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6. Spine MCQs

Practice Set 34 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 661

Topic: 6. Spine

When evaluating a patient for vertebral osteomyelitis, MRI with gadolinium is the imaging modality of choice. What is the hallmark MRI finding of acute pyogenic spondylodiscitis?

. T1 hyperintensity and T2 hypointensity of the disc with no contrast enhancement
. T1 hypointensity and T2 hyperintensity of the disc and adjacent vertebral endplates with contrast enhancement
. Isolated T2 hyperintensity of the posterior elements
. Normal T1 and T2 signals with peripheral enhancement of the annulus fibrosus
. T1 hypointensity of the vertebral body with a completely normal intervening disc

Correct Answer & Explanation

. T1 hypointensity and T2 hyperintensity of the disc and adjacent vertebral endplates with contrast enhancement

Explanation

The hallmark of pyogenic spondylodiscitis on MRI is decreased signal on T1-weighted images and increased signal on T2-weighted images in the intervertebral disc and adjacent subchondral bone, accompanied by gadolinium enhancement.

Question 662

Topic: 6. Spine

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

. Presence of the abscess covering more than three spinal levels
. Concomitant pyogenic vertebral osteomyelitis
. A sudden, progressive neurologic deficit
. Persistent low-grade fever after 48 hours of appropriate antibiotics
. Elevated CRP > 100 mg/L

Correct Answer & Explanation

. A sudden, progressive neurologic deficit

Explanation

While some spinal epidural abscesses can be treated medically, a developing or progressive neurologic deficit (e.g., motor weakness, cauda equina syndrome) is an absolute indication for emergent surgical decompression to prevent permanent paralysis.

Question 663

Topic: 6. Spine

During a posterior lumbar fusion, an incidental dural tear occurs and is primarily repaired. Five days later, the patient develops a high fever, severe headache, and prominent photophobia. The wound is clean and intact. What is the most likely diagnosis?

. Superficial surgical site infection
. Spinal epidural hematoma
. Aseptic arachnoiditis
. Chemical radiculitis
. Postoperative bacterial meningitis

Correct Answer & Explanation

. Postoperative bacterial meningitis

Explanation

A patient with a recent dural tear who develops fever, headache, and photophobia must be evaluated for postoperative bacterial meningitis. This requires prompt diagnosis (often via CSF analysis) and broad-spectrum IV antibiotics.

Question 664

Topic: 6. Spine

A 70-year-old male with a history of recurrent urinary tract infections presents with severe back pain. MRI shows discitis-osteomyelitis at L3-L4. Blood cultures grow Escherichia coli. What is the most likely route of bacterial dissemination to the spine in this specific scenario?

. Direct contiguous spread from the kidney
. Lymphatic spread from the bladder
. Retrograde venous spread via Batson's plexus
. Direct traumatic inoculation
. Spread via the cerebrospinal fluid

Correct Answer & Explanation

. Retrograde venous spread via Batson's plexus

Explanation

Batson's venous plexus is a valveless network of veins connecting the deep pelvic veins to the internal vertebral venous plexus. This route is classic for retrograde spread of genitourinary or pelvic infections to the lumbar spine.

Question 665

Topic: 6. Spine

Which of the following organisms is the most common cause of delayed, indolent post-operative deep wound infections following instrumented spinal fusions, frequently requiring up to 14 days of culture to identify?

. Staphylococcus epidermidis
. Staphylococcus aureus
. Cutibacterium (Propionibacterium) acnes
. Pseudomonas aeruginosa
. Enterobacter cloacae

Correct Answer & Explanation

. Cutibacterium (Propionibacterium) acnes

Explanation

C. acnes is a slow-growing anaerobe known to cause delayed, indolent infections post-spine surgery. It often requires holding cultures for up to 14 days for successful isolation.

Question 666

Topic: 6. Spine

A 24-year-old male suffers a gunshot wound to the abdomen with the bullet lodging in the L3 vertebral body. Exploratory laparotomy reveals a colon perforation. What is the most appropriate management regarding the bullet in the spine?

. Emergent laminectomy and bullet removal
. Bullet extraction through an anterior retroperitoneal approach
. Leave the bullet in place and treat with broad-spectrum IV antibiotics for 7-14 days
. Leave the bullet in place and give a single prophylactic dose of cefazolin
. Immediate posterior spinal fusion without bullet removal

Correct Answer & Explanation

. Leave the bullet in place and treat with broad-spectrum IV antibiotics for 7-14 days

Explanation

In spinal gunshot wounds with hollow viscus injury (like the colon), the bullet should generally be left in place unless causing a progressive neurologic deficit. Broad-spectrum antibiotics for 7-14 days are required.

