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6. Spine MCQs

Practice Set 33 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 641

Topic: 6. Spine

A 40-year-old farmer presents with chronic back pain, undulating fever, and profound fatigue. MRI shows L4-L5 discitis with an intact vertebral body architecture and minimal paraspinal soft tissue involvement. What is the most likely diagnosis?

. Pyogenic spondylodiscitis
. Tuberculous spondylitis
. Brucellar spondylitis
. Fungal spondylodiscitis
. Metastatic disease

Correct Answer & Explanation

. Brucellar spondylitis

Explanation

Brucellar spondylitis often presents in individuals with occupational exposure (e.g., farmers, livestock handlers) with undulating fever. It typically causes less vertebral destruction and smaller paraspinal abscesses compared to tuberculosis.

Question 642

Topic: 6. Spine

What is the most common route of bacterial spread leading to spontaneous pyogenic spondylodiscitis in adults?

. Contiguous spread from an adjacent soft tissue infection
. Direct inoculation from penetrating trauma
. Hematogenous spread via arterial routes
. Hematogenous spread via Batson's venous plexus
. Lymphatic spread from pelvic organs

Correct Answer & Explanation

. Hematogenous spread via arterial routes

Explanation

Hematogenous spread via the arterial supply to the subchondral bone of the vertebral endplates is the most common route of infection in adult spontaneous pyogenic spondylodiscitis.

Question 643

Topic: 6. Spine

A patient with thoracic tuberculous spondylitis presents with progressive kyphosis and myelopathy. Which surgical approach provides the most direct and effective decompression and reconstruction?

. Posterior laminectomy alone
. Anterior corpectomy and strut grafting
. Posterior pedicle screw fixation without decompression
. Posterolateral fusion with interbody cages
. Transpedicular biopsy only

Correct Answer & Explanation

. Anterior corpectomy and strut grafting

Explanation

The anterior approach allows for direct debridement of the infected vertebral bodies, decompression of the spinal cord, and reconstruction of the anterior column with strut grafting, addressing the kyphotic deformity effectively.

Question 644

Topic: 6. Spine

Which of the following patient factors is an independent and major risk factor for deep surgical site infection following instrumented spinal fusion?

. Age over 60 years
. Intraoperative blood loss of 500 mL
. Preoperative hemoglobin of 11 g/dL
. Diabetes mellitus with poor glycemic control
. Use of local autograft bone

Correct Answer & Explanation

. Diabetes mellitus with poor glycemic control

Explanation

Poorly controlled diabetes mellitus, obesity, and smoking are among the strongest independent patient-related risk factors for deep surgical site infections following spinal instrumentation.

Question 645

Topic: 6. Spine

A patient develops a deep wound infection 2 weeks after an instrumented posterior lumbar fusion. During surgical exploration, the hardware is found to be rigidly fixed. What is the standard management regarding the instrumentation?

. Removal of all instrumentation and immediate closure
. Removal of instrumentation and delayed closure
. Retention of instrumentation with aggressive irrigation, debridement, and antibiotics
. Exchange of all hardware for new implants
. Retention of hardware but removal of all bone graft

Correct Answer & Explanation

. Retention of instrumentation with aggressive irrigation, debridement, and antibiotics

Explanation

In acute early postoperative infections (within 3-4 weeks), rigidly fixed spinal instrumentation should generally be retained. Management involves aggressive surgical debridement, copious irrigation, and targeted antibiotic therapy.

Question 646

Topic: 6. Spine

Which spinal region is most frequently associated with postoperative infections caused by Cutibacterium acnes (formerly Propionibacterium acnes)?

. Cervical spine
. Thoracic spine
. Lumbar spine
. Sacral spine
. Coccyx

Correct Answer & Explanation

. Cervical spine

Explanation

Cutibacterium acnes is a slow-growing anaerobe that is part of the normal skin flora heavily concentrated on the shoulders and back of the neck, making it a frequent pathogen in postoperative cervical spine infections.

Question 647

Topic: 6. Spine

A 12-year-old patient with sickle cell disease presents with spondylodiscitis. While S. aureus remains the most common overall, which organism is uniquely highly associated with osteomyelitis in this patient population?

. Pseudomonas aeruginosa
. Salmonella species
. Escherichia coli
. Enterobacter cloacae
. Klebsiella pneumoniae

Correct Answer & Explanation

. Salmonella species

Explanation

Patients with sickle cell disease are at a significantly increased risk for bone and joint infections caused by Salmonella species. This is largely attributed to functional asplenia and bowel ischemia allowing bacterial translocation.

Question 648

Topic: 6. Spine

A 50-year-old intravenous drug user presents with neck pain, fever, and rapidly progressive quadriparesis. MRI confirms a large ventral cervical epidural abscess. What is the preferred surgical intervention?

