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6. Spine MCQs

Practice Set 339 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 6761

Topic: 6. Spine

In a viva setting, an examiner presents a patient with chronic low back pain and significant leg pain, suspected to be lumbar radiculopathy. You've outlined your diagnostic approach. The examiner asks, 'What is the role of an MRI scan in your initial management plan for this patient, and when would you order it?'

. An MRI is always the first diagnostic step for any patient with low back pain and radicular symptoms to confirm the diagnosis and rule out serious pathology.
. An MRI is not typically indicated in the initial 6 weeks of symptoms unless 'red flag' signs suggest serious pathology (e.g., cauda equina syndrome, progressive neurological deficit, tumor, infection), or if symptoms persist despite adequate conservative treatment.
. An MRI is primarily for surgical planning, so it should only be ordered after the patient has failed all conservative measures and has committed to surgery.
. An MRI is primarily useful for assessing soft tissue injuries, so it is rarely helpful for bony pathologies in the spine.
. An MRI is only ordered by neurologists; orthopedic surgeons rely on plain radiographs.

Correct Answer & Explanation

. An MRI is not typically indicated in the initial 6 weeks of symptoms unless 'red flag' signs suggest serious pathology (e.g., cauda equina syndrome, progressive neurological deficit, tumor, infection), or if symptoms persist despite adequate conservative treatment.

Explanation

For most patients with acute low back pain and radiculopathy, an MRI is not indicated in the initial 4-6 weeks unless 'red flag' symptoms (e.g., cauda equina syndrome, progressive motor weakness, signs of infection or malignancy) are present, or if symptoms are severe and debilitating and persist beyond this period despite appropriate conservative management. Early imaging often reveals asymptomatic disc bulges or herniations, leading to over-investigation and potentially unnecessary interventions. Option A is incorrect due to the 'always' clause and potential for over-diagnosis. Option C delays necessary diagnostics. Options D and E are fundamentally incorrect about MRI's utility and ordering practices.

Question 6762

Topic: 6. Spine

During a viva, you are asked to discuss a patient presenting with an acute cervical radiculopathy. You've outlined your initial non-operative approach. The examiner asks, 'What are the 'red flag' symptoms in cervical radiculopathy that would prompt immediate advanced imaging and potentially urgent surgical referral?'

. Persistent neck pain despite over-the-counter analgesics.
. Gradual onset of numbness and tingling in one arm.
. Progressive motor weakness, signs of myelopathy (e.g., gait disturbance, Hoffman's sign, bowel/bladder dysfunction), or intractable pain refractory to all conservative measures.
. Difficulty sleeping due to discomfort.
. Unilateral arm pain radiating below the elbow.

Correct Answer & Explanation

. Progressive motor weakness, signs of myelopathy (e.g., gait disturbance, Hoffman's sign, bowel/bladder dysfunction), or intractable pain refractory to all conservative measures.

Explanation

Red flag symptoms in cervical radiculopathy necessitating urgent evaluation include progressive motor weakness (indicating impending neurological compromise), signs of myelopathy (which suggests spinal cord compression, a much more serious condition than radiculopathy), or intractable pain that is severely debilitating and completely refractory to aggressive conservative measures. Persistent neck pain (A), gradual numbness (B), sleep difficulty (D), and unilateral arm pain (E) are common features of radiculopathy, but without progression or myelopathic signs, they typically fall within the scope of initial conservative management.

Question 6763

Topic: 6. Spine

You are discussing the assessment of a patient with suspected cauda equina syndrome. The examiner asks, 'What is the MOST critical and specific symptom that would raise your suspicion for cauda equina syndrome and necessitate immediate investigation?'

. Bilateral leg pain and weakness.
. Unilateral foot drop.
. Progressive low back pain radiating into the buttocks.
. Saddle anesthesia (numbness in the perineal/genital area), urinary retention or incontinence, and/or fecal incontinence, coupled with varying degrees of motor weakness and sensory changes in the lower extremities.
. Absent ankle reflexes.

Correct Answer & Explanation

. Saddle anesthesia (numbness in the perineal/genital area), urinary retention or incontinence, and/or fecal incontinence, coupled with varying degrees of motor weakness and sensory changes in the lower extremities.

Explanation

The MOST critical and specific symptoms for cauda equina syndrome (CES) are sacral nerve root involvement leading to saddle anesthesia (loss of sensation in the S2-S5 dermatomes), new-onset bladder dysfunction (especially urinary retention with overflow incontinence or true incontinence), and/or bowel incontinence. These, combined with varying degrees of lower extremity motor weakness and sensory changes, necessitate immediate investigation and often urgent surgical decompression. Bilateral leg pain/weakness (A) and absent ankle reflexes (E) can be present but are less specific to CES alone. Unilateral foot drop (B) usually indicates a single nerve root or peripheral nerve issue. Progressive low back pain (C) is common in many spinal conditions.

