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6. Spine MCQs

Practice Set 329 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 6561

Topic: 6. Spine

A 55-year-old breast cancer patient presents with severe mechanical back pain. MRI shows a metastatic lesion at T11. The Spinal Instability Neoplastic Score (SINS) is being calculated to determine if surgical stabilization is indicated. Which of the following variables is NOT a component of the SINS criteria?

. Location of the lesion
. Pain characteristics (mechanical vs. biological)
. Radiographic spinal alignment
. Patient life expectancy
. Vertebral body collapse

Correct Answer & Explanation

. Patient life expectancy

Explanation

The Spinal Instability Neoplastic Score (SINS) consists of six components: Spine location (junctional vs. mobile vs. rigid), Pain (mechanical), Bone lesion type (lytic vs. blastic vs. mixed), Radiographic spinal alignment, Vertebral body collapse, and Posterolateral involvement of spinal elements. Patient life expectancy and tumor histology are crucial for overall decision-making (evaluated by systems like Tokuhashi or Tomita scores) but are NOT components of the SINS.

Question 6562

Topic: 6. Spine

A 48-year-old male presents with severe left lower extremity radicular pain. Examination reveals weakness in left ankle dorsiflexion, an intact Achilles reflex, and numbness over the medial aspect of the left lower leg. MRI reveals a far lateral (extraforaminal) disc herniation at the L4-L5 level. Which nerve root is most likely being compressed?

. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L3

Explanation

A far lateral (extraforaminal) disc herniation at the L4-L5 level compresses the exiting L4 nerve root. In contrast, a paracentral disc herniation at the L4-L5 level typically spares the exiting L4 root and compresses the traversing L5 nerve root. The clinical picture described (ankle dorsiflexion weakness, medial leg numbness) matches an L4 radiculopathy.

Question 6563

Topic: 6. Spine

During posterior spinal fusion for Adolescent Idiopathic Scoliosis, following rod derotation, the neurophysiologist reports an 85% unilateral decrease in motor evoked potentials (MEPs). Somatosensory evoked potentials (SSEPs) remain stable. What is the most appropriate initial management?

. Perform an emergent wake-up test without altering the construct
. Increase mean arterial pressure (MAP) and release the corrective forces
. Administer a bolus of propofol to deepen anesthesia
. Perform a rapid epidural exploration and laminectomy
. Administer high-dose intravenous methylprednisolone

Correct Answer & Explanation

. Increase mean arterial pressure (MAP) and release the corrective forces

Explanation

A significant drop in MEPs (>80% or loss of waveforms) with intact SSEPs suggests anterior spinal cord ischemia or impending cord stretch injury involving the corticospinal tracts. The immediate response should be to optimize hemodynamics by increasing MAP to >90 mmHg, verify no technical issues with monitoring, and release the surgical correction/distraction. Administering a bolus of propofol would further suppress MEP signals, as MEPs are highly sensitive to inhalational and intravenous anesthetics.

Question 6564

Topic: 6. Spine

A 45-year-old immigrant presents with progressive mid-back pain, low-grade fevers, and night sweats. Radiographs reveal a sharp angulation (gibbus deformity) at T9-T10. MRI demonstrates anterior vertebral body destruction with subligamentous spread across three levels and relatively preserved intervertebral disc spaces. What is the most likely diagnosis?

. Pyogenic Staphylococcus aureus spondylodiscitis
. Tuberculous spondylitis (Pott's disease)
. Brucellosis of the spine
. Multiple myeloma
. Metastatic prostate cancer

Correct Answer & Explanation

. Tuberculous spondylitis (Pott's disease)

Explanation

Tuberculous spondylitis (Pott's disease) characteristically involves the anterior aspect of the vertebral bodies, spreads beneath the anterior longitudinal ligament (subligamentous spread) to involve multiple contiguous levels, and paradoxically spares the intervertebral discs until late in the disease process. Pyogenic spondylodiscitis (e.g., S. aureus) typically destroys the intervertebral disc early. A gibbus deformity is a classic sign of the resulting anterior wedge collapse in TB spine.

Question 6565

Topic: 6. Spine

A 22-year-old male is involved in a motor vehicle accident and diagnosed with a Levine-Edwards Type IIA Hangman's fracture (traumatic spondylolisthesis of the axis). Imaging shows an oblique fracture through the pars interarticularis with severe angulation and minimal anterior translation. What is the pathomechanism of this specific fracture type and the appropriate non-operative treatment?