. Posterior cervical laminectomy
. Posterior cervical foraminotomy
. Anterior cervical decompression and fusion
. CT-guided needle aspiration
. Laminectomy and posterior fusion

Correct Answer & Explanation

. Anterior cervical decompression and fusion

Explanation

For ventrally located cervical epidural abscesses with cord compression and neurologic deficit, an anterior approach (ACDF or corpectomy) allows direct decompression of the abscess and immediate stabilization of the spine.

Question 649

Topic: 6. Spine

In a patient with uncomplicated tuberculous spondylitis without neurologic deficit or significant structural deformity, what is the recommended duration of multi-drug antituberculous therapy?

. 3 months
. 6 to 9 months
. 9 to 12 months
. 18 to 24 months
. Lifelong therapy

Correct Answer & Explanation

. 9 to 12 months

Explanation

Uncomplicated spinal tuberculosis is typically managed medically with a 9 to 12-month course of multi-drug antituberculous therapy, which has been shown to be highly effective without the need for routine surgery.

Question 650

Topic: 6. Spine

Which of the following describes the normal postoperative kinetics of the Erythrocyte Sedimentation Rate (ESR) after an uncomplicated spinal fusion?

. Peaks at day 2 and normalizes by day 5
. Peaks at day 5 and normalizes by 2 weeks
. Peaks around day 5-7 and may remain elevated for up to 3-6 weeks
. Continues to rise for 4 weeks before normalizing
. Does not rise postoperatively unless infection is present

Correct Answer & Explanation

. Peaks around day 5-7 and may remain elevated for up to 3-6 weeks

Explanation

Unlike CRP, which peaks early and normalizes within 1-2 weeks, ESR peaks around days 5-7 and can remain elevated for 3 to 6 weeks following uncomplicated spinal surgery. This makes ESR less reliable for early post-op infection screening.

Question 651

Topic: 6. Spine

A patient sustains a gunshot wound to the abdomen with the bullet lodging in the L3 vertebral body, without neurologic deficit. There is a concurrent hollow viscus injury (colon perforation) being treated. What is the most appropriate management of the retained spinal bullet?

. Emergent laminectomy for bullet extraction
. Broad-spectrum IV antibiotics and bullet retention
. Immediate anterior corpectomy and bullet removal to prevent lead toxicity
. Local wound care without antibiotics
. Lumbar puncture to assess CSF for infection before deciding on surgery

Correct Answer & Explanation

. Broad-spectrum IV antibiotics and bullet retention

Explanation

Bullets lodged in the spine are generally retained unless they are within the spinal canal causing a neurologic deficit. Even with concurrent hollow viscus injury, a 7-14 day broad-spectrum antibiotic course is preferred over routine surgical extraction.

Question 652

Topic: 6. Spine

A 55-year-old diabetic male presents with severe lumbar back pain, fever, and progressive lower extremity weakness. MRI reveals a spinal epidural abscess. Which of the following is the most common causative organism?

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

Correct Answer & Explanation

. Staphylococcus aureus

Explanation

Staphylococcus aureus is the most common pathogen responsible for spinal epidural abscesses, accounting for approximately 60% to 90% of cases. Risk factors include diabetes, intravenous drug use, and immunosuppression.

Question 653

Topic: 6. Spine

A 65-year-old patient underwent a posterior lumbar interbody fusion. Three weeks postoperatively, he developed worsening back pain and low-grade fever.

Which inflammatory marker profile most strongly suggests a postoperative deep surgical site infection rather than normal postoperative changes?

. Elevated C-reactive protein (CRP) that had previously normalized
. Erythrocyte sedimentation rate (ESR) that remains elevated at 3 weeks
. Normal white blood cell count with an elevated ESR
. CRP peaking at postoperative day 3
. Gradual decline in both ESR and CRP over 3 weeks

Correct Answer & Explanation

. Elevated C-reactive protein (CRP) that had previously normalized

Explanation

CRP levels typically peak on postoperative day 2 or 3 and normalize within 1 to 2 weeks following uncomplicated spine surgery. A secondary rise or a CRP that remains elevated after previously normalizing is highly suspicious for a postoperative infection.

Question 654

Topic: 6. Spine

An intravenous drug user presents with acute thoracic back pain, fevers, and new-onset lower extremity hyperreflexia. Blood cultures are pending. What is the most appropriate empiric antibiotic regimen pending cultures for a suspected spinal epidural abscess?

. Intravenous Penicillin G and Gentamicin
. Intravenous Ciprofloxacin and Metronidazole
. Intravenous Ceftriaxone monotherapy
. Intravenous Vancomycin and a third- or fourth-generation Cephalosporin
. Oral Linezolid and Moxifloxacin

Correct Answer & Explanation

. Intravenous Vancomycin and a third- or fourth-generation Cephalosporin

Explanation

Empiric coverage for spinal epidural abscess in high-risk patients like IV drug users must cover MRSA and Gram-negative bacilli. Intravenous Vancomycin combined with Cefepime, Ceftazidime, or Ceftriaxone provides broad and appropriate initial coverage.