Question 6764

Topic: 6. Spine

In a viva, you are asked about the non-operative management of lumbar disc herniation with radiculopathy. You outline rest, NSAIDs, and physical therapy. The examiner then asks, 'What is the evidence-based role of epidural corticosteroid injections in this management plan?'

. Epidural corticosteroid injections are curative for disc herniation and prevent the need for surgery in all cases.
. Epidural corticosteroid injections provide definitive, long-term pain relief and should be given repeatedly at monthly intervals.
. Epidural corticosteroid injections can provide short-to-medium term pain relief and reduce inflammation, often facilitating participation in physical therapy. They are not curative and should be used judiciously, with limited frequency, as part of a comprehensive non-operative regimen.
. Epidural corticosteroid injections are primarily used for axial back pain, not radiculopathy.
. Epidural corticosteroid injections have no proven benefit and carry significant risks, so they should be avoided.

Correct Answer & Explanation

. Epidural corticosteroid injections can provide short-to-medium term pain relief and reduce inflammation, often facilitating participation in physical therapy. They are not curative and should be used judiciously, with limited frequency, as part of a comprehensive non-operative regimen.

Explanation

Epidural corticosteroid injections can be a valuable adjunct in the non-operative management of lumbar disc herniation with radiculopathy. They aim to reduce local inflammation around the nerve root, providing short-to-medium term pain relief (weeks to a few months). This pain reduction can facilitate the patient's participation in physical therapy and rehabilitation. However, they are not curative, do not alter the natural history of disc herniation, and should be used judiciously due to potential risks and limited long-term efficacy. Repeated, frequent injections are generally not recommended. Options A, B, D, and E are incorrect or misrepresent their role and efficacy.

Question 6765

Topic: 6. Spine

In a viva, you are asked about the surgical management of scoliosis. The examiner suddenly asks, 'What are the 'wake-up test' and 'somatosensory evoked potentials (SSEPs)' used for during scoliosis surgery, and what is their primary benefit?'

. They are used to assess the depth of anesthesia and ensure the patient is adequately sedated for the procedure.
. They are primary tools for monitoring blood pressure and heart rate fluctuations during spinal instrumentation.
. They are intraoperative neurophysiological monitoring techniques used to detect potential spinal cord ischemia or injury during corrective maneuvers, allowing for immediate intervention to prevent permanent neurological deficits.
. They are post-operative tests to assess the success of spinal fusion.
. They are preoperative tests to determine the patient's baseline neurological function.

Correct Answer & Explanation

. They are intraoperative neurophysiological monitoring techniques used to detect potential spinal cord ischemia or injury during corrective maneuvers, allowing for immediate intervention to prevent permanent neurological deficits.

Explanation

The 'wake-up test' and somatosensory evoked potentials (SSEPs) are critical intraoperative neurophysiological monitoring techniques used during scoliosis correction surgery. Their primary benefit is to detect real-time changes in spinal cord function that might indicate ischemia or injury during spinal manipulation and instrumentation. This allows the surgical team to immediately adjust traction, instrumentation, or even remove implants to avert permanent neurological deficits, such as paraplegia. They are not for assessing anesthesia depth (A), vital signs (B), post-op success (D), or pre-op function (E).

Question 6766

Topic: 6. Spine

In a viva, you are discussing the management of a patient with adolescent idiopathic scoliosis undergoing surgical correction. The examiner asks, 'What is the most common serious complication of spinal fusion for scoliosis, and how is it primarily prevented?'

. Superficial wound infection, prevented by meticulous sterile technique.
. Deep vein thrombosis, prevented by pharmacological prophylaxis.
. Neurological deficit (e.g., paraplegia), primarily prevented by intraoperative neurophysiological monitoring (SSEPs, MEPs), careful surgical technique, and judicious use of corrective forces.
. Pseudarthrosis, prevented by aggressive bone grafting.
. Distal junctional kyphosis, prevented by extending the fusion to the sacrum.

Correct Answer & Explanation

. Neurological deficit (e.g., paraplegia), primarily prevented by intraoperative neurophysiological monitoring (SSEPs, MEPs), careful surgical technique, and judicious use of corrective forces.

