Menu

6. Spine MCQs

Practice Set 333 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 6641

Topic: 6. Spine

What is a common cause of recurrent lumbar spinal stenosis after initial successful decompression?

. Formation of a new disc herniation at a different level.
. Insufficient removal of compressing structures during the initial surgery.
. Development of a chronic epidural abscess.
. Spontaneous new bone growth within the spinal canal.
. Progression of peripheral neuropathy.

Correct Answer & Explanation

. Insufficient removal of compressing structures during the initial surgery.

Explanation

Recurrent lumbar spinal stenosis most commonly occurs due to either insufficient removal of compressing structures during the initial surgery (leading to incomplete decompression) or due to progressive degenerative changes at the same or adjacent levels over time, such as facet hypertrophy or ligamentum flavum regrowth/hypertrophy. While adjacent segment disease (Option A) is also common, the question asks for recurrenceat the same site or due to related causes. Chronic epidural abscess (Option C) and spontaneous new bone growth (Option D) are rare. Peripheral neuropathy (Option E) is a separate condition.

Question 6642

Topic: 6. Spine

In cauda equina syndrome, why is 'sacral sparing' a relevant concept?

. It indicates involvement of the sacral nerve roots only.
. It suggests that bowel and bladder function will always recover fully.
. It implies sparing of the sensory and motor function of the sacral nerve roots, which typically control bowel/bladder and perineal sensation.
. It means the lesion is above the conus medullaris.
. It is a term used exclusively for pediatric cauda equina syndrome.

Correct Answer & Explanation

. It implies sparing of the sensory and motor function of the sacral nerve roots, which typically control bowel/bladder and perineal sensation.

Explanation

Sacral sparing refers to the relative preservation of sensory or motor function in the sacral dermatomes (S2-S5), which supply the perineum, saddle area, and control bowel/bladder function. In incomplete cauda equina syndrome, some sacral functions may be spared, indicating a less severe or incomplete lesion. Its presence (or absence) helps determine the extent of neural compromise and has prognostic implications regarding recovery of bowel/bladder function. Options A, B, D, and E are incorrect.

Question 6643

Topic: 6. Spine

Aside from dynamic X-rays, which clinical finding is most suggestive of potential spinal instability that might necessitate fusion alongside decompression?

. Widespread sensory deficits.
. Severe neurogenic claudication.
. Mechanical low back pain that significantly worsens with flexion/extension movements (segmental instability).
. Presence of a positive straight leg raise test.
. Normal neurological examination.

Correct Answer & Explanation

. Mechanical low back pain that significantly worsens with flexion/extension movements (segmental instability).

Explanation

Mechanical low back pain that significantly worsens with movement, particularly with certain flexion or extension movements (segmental instability), is a key clinical indicator of potential spinal instability. This suggests that the degenerative process has led to hypermobility between vertebral segments. While dynamic X-rays are the primary radiographic tool, clinical assessment for mechanical pain with movement is crucial. Options A, B, D, and E are not direct indicators of spinal instability. Severe claudication (Option B) indicates stenosis severity, not instability.

Question 6644

Topic: 6. Spine

Which preoperative factor has been consistently shown to negatively impact surgical outcomes in lumbar spinal stenosis?

. Short duration of symptoms (<3 months).
. High level of education.
. Significant preoperative depression or anxiety.
. Absence of motor deficits.
. Single-level stenosis.

Correct Answer & Explanation

. Significant preoperative depression or anxiety.

Explanation

Significant preoperative psychological distress, such as depression or anxiety, has consistently been shown to negatively impact patient-reported outcomes after spinal surgery, including for lumbar spinal stenosis. These factors can influence pain perception, coping mechanisms, and overall satisfaction with surgery. Short symptom duration (Option A) often correlates with better outcomes. High education (Option B) is generally neutral or positive. Absence of motor deficits (Option D) is generally a good prognostic sign. Single-level stenosis (Option E) is associated with better outcomes than multilevel.

