Menu

6. Spine MCQs

Practice Set 357 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 7121

Topic: 6. Spine

A 28-year-old patient presents with back pain and right leg pain. During the straight leg raise test, he suddenly drops his leg when it reaches a certain point and then reports severe pain. He also exhibits inconsistent motor weakness and widespread, non-dermatomal sensory loss. These findings are consistent with:

. Severe L5-S1 disc herniation
. Acute lumbar muscle spasm
. Cauda equina syndrome
. Non-organic (Waddell's) signs
. Malingering

Correct Answer & Explanation

. Non-organic (Waddell's) signs

Explanation

The described findings—sudden leg drop on SLR (hoover sign, usually), inconsistent motor weakness, and non-dermatomal sensory loss—are classic 'Waddell's signs' for non-organic components to back pain. While the patient may have genuine underlying pain, these signs indicate a strong psychological or behavioral overlay to their presentation, rather than purely organic pathology. Malingering is a specific form of non-organic presentation where there is conscious feigning of symptoms for secondary gain. While possible, 'non-organic signs' is a broader and more clinically useful description for this pattern of findings. The other options describe organic pathologies that would present with consistent and anatomically plausible signs.

Question 7122

Topic: 6. Spine

A 65-year-old male presents with low back pain and bilateral leg heaviness. He has difficulty distinguishing between neurogenic and vascular claudication. Which of the following historical features would most strongly suggest neurogenic claudication?

. Pain primarily in the calves, relieved quickly by standing still.
. Pain improved by leaning forward or sitting.
. Diminished peripheral pulses on examination.
. Pain worse with uphill walking, relieved by downhill walking.
. History of diabetes and smoking.

Correct Answer & Explanation

. Pain improved by leaning forward or sitting.

Explanation

Pain that is improved by leaning forward or sitting (the 'shopping cart sign') is a classic distinguishing feature of neurogenic claudication, as these positions typically widen the spinal canal and relieve pressure on the neural elements. Vascular claudication is usually relieved by standing still or resting, not necessarily by positional changes, and is more commonly exacerbated by walking (especially uphill), with pain primarily in the calves. Diminished peripheral pulses and a history of diabetes and smoking are risk factors for vascular claudication. Pain worse with uphill walking is also more suggestive of vascular claudication, as it requires greater muscle exertion.

Question 7123

Topic: 6. Spine

In a patient presenting with back pain, which finding on a lumbar MRI is least likely to be clinically significant if isolated?

. Extruded disc fragment causing severe central canal stenosis
. Spinal epidural abscess with cord compression
. Large primary tumor of the vertebral body
. Mild degenerative disc changes at L4-L5 in a 40-year-old without radiculopathy
. Complete L5-S1 spondylolisthesis with associated L5 radiculopathy

Correct Answer & Explanation

. Mild degenerative disc changes at L4-L5 in a 40-year-old without radiculopathy

Explanation

Mild degenerative disc changes (e.g., disc desiccation, mild disc bulge without significant neural impingement) are extremely common findings on MRI, particularly in individuals over 30-40 years old, and are often asymptomatic. When present as an isolated finding without corresponding clinical symptoms (like radiculopathy or neurogenic claudication), they are least likely to be the primary cause of clinically significant back pain. The other options describe severe pathologies with clear clinical implications: disc extrusion with stenosis, epidural abscess, primary tumor, and spondylolisthesis with radiculopathy all require serious clinical attention and intervention.

Question 7124

Topic: 6. Spine

What is the primary role of a diagnostic selective nerve root block in evaluating back pain?

. To definitively treat radicular pain.
. To confirm the presence of a disc herniation.
. To identify the specific nerve root responsible for the patient's radicular pain.
. To assess for spinal instability requiring fusion.
. To rule out a spinal tumor or infection.

Correct Answer & Explanation

. To identify the specific nerve root responsible for the patient's radicular pain.

Explanation

A diagnostic selective nerve root block involves injecting a local anesthetic directly around a specific suspected nerve root. If the patient's radicular pain is significantly and temporarily relieved following the injection, it confirms that the blocked nerve root is indeed the source of their pain. This helps in localizing the pain generator and guiding further treatment (e.g., targeted epidural injections, surgical decompression). It is not a definitive treatment, nor does it confirm the presence of a disc herniation or assess instability or rule out tumor/infection.