Question 667

Topic: 6. Spine

You are treating a patient with early postoperative deep wound infection following a posterior lumbar interbody fusion (PLIF) with pedicle screws. The implants are solidly fixed. Which of the following is the standard of care?

. Removal of all hardware, debridement, and delayed reimplantation
. Irrigation and debridement, retention of stable hardware, and culture-directed antibiotics
. Superficial wound opening and continuous negative pressure wound therapy only
. Suppressive oral antibiotics for 6 weeks without surgical intervention
. Immediate conversion to an anterior fusion construct

Correct Answer & Explanation

. Irrigation and debridement, retention of stable hardware, and culture-directed antibiotics

Explanation

For early deep postoperative spine infections with stable hardware, the standard is aggressive irrigation and debridement with retention of the implants, followed by prolonged culture-specific IV antibiotics.

Question 668

Topic: 6. Spine

Which of the following scenarios is an absolute indication for surgery in a patient with spinal tuberculosis?

. Presence of a small paraspinal abscess
. Mild, non-progressive kyphosis of 10 degrees
. Severe pain managed adequately by oral analgesics
. Progressive neurological deficit despite appropriate antitubercular chemotherapy
. Elevated ESR after 2 weeks of medication

Correct Answer & Explanation

. Progressive neurological deficit despite appropriate antitubercular chemotherapy

Explanation

Indications for surgery in spinal TB include progressive neurological deficit, severe or progressive spinal deformity (kyphosis), and failure of medical management.

Question 669

Topic: 6. Spine

A 35-year-old IV drug user presents with fever, severe focal back pain, and radicular leg pain. Physical exam reveals exquisite point tenderness over the spinous processes. What is the classic clinical triad associated with the most likely diagnosis?

. Fever, back pain, and neurologic deficit
. Fever, night sweats, and weight loss
. Back pain, radiculopathy, and claudication
. Fever, painless weakness, and areflexia
. Back pain, saddle anesthesia, and pulsatile mass

Correct Answer & Explanation

. Fever, back pain, and neurologic deficit

Explanation

The classic triad for a spinal epidural abscess is fever, back pain, and neurological deficit, though not all patients will present with the full triad initially.

Question 670

Topic: 6. Spine

A patient with suspected pyogenic spondylodiscitis has two negative sets of blood cultures. The patient is hemodynamically stable without neurological deficits. What is the next best step?

. Start empiric vancomycin and ceftriaxone immediately
. Perform a percutaneous CT-guided biopsy of the affected disc/vertebra
. Perform an open excisional biopsy and stabilization
. Monitor clinical symptoms and repeat blood cultures in 48 hours
. Administer a 5-day trial of oral antibiotics and reassess

Correct Answer & Explanation

. Perform a percutaneous CT-guided biopsy of the affected disc/vertebra

Explanation

If blood cultures are negative in suspected spondylodiscitis, a CT-guided percutaneous biopsy is indicated to isolate the organism before initiating antibiotics, provided the patient is stable.

Question 671

Topic: 6. Spine

Which of the following imaging modalities is the most sensitive and specific for diagnosing an early spinal epidural abscess?

. Non-contrast Computed Tomography (CT)
. Myelography
. Magnetic Resonance Imaging (MRI) with Gadolinium contrast
. Triple-phase bone scan
. Gallium-67 scan

Correct Answer & Explanation

. Magnetic Resonance Imaging (MRI) with Gadolinium contrast

Explanation

MRI with gadolinium contrast is the gold standard for diagnosing spinal epidural abscesses and vertebral osteomyelitis, offering the highest sensitivity and specificity.

Question 672

Topic: 6. Spine

A 50-year-old farmer from the Mediterranean region presents with chronic undulating fevers, sacroiliitis, and lumbar spondylitis. Radiographs show 'parrot beak' osteophytes and the disc space is relatively maintained. Which of the following tests would best confirm the likely diagnosis?

. Acid-fast bacilli (AFB) smear
. Wright's agglutination test (Rose Bengal test)
. Lyme disease serology
. HLA-B27 antigen
. Rheumatoid factor

Correct Answer & Explanation

. Wright's agglutination test (Rose Bengal test)

Explanation

The clinical picture suggests spinal brucellosis, which is endemic to the Mediterranean. The Wright's agglutination test (or Rose Bengal) confirms Brucella infection.

Question 673

Topic: 6. Spine

In adult patients with hematogenous pyogenic vertebral osteomyelitis, which region of the spine is most frequently affected?

. Cervical spine
. Thoracic spine
. Lumbar spine
. Sacrum
. Occipitocervical junction

Correct Answer & Explanation

. Lumbar spine

Explanation

The lumbar spine is the most common site for pyogenic vertebral osteomyelitis, followed by the thoracic and then cervical spine, due to the high volume of sluggish blood flow in the lumbar region.