. Hyperextension and axial load; treat with heavy cervical traction
. Flexion and distraction; treat with a Halo vest in slight compression and extension
. Flexion and distraction; treat with halo traction followed by posterior fusion
. Lateral bending and rotation; treat with a Miami J collar
. Axial loading; treat with a Minerva cast

Correct Answer & Explanation

. Flexion and distraction; treat with a Halo vest in slight compression and extension

Explanation

Levine-Edwards Type IIA Hangman's fractures are characterized by severe angulation with minimal translation and an oblique fracture line from anterior-inferior to posterior-superior. The mechanism is flexion-distraction. Application of cervical traction is contraindicated as it will distract the fracture fragments and worsen the deformity. The correct treatment is application of a Halo vest under gentle compression and slight extension.

Question 6566

Topic: 6. Spine

Which of the following clinical scenarios is an absolute indication for emergent surgical decompression in a patient with a spinal epidural abscess?

. A 40-year-old intravenous drug user with mechanical back pain and no neurological deficits
. A 50-year-old diabetic with radicular pain, intact motor strength, and an abscess isolated to L4-L5
. A 65-year-old male with 3 days of progressive bilateral lower extremity weakness and new-onset urinary retention
. A 75-year-old male who has been completely paraplegic for 14 days without any retained sensory function
. A 30-year-old female with a pan-spinal epidural abscess from C2 to L5, neurologically intact

Correct Answer & Explanation

. A 65-year-old male with 3 days of progressive bilateral lower extremity weakness and new-onset urinary retention

Explanation

Acute or progressive neurological deficit (such as progressing weakness or cauda equina syndrome) is an absolute indication for emergent surgical decompression in the setting of a spinal epidural abscess. Patients with no neurological deficits or only radicular pain can often be trialed on medical management (IV antibiotics). Patients with complete paralysis present for >48-72 hours have an extremely poor prognosis for recovery, making the benefit of emergency surgery highly questionable.

Question 6567

Topic: 6. Spine

During the neurological examination of a 60-year-old patient with suspected Cervical Spondylotic Myelopathy (CSM), you tap the brachioradialis tendon near the wrist. Instead of forearm flexion and supination, you observe spontaneous flexion of the patient's fingers. What is this clinical sign called and what level of the cervical spine does it implicate?

. Hoffmann sign; indicates a lesion above C5
. Inverted radial reflex; indicates a lesion at C5-C6
. Wartenberg's sign; indicates a lesion at C8-T1
. Lhermitte's sign; indicates a lesion at C4-C5
. Clonus; indicates a lesion anywhere in the lumbar spine

Correct Answer & Explanation

. Inverted radial reflex; indicates a lesion at C5-C6

Explanation

The inverted radial (or brachioradialis) reflex is highly specific for Cervical Spondylotic Myelopathy at the C5-C6 level. Tapping the brachioradialis tendon typically elicits a C6 reflex arc (elbow flexion/supination). If the C6 anterior horn cells are damaged (LMN lesion) while the cord is compressed above the C8 level (UMN lesion), the typical reflex is absent, but hyperreflexia of the C8 distribution (finger flexors) is triggered instead. Hoffmann sign is generalized UMN, Wartenberg's is ulnar nerve/myelopathy intrinsic weakness.

Question 6568

Topic: Thoracolumbar Spine & Deformity

Which of the following is the most classic demographic and anatomical presentation for degenerative spondylolisthesis versus isthmic spondylolisthesis?

. Degenerative: Teenage gymnast at L5-S1. Isthmic: 60-year-old female at L4-L5.
. Degenerative: 60-year-old female at L4-L5. Isthmic: Teenage gymnast at L5-S1.
. Degenerative: 40-year-old male at L3-L4. Isthmic: 60-year-old male at L4-L5.
. Degenerative: 60-year-old male at L5-S1. Isthmic: 20-year-old female at L3-L4.
. Degenerative and Isthmic most commonly both occur at L5-S1 in adult males.

Correct Answer & Explanation

. Degenerative: 60-year-old female at L4-L5. Isthmic: Teenage gymnast at L5-S1.

Explanation

Degenerative spondylolisthesis classically occurs in older females (e.g., >50 years old), most frequently at the L4-L5 level, due to facet joint osteoarthritis and ligamentum flavum hypertrophy. Isthmic spondylolisthesis (secondary to a pars interarticularis defect) most classically presents in adolescents or young adults (frequently athletes involving repetitive hyperextension, like gymnasts), predominantly at the L5-S1 level.

Question 6569

Topic: 6. Spine

A 70-year-old male with known cervical stenosis falls forward and strikes his chin, forcefully hyperextending his neck. He presents with severe bilateral upper extremity weakness (motor strength 2/5) but is able to move his lower extremities well against gravity (motor strength 4/5). The disproportionate upper extremity weakness is due to injury to which aspect of the spinal cord?

