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6. Spine MCQs

Practice Set 328 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 6541

Topic: Thoracolumbar Spine & Deformity

A 35-year-old male falls from a roof and sustains a T12 burst fracture. He is neurologically intact. MRI demonstrates definitive disruption of the posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his score and the recommended management?

. TLICS score 2, non-operative management
. TLICS score 3, non-operative management
. TLICS score 4, surgeon's choice of operative or non-operative
. TLICS score 5, operative management
. TLICS score 7, operative management

Correct Answer & Explanation

. TLICS score 5, operative management

Explanation

The TLICS score is calculated based on three categories: injury morphology, integrity of the PLC, and neurologic status. Burst fracture = 2 points. Intact neurology = 0 points. Disrupted PLC = 3 points. Total score = 5. A TLICS score >= 5 is an indication for operative management. A score of 4 can be managed operatively or non-operatively based on the surgeon's clinical judgment.

Question 6542

Topic: 6. Spine

A 24-year-old male is brought to the emergency department after a motor vehicle collision. He is awake, alert, and able to converse appropriately. Imaging reveals bilateral jumped facets at C5-C6. Neurologic examination demonstrates a C6 ASIA B spinal cord injury. What is the most appropriate initial management?

. Immediate MRI to rule out an intervertebral disc herniation before any reduction attempt
. Anterior cervical discectomy and fusion without attempted reduction
. Closed reduction using cranial traction in the emergency department
. Posterior cervical fusion and reduction
. Immobilization in a hard cervical collar and observation in the ICU

Correct Answer & Explanation

. Closed reduction using cranial traction in the emergency department

Explanation

In an awake, alert, and cooperative patient with a cervical facet dislocation, rapid closed reduction via cranial traction is indicated without the absolute prerequisite of an MRI. The awake patient can provide continuous neurologic feedback during the reduction process. If the patient were obtunded or unable to participate in a neurologic exam, an MRI would be required first to evaluate for a compressive disc herniation that could be pulled into the canal during reduction.

Question 6543

Topic: 6. Spine

A 72-year-old male with long-standing ankylosing spondylitis presents to the ED with severe neck pain following a minor ground-level fall. Lateral radiographs demonstrate a 'chalk-stick' extension fracture through the C6-C7 disc space. He is currently neurologically intact. What is the most appropriate next step in management?

. Discharge with a rigid cervical orthosis and early mobilization
. Immediate CT scan and MRI of the cervical spine, followed by long-segment posterior stabilization
. Halo vest immobilization
. Soft collar for comfort and outpatient follow-up
. Dynamic flexion-extension radiographs to assess instability

Correct Answer & Explanation

. Immediate CT scan and MRI of the cervical spine, followed by long-segment posterior stabilization

Explanation

Patients with ankylosing spondylitis are highly susceptible to highly unstable shear and extension fractures, even from low-energy trauma. These fractures are notoriously associated with epidural hematomas and progressive spinal cord injury. Advanced imaging (CT to fully characterize the fracture and MRI to rule out epidural hematoma) is mandatory. Treatment is typically long-segment operative stabilization, as these highly unstable fractures heal poorly and risk catastrophic neurologic deterioration in orthoses like a halo vest.

Question 6544

Topic: 6. Spine

A 45-year-old female presents with progressive thoracic myelopathy. MRI demonstrates a large, central, calcified disc herniation at T8-T9 causing severe cord compression. Which of the following surgical approaches is generally contraindicated for this pathology?

. Anterior transthoracic approach
. Lateral extracavitary approach
. Posterior wide laminectomy and transdural discectomy
. Costotransversectomy
. Thoracoscopic (VATS) anterior discectomy

Correct Answer & Explanation

. Anterior transthoracic approach

Explanation

A standard posterior laminectomy is strongly contraindicated for central or paracentral thoracic disc herniations, especially if calcified. Attempting to manipulate the thoracic spinal cord posteriorly to access an anteriorly situated central disc leads to a highly unacceptable risk of catastrophic spinal cord injury (paraplegia). An anterior or lateral approach (such as transthoracic, VATS, or lateral extracavitary) must be utilized to safely remove the disc without retracting the cord.

