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6. Spine MCQs

Practice Set 32 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 621

Topic: Thoracolumbar Spine & Deformity
Which patient is at the lowest risk for progression of spondylolisthesis?
. A 45-year-old man with grade II isthmic spondylolisthesis at L5-S1.
. A 5-year-old girl with grade I dysplastic spondylolisthesis at L5-S1.
. A 25-year-old man with a grade I isthmic spondylolisthesis at L4-5.
. A 16-year-old boy with Grade III isthmic spondylolisthesis at L5-S1.
. A 12-year-old girl with Grade II isthmic spondylolisthesis at L5-S1.

Correct Answer & Explanation

. A 45-year-old man with grade II isthmic spondylolisthesis at L5-S1.

Explanation

Young age, dysplastic spondylolisthesis, and spondylolisthesis above L5-S1 are all risk factors for progression. Adults with isthmic spondylolisthesis at L5-S1 (85% of cases) are at a low risk for progression of the slippage.

Question 622

Topic: 6. Spine

What is the most common source of neurologic compression in a patient with lumbar spinal stenosis due to degenerative changes in the lumbar spine:

. Disk
. Inferior articular process
. Superior articular process
. Pars intrarticularis
. Lamina

Correct Answer & Explanation

. Superior articular process

Explanation

Degenerative spinal stenosis is the most common variety of spinal stenosis and usually manifests compression of the thecal sac in the lateral recess of the canal (defined as the area of the spinal canal between the facet joints and the intervertebral disk). The primary cause of stenosis is hypertrophy of the facet joint with compression from the superior articular process. This must be relieved for a patient to achieve an adequate decompression.

Question 623

Topic: 6. Spine

Which of the following cervical spine nerve roots may cause paralysis of the diaphragm if injured during an anterior approach:

. C 3
. C 4
. C 5
. C 6
. C 7

Correct Answer & Explanation

. C 4

Explanation

The C 4 cervical spine nerve root provides the primary innervation of the diaphragm.

Question 624

Topic: 6. Spine

The deltoid muscle may become paralyzed as a result of injury to which of the following cervical spine nerve roots:

. C 4
. C 5
. C 6
. C 7
. C 8

Correct Answer & Explanation

. C 5

Explanation

The deltoid muscle is almost entirely innervated by the C 5 cervical spine nerve root.

Question 625

Topic: 6. Spine

The biceps reflex is diminished by compression of which of the following cervical spine nerve roots:

. C 4
. C 5
. C 6
. C 7
. C 8

Correct Answer & Explanation

. C 5

Explanation

Although there is a small contribution from the C 6 cervical spine nerve root, the biceps reflex is primarily derived from the C 5 cervical spine nerve root.

Question 626

Topic: 6. Spine

Which of the following is the most appropriate initial imaging modality of choice for a patient presenting with suspected pyogenic vertebral osteomyelitis who is hemodynamically stable and has no neurologic deficits?

. Plain radiography of the spine
. Computed tomography (CT) scan without contrast
. Magnetic resonance imaging (MRI) with and without gadolinium
. Technetium-99m bone scan
. Gallium-67 scan

Correct Answer & Explanation

. Magnetic resonance imaging (MRI) with and without gadolinium

Explanation

MRI with gadolinium is the most sensitive and specific imaging modality for the early detection of pyogenic vertebral osteomyelitis and epidural abscess. Plain radiographs often do not show changes for 2-4 weeks after infection onset.

Question 627

Topic: 6. Spine

A 45-year-old intravenous drug user presents with a 1-week history of severe back pain, high fever, and progressive bilateral lower extremity weakness. MRI confirms a large posterior spinal epidural abscess. What is the most appropriate definitive management?

. Intravenous antibiotics alone and close observation
. CT-guided needle aspiration of the abscess
. Emergent surgical decompression and targeted antibiotics
. Placement of a lumbar subarachnoid drain
. High-dose intravenous corticosteroids alone

Correct Answer & Explanation

. Emergent surgical decompression and targeted antibiotics

Explanation

Emergent surgical decompression combined with systemic antibiotics is indicated for patients with a spinal epidural abscess who present with progressive neurologic deficits. Medical management alone is reserved for those without neurologic compromise or those unfit for surgery.

Question 628

Topic: 6. Spine

In contrast to pyogenic vertebral osteomyelitis, spinal tuberculosis (Pott's disease) classically exhibits which of the following radiographic features during the early stages of the disease process?