Question 7125

Topic: 6. Spine

A 30-year-old male presents with persistent low back pain for 4 months. He has tried NSAIDs, physical therapy, and chiropractic care with minimal improvement. His pain is worse with prolonged sitting and certain twisting movements. Physical exam is normal. MRI shows mild degenerative changes at L5-S1 and a small annular tear. Which of the following might be considered in this scenario to further evaluate the pain source, though it remains controversial?

. Lumbar fusion surgery
. Electromyography (EMG)
. Discography
. Systemic corticosteroid course
. Repeated MRI with contrast

Correct Answer & Explanation

. Discography

Explanation

In a patient with chronic discogenic-type back pain (worse with prolonged sitting, twisting), with minimal findings on MRI beyond mild degenerative changes or an annular tear, discography may be considered to assess if a specific disc is the pain generator. This involves injecting contrast into the disc and reproducing the patient's typical pain, usually followed by an anesthetic challenge. However, discography is controversial due to potential for false positives, complications, and acceleration of disc degeneration. Lumbar fusion is premature. EMG is for radiculopathy. Systemic corticosteroids are not indicated for chronic mechanical pain. Repeated MRI with contrast is unlikely to yield new information in this scenario if there's no suspicion for infection or tumor.

Question 7126

Topic: 6. Spine
Which red flag symptom is most suggestive of an abdominal aortic aneurysm (AAA) as a cause of back pain?
. Pain with Valsalva maneuver
. Unexplained weight loss
. Pulsatile abdominal mass and severe, tearing back pain
. Fever and chills
. Bilateral leg weakness

Correct Answer & Explanation

. Pulsatile abdominal mass and severe, tearing back pain

Explanation

A pulsatile abdominal mass, especially when combined with sudden onset of severe, tearing back pain (which may radiate to the groin or flank), is highly suggestive of a ruptured or expanding abdominal aortic aneurysm (AAA). This is a life-threatening emergency. Pain with Valsalva is typical of discogenic pain. Unexplained weight loss and fever/chills are red flags for malignancy or infection. Bilateral leg weakness suggests cauda equina syndrome or myelopathy.

Question 7127

Topic: 6. Spine

A 40-year-old patient with no prior medical history presents with 2 weeks of acute low back pain and severe left leg pain radiating to the foot. He has a positive straight leg raise test at 45 degrees, 3/5 strength in left great toe extension, and decreased sensation on the dorsum of the left foot. What is the most likely initial treatment strategy?

. Urgent surgical microdiscectomy
. Strict bed rest for 2 weeks
. Physical therapy focusing on McKenzie exercises and NSAIDs
. Transforaminal epidural steroid injection immediately
. Long-term opioid prescription for pain control

Correct Answer & Explanation

. Physical therapy focusing on McKenzie exercises and NSAIDs

Explanation

This patient has acute radiculopathy likely from a lumbar disc herniation, with moderate motor weakness (3/5 strength). While the weakness is significant, it's not a complete motor deficit or cauda equina syndrome. The initial treatment strategy for such cases is typically conservative, including physical therapy (often with a McKenzie approach which focuses on extension exercises to centralize pain), NSAIDs, and activity modification. Most disc herniations improve spontaneously. Urgent microdiscectomy is reserved for cauda equina syndrome or progressive/severe neurological deficits unresponsive to conservative care. Strict bed rest is outdated and generally harmful. Epidural steroid injections may be considered if conservative management fails, but usually not as the immediate first step. Long-term opioids are inappropriate for acute pain management.

Question 7128

Topic: 6. Spine

A 28-year-old female is diagnosed with Gorham-Stout disease involving the thoracic spine and ribs.

She is at greatest risk for which of the following potentially fatal complications?

. Malignant transformation to angiosarcoma
. Spontaneous pneumothorax
. Chylothorax
. Aortic aneurysm rupture
. Pulmonary embolism

Correct Answer & Explanation

. Chylothorax

Explanation

When Gorham-Stout disease involves the ribs, scapula, or thoracic spine, it can lead to chylothorax due to extension of the lymphatic proliferation into the pleural cavity, which is a major cause of mortality.

Question 7129

Topic: 6. Spine

A patient with confirmed Gorham-Stout disease (massive osteolysis) of the cervicothoracic spine and ribs is admitted.