. The anterior horn cells exclusively
. The lateral spinothalamic tracts
. The medial fibers of the lateral corticospinal tract
. The dorsal columns
. The lateral fibers of the lateral corticospinal tract

Correct Answer & Explanation

. The medial fibers of the lateral corticospinal tract

Explanation

Central Cord Syndrome commonly occurs following a hyperextension injury in a patient with pre-existing cervical spondylosis. The injury preferentially damages the central portion of the cord. In the lateral corticospinal tract (the primary descending motor pathway), the fibers controlling the upper extremities are located medially, while the fibers controlling the lower extremities and sacral regions are located laterally. Thus, central cord edema/damage disproportionately affects the medially located cervical motor fibers.

Question 6570

Topic: 6. Spine
A patient arrives in the trauma bay following a motorcycle collision. Neurological examination reveals absent motor function below the level of the umbilicus. However, the patient can feel light touch and pinprick around the perianal area (S4-S5), and voluntary anal contraction is absent. According to the ASIA Impairment Scale, how is this injury classified?
. ASIA A
. ASIA B
. ASIA C
. ASIA D
. ASIA E

Correct Answer & Explanation

. ASIA B

Explanation

The ASIA Impairment Scale evaluates the completeness of a spinal cord injury. ASIA A = Complete (no sensory or motor function preserved in sacral segments S4-S5). ASIA B = Sensory incomplete (sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5). ASIA C = Motor incomplete (motor function is preserved, and more than half of key muscles below the neurological level have a muscle grade < 3). ASIA D = Motor incomplete (at least half of key muscles below level have grade ≥ 3). The presence of sacral sensation without motor function defines ASIA B.

Question 6571

Topic: Cervical Spine

An 82-year-old female presents after a ground-level fall with neck pain. CT shows a Type II odontoid fracture with 2mm of posterior displacement. Neurologic examination is completely intact. What is the most appropriate initial management for this patient?

. Rigid cervical collar
. Halo vest immobilization
. Anterior odontoid screw fixation
. Posterior C1-C2 fusion
. Traction and observation

Correct Answer & Explanation

. Rigid cervical collar

Explanation

In elderly patients with a Type II odontoid fracture, halo vest immobilization has an unacceptably high morbidity and mortality rate. A rigid cervical collar is the preferred initial management for minimally displaced fractures in frail or elderly demographics.

Question 6572

Topic: 6. Spine

A 60-year-old male with long-standing ankylosing spondylitis presents after a minor fall. He has severe lower cervical pain but is neurologically intact. Standard 3-view cervical radiographs are unremarkable. What is the most appropriate next step in management?

. Discharge with NSAIDs and a soft collar
. Flexion-extension cervical radiographs
. CT scan of the entire cervical spine
. MRI of the cervical spine with contrast
. DEXA scan to assess bone density

Correct Answer & Explanation

. CT scan of the entire cervical spine

Explanation

Patients with ankylosing spondylitis are at high risk for highly unstable extension-distraction fractures even from minor trauma. Because standard radiographs frequently miss these injuries due to altered anatomy, a CT scan of the entire cervical spine is mandatory.

Question 6573

Topic: 6. Spine
A 70-year-old male with known cervical stenosis presents after a hyperextension injury. He exhibits significant bilateral upper extremity weakness, particularly hand intrinsic wasting, with relatively preserved lower extremity strength and intact bowel/bladder function. What is the most likely diagnosis?
. Anterior cord syndrome
. Central cord syndrome
. Brown-Séquard syndrome
. Posterior cord syndrome
. Conus medullaris syndrome

Correct Answer & Explanation

. Central cord syndrome

Explanation

Central cord syndrome classically occurs following a hyperextension injury in patients with preexisting cervical spondylosis. It presents with disproportionately greater motor impairment in the upper extremities compared to the lower extremities.

Question 6574

Topic: 6. Spine

A 55-year-old diabetic male presents with severe back pain, fevers, and progressive bilateral lower extremity weakness over the past 12 hours. MRI reveals a ventral epidural abscess at L3-L4 compressing the cauda equina. What is the most appropriate immediate management?

. Intravenous vancomycin and ceftriaxone and close observation
. CT-guided aspiration of the fluid collection
. Emergent surgical decompression and debridement
. Placement of a lumbar drain
. Strict bed rest and TLSO bracing

Correct Answer & Explanation

. Emergent surgical decompression and debridement

Explanation

A spinal epidural abscess presenting with progressive neurologic deficits is a surgical emergency. Emergent surgical decompression and debridement must be performed to prevent irreversible neurologic damage.

Question 6575

Topic: Cervical Spine

A 50-year-old male presents with progressive clumsiness in his hands and an unsteady gait. CT demonstrates a continuous band of dense ossification along the posterior aspect of the C3-C6 vertebral bodies. The ossified mass occupies 65% of the spinal canal, and his cervical spine is lordotic. Which surgical approach is generally preferred?

