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6. Spine MCQs

Practice Set 35 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 681

Topic: 6. Spine

Appropriate treatment for spinal infection may include all the following except:

. Antibiotics
. Surgical decompression
. Brace immobilization
. Removal of spinal hardware in the acute postoperative setting
. Removal of spinal hardware in the chronic infection

Correct Answer & Explanation

. Removal of spinal hardware in the acute postoperative setting

Explanation

Spinal stability appears to improve healing of spinal infection. C hronic, persistent infections may require removal of hardware. Antibiotics and immobilization are the mainstays of treatment. Neurological deficit from epidural abscess or kyphotic collapse may require operative decompression.

Question 682

Topic: 6. Spine

Which of the following is not a surgical indication in the treatment of spinal column infection:

. Persistent back pain and elevated c-reactive protein despite 8 weeks of intravenous antibiotics and bracing
. Progressive neurological deficit and magnetic resonance image evidence of epidural abscess
. Progressive kyphotic collapse
. Development of sepsis
. Extension of infection into the disk space

Correct Answer & Explanation

. Extension of infection into the disk space

Explanation

Uncomplicated spinal osteomyelitis and diskitis are treated nonoperatively. Operative debridement, decompression, and stabilization may be useful in cases of abscess, sepsis, neurological deficit, and progressive deformity.

Question 683

Topic: 6. Spine

Which of the following is more characteristic of tuberculoid rather than pyogenic spinal infection:

. Bony destruction on plain radiography
. Elevated erythrocyte sedimentation rate
. Prolonged onset of mild back pain despite extensive destruction seen on radiograph
. High fevers, weight loss, and night pain
. Predilection for the cervical spine

Correct Answer & Explanation

. Prolonged onset of mild back pain despite extensive destruction seen on radiograph

Explanation

Spinal tuberculosis typically follows an indolent course early on despite radioqraphic findings out of proportion to the exam. Pyogenic and tuberculoid spinal infections involve the thoracic spine more commonly than the cervical spine. Both spinal infections may result in bony destruction, elevated erythrocyte sedimentation rates, and may or may not present with constitutional symptoms.

Question 684

Topic: 6. Spine

Which of the following is a risk factor for neurological deficit associated with tuberculoid spinal infection:

. Age
. Pulmonary involvement
. Erythrocyte sedimentation rate higher than 90
. History of smoking
. History of hypertension

Correct Answer & Explanation

. Age

Explanation

Tuberculosis in the cervical spine of children younger than 10 years of age carries a significantly lower risk of paralysis than in older patients (17% vs 81%).

Question 685

Topic: 6. Spine

All of the following organisms may cause granulomatous opportunistic spinal infection in immunocompromised patients except:

. Mycobacteria
. Nocardia
. Actinomyces
. Staphylococcus
. Brucella

Correct Answer & Explanation

. Staphylococcus

Explanation

Staphylococcal infection is typically pyogenic, not granulomatous.

Question 686

Topic: 6. Spine

What percentage of spinal infections have concurrent positive blood cultures:

. 5%
. 25%
. 55%
. 75%
. 95%

Correct Answer & Explanation

. 25%

Explanation

Even though the majority of spinal infections are considered hematogenous in origin, only 25% of infections occur with positive blood cultures.

Question 687

Topic: 6. Spine

The treatment of choice for spinal epidural abscess is:

. Four weeks of antibiotics
. Parenteral antibiotics until the erythrocyte sedimentation rate falls to half of its pretreatment value
. Surgical drainage plus a prolonged course of antibiotics
. Spinal fusion
. Bracing and analgesia

Correct Answer & Explanation

. Surgical drainage plus a prolonged course of antibiotics

Explanation

It is generally believed that pockets of pus, whether they are epidural, paravertebral, or psoas abscesses, must be drained in addition to antimicrobial therapy.

Question 688

Topic: 6. Spine

Which surgical approach is absolutely contraindicated for a massive, calcified, central thoracic disk herniation causing myelopathy?