Explanation

The most serious and feared complication of spinal fusion for scoliosis is neurological deficit, particularly spinal cord injury (paraplegia). This is primarily prevented by meticulous intraoperative neurophysiological monitoring (Somatosensory Evoked Potentials - SSEPs; Motor Evoked Potentials - MEPs), strict adherence to careful surgical technique, and judicious application of corrective forces during instrumentation. Superficial infection (A) and DVT (B) are general surgical complications, not the most serious or specific to scoliosis. Pseudarthrosis (D) and DJK (E) are also important complications but neurological injury is the most devastating.

Question 6767

Topic: 6. Spine

When asked to discuss a 'red flag' symptom in spine surgery, what should your response prioritize?

. Listing all possible causes of back pain.
. Immediately recommending surgical intervention.
. Identifying the specific red flag (e.g., cauda equina symptoms, progressive neurological deficit, unexplained weight loss, fever), explaining its significance, outlining immediate investigations (e.g., urgent MRI), and discussing time-sensitive management strategies.
. Stating that red flags are rare.
. Minimizing the urgency of the situation.

Correct Answer & Explanation

. Identifying the specific red flag (e.g., cauda equina symptoms, progressive neurological deficit, unexplained weight loss, fever), explaining its significance, outlining immediate investigations (e.g., urgent MRI), and discussing time-sensitive management strategies.

Explanation

A 'red flag' question tests your ability to recognize critical, time-sensitive conditions. The response should prioritize identification of the specific red flag, understanding its clinical urgency, outlining the appropriate immediate diagnostic steps, and discussing prompt, often emergency, management. This demonstrates patient safety awareness and critical decision-making under high-stakes conditions.

Question 6768

Topic: 6. Spine

A 68-year-old male presents with bilateral leg pain that worsens with walking and improves when leaning over a shopping cart. Which of the following is the most likely finding on physical examination or diagnostic testing?

. Decreased ankle-brachial index
. Pain relief with lumbar extension
. Normal pulses but absent Achilles reflex
. Pain radiating from the groin to the knee
. Worsening of pain with stationary cycling

Correct Answer & Explanation

. Normal pulses but absent Achilles reflex

Explanation

The clinical presentation is classic for neurogenic claudication secondary to lumbar spinal stenosis. Patients typically have preserved pulses but may show diminished reflexes (e.g., Achilles). Pain improves with lumbar flexion (leaning over a shopping cart, stationary cycling) and worsens with extension.

Question 6769

Topic: 6. Spine

A 55-year-old female presents with progressive clumsiness in her hands and difficulty walking. Examination reveals a positive Hoffman's sign and inverted brachioradialis reflex. An MRI of the cervical spine shows severe stenosis at C5-C6 with cord signal change. Which of the following best describes the pathogenesis of the inverted brachioradialis reflex?

. Compression of the C5 nerve root with hyperreflexia of C6
. Compression of the C6 nerve root and hyperreflexia of C5
. Lower motor neuron lesion at C5 and upper motor neuron lesion at C6
. Lower motor neuron lesion at C6 and upper motor neuron lesion below C6
. Upper motor neuron lesion at C6 and lower motor neuron lesion below C6

Correct Answer & Explanation

. Lower motor neuron lesion at C6 and upper motor neuron lesion below C6

Explanation

The inverted brachioradialis (supinator) reflex involves a diminished brachioradialis reflex (LMN lesion at C6) and a hyperactive finger flexor response (UMN lesion below C6). It is a classic sign of cervical spondylotic myelopathy at the C5-C6 level.

Question 6770

Topic: Thoracolumbar Spine & Deformity

In adult spinal deformity surgery, achieving appropriate sagittal balance is critical for good clinical outcomes. According to the SRS-Schwab classification, which of the following spinopelvic parameter targets is most strongly correlated with improved health-related quality of life (HRQOL)?

. Pelvic incidence minus lumbar lordosis (PI-LL) < 10 degrees
. Pelvic tilt (PT) > 20 degrees
. Sagittal vertical axis (SVA) > 5 cm
. Sacral slope (SS) < 20 degrees
. Thoracic kyphosis (TK) > 40 degrees

Correct Answer & Explanation

. Pelvic incidence minus lumbar lordosis (PI-LL) < 10 degrees

Explanation

The SRS-Schwab targets for adult spinal deformity correction are: PI-LL < 10 degrees, PT < 20 degrees, and SVA < 5 cm. Normalizing PI-LL mismatch is paramount for surgical success.

Question 6771

Topic: 6. Spine

A 65-year-old female presents with a far-lateral (extraforaminal) disc herniation at the L4-L5 level. Which nerve root is most likely to be compressed, and what is the expected clinical motor deficit?