Question 6645

Topic: 6. Spine

A patient presents with symptoms of multilevel lumbar spinal stenosis (e.g., L2-3, L3-4, L4-5). What is a key consideration when planning surgical decompression in such a case?

. To always perform fusion at all stenotic levels.
. To limit decompression to only the most symptomatic level to minimize surgical invasiveness.
. To meticulously decompress all symptomatic levels while preserving spinal stability where possible.
. To exclusively use minimally invasive techniques regardless of stenosis severity.
. To treat only with conservative management, as surgery for multilevel stenosis has poor outcomes.

Correct Answer & Explanation

. To meticulously decompress all symptomatic levels while preserving spinal stability where possible.

Explanation

When dealing with multilevel stenosis, the goal is to adequately decompress all symptomatic levels. However, it's crucial to do so while preserving as much spinal stability as possible. This often involves careful bone and ligament removal to avoid iatrogenic instability. Fusion is not always necessary for all levels (Option A), and limiting decompression to only one level (Option B) may leave residual symptoms. While MIS techniques can be used (Option D), their applicability and extent of decompression might be limited in complex multilevel cases. Surgery for multilevel stenosis (Option E) can have good outcomes with appropriate planning.

Question 6646

Topic: 6. Spine

Which of the following features is most characteristic of severe cauda equina compression, warranting urgent intervention?

. Unilateral L4 radicular pain.
. Bilateral lower extremity numbness and weakness without bowel/bladder involvement.
. Progressive neurogenic claudication over several months.
. Acute onset of bowel and bladder dysfunction with saddle anesthesia.
. Isolated foot drop of gradual onset.

Correct Answer & Explanation

. Acute onset of bowel and bladder dysfunction with saddle anesthesia.

Explanation

Acute onset of bowel and bladder dysfunction (e.g., urinary retention or incontinence, fecal incontinence) coupled with saddle anesthesia (sensory loss in the S2-S5 dermatomes) are the hallmarks of Cauda Equina Syndrome (CES) and constitute a surgical emergency. This requires urgent decompression to maximize the chance of neurological recovery, particularly for bowel and bladder function. The other options describe less acute or severe conditions (Options A, B, E) or a chronic progression (Option C) that do not necessitate emergency surgery in the same way.

Question 6647

Topic: 6. Spine

A patient develops new or worsening radicular symptoms immediately after successful lumbar decompression for stenosis. What is the most common cause?

. Insufficient decompression of the nerve root.
. Development of an epidural hematoma.
. Postoperative nerve root edema or inflammation.
. Surgical site infection.
. New disc herniation at the decompressed level.

Correct Answer & Explanation

. Postoperative nerve root edema or inflammation.

Explanation

Postoperative nerve root edema or inflammation is the most common cause of new or worsening radicular symptoms immediately after technically successful decompression. The nerve roots, having been chronically compressed, can swell and become inflamed after the pressure is relieved, leading to transient exacerbation of symptoms. This usually resolves with anti-inflammatory measures and time. While other options can cause symptoms, they are generally less common than temporary nerve root irritation. Insufficient decompression (Option A) would mean the symptoms never really improved. Epidural hematoma (Option B) is a serious but less common immediate cause.

Question 6648

Topic: 6. Spine

For a patient with symptomatic degenerative lumbar spinal stenosis and Grade 1 degenerative spondylolisthesis, who has failed conservative treatment, what is the current evidence-based recommendation regarding fusion vs. decompression alone?

. Decompression alone is always sufficient and has better outcomes.
. Fusion should always be performed to prevent progression of the spondylolisthesis.
. Decompression with concomitant fusion results in better long-term functional outcomes than decompression alone.
. The choice between decompression alone and decompression with fusion is purely based on surgeon preference.
. Spinal fusion is contraindicated in the presence of degenerative spondylolisthesis.

Correct Answer & Explanation

. Decompression with concomitant fusion results in better long-term functional outcomes than decompression alone.