Question 6545

Topic: 6. Spine
A 3-year-old female is diagnosed with congenital scoliosis secondary to a fully segmented hemivertebra at L2. Beside a total spine MRI to evaluate for neural axis abnormalities, what routine screening test is most critical to obtain?
. Brain MRI to rule out hydrocephalus
. Renal ultrasound
. Pulmonary function tests
. Echocardiography for septal defects
. DEXA scan

Correct Answer & Explanation

. Renal ultrasound

Explanation

Congenital scoliosis occurs due to a failure of formation or failure of segmentation during embryogenesis (weeks 4-6). It is highly associated with other congenital anomalies in the VACTERL spectrum. Up to 20-30% of these patients will have genitourinary anomalies (unilateral kidney, horseshoe kidney, etc.). Therefore, a renal ultrasound is a mandatory screening test for all patients diagnosed with congenital scoliosis, in addition to an echocardiogram and total spine MRI.

Question 6546

Topic: 6. Spine

A 14-year-old gymnast presents with severe low back pain and radiating right leg pain. Imaging reveals a Grade II isthmic spondylolisthesis at L5-S1. She has failed 6 months of non-operative management. Her leg pain is primarily in the L5 dermatome. What is the pathomechanism of her specific radiculopathy?

. Compression of the exiting L4 root by the L4-L5 disc
. Compression of the traversing L5 root by an associated central disc herniation
. Compression of the exiting L5 root by the pars fibrocartilaginous tissue in the neural foramen
. Compression of the traversing S1 root in the lateral recess
. Traction injury to the cauda equina from severe slip angle

Correct Answer & Explanation

. Compression of the exiting L5 root by the pars fibrocartilaginous tissue in the neural foramen

Explanation

In L5-S1 isthmic spondylolisthesis, the nerve root most commonly affected is the L5 nerve root (the exiting root). It gets compressed within the neural foramen by the hypertrophied fibrocartilaginous mass at the pars interarticularis defect (Gill nodule). This is in contrast to a classic L4-L5 degenerative spondylolisthesis, which most commonly compresses the traversing L5 nerve root in the lateral recess.

Question 6547

Topic: 6. Spine

A 65-year-old female with long-standing rheumatoid arthritis presents with severe suboccipital neck pain. Flexion-extension radiographs demonstrate an anterior atlantodens interval (ADI) of 8 mm and a posterior atlantodens interval (PADI) of 12 mm. She has mild signs of myelopathy. If surgical stabilization is performed, what radiographic parameter is the most important predictor of postoperative neurologic recovery?

. Anterior atlantodens interval (ADI)
. Posterior atlantodens interval (PADI)
. Basilar invagination depth
. C2-C7 sagittal vertical axis
. Cervical lordosis

Correct Answer & Explanation

. Posterior atlantodens interval (PADI)

Explanation

In rheumatoid cervical spine instability (specifically atlantoaxial subluxation), the posterior atlantodens interval (PADI), also known as the space available for the cord (SAC), is the most reliable predictor of neurologic recovery. A PADI < 14 mm is generally an absolute indication for surgery. A PADI < 10 mm indicates a very poor prognosis for significant neurologic recovery even after adequate surgical decompression and stabilization.

Question 6548

Topic: 6. Spine

A 45-year-old male presents with acute severe right arm pain. Examination reveals numbness in the right middle finger, weakness in right elbow extension, and an absent right triceps reflex. Which cervical nerve root is most likely compressed?

. C5
. C6
. C7
. C8
. T1

Correct Answer & Explanation

. C7

Explanation

The clinical presentation is classic for a C7 radiculopathy. The C7 nerve root provides sensation to the middle finger, motor function for elbow extension (triceps) and wrist flexion, and is associated with the triceps reflex. A C6 radiculopathy would affect the thumb/index finger, wrist extension, and brachioradialis reflex.

Question 6549

Topic: 6. Spine

An 8-year-old boy is evaluated for a short, webbed neck and a low posterior hairline. He has significantly restricted cervical motion. Diagnosis of Klippel-Feil syndrome is made. Due to the altered biomechanics of his cervical spine, at which location is he at the greatest risk for developing clinically significant hypermobility and subsequent neurologic injury?

