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6. Spine MCQs

Practice Set 334 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 6661

Topic: 6. Spine

In the management of spinal epidural abscess, what is the primary role of serial erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) measurements?

. Diagnostic confirmation of the abscess
. Identification of the causative pathogen
. Guidance for the duration of antibiotic therapy
. Assessment of spinal cord compression severity
. Screening for asymptomatic carriers

Correct Answer & Explanation

. Guidance for the duration of antibiotic therapy

Explanation

ESR and CRP are inflammatory markers that are typically elevated in spinal infections. Their primary role in management is to monitor the response to antibiotic therapy and help guide the duration of treatment. A sustained decrease in these markers, often normalizing, indicates successful infection control and helps determine when to transition from IV to oral antibiotics and when to cease treatment. They are non-specific and do not confirm diagnosis, identify pathogens, assess cord compression directly, or screen for asymptomatic carriers.

Question 6662

Topic: 6. Spine

A child with a history of successfully treated lumbar discitis at age 5 presents at age 12 with progressive scoliotic deformity. Which of the following is the most likely cause of this deformity?

. Idiopathic scoliosis unrelated to discitis
. Residual muscle spasm from previous infection
. Growth disturbance secondary to disc space narrowing and adjacent endplate damage
. Connective tissue disorder unmasked by infection
. Compensatory changes due to chronic pain

Correct Answer & Explanation

. Growth disturbance secondary to disc space narrowing and adjacent endplate damage

Explanation

Spinal infections in children, such as discitis and osteomyelitis, can cause damage to the vertebral endplates and growth plates, leading to growth disturbances. This can result in progressive kyphosis, scoliosis, or a combination (kyphoscoliosis) as the child grows, years after the initial infection. This is a well-recognized late complication. While other causes of scoliosis exist, the history of childhood discitis makes this the most direct and likely etiology.

Question 6663

Topic: 6. Spine

A 60-year-old diabetic patient with a chronic foot ulcer develops severe thoracolumbar back pain, fever, and progressive myelopathy over 3 days. MRI confirms a large T11-L1 epidural abscess with significant cord compression. What is the most appropriate immediate management?

. Oral antibiotics and close observation
. Urgent surgical decompression and debridement
. Percutaneous aspiration and IV antibiotics
. Steroid administration to reduce cord edema
. Physical therapy and pain management

Correct Answer & Explanation

. Urgent surgical decompression and debridement

Explanation

This patient presents with rapidly progressive myelopathy and significant cord compression secondary to a large epidural abscess, which is an absolute indication for urgent surgical decompression and debridement. Diabetes and chronic ulcers are risk factors for spinal infection, often polymicrobial. Oral antibiotics alone are insufficient and dangerous. Percutaneous aspiration might be considered for stable patients without neurological deficits, but not in this acute setting with cord compression. Steroids are generally contraindicated as they can worsen bacterial infections and do not remove the compressive pus. Physical therapy is not an immediate treatment for active infection and neurological compromise.

Question 6664

Topic: 6. Spine

When is CT scan most useful in the diagnosis and management of spinal epidural abscess, compared to MRI?

. Initial screening for all suspected cases
. For evaluating the extent of soft tissue involvement and cord compression
. When MRI is contraindicated (e.g., pacemaker or non-MRI compatible metallic implants)
. To identify early discitis without bony involvement
. To differentiate between bacterial and fungal abscesses

Correct Answer & Explanation

. When MRI is contraindicated (e.g., pacemaker or non-MRI compatible metallic implants)

Explanation

MRI is the gold standard for diagnosing spinal epidural abscess and evaluating soft tissue involvement, cord compression, and discitis. CT is most useful when MRI is contraindicated (e.g., pacemakers, non-MRI compatible metallic implants) or when better bony detail is required, such as assessing vertebral body destruction, stability, or for pre-operative planning of complex bony debridement. It's less sensitive than MRI for early discitis or purely soft tissue collections without significant bony changes. It does not differentiate pathogen types.

Question 6665

Topic: 6. Spine

Which factor is most strongly associated with a poorer neurological outcome in patients with spinal epidural abscess?

. Age > 60 years
. Lumbar location of the abscess
. Pre-existing diabetes mellitus
. Pre-operative complete neurological deficit
. Staphylococcus aureus as the causative organism

Correct Answer & Explanation

. Pre-operative complete neurological deficit

Explanation

The most critical prognostic factor for neurological recovery in spinal epidural abscess is the preoperative neurological status. Patients presenting with a complete neurological deficit (e.g., complete paraplegia or quadriplegia) prior to surgery have a significantly worse prognosis for recovery compared to those with partial deficits or no deficits. While age, diabetes, and S. aureus can worsen overall prognosis or increase risk, they are not as strong predictors ofneurological recoveryas the initial neurological status. Lumbar location is often associated with better outcomes than cervical/thoracic due to larger canal space.