. Rapid and extensive destruction of the intervertebral disc
. Relative preservation of the intervertebral disc space
. Early sclerotic margins around the vertebral bodies
. Primary involvement of the posterior spinal elements
. Diffuse gas formation within the disc space

Correct Answer & Explanation

. Relative preservation of the intervertebral disc space

Explanation

Spinal tuberculosis typically spares the intervertebral disc early in the disease course because Mycobacterium tuberculosis lacks the proteolytic enzymes that actively destroy cartilage, unlike pyogenic organisms such as S. aureus.

Question 629

Topic: 6. Spine

A 30-year-old male sustains a transcolonic gunshot wound to the abdomen, with the bullet lodging in the L3 vertebral body. He is neurologically intact. During exploratory laparotomy, bowel perforation is confirmed and repaired. What is the standard orthopedic management regarding the spinal injury?

. Emergent anterior retroperitoneal approach for bullet removal
. Washout of the spinal tract through a posterior laminectomy
. Broad-spectrum intravenous antibiotics without routine bullet extraction
. Immediate instrumented posterior spinal fusion
. Local wound care and observation without antibiotics

Correct Answer & Explanation

. Broad-spectrum intravenous antibiotics without routine bullet extraction

Explanation

Penetrating spinal injuries associated with viscus perforation (transcolonic) require broad-spectrum antibiotics for 7-14 days. Routine surgical extraction of the bullet is not indicated unless there is a progressive neurologic deficit or spinal instability.

Question 630

Topic: 6. Spine

Regarding spontaneous pediatric discitis, which of the following statements is most accurate?

. It is primarily a viral etiology requiring supportive care only.
. It routinely requires surgical debridement for cure.
. It often presents as a refusal to walk or sit in toddlers.
. It is best diagnosed early using plain radiography.
. It rarely involves the lumbar spine.

Correct Answer & Explanation

. It often presents as a refusal to walk or sit in toddlers.

Explanation

Pediatric discitis frequently presents in children under 5 years of age with non-specific symptoms such as irritability, back pain, or a refusal to walk. It usually involves the lumbar spine and is primarily managed conservatively or with antibiotics.

Question 631

Topic: 6. Spine

Review the following clinical image.

In a patient presenting with severe back pain and elevated inflammatory markers, what are the classic MRI findings of pyogenic spondylodiscitis demonstrated on T1 and T2-weighted images?

. High T1 signal and low T2 signal in the affected disc.
. Low T1 signal and high T2 signal in the affected disc and adjacent bone marrow.
. Normal T1 signal with isolated high T2 signal in the disc space only.
. Diffuse low T1 and low T2 signal in the adjacent vertebral bodies with disc sparing.
. High T1 and high T2 signal with a peripheral hypointense rim.

Correct Answer & Explanation

. Low T1 signal and high T2 signal in the affected disc and adjacent bone marrow.

Explanation

Pyogenic spondylodiscitis classically demonstrates decreased (low) signal intensity on T1-weighted images and increased (high) signal intensity on T2-weighted images within the intervertebral disc and adjacent vertebral endplates due to edema and inflammation.

Question 632

Topic: 6. Spine

A 40-year-old farmer from the Mediterranean region presents with chronic back pain, undulating fevers, and night sweats. MRI shows focal osteolysis with anterior endplate erosions in the lower lumbar spine, without massive disc destruction. What is the most likely etiology?

. Mycobacterium tuberculosis
. Brucella species
. Coccidioides immitis
. Actinomyces israelii
. Treponema pallidum

Correct Answer & Explanation

. Brucella species

Explanation

Spinal brucellosis often presents with focal anterior endplate erosions (epiphysitis or Pons sign) and intact discs early on. It is common in endemic regions (Mediterranean, Middle East) and associated with occupational exposure.

Question 633

Topic: 6. Spine

What is the classic clinical triad of symptoms associated with a spinal epidural abscess?

. Back pain, fever, and neurologic deficit
. Back pain, weight loss, and night sweats
. Radiculopathy, bowel incontinence, and fever
. Fever, rigors, and saddle anesthesia
. Back pain, hematuria, and fever

Correct Answer & Explanation

. Back pain, fever, and neurologic deficit

Explanation

The classic triad of a spinal epidural abscess consists of severe back pain, fever, and progressive neurologic deficit. However, only a minority of patients present with all three findings simultaneously.