Question 674

Topic: 6. Spine

A 60-year-old female presents with neck pain, fever, and progressive quadriparesis over 48 hours. MRI reveals an anterior cervical epidural abscess behind C4 and C5 with cord compression. What is the preferred surgical approach?

. Posterior cervical laminectomy C3-C6
. Anterior cervical corpectomy and fusion
. Posterior laminoplasty
. Percutaneous CT-guided drainage
. Cervical laminectomy with delayed anterior fusion

Correct Answer & Explanation

. Anterior cervical corpectomy and fusion

Explanation

For an anterior cervical epidural abscess causing cord compression, an anterior approach (corpectomy or discectomy and fusion) is preferred to directly decompress the cord without manipulating it over the ventral mass.

Question 675

Topic: 6. Spine

Which anatomical structure is primarily responsible for the spread of pelvic infections to the vertebral bodies, bypassing the systemic venous circulation?

. The azygous vein
. Batson's venous plexus
. The thoracic duct
. The ligamentum flavum
. The epidural arterial arcade

Correct Answer & Explanation

. Batson's venous plexus

Explanation

Batson's venous plexus is a valveless paraspinal venous network that allows retrograde flow, facilitating the direct spread of pelvic and urological infections to the spine.

Question 676

Topic: 6. Spine

A patient undergoes a posterior spinal fusion. 10 days postoperatively, the wound demonstrates purulent drainage. Debridement is performed. In addition to Staphylococcus aureus, which gram-negative organism is a common culprit in post-operative spinal infections, especially in cases with prolonged intensive care stays or urinary catheter use?

. Pseudomonas aeruginosa
. Neisseria meningitidis
. Haemophilus influenzae
. Streptococcus pyogenes
. Treponema pallidum

Correct Answer & Explanation

. Pseudomonas aeruginosa

Explanation

Pseudomonas aeruginosa and other Gram-negative bacilli are significant causes of post-operative spinal infections, particularly in patients with prolonged hospital stays, ICU admissions, or indwelling urinary catheters.

Question 677

Topic: Thoracolumbar Spine & Deformity

An absolute indication for surgical management of thoracolumbar burst fractures is:

. Canal compromise greater than 10%
. Canal compromise greater than 30%
. Kyphotic deformity greater than 10%
. Kyphotic deformity greater than 30%
. Progressive neurologic deficit

Correct Answer & Explanation

. Progressive neurologic deficit

Explanation

Patients with a neurologic deficit or a progressive neurologic deficit should undergo operative decompression. C ontroversy exists as to the amount of kyphosis and canal compression that is considered acceptable. Support can be found in the literature for both operative and nonoperative management of neurologically intact burst fractures. Each patient must be evaluated on a case by case basis and followed closely after injury.

Question 678

Topic: 6. Spine
A 12-year-old girl presents with back pain of 3 months' duration. She is a Risser stage 2. She displays a left thoracic curve of 27° on radiographs. The next study obtained in the work-up should be:
. Lateral bending films
. Computerized tomography scan of the spine
. Head computerized tomography
. Magnetic resonance image of the thoracic spine
. Ultrasound of the kidneys

Correct Answer & Explanation

. Magnetic resonance image of the thoracic spine

Explanation

Left thoracic curves are unusual in idiopathic scoliosis. A magnetic resonance image of the thoracic spine is mandatory in the work-up to rule out diastematomyelia, tethered spinal cord, spinal tumor, or other type of congenital anomaly.

Question 679

Topic: 6. Spine

The most common organism responsible for vertebral column infection is:

. Pseudomonas aeruginosa
. Staphylococcus epidermidis
. Staphylococcus aureus
. Escherechia coli
. Mycobacterium tuberculosis

Correct Answer & Explanation

. Staphylococcus aureus

Explanation

Staphylococcus aureus accounts for more than 50% of spinal infections and often results from hematogenous dissemination. Gram-negative organisms are more common following genitourinary procedures or urinary tract infections. Staphylococcus epidermidis can complicate spinal surgical wounds, and polymicrobial infection is more common in these circumstances.

Question 680

Topic: 6. Spine

Symptoms of spinal infection may include all of the following except:

. Activity-related back pain
. Fever
. Neurological deficit
. Torticollis
. Decreased spinal range of motion

Correct Answer & Explanation

. Activity-related back pain

Explanation

Neck or back pain associated with spinal infection is relentless and constant. The pain is not usually associated with activity. There may be night pain as well. Other symptoms and signs are variable, requiring a high degree of suspicion. Fever occurs less than 50% of the time and neurological deficit less than 10% of the time. Paraspinal muscle spasms may result in decreased range of motion or torticollis.

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