. Anterior cervical discectomy and fusion (ACDF)
. Anterior cervical corpectomy and fusion (ACCF)
. Posterior laminectomy and fusion
. Microendoscopic posterior foraminotomy
. Combined anterior-posterior 360-degree decompression

Correct Answer & Explanation

. Posterior laminectomy and fusion

Explanation

For Ossification of the Posterior Longitudinal Ligament (OPLL) occupying >50-60% of the canal or involving more than 3 levels in a lordotic spine, a posterior approach (laminectomy and fusion or laminoplasty) is preferred. Anterior corpectomy carries an unacceptably high risk of dural tear and cord injury in severe OPLL.

Question 6576

Topic: 6. Spine

A 62-year-old female with a history of breast cancer presents with intractable back pain. MRI shows a metastatic lesion at T8 with spinal cord compression. Her Tokuhashi score is calculated to be 13. What is the most appropriate treatment recommendation?

. Palliative care and observation
. Radiation therapy alone
. Excisional surgery or decompression with stabilization
. Percutaneous kyphoplasty
. Systemic chemotherapy alone

Correct Answer & Explanation

. Excisional surgery or decompression with stabilization

Explanation

A Tokuhashi score of 12-15 indicates an expected survival prognosis of greater than 1 year. These patients are optimal candidates for excisional surgery or aggressive decompression and stabilization to improve neurologic outcomes and quality of life.

Question 6577

Topic: Thoracolumbar Spine & Deformity

A 14-year-old female gymnast complains of chronic low back pain. Radiographs demonstrate a Grade II L5-S1 isthmic spondylolisthesis. After 6 months of failed physical therapy and bracing, what is the most appropriate surgical treatment?

. L5-S1 anterior lumbar interbody fusion (ALIF) alone
. L5 pars repair (Buck technique)
. L5-S1 posterolateral fusion in situ
. L4-S1 posterior instrumented fusion with full reduction
. L5 laminectomy without fusion

Correct Answer & Explanation

. L5-S1 posterolateral fusion in situ

Explanation

For a symptomatic Grade II isthmic spondylolisthesis in an adolescent that has failed conservative care, an L5-S1 posterolateral fusion in situ is the standard of care. Pars repair is typically reserved for L4 or higher and only for Grade 0-I slips.

Question 6578

Topic: 6. Spine

A 15-year-old male presents with progressive upper back rounding. Standing lateral radiographs show a thoracic kyphosis of 65 degrees and anterior wedging of 3 consecutive vertebrae of 6 degrees each. What is the most appropriate initial management?

. Physical therapy and core strengthening alone
. Extension bracing (e.g., Milwaukee brace)
. Posterior spinal fusion
. Anterior release and posterior spinal fusion
. Observation with annual radiographs

Correct Answer & Explanation

. Extension bracing (e.g., Milwaukee brace)

Explanation

This patient meets the classic radiographic criteria for Scheuermann's kyphosis. For a skeletally immature patient with a flexible curve between 50 and 75 degrees, extension bracing combined with physical therapy is the recommended first-line treatment.

Question 6579

Topic: 6. Spine

A 40-year-old male presents with severe low back pain, bilateral sciatica, and perianal numbness. A bladder scan shows a post-void residual volume of 400 mL. MRI reveals a massive L4-L5 disc herniation. What is the most critical factor in predicting his functional recovery?

. The degree of canal compromise measured on MRI
. The timing of surgical decompression
. The specific type of surgical approach utilized
. The administration of preoperative high-dose methylprednisolone
. The patient's age and baseline BMI

Correct Answer & Explanation

. The timing of surgical decompression

Explanation

In Cauda Equina Syndrome, the timing of surgical decompression is the most critical factor determining neurologic and urologic recovery. Surgery should ideally be performed within 24 to 48 hours of symptom onset to minimize the risk of permanent bladder and bowel dysfunction.

Question 6580

Topic: Cervical Spine

A 5-year-old boy is evaluated after a minor fall. His lateral cervical spine radiograph shows 3mm of anterior displacement of C2 on C3. The Swischuk line passes 1mm anterior to the anterior aspect of the C3 posterior arch. What is the correct interpretation?

. Pathologic C2-C3 subluxation requiring a halo vest
. Hangman's fracture
. Physiologic pseudosubluxation
. Atlantodental interval (ADI) widening requiring MRI
. Unstable ligamentous injury requiring immediate fusion

Correct Answer & Explanation

. Physiologic pseudosubluxation

Explanation

Pseudosubluxation of C2 on C3 is a normal physiologic finding in children up to age 8. A Swischuk line passing within 2mm (anterior or posterior) of the anterior aspect of the C3 spinous process confirms that the displacement is physiologic and benign.

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