Explanation

For patients with symptomatic degenerative lumbar spinal stenosis and associated Grade 1 degenerative spondylolisthesis, randomized controlled trials (e.g., SPORT trial) have shown that decompression with concomitant fusion results in better long-term functional outcomes compared to decompression alone, primarily due to improved stability and reduced rates of reoperation for progressive slip or recurrent stenosis. While decompression alone can be an option for stable slips, the evidence supports adding fusion for superior long-term results. Options A, B, D, and E are incorrect interpretations of current evidence.

Question 6649

Topic: 6. Spine

How does maintaining appropriate sagittal balance relate to outcomes in lumbar spine surgery for stenosis?

. Sagittal balance is only relevant for large deformity corrections, not for stenosis surgery.
. Restoring sagittal balance is crucial for optimizing surgical outcomes and reducing the risk of adjacent segment disease and mechanical back pain.
. Loss of sagittal balance after decompression is a benign finding.
. Hyperlordosis is always the ideal sagittal alignment.
. The patient's sagittal balance cannot be altered surgically during decompression.

Correct Answer & Explanation

. Restoring sagittal balance is crucial for optimizing surgical outcomes and reducing the risk of adjacent segment disease and mechanical back pain.

Explanation

Maintaining or restoring appropriate sagittal balance is increasingly recognized as crucial for optimizing long-term surgical outcomes in lumbar spine surgery, including for stenosis, particularly when fusion is involved. Poor sagittal alignment can lead to increased stress on adjacent segments (adjacent segment disease), persistent mechanical back pain, and poorer functional outcomes. Option A is incorrect, as it applies to smaller corrections too. Option C is incorrect; it's a significant finding. Hyperlordosis (Option D) is not always ideal; a balanced alignment is. Sagittal balance (Option E) can be significantly altered and improved through appropriate surgical techniques, especially fusion.

Question 6650

Topic: 6. Spine

Which of the following findings would most strongly suggest diabetic neuropathy rather than neurogenic claudication as the primary cause of lower extremity symptoms?

. Symptoms relieved by leaning forward.
. Diminished patellar and Achilles reflexes bilaterally.
. Pain exacerbated by standing and walking.
. Presence of a sensory 'stocking-glove' distribution.
. Normal ankle-brachial index.

Correct Answer & Explanation

. Presence of a sensory 'stocking-glove' distribution.

Explanation

A sensory 'stocking-glove' distribution (symptoms affecting the distal extremities symmetrically, gradually progressing proximally) is highly characteristic of diabetic peripheral neuropathy. While both conditions can cause diminished reflexes (Option B) and be worse with activity (Option C), and neurogenic claudication can be relieved by leaning forward (Option A), the specific 'stocking-glove' pattern is a key differentiator for neuropathy. A normal ABI (Option E) rules out vascular claudication but doesn't distinguish between neurogenic claudication and neuropathy.

Question 6651

Topic: 6. Spine

Long-term systemic steroid use for managing pain from spinal stenosis increases the risk of which orthopedic complication?

. Osteoarthritis progression.
. Ligamentum flavum hypertrophy.
. Avascular necrosis (AVN) of the femoral head.
. New onset disc herniation.
. Increased bone density.

Correct Answer & Explanation

. Avascular necrosis (AVN) of the femoral head.

Explanation

Long-term systemic corticosteroid use is a well-known risk factor for avascular necrosis (AVN), particularly of the femoral head, as well as osteoporosis and increased fracture risk. While steroid use for spinal stenosis is typically epidural (local), prolonged or frequent systemic courses for any condition (or high-dose local injections) can have systemic effects. Options A, B, D are not direct complications of systemic steroid use. Option E is incorrect; steroids lead to decreased bone density.

Question 6652

Topic: 6. Spine

What is the primary goal of physical therapy in the conservative management of lumbar spinal stenosis?

. To strengthen the erector spinae muscles to maintain an extended lumbar posture.
. To achieve complete spinal immobility to prevent pain.
. To improve core strength, flexibility, and promote a slightly flexed lumbar posture during activities of daily living.
. To increase nerve conduction velocity in the cauda equina.
. To surgically decompress the spinal canal without incisions.