. At the unfused segments adjacent to the congenital fusions (often the occipitocervical junction or lower cervical spine)
. Strictly at the C7-T1 cervicothoracic junction
. Within the fused segments due to occult pseudarthrosis
. At the mid-thoracic spine
. At the lumbar spine

Correct Answer & Explanation

. At the unfused segments adjacent to the congenital fusions (often the occipitocervical junction or lower cervical spine)

Explanation

Klippel-Feil syndrome is characterized by congenital fusion of two or more cervical vertebrae. The classic clinical triad is short neck, low hairline, and limited motion. The segments adjacent to the fused vertebrae (frequently the occipitocervical junction or segments immediately caudad) are subjected to massively increased biomechanical stress, leading to hypermobility, instability, and potential spinal cord compression over time.

Question 6550

Topic: Thoracolumbar Spine & Deformity

A 68-year-old female presents with severe back pain and forward-leaning posture. Standing 36-inch radiographs demonstrate adult spinal deformity. Her pelvic incidence (PI) is measured at 55 degrees, pelvic tilt (PT) is 30 degrees, and lumbar lordosis (LL) is 25 degrees. What is her PI-LL mismatch, and what is the generally accepted surgical target for this parameter?

. Mismatch is 15 degrees; target is < 30 degrees
. Mismatch is 25 degrees; target is < 20 degrees
. Mismatch is 30 degrees; target is within 10 degrees
. Mismatch is 55 degrees; target is within 15 degrees
. Mismatch is 85 degrees; target is > 40 degrees

Correct Answer & Explanation

. Mismatch is 30 degrees; target is within 10 degrees

Explanation

The Pelvic Incidence minus Lumbar Lordosis (PI - LL) mismatch is a critical parameter in adult spinal deformity correction. In this patient, PI (55) - LL (25) = 30 degrees. The SRS-Schwab classification defines the ideal target for surgical correction as a PI-LL mismatch of within 10 degrees (ideally < 9 degrees) to optimize sagittal balance, reduce adjacent segment disease, and improve patient-reported outcomes.

Question 6551

Topic: 6. Spine

A 35-year-old male complains of severe, shooting left leg pain that wraps around the front of his knee and down the medial aspect of his lower leg. MRI reveals a massive 'far lateral' (extraforaminal) disc herniation at the L4-L5 level on the left side. Which nerve root is most likely being compressed?

. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L4

Explanation

The anatomy of lumbar nerve roots dictates that a central or paracentral disc herniation compresses the traversing nerve root (e.g., L4-L5 paracentral disc compresses the L5 root). However, a 'far lateral' or extraforaminal disc herniation compresses the exiting nerve root at that level. At L4-L5, the exiting nerve root is L4. Compression of L4 results in pain over the anterior thigh and medial leg, with possible quadriceps weakness and decreased patellar reflex.

Question 6552

Topic: 6. Spine

A 16-year-old male is evaluated for a progressive 'hump back'. Standing lateral radiographs reveal a thoracic kyphosis of 65 degrees. He is diagnosed with Scheuermann's kyphosis. According to the classic Sorensen criteria, what specific radiographic finding confirms this diagnosis?

. Anterior wedging of >= 5 degrees in at least 3 consecutive vertebrae
. Presence of Schmorl's nodes in 2 non-consecutive vertebrae
. A Cobb angle of > 45 degrees with complete loss of lumbar lordosis
. Vertebral body height loss of > 25% at a single level
. Apophyseal ring fractures at the apex of the curve

Correct Answer & Explanation

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

Explanation

Scheuermann's disease is a structural kyphosis of the thoracic or thoracolumbar spine occurring during adolescence. The classic Sorensen radiographic criteria require the presence of anterior wedging of at least 5 degrees in three or more consecutive vertebrae. Other associated findings include endplate irregularities, Schmorl's nodes, and narrowing of the disc spaces, but the multi-level wedging is the defining diagnostic criterion.

Question 6553

Topic: 6. Spine
A 65-year-old male with a known history of severe cervical spinal stenosis trips and falls forward, striking his chin on a coffee table. In the ED, he demonstrates profound weakness in his bilateral hands and arms (1/5 strength), but is able to move his legs relatively well against resistance (4/5 strength). He has patchy sensory loss below the neck. Which spinal cord syndrome does this represent?
. Anterior cord syndrome
. Brown-Séquard syndrome
. Central cord syndrome
. Posterior cord syndrome
. Conus medullaris syndrome

Correct Answer & Explanation

. Central cord syndrome

Explanation

This is a classic presentation of Central Cord Syndrome, which typically occurs after a hyperextension injury in an older patient with pre-existing cervical spondylosis. The injury disproportionately affects the central grey matter and medial aspects of the corticospinal tracts. Because the cervical motor tracts (arms/hands) are located more medially than the lumbar/sacral tracts (legs) in the spinal cord, patients exhibit much greater upper extremity weakness compared to the lower extremities.