Question 6666

Topic: 6. Spine

Following surgical decompression and debridement of a spinal epidural abscess, what is the most important parameter to monitor for early detection of recurrence or persistent infection?

. White blood cell count
. Serum creatinine
. Daily neurological examination
. Liver function tests
. Plain radiographs of the spine

Correct Answer & Explanation

. Daily neurological examination

Explanation

While WBC and inflammatory markers (ESR/CRP) are important for monitoring overall infection resolution, daily neurological examination is paramount post-operatively. Any new or worsening neurological deficit can indicate persistent compression, new abscess formation, or a surgical complication requiring immediate re-evaluation and potentially re-imaging/re-operation. Plain radiographs are not useful for early detection of soft tissue recurrence. Serum creatinine and LFTs are general health markers.

Question 6667

Topic: 6. Spine

A 40-year-old healthy male presents with localized thoracic back pain and low-grade fever. MRI shows a small (5mm x 1cm) thoracic epidural abscess at T8, without cord compression or neurological deficits. Blood cultures are positive for MSSA. What is the most appropriate initial management?

. Urgent surgical decompression
. High-dose steroids
. IV antibiotics with close neurological monitoring
. Percutaneous drainage and IV antibiotics
. Discharge with oral antibiotics

Correct Answer & Explanation

. IV antibiotics with close neurological monitoring

Explanation

For patients with small, localized spinal epidural abscesses, stable neurological status (no deficits), and identified sensitive organisms, a trial of intravenous antibiotics with very close neurological monitoring can be an appropriate initial management strategy. Urgent surgery is reserved for progressive deficits or larger abscesses causing compression. Steroids are contraindicated. Percutaneous drainage can be considered, but initial primary treatment is IV antibiotics. Oral antibiotics are insufficient for initial treatment of a spinal epidural abscess.

Question 6668

Topic: 6. Spine

A 75-year-old female undergoes extensive laminectomy and debridement for a large L3-L4 epidural abscess, with significant destruction of the L3 vertebral body. What is the most significant long-term concern related to spinal stability following this procedure?

. Adjacent segment disease
. Post-laminectomy kyphosis and instability
. Increased risk of future disc herniation
. Development of facet arthropathy
. Sacral stress fracture

Correct Answer & Explanation

. Post-laminectomy kyphosis and instability

Explanation

Extensive laminectomy, especially when combined with significant vertebral body destruction from infection, can severely compromise spinal stability. This often leads to iatrogenic post-laminectomy kyphosis or progressive instability, which may necessitate concurrent or staged spinal fusion and instrumentation to prevent deformity and protect neurological structures. Adjacent segment disease is a concern typically after spinal fusion. Disc herniation and facet arthropathy are degenerative issues. Sacral stress fractures are unrelated.

Question 6669

Topic: 6. Spine

The use of gadolinium contrast in spinal MRI for suspected epidural abscess is primarily to:

. Visualize bony anatomy more clearly
. Improve visualization of abscess margins and inflammatory tissue
. Reduce scan time and patient discomfort
. Differentiate between CSF and solid tumor
. Assess spinal cord edema directly

Correct Answer & Explanation

. Improve visualization of abscess margins and inflammatory tissue

Explanation

Gadolinium contrast significantly enhances the margins of the abscess capsule, granulation tissue, and any associated inflammatory changes or osteomyelitis, allowing for better delineation of the extent of the infection and differentiation from surrounding edema or normal tissue. It does not primarily visualize bony anatomy better than non-contrast MRI, reduce scan time, or primarily differentiate CSF from tumor (though it aids in tumor characterization). Spinal cord edema is better seen on T2-weighted sequences.

Question 6670

Topic: 6. Spine

A patient presents with a T12-L1 vertebral osteomyelitis. Which of the following deep tissue collections is most likely to develop as a direct extension from this specific spinal level?

. Retropharyngeal abscess
. Subdural empyema
. Psoas abscess
. Gluteal abscess
. Ischiorectal abscess

Correct Answer & Explanation

. Psoas abscess

Explanation

The psoas major muscle originates from the T12 to L5 vertebrae and inserts into the lesser trochanter of the femur. Infections (like osteomyelitis) in the thoracolumbar spine, particularly in the lumbar region, can easily track along the psoas muscle sheath, leading to a psoas abscess. Retropharyngeal abscesses are cervical. Subdural empyema is intracranial/intraspinal. Gluteal and ischiorectal abscesses are lower body soft tissue infections less directly related to thoracolumbar spinal infection.