Correct Answer & Explanation

. To improve core strength, flexibility, and promote a slightly flexed lumbar posture during activities of daily living.

Explanation

The primary goal of physical therapy for lumbar spinal stenosis is to improve core strength, flexibility, and to teach patients strategies to maintain a slightly flexed lumbar posture during activities. Lumbar flexion increases the spinal canal diameter, alleviating pressure on nerve roots. Strengthening erector spinae (Option A) for extension is counterproductive for stenosis. Spinal immobility (Option B) is detrimental. PT does not directly increase nerve conduction velocity (Option D) or perform surgery (Option E).

Question 6653

Topic: 6. Spine

What is the primary role of intraoperative neuromonitoring (e.g., SSEP, MEP) during lumbar decompression surgery?

. To guide the placement of pedicle screws during fusion.
. To confirm the diagnosis of spinal stenosis.
. To detect potential neurological injury to the spinal cord or nerve roots during surgery.
. To measure the effectiveness of the decompression in real-time.
. To monitor the patient's vital signs.

Correct Answer & Explanation

. To detect potential neurological injury to the spinal cord or nerve roots during surgery.

Explanation

Intraoperative neuromonitoring (IONM), primarily somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs), is used to detect potential neurological injury to the spinal cord or nerve roots during spinal surgery. Changes in these potentials can alert the surgical team to impending or ongoing neural compromise, allowing for corrective actions. While pedicle screw placement (Option A) can be guided by fluoroscopy or navigation, not typically SSEPs/MEPs, and IONM is not for diagnosis (Option B), measuring decompression effectiveness in real-time (Option D), or vital signs (Option E).

Question 6654

Topic: 6. Spine

How does facet joint hypertrophy contribute to central and foraminal stenosis in the lumbar spine?

. It causes the vertebral bodies to collapse, leading to indirect compression.
. The enlarged facet joints bulge into the spinal canal and foramina, directly narrowing these spaces.
. It stimulates disc degeneration, which is the primary cause of stenosis.
. It leads to excessive lumbar lordosis, which widens the canal.
. It is a benign finding with no clinical significance in stenosis.

Correct Answer & Explanation

. The enlarged facet joints bulge into the spinal canal and foramina, directly narrowing these spaces.

Explanation

Facet joint hypertrophy is a significant contributor to both central and foraminal stenosis. The enlarged facet joints, often accompanied by osteophyte formation, bulge into the spinal canal posteriorly and into the neural foramina laterally, directly reducing the space available for the cauda equina nerve roots. Options A, C, D, and E are incorrect.

Question 6655

Topic: 6. Spine

What is the most critical factor influencing the prognosis for recovery of bowel and bladder function in cauda equina syndrome?

. The patient's age.
. The specific level of compression (e.g., L2 vs S1).
. The duration of symptoms, particularly the time from onset of bowel/bladder dysfunction to surgical decompression.
. The severity of motor weakness in the lower extremities.
. The presence of saddle anesthesia.

Correct Answer & Explanation

. The duration of symptoms, particularly the time from onset of bowel/bladder dysfunction to surgical decompression.

Explanation

The most critical factor influencing the prognosis for recovery of bowel and bladder function in cauda equina syndrome is the duration of symptoms, particularly the time interval from the onset of bowel and bladder dysfunction to surgical decompression. Earlier decompression (ideally within 24-48 hours) is associated with a significantly better chance of neurological recovery, especially for sphincter function. While other factors might play a role, timeliness of decompression is paramount. Options A, B, D, and E are less critical than the time to surgery for bowel/bladder recovery.

Question 6656

Topic: 6. Spine

A 3-year-old child presents with refusal to walk, irritability, and low-grade fever for 3 days. Physical examination reveals tenderness to palpation over the lumbar spine and a limping gait. Inflammatory markers are elevated. The most common site for a spinal infection in this age group is:

. Thoracic epidural space
. Lumbar disc space (discitis)
. Cervical vertebral body
. Sacral epidural space
. Psoas muscle

Correct Answer & Explanation

. Lumbar disc space (discitis)

Explanation

In young children, discitis (inflammation or infection of the intervertebral disc space) is more common than true epidural abscess, although they can coexist or discitis can progress to an abscess. The lumbar spine is the most frequently affected region. Symptoms like refusal to walk, irritability, and a limping gait are classic presentations in this age group.

