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6. Spine MCQs

Practice Set 345 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 6881

Topic: 6. Spine

A 62-year-old female presents with progressive hand clumsiness and difficulty buttoning her shirt. Examination reveals a positive Hoffman sign and hyperreflexia in the lower extremities. Which of the following additional physical examination findings is most specific for cervical spondylotic myelopathy at the C5-C6 level?

. Absent biceps reflex
. Positive Lhermitte's sign
. Inverted brachioradialis reflex
. Jaw jerk reflex
. Positive Spurling's test

Correct Answer & Explanation

. Inverted brachioradialis reflex

Explanation

The inverted brachioradialis reflex indicates a lower motor neuron lesion at C5 or C6 (diminished brachioradialis reflex) and an upper motor neuron lesion below that level (hyperactive finger flexion). It is highly specific for cervical myelopathy at the C5-C6 level.

Question 6882

Topic: 6. Spine

A 60-year-old male complains of deteriorating handwriting and unsteadiness while walking. On examination, flicking the nail of his middle finger downward results in reflexive flexion of his thumb and index finger. What is the name of this clinical sign and what does it indicate?

. Babinski sign; upper motor neuron lesion
. Lhermitte's sign; multiple sclerosis
. Hoffmann's sign; cervical myelopathy
. Spurling's test; cervical radiculopathy
. Wartenberg's sign; ulnar neuropathy

Correct Answer & Explanation

. Hoffmann's sign; cervical myelopathy

Explanation

Hoffmann's sign is elicited by flicking the distal phalanx of the middle finger, with a positive response being reflexive flexion of the thumb and index finger. It indicates upper motor neuron dysfunction, commonly seen in cervical spondylotic myelopathy.

Question 6883

Topic: Thoracolumbar Spine & Deformity

A 19-year-old female presents to the ED following a high-speed motor vehicle collision where she was wearing a lap-belt only. Radiographs demonstrate a horizontal fracture through the spinous process, pedicles, and vertebral body of L1. What associated injury must be actively excluded in this patient?

. Aortic dissection
. Pulmonary contusion
. Hollow viscus gastrointestinal injury
. Renal artery thrombosis
. Diaphragmatic rupture

Correct Answer & Explanation

. Hollow viscus gastrointestinal injury

Explanation

Chance fractures are flexion-distraction injuries commonly associated with lap-belt use in motor vehicle collisions. There is a high incidence (up to 50%) of associated intra-abdominal injuries, particularly hollow viscus ruptures, which must be carefully evaluated.

Question 6884

Topic: 6. Spine

A 72-year-old man presents with deteriorating handwriting and frequent tripping. On exam, briskly flicking the distal phalanx of his middle finger results in spontaneous flexion of the thumb and index finger. What is this sign called, and what does it indicate?

. Babinski sign; upper motor neuron lesion
. Hoffmann sign; cervical myelopathy
. Lhermitte sign; multiple sclerosis
. Tinel sign; peripheral nerve entrapment
. Spurling sign; cervical radiculopathy

Correct Answer & Explanation

. Hoffmann sign; cervical myelopathy

Explanation

The Hoffmann sign is elicited by flicking the distal phalanx of the middle finger, causing reflex flexion of the thumb and index finger. It is an upper motor neuron sign indicative of cervical myelopathy, often due to spinal stenosis.

Question 6885

Topic: 6. Spine

A 60-year-old man presents with progressive gait clumsiness, loss of fine motor skills in his hands, and frequent falls. Physical examination reveals a positive Hoffman's sign and bilateral hyperreflexia at the patella. This clinical picture is most directly caused by compression of which of the following spinal cord structures?

. Dorsal root ganglia
. Anterior horn cells
. Spinothalamic tracts
. Corticospinal tracts
. Posterior columns

Correct Answer & Explanation

. Corticospinal tracts

Explanation

Cervical spondylotic myelopathy causes upper motor neuron signs such as hyperreflexia, spastic gait, and a positive Hoffman's sign. These upper motor neuron signs are due to compression of the descending corticospinal tracts.