. L4 nerve root; weakness in ankle dorsiflexion
. L4 nerve root; weakness in knee extension
. L5 nerve root; weakness in great toe extension
. L5 nerve root; weakness in ankle plantarflexion
. S1 nerve root; weakness in ankle plantarflexion

Correct Answer & Explanation

. L4 nerve root; weakness in knee extension

Explanation

In the lumbar spine, a far-lateral (extraforaminal) disc herniation compresses the exiting nerve root at the same level (e.g., L4 root at L4-L5). The L4 nerve root innervates the quadriceps (knee extension) and tibialis anterior (ankle dorsiflexion, shared with L5). Knee extension is more specific to L4. An L5 root compression affects EHL.

Question 6772

Topic: 6. Spine

A 42-year-old male with long-standing ankylosing spondylitis sustains a minor fall and complains of new-onset neck pain. Neurological examination is normal. Radiographs of the cervical spine are difficult to interpret due to marked deformity and osteoporosis. What is the most appropriate next step in management?

. Discharge with a soft cervical collar and NSAIDs
. Flexion-extension radiographs
. CT scan of the entire cervical spine
. MRI of the cervical spine only if neurological deficits develop
. Reassurance and physical therapy

Correct Answer & Explanation

. CT scan of the entire cervical spine

Explanation

Patients with ankylosing spondylitis have highly rigid, osteoporotic spines and are at high risk for highly unstable, often occult fractures even after low-energy trauma. A CT scan of the entire cervical spine is mandatory in evaluating neck pain after a fall in these patients, as standard radiographs often miss fractures.

Question 6773

Topic: 6. Spine

A 45-year-old diabetic male presents with severe mid-thoracic back pain, subjective fevers, and acute onset of lower extremity weakness and urinary retention. MRI reveals a large epidural fluid collection at T8-T10 with peripheral enhancement and cord compression. What is the most appropriate definitive management?

. Intravenous antibiotics alone for 6 weeks
. CT-guided aspiration and antibiotics
. Immediate surgical decompression and debridement
. High-dose intravenous corticosteroids
. Radiation therapy

Correct Answer & Explanation

. Immediate surgical decompression and debridement

Explanation

The clinical picture and MRI findings are classic for a spinal epidural abscess causing acute neurological compromise. The standard of care is emergent surgical decompression and debridement, followed by culture-directed intravenous antibiotics.

Question 6774

Topic: Thoracolumbar Spine & Deformity

Which of the following describes the correct formula defining the relationship between spinopelvic parameters in a standing individual?

. Pelvic Incidence (PI) = Pelvic Tilt (PT) + Sacral Slope (SS)
. Pelvic Tilt (PT) = Pelvic Incidence (PI) + Sacral Slope (SS)
. Sacral Slope (SS) = Pelvic Incidence (PI) + Pelvic Tilt (PT)
. Pelvic Incidence (PI) = Lumbar Lordosis (LL) + Pelvic Tilt (PT)
. Lumbar Lordosis (LL) = Pelvic Incidence (PI) + Sacral Slope (SS)

Correct Answer & Explanation

. Pelvic Incidence (PI) = Pelvic Tilt (PT) + Sacral Slope (SS)

Explanation

Pelvic incidence (PI) is a fixed morphological parameter defined as the sum of the pelvic tilt (PT) and the sacral slope (SS). PI = PT + SS. As a person changes position, the PT and SS change inversely, but PI remains constant.

Question 6775

Topic: 6. Spine

A 50-year-old male with a history of intravenous drug use presents with worsening axial back pain, fevers, and elevated inflammatory markers. MRI of the lumbar spine reveals discitis and osteomyelitis at L3-L4 with endplate destruction and a small epidural phlegmon. Neurological examination is fully intact. Blood cultures are positive for Methicillin-sensitive Staphylococcus aureus (MSSA). What is the most appropriate initial management?

. Anterior lumbar interbody fusion
. Posterior laminectomy and non-instrumented fusion
. Percutaneous drainage of the intervertebral disc
. 6 weeks of intravenous antibiotics
. Immediate posterior instrumentation without decompression

Correct Answer & Explanation

. 6 weeks of intravenous antibiotics

Explanation

The patient has pyogenic spondylodiscitis with no neurological deficits and no gross instability. Pathogen is identified via blood cultures. The mainstay of treatment is long-term intravenous antibiotics. Surgery is indicated for neurological deficits, gross spinal instability, progressive deformity, or failure of medical management.