. Costotransversectomy
. Standard laminectomy
. Transthoracic discectomy
. Transpedicular approach
. Video-assisted thoracoscopic surgery (VATS)

Correct Answer & Explanation

. Standard laminectomy

Explanation

Standard laminectomy is contraindicated for central thoracic disc herniations due to the high risk of catastrophic spinal cord injury. The thoracic cord does not tolerate retraction, and the kyphotic alignment drapes the cord over the anterior compressive lesion.

Question 689

Topic: 6. Spine

The Artery of Adamkiewicz, which provides major blood supply to the anterior lower two-thirds of the spinal cord, most commonly arises from which region?

. Right side between T4 and T8
. Left side between T8 and L1
. Right side between T8 and L1
. Left side between T4 and T8
. Bilaterally at L2

Correct Answer & Explanation

. Left side between T8 and L1

Explanation

The Artery of Adamkiewicz usually originates on the left side between T8 and L1 in approximately 70-80% of individuals. Injury to this vessel during anterior thoracic approaches can lead to anterior spinal artery syndrome.

Question 690

Topic: 6. Spine

A 50-year-old female presents with progressive gait ataxia and lower extremity spasticity. MRI reveals a large central calcified thoracic disc herniation at T10-T11. What is the most appropriate surgical approach?

. Bilateral laminectomies
. Left-sided transthoracic approach
. Posterior spinal fusion alone
. Posterior interlaminar approach
. Lumbar drain placement

Correct Answer & Explanation

. Left-sided transthoracic approach

Explanation

A transthoracic approach allows direct visualization and removal of anterior central calcified discs without manipulating the spinal cord. Laminectomy and posterior interlaminar approaches risk cord injury due to required retraction.

Question 691

Topic: 6. Spine

During a right-sided transthoracic approach for a T4-T5 disc herniation, the surgeon injures a longitudinal neural structure running along the heads of the ribs. What is the most likely clinical consequence of this injury?

. Diaphragmatic paralysis
. Horner's syndrome
. Recurrent laryngeal nerve palsy
. Chylothorax
. Intercostal neuralgia

Correct Answer & Explanation

. Horner's syndrome

Explanation

The sympathetic chain runs longitudinally along the rib heads in the upper thoracic spine. Injury to the chain in the upper thoracic region (T1-T4) can result in ipsilateral Horner's syndrome (ptosis, miosis, anhidrosis).

Question 692

Topic: 6. Spine

A 55-year-old man undergoes a costotransversectomy for a T8-T9 paracentral disc herniation. Postoperatively, he develops a pleural effusion, and fluid analysis reveals high triglyceride levels and lymphocytes. Which structure was most likely injured?

. Azygos vein
. Thoracic duct
. Segmental artery
. Pleural membrane
. Sympathetic chain

Correct Answer & Explanation

. Thoracic duct

Explanation

A chylothorax results from injury to the thoracic duct, characterized by milky pleural fluid high in triglycerides. The thoracic duct typically ascends on the right side of the lower thoracic spine and crosses to the left around T4-T5.

Question 693

Topic: 6. Spine

When performing a transpedicular approach for a thoracic disc herniation, which of the following boundaries must be removed to access the disc space safely?

. The lamina and spinous process
. The entire vertebral body
. The facet joint and pedicle
. The anterior longitudinal ligament
. The rib head entirely

Correct Answer & Explanation

. The facet joint and pedicle

Explanation

The transpedicular approach involves removal of the facet joint and the pedicle to access the lateral aspect of the disc space and the ventral spinal canal. This approach is best for lateral or foraminal disc herniations.

Question 694

Topic: 6. Spine

Which of the following physical examination findings is most specific for thoracic myelopathy rather than a lumbar pathology?

. Absent Achilles reflex
. Positive straight leg raise test
. Bilateral lower extremity weakness
. Hyperreflexia and a positive Babinski sign
. Decreased perianal sensation

Correct Answer & Explanation

. Hyperreflexia and a positive Babinski sign

Explanation

Upper motor neuron signs such as hyperreflexia, spasticity, and a positive Babinski sign differentiate spinal cord compression (thoracic or cervical myelopathy) from lower motor neuron lumbar pathology.