Question 6886

Topic: 6. Spine

A 65-year-old male presents with progressive clumsiness of his hands, difficulty buttoning his shirt, and a broad-based, unsteady gait. MRI of the cervical spine demonstrates severe stenosis at C5-C6 with T2 signal hyperintensity and T1 signal hypointensity within the spinal cord. Which of the following findings is the strongest predictor of poor neurological recovery following surgical decompression?

. Patient age over 60 years
. Presence of T1 hypointensity in the spinal cord
. A positive bilateral Hoffman's sign
. Symptoms present for greater than 3 months
. Narrowing of the spinal canal to less than 12 mm

Correct Answer & Explanation

. Presence of T1 hypointensity in the spinal cord

Explanation

In patients with cervical spondylotic myelopathy, T1 signal hypointensity within the spinal cord on MRI suggests permanent cystic cord changes or myelomalacia. This specific neuroimaging finding is a strong, independent predictor of poorer clinical recovery after decompression.

Question 6887

Topic: 6. Spine

A 45-year-old female presents with severe back pain, bilateral lower extremity weakness, and urinary incontinence following a heavy lifting injury. On examination, she has symmetric saddle anesthesia, preserved knee reflexes, but absent ankle reflexes. Which of the following differentiates Conus Medullaris Syndrome from Cauda Equina Syndrome?

. Conus Medullaris presents with asymmetric radicular pain
. Cauda Equina Syndrome presents with sudden and bilateral symptoms
. Conus Medullaris often involves upper motor neuron signs such as hyperreflexia
. Cauda Equina Syndrome is typically painless
. Conus Medullaris has late-onset bowel/bladder dysfunction

Correct Answer & Explanation

. Conus Medullaris often involves upper motor neuron signs such as hyperreflexia

Explanation

Conus medullaris syndrome results from injury to the terminal spinal cord and can present with a mix of upper motor neuron (hyperreflexia, spasticity) and lower motor neuron signs. Cauda equina syndrome involves injury to the lumbosacral nerve roots (LMN only) and typically presents with asymmetric pain, lower extremity weakness, and absent lower extremity reflexes.

Question 6888

Topic: 6. Spine

A 65-year-old man presents with deteriorating handwriting, difficulty buttoning his shirt, and gait instability. Examination reveals a positive Hoffman's sign. What does a positive Hoffman's sign indicate?

. Lower motor neuron lesion at C5-C6
. Upper motor neuron lesion in the cervical spine or higher
. Peripheral neuropathy
. Amyotrophic lateral sclerosis (specific sign)
. Central cord syndrome

Correct Answer & Explanation

. Upper motor neuron lesion in the cervical spine or higher

Explanation

Hoffman's sign (flicking the distal phalanx of the middle finger resulting in flexion of the thumb and index finger) is indicative of an upper motor neuron lesion (hyperreflexia) above the level of C5, such as in cervical spondylotic myelopathy.

Question 6889

Topic: Thoracolumbar Spine & Deformity

A 14-year-old female gymnast presents with progressive lower back pain. Radiographs demonstrate an L5-S1 isthmic spondylolisthesis (Grade 2). What is the primary anatomic abnormality responsible for this condition?

. Defect or stress fracture of the pars interarticularis
. Degeneration of the facet joints and ligamentum flavum hypertrophy
. Congenital pedicle elongation
. Sacral agenesis and pelvic ring instability
. Herniation of the L5-S1 intervertebral disc

Correct Answer & Explanation

. Defect or stress fracture of the pars interarticularis

Explanation

Isthmic spondylolisthesis is most commonly caused by a stress fracture or elongation of the pars interarticularis (spondylolysis), typically seen in adolescent athletes subject to repetitive spinal hyperextension (e.g., gymnasts, football linemen).

Question 6890

Topic: 6. Spine

A 60-year-old male with a history of intravenous drug use presents with severe back pain, fevers, and acute lower extremity weakness. An MRI of the lumbar spine reveals pyogenic vertebral osteomyelitis with a compressive epidural abscess. Which of the following organisms is the most common cause of this condition?

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

Correct Answer & Explanation

. Staphylococcus aureus

Explanation

Staphylococcus aureus is the most common causative organism for pyogenic vertebral osteomyelitis and epidural abscess in all populations, including intravenous drug users (IVDU). While Pseudomonas aeruginosa has a higher relative incidence in IVDU compared to the general population, S. aureus remains the most common overall.