Question 6671

Topic: 6. Spine

Which patient characteristic or finding would suggest a more acute, rapidly progressing spinal epidural abscess rather than a chronic or indolent process?

. Weight loss and night sweats for 3 months
. Insidious onset of back pain over 6 months
. Rapid progression of neurological deficits over 24-48 hours
. ESR 30 mm/hr and CRP 15 mg/L
. Presence of multiple small cold abscesses

Correct Answer & Explanation

. Rapid progression of neurological deficits over 24-48 hours

Explanation

Rapid progression of neurological deficits over a short period (hours to days) is a hallmark of acute, rapidly expanding spinal epidural abscesses and necessitates urgent intervention. The other options (weight loss, night sweats, insidious pain, mildly elevated inflammatory markers, cold abscesses) are more suggestive of a chronic or indolent process, such as tuberculous spondylitis.

Question 6672

Topic: 6. Spine

A patient presents with a rapidly developing C7-T1 epidural abscess. During history taking, she admits to recent illicit intravenous drug use. This history significantly increases the likelihood of which specific microorganism?

. Streptococcus pneumoniae
. Anaerobic bacteria
. Pseudomonas aeruginosa
. Bartonella henselae
. Nocardia asteroides

Correct Answer & Explanation

. Pseudomonas aeruginosa

Explanation

While S. aureus is the most common pathogen in IV drug users overall, Pseudomonas aeruginosa is disproportionately common in spinal infections, especially osteomyelitis and epidural abscesses, in IV drug users due to contaminated drug paraphernalia and skin flora. Its presence often necessitates specific antibiotic coverage (e.g., Ciprofloxacin, Piperacillin-tazobactam). The cervical and thoracic spine are common sites for Pseudomonas osteomyelitis/abscess in this population.

Question 6673

Topic: 6. Spine

During an urgent laminectomy for a spinal epidural abscess, an incidental dural tear is noted. The dura is repaired primarily. What is the most appropriate post-operative management regarding ambulation and activity?

. Immediate full weight-bearing and mobilization
. Strict bed rest for 24 hours, followed by gradual mobilization
. Strict bed rest for 3-5 days
. Head of bed elevated 30 degrees only
. Placement of a lumbar drain for 48 hours

Correct Answer & Explanation

. Strict bed rest for 3-5 days

Explanation

For intraoperative dural tears, especially those repaired primarily, a period of strict bed rest (typically 3-5 days, though guidelines vary from 2-7 days) is usually recommended to allow the dural repair to heal and minimize the risk of cerebrospinal fluid (CSF) leak or pseudomeningocele formation by reducing intracranial and intraspinal CSF pressure. Immediate or early mobilization increases CSF pressure and the risk of failure of the repair. Lumbar drains are used for persistent leaks or larger tears, not routinely for all primary repairs.

Question 6674

Topic: 6. Spine

A patient treated successfully for a lumbar epidural abscess 6 months ago now presents with recurrent back pain, fever, and new neurological symptoms. What is the most critical initial diagnostic step?

. Repeat inflammatory markers
. Empiric broad-spectrum antibiotics
. Repeat MRI of the lumbar spine with gadolinium
. Lumbar puncture
. Consultation with infectious disease specialist

Correct Answer & Explanation

. Repeat MRI of the lumbar spine with gadolinium

Explanation

Given the recurrent symptoms (back pain, fever, new neurological deficits) and history of spinal abscess, the most critical initial diagnostic step is a repeat MRI of the lumbar spine with gadolinium to definitively assess for a recurrent abscess or osteomyelitis. While inflammatory markers, antibiotics, and ID consultation are important, they follow the definitive imaging diagnosis. Lumbar puncture is generally avoided in suspected epidural abscess.

Question 6675

Topic: 6. Spine

When managing a patient with vertebral osteomyelitis and epidural abscess, which imaging finding on plain radiographs or CT scan raises the greatest concern for spinal instability requiring surgical stabilization?

. Endplate erosion at a single level
. Mild disc space narrowing
. >50% destruction of a vertebral body
. Pedicle sclerosis
. Adjacent soft tissue swelling

Correct Answer & Explanation

. >50% destruction of a vertebral body

Explanation

Significant destruction of a vertebral body (typically >50% height loss or involvement of multiple spinal columns: anterior, middle, posterior) is a major concern for spinal instability, especially in the context of infection where bone quality is compromised. This degree of destruction may lead to progressive kyphosis or translation, necessitating surgical stabilization in addition to decompression and debridement. Endplate erosion, disc narrowing, pedicle sclerosis, and soft tissue swelling do not inherently indicate instability to the same degree.

Question 6676

Topic: 6. Spine

A 60-year-old male with a thoracic epidural abscess is noted to have a new-onset motor deficit (4/5 strength in bilateral lower extremities) on morning rounds. He is scheduled for surgery in 6 hours. What is the appropriate action?