Question 695

Topic: 6. Spine

In a patient presenting with an isolated band-like chest pain radiating horizontally around the thorax, which condition must be ruled out before diagnosing a thoracic radiculopathy from a disc herniation?

. Lumbar spinal stenosis
. Cervical spondylotic myelopathy
. Herpes zoster (shingles)
. Cauda equina syndrome
. Spondylolisthesis

Correct Answer & Explanation

. Herpes zoster (shingles)

Explanation

Herpes zoster (shingles) frequently presents with intense, radicular band-like pain in a thoracic dermatome before the appearance of the classic vesicular rash, mimicking a thoracic disc herniation.

Question 696

Topic: 6. Spine

What is the primary advantage of the video-assisted thoracoscopic surgery (VATS) approach over an open thoracotomy for thoracic disc herniations?

. Better visualization of the posterior epidural space
. Reduced risk of vascular injury
. Decreased postoperative incisional pain and pulmonary morbidity
. Ability to easily perform multi-level laminectomies
. No need for single-lung ventilation

Correct Answer & Explanation

. Decreased postoperative incisional pain and pulmonary morbidity

Explanation

VATS is minimally invasive and avoids the significant morbidity of a thoracotomy, including rib retraction, thereby reducing postoperative pain and improving pulmonary recovery.

Question 697

Topic: 6. Spine
A 45-year-old patient with an acute T7-T8 disc herniation presents with profound weakness of the right leg, loss of proprioception in the right leg, and loss of pain and temperature sensation in the left leg. This clinical picture is most consistent with:
. Central cord syndrome
. Anterior cord syndrome
. Brown-Séquard syndrome
. Posterior cord syndrome
. Cauda equina syndrome

Correct Answer & Explanation

. Brown-Séquard syndrome

Explanation

Brown-Séquard syndrome results from hemisection of the spinal cord, causing ipsilateral motor and dorsal column deficits (proprioception) and contralateral spinothalamic deficits (pain/temperature).

Question 698

Topic: 6. Spine

A surgeon is evaluating a patient with a paracentral, non-calcified thoracic disc herniation at T6-T7 causing radicular pain but no myelopathy. The patient failed 6 months of conservative therapy. What is the most appropriate next step?

. Anterior vertebrectomy
. Translaminar approach
. Transpedicular or costotransversectomy discectomy
. Diagnostic thoracoscopy
. Standard laminectomy

Correct Answer & Explanation

. Transpedicular or costotransversectomy discectomy

Explanation

For a lateral or paracentral soft disc herniation, posterior-lateral approaches (transpedicular or costotransversectomy) provide excellent access without the morbidity of an anterior approach or the dangers of laminectomy.

Question 699

Topic: 6. Spine

When repairing an incidental dural tear during an anterior transthoracic approach for a disc herniation, which of the following techniques is most commonly utilized if primary closure is impossible?

. Lumbar subarachnoid drain placement only
. Application of a muscle, fat, or fascial graft with fibrin glue
. Leaving the defect open to drain into the pleural cavity
. Immediate conversion to a posterior laminectomy
. Epidural blood patch

Correct Answer & Explanation

. Application of a muscle, fat, or fascial graft with fibrin glue

Explanation

Inaccessible anterior dural tears are managed with onlay grafts (muscle, fat, fascia) combined with sealants. Dural tears draining into the pleural space can lead to pleural effusions and require meticulous closure.

Question 700

Topic: 6. Spine

Intraoperative neuromonitoring (IONM) during thoracic disc surgery typically includes Somatosensory Evoked Potentials (SSEPs) and Motor Evoked Potentials (MEPs). Which specific complication is MEP monitoring best suited to detect early during anterior approaches?

. Dorsal column contusion
. Anterior spinal artery ischemia
. Sympathetic chain avulsion
. Recurrent laryngeal nerve stretch
. Dural tear

Correct Answer & Explanation

. Anterior spinal artery ischemia

Explanation

MEPs monitor the anterior and lateral corticospinal tracts, which are supplied by the anterior spinal artery. They are highly sensitive to ischemic changes in the anterior spinal cord, which SSEPs might miss.

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