Question 6891

Topic: Cervical Spine

A 65-year-old female with long-standing rheumatoid arthritis presents with neck pain and mild hand clumsiness. Flexion-extension radiographs reveal 8 mm of atlantoaxial instability. What is the most critical radiographic parameter to evaluate her risk of impending neurologic deterioration?

. Anterior atlantodental interval (ADI)
. Posterior atlantodental interval (PADI)
. Ranawat line
. McGregor's line
. Wackenheim's clivus baseline

Correct Answer & Explanation

. Posterior atlantodental interval (PADI)

Explanation

The Posterior Atlantodental Interval (PADI), also known as the Space Available for the Cord (SAC), is the most reliable predictor of neurologic deficit in rheumatoid atlantoaxial subluxation. A PADI < 14 mm is a strong indication for surgical stabilization to prevent permanent neurologic deficit.

Question 6892

Topic: 6. Spine

The Thoracolumbar Injury Classification and Severity Score (TLICS) guides surgical decision-making. According to the TLICS, which of the following neurological statuses receives the highest point value (3 points)?

. Neurologically intact
. Nerve root injury
. Complete spinal cord injury
. Incomplete spinal cord injury
. Transient neurapraxia

Correct Answer & Explanation

. Incomplete spinal cord injury

Explanation

In the TLICS system, an incomplete spinal cord injury (or cauda equina syndrome) receives 3 points, which is higher than a complete spinal cord injury (2 points). This reflects the higher surgical urgency to decompress the neural elements and preserve remaining neurologic function in an incomplete injury.

Question 6893

Topic: Cervical Spine

A 45-year-old male sustains a burst fracture of the atlas (Jefferson fracture). Which of the following radiographic findings dictates the need for rigid stabilization (e.g., halo-vest or surgery) due to transverse ligament rupture?

. Combined lateral mass overhang of > 2 mm on open-mouth odontoid view
. Combined lateral mass overhang of > 6.9 mm on open-mouth odontoid view
. Prevertebral soft tissue swelling > 5 mm at C2
. Atlantodental interval (ADI) of 2 mm on lateral radiograph
. Loss of cervical lordosis on lateral radiograph

Correct Answer & Explanation

. Combined lateral mass overhang of > 6.9 mm on open-mouth odontoid view

Explanation

A combined lateral mass displacement (overhang) of greater than 6.9 mm on an open-mouth odontoid radiograph indicates rupture of the transverse alar ligament (Spence's rule). This implies significant C1-C2 instability.

Question 6894

Topic: 6. Spine

A 28-year-old male presents with a severe burst fracture of T12 and paraplegia following a motor vehicle accident. Which of the following findings indicates the resolution of spinal shock?

. Return of the bulbocavernosus reflex
. Return of normal resting heart rate
. Return of voluntary toe flexion
. Normalization of mean arterial pressure
. Resolution of flaccid paralysis in the upper extremities

Correct Answer & Explanation

. Return of the bulbocavernosus reflex

Explanation

Spinal shock is characterized by areflexia and flaccidity below the level of the spinal cord injury. The return of the bulbocavernosus reflex marks the end of the spinal shock phase, allowing for the accurate determination of neurologic deficits.

Question 6895

Topic: 6. Spine

A 65-year-old male presents with difficulty buttoning his shirt, deteriorating handwriting, and frequent tripping. Physical examination reveals a positive Hoffman's sign and an inverted brachioradialis reflex. An inverted brachioradialis reflex specifically indicates spinal cord compression at which of the following levels?

. C3-C4
. C4-C5
. C5-C6
. C6-C7
. C7-T1

Correct Answer & Explanation

. C5-C6

Explanation

An inverted brachioradialis reflex is characterized by an absent or diminished brachioradialis reflex with simultaneous hyperactive finger flexion. It is a highly specific upper motor neuron sign for cervical myelopathy localizing to the C5-C6 spinal level. Compression at this level disrupts the lower motor neurons for the C6 reflex arc (diminished BR reflex) while exhibiting upper motor neuron disinhibition of the C8 reflex arc (hyperactive finger flexors).