. Proceed with the scheduled surgery as planned
. Delay surgery to optimize medical comorbidities
. Administer a bolus of steroids immediately
. Expedite surgery to the earliest possible time
. Order an immediate repeat MRI

Correct Answer & Explanation

. Expedite surgery to the earliest possible time

Explanation

An acute decline in neurological function (e.g., new motor deficit) in a patient with a spinal epidural abscess mandates expediting surgical decompression to the earliest possible time, ideally immediately. Every hour of delay in decompression for acute neurological compromise can lead to irreversible neurological damage. Delaying for comorbidities or administering steroids are inappropriate. Repeat MRI might delay definitive treatment further and is usually not necessary for an acute decline in a known abscess.

Question 6677

Topic: 6. Spine

Percutaneous drainage of a spinal epidural abscess may be considered in which of the following scenarios?

. Rapidly progressive neurological deficit
. Large multiloculated abscess causing significant cord compression
. Small, well-circumscribed abscess in a hemodynamically stable patient without neurological deficits
. Abscess with associated spinal instability
. Failed medical management with ongoing sepsis

Correct Answer & Explanation

. Small, well-circumscribed abscess in a hemodynamically stable patient without neurological deficits

Explanation

Percutaneous drainage can be an option for small, well-circumscribed, accessible spinal epidural abscesses in hemodynamically stable patients who do not have neurological deficits or rapidly progressive symptoms. It may also be used for diagnostic purposes. It is generally not suitable for rapidly progressive deficits, large multiloculated abscesses, those with significant cord compression, or spinal instability, which typically require open surgical debridement. Failed medical management with sepsis is also a strong indication for open surgery.

Question 6678

Topic: 6. Spine

When should a follow-up MRI be considered after successful surgical decompression and several weeks of antibiotic therapy for a spinal epidural abscess?

. Only if symptoms recur
. Routinely at 6 months post-op regardless of symptoms
. To confirm resolution of the abscess and assess for stability
. To monitor bone mineral density changes
. Immediately after discontinuing antibiotics

Correct Answer & Explanation

. To confirm resolution of the abscess and assess for stability

Explanation

A follow-up MRI, typically after a significant course of antibiotics (e.g., 6-8 weeks) or upon completion of antibiotic therapy, is often recommended to confirm the resolution of the abscess, assess for any residual collections, and evaluate for spinal stability, especially if there was significant bony destruction. This helps guide further management and confirm treatment success. Waiting for symptom recurrence is reactive, and routine imaging at a fixed time without clinical rationale is less evidence-based.

Question 6679

Topic: 6. Spine

A patient on chronic immunosuppression for rheumatoid arthritis develops new onset back pain, fevers, and neurological deficits. An MRI confirms a spinal epidural abscess. What additional diagnostic step should be considered, beyond routine bacterial cultures?

. HIV testing
. Fungal cultures and serology
. Genetic testing for primary immunodeficiency
. Toxicology screen
. Repeat blood cultures every 4 hours

Correct Answer & Explanation

. Fungal cultures and serology

Explanation

In immunocompromised patients, the risk of atypical organisms, particularly fungal pathogens (e.g., Candida, Aspergillus), is significantly increased. Therefore, fungal cultures (blood, tissue) and serology should be considered in the diagnostic workup in addition to routine bacterial cultures. While HIV testing might be relevant as a general health screen in some immunocompromised patients, it is not directly about identifying the abscess's microbiology in this context. Genetic testing or toxicology screens are less immediately relevant to identifying the pathogen of the current infection. Repeat blood cultures are routine but will not detect fungal organisms.

Question 6680

Topic: 6. Spine

For a large anterior thoracic epidural abscess causing severe cord compression from T6 to T8, which surgical approach is generally favored for decompression and debridement?

. Posterior laminectomy alone
. Transpedicular approach
. Costotransversectomy or Transthoracic approach
. Lumbar drain placement
. Anterior cervical discectomy and fusion

Correct Answer & Explanation

. Costotransversectomy or Transthoracic approach

Explanation

Anterior thoracic epidural abscesses causing significant cord compression require an anterior approach for direct decompression and debridement of the anterior pathology. A costotransversectomy or a formal transthoracic approach (thoracotomy) allows direct access to the anterior epidural space and vertebral bodies in the thoracic spine. Posterior laminectomy alone is contraindicated for anterior compression as it can worsen kyphosis and not adequately decompress the anterior cord. Transpedicular approaches are less extensive and may not provide sufficient decompression for large, multi-level anterior collections. Lumbar drain is for CSF leaks. Anterior cervical approach is for the cervical spine.

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