Question 655

Topic: 6. Spine

When performing surgical debridement for an acute deep postoperative wound infection (within 2 weeks of surgery) following an instrumented posterolateral spinal fusion, what is the standard recommendation regarding the spinal instrumentation?

. Retain the instrumentation, perform thorough irrigation and debridement, and administer prolonged antibiotics
. Remove all instrumentation immediately to clear the biofilm
. Exchange the titanium rods but retain the pedicle screws
. Remove the instrumentation and place a temporary antibiotic cement spacer
. Retain the instrumentation only if the fusion mass appears solid

Correct Answer & Explanation

. Retain the instrumentation, perform thorough irrigation and debridement, and administer prolonged antibiotics

Explanation

For acute postoperative deep surgical site infections in spine surgery, standard practice dictates aggressive surgical debridement with retention of stable spinal instrumentation, followed by targeted prolonged antibiotic therapy.

Question 656

Topic: 6. Spine

Which of the following organism profiles is most frequently isolated in spinal infections associated with penetrating trauma (e.g., gunshot wounds) to the spine involving a trans-bowel trajectory?

. Methicillin-resistant Staphylococcus aureus exclusively
. Mycobacterium tuberculosis
. Fungal organisms such as Candida species
. Polymicrobial flora including Gram-negative bacilli and anaerobes
. Streptococcus viridans

Correct Answer & Explanation

. Polymicrobial flora including Gram-negative bacilli and anaerobes

Explanation

Gunshot wounds that traverse the bowel before hitting the spine often introduce gastrointestinal flora into the spinal column. Prophylactic broad-spectrum antibiotics covering Gram-negatives and anaerobes are required to prevent polymicrobial infections.

Question 657

Topic: 6. Spine

Brucellosis of the spine can clinically mimic other granulomatous infections. Which of the following radiographic features is most characteristic of Brucella spondylitis?

. Early disc space obliteration with rapid endplate destruction
. Massive paraspinal abscesses extending over multiple levels
. Anterior 'parrot beak' osteophytes with relatively intact disc spaces
. Posterior element destruction sparing the vertebral body
. Ivory vertebra sign with diffuse sclerosis

Correct Answer & Explanation

. Anterior 'parrot beak' osteophytes with relatively intact disc spaces

Explanation

Brucella spondylitis often presents with characteristic anterior osteophytosis ('parrot beak' or Pons d'Asin sign) and tends to spare the disc space until late in the disease process, differentiating it from pyogenic infections.

Question 658

Topic: 6. Spine

The classic triad of spontaneous spinal epidural abscess includes back pain, fever, and neurologic deficit. In what percentage of patients does this classic triad present initially?

. Less than 20%
. Approximately 40%
. Approximately 60%
. Approximately 80%
. Nearly 100%

Correct Answer & Explanation

. Less than 20%

Explanation

The classic diagnostic triad for spinal epidural abscess (back pain, fever, and neurologic deficit) is present at initial presentation in a minority of patients, typically less than 20%, which can lead to delayed diagnosis.

Question 659

Topic: 6. Spine

According to the expected kinetics of inflammatory markers, when does the Erythrocyte Sedimentation Rate (ESR) typically peak following an uncomplicated lumbar decompression and fusion?

. Postoperative day 1
. Postoperative day 3
. Postoperative day 5 to 7
. Postoperative day 14
. Postoperative day 21

Correct Answer & Explanation

. Postoperative day 5 to 7

Explanation

Following uncomplicated spine surgery, ESR typically peaks around postoperative days 5 to 7 and can take up to 3 to 6 weeks to normalize. In contrast, CRP peaks around day 2 to 3 and normalizes much faster.

Question 660

Topic: Thoracolumbar Spine & Deformity

A 30-year-old immigrant presents with an 8-month history of middle back pain, weight loss, and progressive lower extremity weakness. Imaging shows severe thoracic kyphosis, destruction of T7 and T8 vertebral bodies, and a large calcified paraspinal abscess. What is the most appropriate surgical approach?

. Posterior laminectomy without fusion
. Posterior decompression and pedicle screw fixation only
. Anterior decompression, debridement, and strut graft reconstruction
. Minimally invasive percutaneous drainage of the abscess
. Posterolateral transpedicular biopsy without decompression

Correct Answer & Explanation

. Anterior decompression, debridement, and strut graft reconstruction

Explanation

In advanced tuberculous spondylitis (Pott's disease) presenting with progressive neurologic deficit and significant anterior column destruction (kyphosis), anterior decompression and structural grafting (the Hong Kong procedure) is the gold standard surgical treatment.

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