Question 6896

Topic: Thoracolumbar Spine & Deformity

A 15-year-old female gymnast complains of an insidious onset of lower back pain, exacerbated by extension. Radiographs confirm an L5-S1 isthmic spondylolisthesis (Meyerding Grade II). Which of the following classic radiographic findings is specifically associated with the defect causing this condition?

. A fluid sign within the facet joint on MRI
. Elongation of the pars interarticularis without a defect
. A 'Scotty dog' with a collar on oblique lumbar radiographs
. Sagittal orientation of the facet joints on axial imaging
. Subchondral sclerosis of the sacroiliac joint

Correct Answer & Explanation

. A 'Scotty dog' with a collar on oblique lumbar radiographs

Explanation

Isthmic spondylolisthesis is most commonly caused by a pars interarticularis defect (spondylolysis), typically at L5. On oblique lumbar radiographs, the posterior elements of the vertebra resemble a 'Scotty dog'. A defect or fracture in the pars interarticularis appears as a radiolucent line across the neck of the dog, often described as a 'Scotty dog with a collar'. Dysplastic spondylolisthesis features an elongated pars, and degenerative spondylolisthesis is often associated with sagittally oriented facets or a facet fluid sign.

Question 6897

Topic: 6. Spine

A 65-year-old man presents with bilateral leg pain that worsens with walking and prolonged standing. Which of the following physical examination findings or clinical tests best differentiates neurogenic claudication from vascular claudication?

. Diminished dorsalis pedis pulses
. Relief of symptoms with lumbar extension
. Pain radiating past the knee
. Ability to pedal a stationary bicycle for prolonged periods while flexed forward
. Presence of a positive straight leg raise

Correct Answer & Explanation

. Ability to pedal a stationary bicycle for prolonged periods while flexed forward

Explanation

The bicycle test helps differentiate neurogenic from vascular claudication. Patients with neurogenic claudication (lumbar spinal stenosis) experience relief when flexed forward, opening the spinal canal and neuroforamina, allowing them to pedal indefinitely. Those with vascular claudication experience ischemic pain related to muscle exertion regardless of posture.

Question 6898

Topic: 6. Spine

A 24-year-old male is brought to the ED after a motorcycle collision. He has flaccid paralysis below the C6 level, a blood pressure of 80/50 mmHg, and a heart rate of 52 bpm. His extremities are warm and well-perfused. Which of the following is the primary mechanism for his hemodynamic instability?

. Hemorrhagic shock from an occult visceral injury
. Loss of sympathetic vascular tone
. Vagal nerve severing
. Cardiac tamponade
. Adrenal insufficiency

Correct Answer & Explanation

. Loss of sympathetic vascular tone

Explanation

The patient is exhibiting neurogenic shock, characterized by hypotension and bradycardia. This occurs due to the loss of descending sympathetic tone in high spinal cord injuries (above T6), leading to unchecked parasympathetic (vagal) activity, peripheral vasodilation, and warm extremities.

Question 6899

Topic: 6. Spine

A 65-year-old male is involved in a high-speed motor vehicle collision and sustains a burst fracture of L1 with retropulsion of bone fragments occupying 50% of the spinal canal. He has isolated weakness in his bilateral extensor hallucis longus (EHL). Which of the following nerve root levels is most likely compromised?

. L3
. L4
. L5
. S1
. S2

Correct Answer & Explanation

. L5

Explanation

The extensor hallucis longus (EHL) is primarily innervated by the L5 nerve root. Impairment of great toe extension strongly indicates an L5 neurologic deficit.

Question 6900

Topic: 6. Spine

A 72-year-old female presents with severe neurogenic claudication secondary to lumbar spinal stenosis. Her symptoms improve when she leans forward over a shopping cart. What is the primary anatomical rationale for this positional relief?

. Flexion decreases the bulging of the ligamentum flavum
. Flexion decreases the diameter of the neural foramina
. Extension unloads the facet joints reducing capsular swelling
. Flexion causes posterior disc bulging away from the canal
. Extension tightens the posterior longitudinal ligament

Correct Answer & Explanation

. Flexion decreases the bulging of the ligamentum flavum

Explanation

Lumbar flexion widens the spinal canal and neural foramina while simultaneously stretching the ligamentum flavum, reducing its inward buckling. This transient increase in canal volume mechanically relieves compression on the cauda equina and nerve roots.

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