft is the gold standard. Direct pars repair (e.g., Scott wiring or pedicle screw-hook construct) is typically reserved for young patients with a pars defect but no significant slip (Grade 0), usually at L4 or above. Decompression alone is contraindicated in pediatric isthmic spondylolisthesis due to the risk of progressive slip.

Question 6254

Topic: Thoracolumbar Spine & Deformity

A 25-year-old female is involved in a motor vehicle collision while wearing only a lap belt. She presents with severe lower back pain and abdominal ecchymosis.

Radiographs and CT reveal a pure bony flexion-distraction injury (Chance fracture) extending through the spinous process, pedicles, and vertebral body of L2. She is neurologically intact. What is an acceptable nonoperative treatment modality?

. TLSO brace molded in flexion
. Extension orthosis or hyperextension casting
. Halo-pelvic traction
. Lumbar corset brace
. Strict bed rest for 6 weeks without bracing

Correct Answer & Explanation

. TLSO brace molded in flexion

Explanation

A purely bony Chance fracture (flexion-distraction injury) has an excellent healing potential because of the broad cancellous bony surfaces. Assuming there is no severe kyphotic deformity, anterior column compromise, or neurologic deficit, it can be treated nonoperatively with an extension orthosis (TLSO) or hyperextension cast. The extension maneuver closes the posterior hinge created by the injury.

Question 6255

Topic: 6. Spine

A 70-year-old male with pre-existing cervical spondylosis falls forward, striking his chin. He presents to the ER with marked weakness in his hands and upper extremities, but relatively preserved strength in his lower extremities.

What is the primary pathophysiologic mechanism responsible for this specific neurologic deficit?

. Traumatic avulsion of the cervical nerve roots
. Hyperextension injury causing pinching of the spinal cord between an anterior osteophyte and the posterior ligamentum flavum
. Acute hyperflexion injury causing severe retropulsion of the C5-C6 intervertebral disc
. Ischemia from disruption of the anterior spinal artery
. Traumatic herniation of the cerebellar tonsils through the foramen magnum

Correct Answer & Explanation

. Traumatic avulsion of the cervical nerve roots

Explanation

This patient has Central Cord Syndrome, which classically presents with upper extremity weakness greater than lower extremity weakness following a hyperextension injury in an older patient with pre-existing cervical spondylosis. The mechanism involves the spinal cord being "pinched" between an anterior osteophyte/disc complex and a buckling, hypertrophied posterior ligamentum flavum.

Question 6256

Topic: 6. Spine

A 45-year-old male presents with severe shooting pain down his right anterior thigh and prominent weakness in knee extension. The right patellar reflex is absent.

MRI demonstrates a far-lateral (extraforaminal) disc herniation at the L4-L5 level. Which nerve root is most likely compressed?

. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L3

Explanation

In the lumbar spine, a far-lateral (extraforaminal) disc herniation compresses the exiting nerve root at that level. At the L4-L5 level, the exiting nerve root is L4. A paracentral disc herniation at the same level would compress the traversing nerve root, which is L5. The clinical findings of anterior thigh pain, knee extension weakness, and an absent patellar reflex correspond perfectly to an L4 radiculopathy.

Question 6257

Topic: 6. Spine
A 6-year-old boy is brought to the trauma bay after a high-speed motor vehicle collision. He exhibits significant upper and lower extremity weakness and diffuse hyperreflexia. Comprehensive plain radiographs and a non-contrast CT scan of the cervical spine demonstrate no fractures or subluxations. What is the most appropriate next step in his diagnostic workup?
. Dynamic flexion-extension radiographs of the cervical spine
. MRI of the cervical spine
. Administration of high-dose methylprednisolone and observation
. Cervical myelography
. SSEP/MEP neuro-monitoring

Correct Answer & Explanation

. MRI of the cervical spine

Explanation

The patient is presenting with Spinal Cord Injury Without Radiographic Abnormality (SCIWORA), which is most common in the pediatric population due to the inherent elasticity and hypermobility of their spinal column. When a neurologic deficit is present but plain films and CT are negative, MRI is the gold standard diagnostic test to evaluate for spinal cord edema, hemorrhage, or subtle ligamentous injury.

Question 6258

Topic: Thoracolumbar Spine & Deformity

A 65-year-old female presents with progressive stooped posture, early satiety, and severe low back pain. Radiographs reveal degenerative adult spinal deformity.

Which of the following spinopelvic parameters is most strongly correlated with poorer health-related quality of life (HRQOL) outcomes if it exceeds normative thresholds?

. Thoracic Kyphosis (TK)
. Coronal Cobb Angle
. Sagittal Vertical Axis (SVA)
. Sacral Slope (SS)
. Lumbar Lordosis (LL) independent of Pelvic Incidence

Correct Answer & Explanation

. Thoracic Kyphosis (TK)

Explanation

In adult spinal deformity, sagittal plane parameters correlate much more strongly with HRQOL outcomes than coronal plane parameters. The Sagittal Vertical Axis (SVA), defined by a plumb line dropped from the C7 vertebral body relative to the posterior superior corner of S1, is strongly correlated with clinical symptoms when it exceeds 5 cm. Other critical parameters include Pelvic Tilt (PT > 20 degrees) and PI-LL mismatch (>10 degrees).

Question 6259

Topic: Thoracolumbar Spine & Deformity

A 16-year-old male is brought to the clinic by his mother, who is concerned about his "round back." He complains of dull mid-back pain after standing for long periods. Standing lateral radiographs reveal a thoracic kyphosis of 65 degrees.

According to the Sorensen criteria, what specific radiographic finding is required to confirm the diagnosis of classic Scheuermann's disease?

. Anterior wedging of at least 5 degrees in 3 or more consecutive vertebrae
. Anterior wedging of at least 10 degrees in 3 or more consecutive vertebrae
. The presence of Schmorl's nodes in at least 5 vertebrae
. Intervertebral disc space widening at the apex of the curve
. A rigid curve that corrects fully on a supine bolster

Correct Answer & Explanation

. Anterior wedging of at least 5 degrees in 3 or more consecutive vertebrae

Explanation

The classic Sorensen criteria for diagnosing Scheuermann's kyphosis require the presence of anterior wedging of 5 degrees or more in at least 3 consecutive adjacent vertebrae. Other common findings include Schmorl's nodes, endplate irregularities, and narrowed disc spaces, but the multi-level wedging is the defining diagnostic criterion.

Question 6260

Topic: 6. Spine

A 45-year-old male with a 20-year history of ankylosing spondylitis presents to the emergency department after a low-energy trip and fall at home. He complains of new-onset, severe lower cervical neck pain. Neurologic examination is unremarkable.

Standard AP, lateral, and odontoid plain radiographs are interpreted as normal. What is the most appropriate next step in management?

. Discharge home with NSAIDs and muscle relaxants
. Dynamic flexion-extension cervical radiographs
. CT scan of the cervical spine
. Placement in a soft cervical collar and outpatient follow-up
. Electromyography (EMG) of the upper extremities

Correct Answer & Explanation

. Discharge home with NSAIDs and muscle relaxants

Explanation

Patients with ankylosing spondylitis have rigidly fused, osteopenic spines that are highly susceptible to fracture even from minor trauma. These fractures are notoriously unstable (often traversing the disk space or fused vertebral bodies) and are easily missed on plain radiographs due to overlapping anatomy and altered bone density. A CT scan of the entire cervical spine (often extending to the upper thoracic spine) is mandatory in any AS patient presenting with new neck pain after trauma.

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