Question 6657

Topic: 6. Spine

A 55-year-old male undergoes a lumbar fusion for degenerative spondylolisthesis. On post-operative day 7, he develops fever, increasing back pain, and purulent drainage from the surgical incision. Which of the following is the most likely pathogen?

. Propionibacterium acnes
. Coagulase-negative Staphylococcus
. Staphylococcus aureus
. Enterococcus faecalis
. Candida albicans

Correct Answer & Explanation

. Staphylococcus aureus

Explanation

Staphylococcus aureus, including MRSA, is the most common cause of acute surgical site infections (SSI) in orthopedic spine surgery, often manifesting within the first week post-op with fever, pain, and wound drainage. Coagulase-negative Staphylococcus and Propionibacterium acnes are more commonly associated with delayed or chronic hardware-related infections. Enterococcus and Candida can occur but are less frequent than S. aureus in acute SSI.

Question 6658

Topic: 6. Spine
Which of the following statements regarding the pathophysiology of spinal epidural abscess is INCORRECT?
. Hematogenous spread from a distant infection is a common route.
. Direct extension from adjacent osteomyelitis or discitis can lead to SEA.
. The posterior epidural space is more commonly involved than the anterior epidural space in pyogenic spinal epidural abscesses.
. Neurological deficits primarily result from spinal cord compression and ischemia.
. The lumbar spine is the most frequent location.

Correct Answer & Explanation

. The posterior epidural space is more commonly involved than the anterior epidural space in pyogenic spinal epidural abscesses.

Explanation

The statement 'The posterior epidural space is more commonly involved than the anterior epidural space in pyogenic spinal epidural abscesses' is incorrect. Most pyogenic spinal epidural abscesses originate from vertebral body osteomyelitis or discitis (which spread anteriorly) or via hematogenous spread to Batson's plexus (primarily anterior). Therefore, the anterior epidural space is actually more frequently involved in pyogenic SEA, especially in the lumbar region. The other statements are generally considered correct.

Question 6659

Topic: 6. Spine

Which of the following is a recognized complication specifically associated with anterior surgical approaches for cervical spinal epidural abscesses?

. Superficial wound infection
. Recurrent laryngeal nerve palsy
. Dural tear
. Persistent neurological deficit
. Deep vein thrombosis

Correct Answer & Explanation

. Recurrent laryngeal nerve palsy

Explanation

Recurrent laryngeal nerve palsy leading to hoarseness or dysphonia is a well-known complication unique to anterior cervical approaches due to the nerve's anatomical course. While superficial wound infection, dural tear, persistent neurological deficit, and deep vein thrombosis can occur with any spinal surgery (or general surgery), recurrent laryngeal nerve palsy is specific to anterior cervical access.

Question 6660

Topic: 6. Spine

A patient with a C2 epidural abscess presents with myelopathy. Given the location, what is a critical consideration during surgical planning that might differ from a lumbar abscess?

. Need for awake intubation
. Higher risk of respiratory compromise and aspiration
. Requirement for pre-operative cardiac stress test
. Greater likelihood of hardware removal
. Lower threshold for non-operative management

Correct Answer & Explanation

. Higher risk of respiratory compromise and aspiration

Explanation

Cervical spinal epidural abscesses, particularly at high cervical levels (C1-C4), pose a higher risk of brainstem involvement, respiratory compromise, and aspiration due to proximity to pharyngeal structures and vital respiratory centers. This necessitates careful airway management pre- and intraoperatively. While awake intubation may be considered in certain unstable cervical spine cases, it's not universally required. Hardware removal is dependent on the infection's relation to hardware, not purely location. Cardiac stress tests are general preoperative assessments. Non-operative management threshold is generally similar unless the patient is extremely frail and non-operative is the only option.

Test Yourself

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

On this Page