Menu

6. Spine MCQs

Practice Set 316 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 6301

Topic: 6. Spine

A 35-year-old male presents after a rollover motor vehicle crash. Imaging demonstrates a bilateral pars interarticularis fracture of C2 with severe angulation and 1 mm of anterior translation (Levine-Edwards Type IIA Hangman's fracture). What maneuver is strictly contraindicated in the management of this specific fracture pattern?

. Application of a hard cervical collar
. Longitudinal cervical traction
. Gentle axial compression in a halo vest
. Open reduction and internal fixation
. Flexion of the neck

Correct Answer & Explanation

. Application of a hard cervical collar

Explanation

A Type IIA Hangman's fracture involves severe angulation with minimal translation and is caused by a flexion-distraction injury with an intact anterior longitudinal ligament but torn posterior disc space. Longitudinal traction is strictly contraindicated as it can exacerbate the distraction and lead to catastrophic neurologic injury. Treatment requires gentle extension and compression, often utilizing a halo vest.

Question 6302

Topic: 6. Spine

A 62-year-old male with a 20-year history of ankylosing spondylitis presents to the emergency department complaining of new-onset, severe neck pain after a minor fall from a chair. He has no neurologic deficits. Plain radiographs of the cervical spine demonstrate extensive syndesmophytes but no obvious fracture. What is the most appropriate next step in management?

. Discharge with a soft cervical collar and NSAIDs
. Flexion-extension radiographs of the cervical spine
. CT scan of the entire cervical and thoracic spine
. Immediate administration of intravenous corticosteroids
. Application of a halo vest

Correct Answer & Explanation

. Discharge with a soft cervical collar and NSAIDs

Explanation

Patients with ankylosing spondylitis have rigid, osteopenic spines that are highly susceptible to unstable fractures from low-energy trauma, which may be occult on plain radiographs. A CT scan of the entire spine is critical to rule out a fracture. Flexion-extension views are dangerous and contraindicated in this setting due to the risk of iatrogenic spinal cord injury.

Question 6303

Topic: Thoracolumbar Spine & Deformity

A 40-year-old construction worker falls from a ladder and sustains an L1 burst fracture. He is neurologically intact. An MRI of the lumbar spine confirms complete disruption of the posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the most appropriate treatment recommendation?

. Mobilization in a Jewett brace
. Strict bed rest for 6 weeks
. Surgical stabilization
. Mobilization without bracing
. Serial casting

Correct Answer & Explanation

. Mobilization in a Jewett brace

Explanation

The TLICS score for this patient is 5 (Burst morphology = 2, PLC disruption = 3, Neurologically intact = 0). A TLICS score of 4 is indeterminate, while a score of 5 or greater is an indication for surgical stabilization. Non-operative management is generally reserved for a score of 3 or less.

Question 6304

Topic: Thoracolumbar Spine & Deformity

In the preoperative planning for a 65-year-old female undergoing surgical correction for adult degenerative scoliosis, the surgeon calculates a pelvic incidence (PI) of 55 degrees. According to the SRS-Schwab classification, what is the ideal radiographic target for her postoperative lumbar lordosis (LL)?

. 10 to 20 degrees
. 25 to 35 degrees
. 45 to 65 degrees
. 70 to 85 degrees
. Equal to her sacral slope (SS)

Correct Answer & Explanation

. 10 to 20 degrees

Explanation

A key principle in adult spinal deformity surgery is restoring sagittal balance by minimizing the PI-LL mismatch. The ideal postoperative lumbar lordosis should be within 10 degrees of the patient's pelvic incidence (PI-LL < 10 degrees). Therefore, a target LL of approximately 45 to 65 degrees is optimal for a PI of 55 degrees.

Question 6305

Topic: 6. Spine

A 68-year-old male undergoes a C3-C7 posterior cervical laminectomy and instrumented fusion for severe cervical spondylotic myelopathy. On postoperative day two, he develops isolated 2/5 weakness in right shoulder abduction and elbow flexion, with no sensory deficits or long tract signs. An MRI shows adequate decompression with no hematoma. What is the most appropriate initial management?

. Immediate return to the operating room for exploration
. Intravenous methylprednisolone for 48 hours
. Observation and physical therapy
. Revision to an anterior cervical discectomy and fusion
. Cervical traction

Correct Answer & Explanation

. Immediate return to the operating room for exploration

Explanation

This patient has developed a C5 palsy, a known complication following cervical decompression (especially posterior laminectomy), thought to be caused by posterior spinal cord shift and subsequent traction on the short C5 nerve roots. In the absence of an epidural hematoma or inadequate decompression on MRI, the best management is observation and supportive physical therapy, as most cases spontaneously improve over several months.