Question 6554

Topic: Thoracolumbar Spine & Deformity

A 22-year-old male is a restrained driver (lap belt only) in a high-speed MVC. He presents with a transverse ecchymosis across his abdomen. Radiographs and CT show a horizontal fracture line passing through the spinous process, pedicles, and vertebral body of L2. What associated injury is classically most critical to rule out in this specific fracture pattern?

. Aortic dissection
. Hollow viscus (gastrointestinal) injury
. Renal artery thrombosis
. Diaphragmatic rupture
. Pulmonary contusion

Correct Answer & Explanation

. Hollow viscus (gastrointestinal) injury

Explanation

The patient has sustained a Chance fracture, which is a flexion-distraction injury often caused by a lap-belt acting as a fulcrum during rapid deceleration. This injury mechanism causes significant anterior compression and massive posterior column distraction. Chance fractures are highly associated with intra-abdominal injuries, particularly hollow viscus injuries (bowel rupture/ischemia), which occur in up to 30-50% of cases and require urgent general surgery evaluation.

Question 6555

Topic: 6. Spine

A 65-year-old female presents with severe neurogenic claudication and is found to have a grade 1 degenerative spondylolisthesis at L4-L5 with severe central stenosis. She has failed 6 months of comprehensive non-operative management. According to the results of the Spine Patient Outcomes Research Trial (SPORT) for degenerative spondylolisthesis, what is the expected outcome if she elects for surgery versus continued non-operative care?

. Non-operative treatment will provide superior functional outcomes at 4 years
. Surgery will show significantly greater improvement in pain and function at 4 years
. Both treatment groups will show identical functional outcomes at both 1 and 4 years
. Surgery carries an unacceptably high rate of catastrophic neurologic complications outweighing benefits
. Epidural steroid injections are definitively superior to surgical decompression and fusion at 2 years

Correct Answer & Explanation

. Surgery will show significantly greater improvement in pain and function at 4 years

Explanation

The SPORT trial for degenerative spondylolisthesis demonstrated that patients treated with surgical decompression and fusion had significantly greater improvement in pain, function, and satisfaction compared to those treated non-operatively. This treatment effect was maintained at 4-year and 8-year follow-ups. While non-operative patients did show modest improvements, the operative cohort experienced definitively superior outcomes.

Question 6556

Topic: 6. Spine

A 55-year-old male undergoes a 9-hour posterior instrumented spinal fusion for adult spinal deformity. He has a history of obesity, hypertension, and obstructive sleep apnea. On postoperative day 1, he complains of painless, bilateral vision loss. Pupillary reflexes are sluggish. What is the most significant intraoperative risk factor associated with this patient's postoperative visual loss (POVL)?

. Direct mechanical pressure on the globes from a Mayfield headholder
. Prone positioning combined with prolonged operative time and high blood loss
. Hypothermia maintained at 34°C during the procedure
. Intraoperative use of tranexamic acid (TXA)
. Anesthetic management with total intravenous anesthesia (TIVA)

Correct Answer & Explanation

. Prone positioning combined with prolonged operative time and high blood loss

Explanation

The patient is experiencing Ischemic Optic Neuropathy (ION), the most common cause of Postoperative Visual Loss (POVL) after spine surgery. Key risk factors include prone positioning, prolonged operative time (>6 hours), high estimated blood loss (>1000 mL), male sex, obesity, and the use of a Wilson frame (which places the head dependent). Direct ocular pressure causes central retinal artery occlusion (CRAO), which is typically unilateral and painful with periorbital swelling, whereas ION is typically bilateral and painless.

Question 6557

Topic: 6. Spine

A 68-year-old male with a long-standing history of Ankylosing Spondylitis presents to the emergency department with severe neck pain following a ground-level fall. Initial plain radiographs of the cervical spine are obscured by the shoulders and appear 'unremarkable'. The patient is neurologically intact. What is the most appropriate next step in management?