Question 634

Topic: 6. Spine

A 55-year-old patient presents with vague neck pain and a delayed, low-grade infection 6 months after a posterior cervical fusion. Intraoperative tissue cultures are initially negative but eventually become positive at 10 days. The most likely organism is:

. Staphylococcus aureus
. Streptococcus pyogenes
. Pseudomonas aeruginosa
. Cutibacterium acnes
. Enterococcus faecalis

Correct Answer & Explanation

. Cutibacterium acnes

Explanation

Cutibacterium (formerly Propionibacterium) acnes is a slow-growing anaerobe commonly associated with delayed postoperative infections following spinal instrumentation, particularly in the cervical and shoulder regions. It requires prolonged culture observation (up to 14 days).

Question 635

Topic: 6. Spine

In the surgical reconstruction of a patient with spinal tuberculosis presenting with a progressive neurologic deficit and a severe, rigid kyphosis of 50 degrees, which surgical approach generally provides the most direct and effective complete debridement?

. Posterior laminectomy alone
. Anterior approach with radical debridement and strut grafting
. Percutaneous pedicle screw fixation
. Transforaminal lumbar interbody fusion (TLIF)
. Multilevel posterior column osteotomies without debridement

Correct Answer & Explanation

. Anterior approach with radical debridement and strut grafting

Explanation

Tuberculosis primarily destroys the anterior column (vertebral bodies). An anterior approach allows for direct visualization, radical debridement of infected tissue, decompression of the spinal canal, and structural strut grafting.

Question 636

Topic: 6. Spine

In adult patients diagnosed with hematogenous pyogenic vertebral osteomyelitis, which region of the spine is most frequently affected?

. Cervical spine
. Upper thoracic spine
. Lower thoracic spine
. Lumbar spine
. Sacral spine

Correct Answer & Explanation

. Lumbar spine

Explanation

The lumbar spine is the most commonly affected region in adult pyogenic vertebral osteomyelitis, followed by the thoracic and cervical spine. This is thought to be related to the rich venous plexus and arterial supply.

Question 637

Topic: 6. Spine

A 55-year-old male presents with severe back pain and fever. An MRI is obtained:

What is the most common organism responsible for the condition typically shown in such presentations?

. Staphylococcus aureus
. Mycobacterium tuberculosis
. Pseudomonas aeruginosa
. Escherichia coli
. Streptococcus pneumoniae

Correct Answer & Explanation

. Staphylococcus aureus

Explanation

Staphylococcus aureus is the most common causative organism for spontaneous pyogenic spondylodiscitis in adults. Hematogenous spread via the arterial system to the vertebral endplates is the usual route.

Question 638

Topic: 6. Spine

Which of the following MRI findings most strongly differentiates tuberculous spondylitis from pyogenic spondylodiscitis?

. Early destruction of the intervertebral disc
. Extensive paraspinal abscess with relative sparing of the disc
. High T2 signal in the adjacent vertebral bodies
. Epidural abscess formation causing cord compression
. Involvement of only a single vertebral endplate

Correct Answer & Explanation

. Extensive paraspinal abscess with relative sparing of the disc

Explanation

Tuberculous spondylitis characteristically features large, calcified paraspinal abscesses and relative sparing of the intervertebral disc until late in the disease process. This contrasts with pyogenic infections, which rapidly destroy the intervertebral disc.

Question 639

Topic: 6. Spine

The classic clinical triad of a spinal epidural abscess includes back pain, fever, and which of the following?

. Bowel/bladder dysfunction
. Neurologic deficits
. Radicular pain
. Night sweats
. Unexplained weight loss

Correct Answer & Explanation

. Neurologic deficits

Explanation

The classic triad for a spinal epidural abscess consists of severe back pain, fever, and progressive neurologic deficits. Early recognition is critical to prevent irreversible paralysis.

Question 640

Topic: 6. Spine

In a patient with a known spinal epidural abscess, which of the following is an absolute indication for emergent surgical decompression?

. Isolated radicular pain
. Positive blood cultures for MRSA
. Severe axial back pain refractory to opioids
. Acute progressive neurologic deficit
. Elevated ESR greater than 100 mm/hr

Correct Answer & Explanation

. Acute progressive neurologic deficit

Explanation

Acute and progressive neurologic deficits, such as paraparesis or bowel/bladder dysfunction, mandate emergent surgical decompression to prevent permanent neurological injury. Medical management alone is contraindicated in this scenario.

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