Question 6306

Topic: Cervical Spine

A 22-year-old male is evaluated after a diving accident. An open-mouth odontoid radiograph demonstrates a C1 ring fracture (Jefferson fracture). Which of the following radiographic measurements on the open-mouth view strongly suggests an incompetent transverse atlantal ligament (TAL)?

. An atlantodens interval (ADI) > 3 mm
. Combined overhang of the C1 lateral masses on C2 > 6.9 mm
. A basion-dental interval (BDI) > 10 mm
. Prevertebral soft tissue swelling > 7 mm at C2
. C2-C3 angulation > 11 degrees

Correct Answer & Explanation

. An atlantodens interval (ADI) > 3 mm

Explanation

The Rule of Spence states that a combined lateral mass overhang of C1 on C2 of greater than 6.9 mm on an open-mouth radiograph suggests rupture of the transverse atlantal ligament (TAL). A ruptured TAL renders the fracture highly unstable, often necessitating surgical stabilization or a rigid halo, rather than simple collar immobilization.

Question 6307

Topic: Thoracolumbar Spine & Deformity

A 15-year-old female gymnast complains of chronic lower back pain and tightness in her hamstrings. Imaging reveals a Meyerding Grade II isthmic spondylolisthesis at L5-S1. Despite 6 months of dedicated physical therapy, bracing, and activity modification, her symptoms severely limit her daily activities. What is the most appropriate surgical intervention?

. L5 pars interarticularis repair (Buck's repair)
. L4-L5 posterior spinal fusion
. L5-S1 posterior instrumented fusion
. Laminectomy of L5 without fusion
. Anterior lumbar interbody fusion at L4-L5

Correct Answer & Explanation

. L5 pars interarticularis repair (Buck's repair)

Explanation

For a symptomatic Grade II isthmic spondylolisthesis at L5-S1 that fails conservative management, L5-S1 posterior instrumented fusion is the gold standard treatment. Pars repair (Buck's repair) is typically reserved for young patients with a pars defect but no significant slip (Grade 0 or early Grade I) at levels above L5-S1. Laminectomy alone in a pediatric patient with an unstable slip is contraindicated.

Question 6308

Topic: 6. Spine

A 4-year-old boy is brought to the emergency department after falling from a trampoline. He is moving all extremities but guards his neck. A lateral cervical spine radiograph shows 3 mm of anterior displacement of C2 on C3. The Swischuk line (drawn from the anterior aspect of the C1 posterior arch to the C3 posterior arch) passes 1 mm anterior to the anterior aspect of the C2 spinous process. What is the most appropriate next step?

. Rigid cervical collar and immediate MRI of the cervical spine
. Closed reduction under conscious sedation
. Surgical stabilization of C2-C3
. Reassurance and discharge with symptomatic care
. Application of a halo vest

Correct Answer & Explanation

. Rigid cervical collar and immediate MRI of the cervical spine

Explanation

This presentation is classic for pseudosubluxation of C2 on C3, a normal physiologic variant common in children under 8 years of age due to ligamentous laxity and horizontal facet joints. A Swischuk line passing within 2 mm of the anterior aspect of the C2 spinous process confirms this is a benign, physiologic variant rather than a true traumatic subluxation. Reassurance and discharge are appropriate.

Question 6309

Topic: 6. Spine

A 16-year-old male presents with cosmetic concerns regarding a "hunchback" posture. Radiographs reveal hyperkyphosis of the thoracic spine. To establish a formal radiographic diagnosis of Scheuermann's kyphosis (Sorensen criteria), what specific parameters must be met?

. Anterior wedging of > 5 degrees in at least 3 consecutive vertebrae
. Thoracic kyphosis > 40 degrees with associated Schmorl's nodes
. Anterior wedging of > 10 degrees in at least 2 consecutive vertebrae
. Cervical lordosis loss combined with thoracic kyphosis > 50 degrees
. A single vertebra with > 15 degrees of anterior wedging

Correct Answer & Explanation

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

Explanation

The classic Sorensen criteria for diagnosing Scheuermann's disease requires anterior wedging of greater than 5 degrees in at least 3 consecutive thoracic vertebrae. Additional supportive findings often include Schmorl's nodes, endplate irregularities, and narrowing of the intervertebral disc spaces.