. Discharge with a soft cervical collar and outpatient physical therapy
. Perform dynamic flexion-extension cervical spine radiographs
. Obtain an MRI or CT scan of the entire cervical spine
. Administer high-dose intravenous methylprednisolone
. Apply a Halo vest immediately

Correct Answer & Explanation

. Obtain an MRI or CT scan of the entire cervical spine

Explanation

Patients with Ankylosing Spondylitis (AS) have a highly rigid, osteopenic spine that is extremely susceptible to fracture even from minor trauma. A 'chalk stick' fracture must be assumed in an AS patient with new back or neck pain. Plain radiographs are notoriously inadequate due to altered anatomy and overlapping structures. CT or MRI of the entire spine is mandatory. MRI is particularly useful to rule out epidural hematoma, which occurs in up to 20% of these fractures and can lead to delayed neurologic deterioration.

Question 6558

Topic: Thoracolumbar Spine & Deformity
A 34-year-old female sustains a T12 burst fracture following a motor vehicle collision. She has normal strength and sensation in bilateral lower extremities (ASIA E). MRI demonstrates definitive disruption of the posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity Score (TLICS), what is her total score and the recommended management?
. Score of 3; non-operative management with a TLSO brace
. Score of 4; surgeon's discretion regarding operative versus non-operative management
. Score of 5; operative stabilization
. Score of 6; operative stabilization
. Score of 7; operative stabilization

Correct Answer & Explanation

. Score of 5; operative stabilization

Explanation

The TLICS score is calculated based on three categories. 1. Morphology: Burst fracture = 2 points. 2. Neurologic status: Intact = 0 points. 3. Posterior Ligamentous Complex (PLC): Definitively disrupted = 3 points. Total score = 5 points. A score of ≤3 suggests non-operative treatment, 4 is indeterminate (surgeon's choice), and ≥5 indicates surgical stabilization.

Question 6559

Topic: Thoracolumbar Spine & Deformity
In the surgical planning for a 62-year-old female with adult spinal deformity, achieving optimal sagittal balance is critical to prevent adjacent segment disease and mechanical failure. Which of the following defines the ideal relationship between Pelvic Incidence (PI) and Lumbar Lordosis (LL)?
. PI and LL should be inversely proportional
. PI - LL should be ≤ 10 degrees
. LL should exceed PI by at least 20 degrees
. PI should be exactly half of the LL
. PI + LL should equal Pelvic Tilt (PT)

Correct Answer & Explanation

. PI - LL should be ≤ 10 degrees

Explanation

Pelvic incidence (PI) is a fixed morphologic parameter of the pelvis, while lumbar lordosis (LL) is a dynamic postural parameter. The goal of adult spinal deformity surgery is to restore harmonious spinopelvic alignment. Schwab's criteria for successful realignment indicate that the mismatch between PI and LL should be ≤ 10 degrees (PI - LL ≤ 10°). Pelvic Tilt (PT) should ideally be < 20°, and the Sagittal Vertical Axis (SVA) < 5 cm.

Question 6560

Topic: 6. Spine

A 40-year-old male is brought to the trauma bay intubated and obtunded following a high-speed rollover collision. Lateral cervical spine radiographs demonstrate a bilateral C5-C6 facet dislocation. What is the most appropriate next step in management?

. Immediate awake closed reduction with cranial tong traction
. Emergent anterior cervical discectomy and fusion (ACDF) without further imaging
. MRI of the cervical spine to evaluate for disc herniation prior to reduction
. Application of a hard cervical collar and observation until the patient can participate in an exam
. Posterior cervical instrumented fusion as the initial approach

Correct Answer & Explanation

. MRI of the cervical spine to evaluate for disc herniation prior to reduction

Explanation

In an obtunded patient with a cervical facet dislocation, clinical neuromonitoring during reduction is impossible. Therefore, an MRI must be obtained prior to any reduction maneuvers (closed or open) to rule out an anterior disc herniation. If a disc herniation is present, reduction without prior discectomy can cause the herniated disc material to be pulled back into the spinal canal, leading to acute spinal cord compression and catastrophic neurologic injury. If the patient were awake and cooperative, an immediate closed reduction under traction could be attempted before MRI.

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