Question 6776

Topic: 6. Spine

A 38-year-old construction worker presents with acute onset of severe low back pain and left leg pain extending to the dorsum of the foot. Examination reveals 4/5 strength in ankle dorsiflexion and decreased sensation over the first dorsal web space. The patellar and Achilles reflexes are 2+ and symmetric. An MRI confirms a herniated nucleus pulposus. At which level and location is the most likely disc herniation?

. L3-L4 central disc herniation
. L4-L5 paracentral disc herniation
. L4-L5 far lateral disc herniation
. L5-S1 paracentral disc herniation
. L5-S1 far lateral disc herniation

Correct Answer & Explanation

. L4-L5 paracentral disc herniation

Explanation

Weakness in ankle dorsiflexion and decreased sensation in the first dorsal web space are classic signs of L5 nerve root compression. A paracentral disc herniation at L4-L5 compresses the traversing L5 nerve root.

Question 6777

Topic: 6. Spine

A 62-year-old female presents with neck pain and right arm radiating pain. She has weakness in triceps extension and wrist flexion, with a diminished triceps reflex. Sensation is decreased over the middle finger. Which cervical nerve root is most likely involved, and what is the corresponding intervertebral disc level?

. C6 nerve root; C5-C6 disc level
. C7 nerve root; C6-C7 disc level
. C8 nerve root; C7-T1 disc level
. T1 nerve root; T1-T2 disc level
. C5 nerve root; C4-C5 disc level

Correct Answer & Explanation

. C7 nerve root; C6-C7 disc level

Explanation

The patient exhibits signs of a C7 radiculopathy: weakness in triceps and wrist flexors, diminished triceps reflex, and sensory loss in the middle finger. The C7 nerve root exits the intervertebral foramen between C6 and C7, typical for a C6-C7 disc herniation.

Question 6778

Topic: 6. Spine

A 65-year-old male with a history of prior posterior spinal fusion from L2 to L5 presents with a new onset of severe proximal thigh pain and weakness in hip flexion. Radiographs demonstrate a solid fusion from L2 to L5 but reveal adjacent segment disease with severe spinal stenosis and spondylolisthesis at L1-L2. Which nerve root is most likely compromised, and what is the primary muscle affected?

. L1 nerve root; Iliopsoas
. L2 nerve root; Iliopsoas
. L3 nerve root; Quadriceps
. L4 nerve root; Tibialis anterior
. L5 nerve root; Extensor hallucis longus

Correct Answer & Explanation

. L2 nerve root; Iliopsoas

Explanation

The traversing nerve root at L1-L2 is L2. The L2 nerve root provides primary innervation to the iliopsoas muscle, responsible for hip flexion. Symptoms of L2 radiculopathy include pain in the anterior proximal thigh and weakness in hip flexion.

Question 6779

Topic: Thoracolumbar Spine & Deformity

In the setting of adult degenerative scoliosis, which radiographic parameter is considered the most significant predictor of patient-reported clinical outcomes and disability (e.g., ODI scores)?

. Coronal Cobb angle > 40 degrees
. Apical vertebral rotation
. Sagittal vertical axis (SVA) > 5 cm
. Lumbar lordosis > 60 degrees
. Thoracic kyphosis < 20 degrees

Correct Answer & Explanation

. Sagittal vertical axis (SVA) > 5 cm

Explanation

Positive sagittal balance, most commonly measured by a Sagittal Vertical Axis (SVA) greater than 5 cm, has been consistently shown in the literature to be the most significant radiographic predictor of poor patient-reported outcomes, pain, and disability (ODI) in adult spinal deformity.

Question 6780

Topic: 6. Spine

A 40-year-old female presents with axial low back pain. Radiographs demonstrate an isthmic spondylolisthesis at L5-S1 with a 25% slip (Grade I). Flexion-extension views show 4 mm of dynamic translation. She has failed 6 months of comprehensive non-operative management including physical therapy and epidural steroid injections. What is the most appropriate surgical intervention?

. L5 laminectomy without fusion
. Anterior lumbar interbody fusion (ALIF) alone
. In situ posterolateral fusion with pedicle screw instrumentation at L5-S1
. L5-S1 disc arthroplasty
. Multi-level posterior spinal fusion from L3 to S1

Correct Answer & Explanation

. In situ posterolateral fusion with pedicle screw instrumentation at L5-S1

Explanation

For a symptomatic low-grade isthmic spondylolisthesis that has failed conservative care, the standard surgical treatment is an instrumented posterior (or posterolateral) fusion of L5-S1. Laminectomy alone is contraindicated as it destabilizes the spine further by removing the posterior tether.

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