Question 6310

Topic: 6. Spine

A spine surgeon is performing an anterior cervical discectomy and fusion (ACDF) at C6-C7. Depending on the side of the approach, there are differing risks regarding the recurrent laryngeal nerve (RLN). Which of the following statements regarding the RLN anatomy is true?

. The left RLN has a highly variable course and is frequently non-recurrent.
. A right-sided approach carries a higher risk of injury to a non-recurrent laryngeal nerve.
. The left RLN loops under the subclavian artery.
. The right RLN consistently loops under the aortic arch.
. Both nerves descend within the carotid sheath before looping back superiorly.

Correct Answer & Explanation

. The left RLN has a highly variable course and is frequently non-recurrent.

Explanation

The right recurrent laryngeal nerve has a more variable course and loops under the right subclavian artery, making it susceptible to being a 'non-recurrent' laryngeal nerve (arising directly from the vagus in the neck) in about 1% of the population. The left RLN has a more consistent, protected course looping under the aortic arch, leading some surgeons to prefer a left-sided approach for lower cervical levels.

Question 6311

Topic: 6. Spine

A 70-year-old male complains of bilateral leg and buttock pain that progressively worsens after walking two blocks. The pain is rapidly relieved when he sits or pushes a shopping cart. Pedal pulses are bounding. This classic presentation of neurogenic claudication is primarily caused by hypertrophy of which of the following structures?

. Posterior longitudinal ligament
. Ligamentum flavum and facet joints
. Anterior longitudinal ligament
. Interspinous ligaments
. Sacrotuberous ligament

Correct Answer & Explanation

. Posterior longitudinal ligament

Explanation

Neurogenic claudication is the hallmark symptom of lumbar spinal stenosis. It is typically caused by degenerative hypertrophy of the ligamentum flavum and facet joint osteoarthropathy, leading to central canal narrowing. Symptoms are relieved by lumbar flexion (e.g., sitting or leaning on a shopping cart), which increases the cross-sectional area of the spinal canal.

Question 6312

Topic: Cervical Spine

An 80-year-old female sustains a Type II odontoid fracture after a ground-level fall. Her family prefers conservative management over surgery due to her severe cardiac comorbidities. Which of the following is the strongest risk factor for non-union of a Type II odontoid fracture treated with a rigid cervical collar?

. Initial fracture displacement > 5 mm
. Female gender
. Age greater than 60 years
. Anterior angulation of 5 degrees
. Presence of a concurrent C1 arch fracture

Correct Answer & Explanation

. Initial fracture displacement > 5 mm

Explanation

The strongest risk factors for non-union in Type II odontoid fractures include initial displacement > 5 mm, posterior displacement, age > 50 years, and a delay in diagnosis or treatment. Among the choices provided, initial displacement > 5 mm is a classic, highly predictive factor for non-union.

Question 6313

Topic: 6. Spine

A 72-year-old male with type 2 diabetes presents with progressive dysphagia. Lateral cervical spine radiographs demonstrate flowing, continuous ossification along the anterior aspect of five contiguous vertebral bodies, with preservation of the intervertebral disc spaces. His sacroiliac joints are radiographically normal. What is the most likely diagnosis?

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

Correct Answer & Explanation

. Ankylosing spondylitis

Explanation

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by flowing anterior ossification over at least four contiguous vertebral levels with preserved disc heights. Unlike ankylosing spondylitis, DISH does not involve the sacroiliac joints and typically presents in older patients, often with metabolic syndrome or diabetes. Dysphagia is a known complication due to massive anterior cervical osteophytes.

Question 6314

Topic: Thoracolumbar Spine & Deformity

A 35-year-old male falls from a ladder and sustains localized thoracolumbar pain. He is neurologically intact. CT and MRI confirm an L1 burst fracture with 15 degrees of kyphosis, 30% canal compromise, and an intact posterior ligamentous complex.

Based on the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the most appropriate management?

. Urgent surgical decompression
. Posterior spinal fusion without decompression
. Thoracolumbosacral orthosis (TLSO)
. Anterior corpectomy and plating
. Short-segment percutaneous pedicle screw fixation

Correct Answer & Explanation

. Urgent surgical decompression

Explanation

The patient's TLICS score is 2 (Burst fracture = 2, Neurologically intact = 0, PLC intact = 0). A score of 3 or less indicates non-operative management, typically with a TLSO.

Question 6315

Topic: 6. Spine

A 68-year-old female with adult spinal deformity presents with progressive back pain and forward truncal lean. Her spinopelvic parameters reveal a Pelvic Incidence (PI) of 60 degrees. To achieve a harmonious sagittal profile postoperatively, what is the most appropriate target for her Lumbar Lordosis (LL)?

. 30 degrees
. 40 degrees
. 50 degrees
. 60 degrees
. 80 degrees

Correct Answer & Explanation

. 30 degrees

Explanation

The formula PI - LL mismatch < 10 degrees is standard for restoring sagittal balance. With a PI of 60, an ideal postoperative LL target is approximately 60 degrees.

Question 6316

Topic: 6. Spine

A 50-year-old male with severe, long-standing ankylosing spondylitis presents to the emergency department with new-onset neck pain after a low-speed motor vehicle collision. Neurological examination is normal. An initial cross-table lateral radiograph of the cervical spine is read as negative for acute fracture. What is the most appropriate next step in management?

. Discharge with a soft collar
. Flexion-extension cervical radiographs
. Discharge with muscle relaxants and physical therapy
. CT of the cervical spine
. Fluoroscopic stress testing

Correct Answer & Explanation

. Discharge with a soft collar

Explanation

Patients with ankylosing spondylitis are at high risk for highly unstable occult fractures even from minor trauma. Standard plain films are often inadequate; therefore, a CT of the cervical spine (or whole spine) is mandatory if there is clinical suspicion.

Question 6317

Topic: 6. Spine

A 55-year-old Asian male presents with progressive clumsiness in his hands and a wide-based gait. Imaging reveals ossification of the posterior longitudinal ligament (OPLL) from C3 to C6. The sagittal MRI shows that the OPLL mass crosses the K-line (K-line negative), and the cervical spine has 15 degrees of local kyphosis. Which surgical approach is most appropriate?

. Posterior cervical laminectomy without fusion
. Posterior cervical laminoplasty
. Anterior cervical corpectomy and fusion
. Cervical disc replacement
. Minimally invasive posterior foraminotomy

Correct Answer & Explanation

. Posterior cervical laminectomy without fusion

Explanation

A negative K-line and local kyphosis are contraindications to pure posterior indirect decompression techniques like laminoplasty. An anterior approach (or combined approach) is necessary to directly decompress the cord and correct the kyphosis.

Question 6318

Topic: 6. Spine

A 45-year-old male presents with acute, severe right leg radicular pain. MRI of the lumbar spine reveals a far lateral (extra-foraminal) disc herniation at the L4-L5 level on the right side. Which nerve root is most likely compressed, and what clinical finding is expected?

. L4 root; weak ankle dorsiflexion
. L4 root; weak knee extension and decreased patellar reflex
. L5 root; weak extensor hallucis longus
. L5 root; decreased Achilles reflex
. S1 root; weak ankle plantarflexion

Correct Answer & Explanation

. L4 root; weak ankle dorsiflexion

Explanation

A far lateral disc herniation at L4-L5 compresses the exiting L4 nerve root. Compression of the L4 root presents with quadriceps weakness (knee extension) and a diminished patellar reflex.

Question 6319

Topic: 6. Spine

A 65-year-old male undergoes a C3-C6 posterior laminectomy and fusion for cervical spondylotic myelopathy. On postoperative day 2, he develops profound weakness of bilateral deltoid and biceps muscles without new sensory deficits. Lower extremity function remains intact. What is the most likely etiology of this complication?

. Epidural hematoma
. Spinal cord ischemia
. Iatrogenic injury to the anterior horn cells
. Nerve root tethering from posterior cord shift
. Incorrect pedicle screw placement

Correct Answer & Explanation

. Epidural hematoma

Explanation

C5 palsy is a well-known complication after posterior cervical decompression. It is most commonly attributed to a posterior shift of the spinal cord, leading to traction and tethering of the relatively short C5 nerve roots.

Question 6320

Topic: 6. Spine

A 24-year-old male is involved in a high-speed collision and sustains a Levine-Edwards Type IIa traumatic spondylolisthesis of the axis (Hangman's fracture). Radiographs show significant angular deformity with minimal translation. What is the most appropriate management?

. Immediate cervical traction with 15 lbs
. Halo vest immobilization applied in slight compression and extension
. Anterior C2-C3 discectomy and fusion
. Posterior C1-C2 transarticular screws
. Soft cervical collar

Correct Answer & Explanation

. Immediate cervical traction with 15 lbs

Explanation

Type IIa Hangman's fractures feature severe angulation with flexion-distraction injury of the C2-3 disc. Traction is strictly contraindicated as it causes over-distraction; treatment consists of a Halo vest with slight compression and extension.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page