What is the most common life-threatening complication associated with this specific anatomical presentation?

. Spinal cord transection from pathologic fracture
. Chylothorax leading to respiratory failure
. Malignant transformation to angiosarcoma
. Massive spontaneous hemothorax
. High-output cardiac failure

Correct Answer & Explanation

. Chylothorax leading to respiratory failure

Explanation

In Gorham-Stout disease affecting the ribs, shoulder girdle, or thoracic spine, lymphatic malformations can extend into the pleural cavity, causing a chylothorax. This is a severe and potentially fatal complication requiring prompt multidisciplinary management.

Question 7130

Topic: 6. Spine

When evaluating a pelvic radiograph, the radiographic 'teardrop' is an important landmark for hardware placement. This structure represents a thick column of bone extending between which two anatomic landmarks?

. Anterior superior iliac spine to the ischial tuberosity
. Anterior inferior iliac spine to the posterior superior iliac spine
. Posterior inferior iliac spine to the ischial spine
. Iliopubic eminence to the posterior superior iliac spine
. Anterior inferior iliac spine to the ischial spine

Correct Answer & Explanation

. Anterior inferior iliac spine to the posterior superior iliac spine

Explanation

Correct Answer: BThe radiographic teardrop, best visualized on the obturator outlet view of the pelvis, represents a thick column of bone that runs from the anterior inferior iliac spine (AIIS) to the posterior superior iliac spine (PSIS). This dense corridor of bone is an excellent site for the insertion of half pins for supra-acetabular external fixation or for screw fixation during pelvic ring reconstruction.

Question 7131

Topic: 6. Spine

The radiographic 'teardrop' seen on the obturator outlet view of the pelvis represents a dense corridor of bone frequently used for external fixation pin placement. Between which two anatomic landmarks does this column of bone extend?

. Anterior superior iliac spine (ASIS) to the posterior inferior iliac spine (PIIS)
. Anterior inferior iliac spine (AIIS) to the posterior superior iliac spine (PSIS)
. Ischial tuberosity to the posterior superior iliac spine (PSIS)
. Anterior inferior iliac spine (AIIS) to the ischial spine
. Pubic tubercle to the anterior superior iliac spine (ASIS)

Correct Answer & Explanation

. Anterior inferior iliac spine (AIIS) to the posterior superior iliac spine (PSIS)

Explanation

Correct Answer: B. Anterior inferior iliac spine (AIIS) to the posterior superior iliac spine (PSIS)The teardrop visualized on the obturator outlet view of the pelvis represents a thick, dense column of bone that runs from the anterior inferior iliac spine (AIIS) to the posterior superior iliac spine (PSIS). This corridor provides excellent purchase for supra-acetabular external fixation pins or internal fixation screws.

Question 7132

Topic: 6. Spine

A 45-year-old man presents with severe neck pain radiating down his left arm. Physical examination reveals numbness over the middle finger, weakness in elbow extension and wrist flexion, and a diminished triceps reflex. Which of the following cervical disc herniations is the most likely cause of these findings?

. C4-C5
. C5-C6
. C6-C7
. C7-T1
. T1-T2

Correct Answer & Explanation

. C6-C7

Explanation

Correct Answer: CThe patient's symptoms are classic for a C7 radiculopathy. In the cervical spine, the exiting nerve root is named for the lower vertebral body of the motion segment (e.g., the C7 nerve root exits at the C6-C7 level). A C7 radiculopathy typically presents with sensory changes in the middle finger, motor weakness in the triceps (elbow extension) and wrist flexors/extensors, and a diminished or absent triceps reflex.

Question 7133

Topic: 6. Spine

The radiographic "teardrop" seen on an obturator oblique view of the pelvis (marked with an asterisk in the provided image) represents a dense corridor of bone frequently used for external fixation pin placement. This column of bone extends between which two anatomic landmarks?

. Anterior superior iliac spine to the ischial tuberosity
. Anterior inferior iliac spine to the posterior superior iliac spine
. Anterior inferior iliac spine to the ischial spine
. Posterior superior iliac spine to the greater sciatic notch
. Pubic tubercle to the anterior inferior iliac spine

Correct Answer & Explanation

. Anterior inferior iliac spine to the posterior superior iliac spine

Explanation

Correct Answer: BThe teardrop can be visualized on the obturator outlet view of the pelvis and represents a thick column of bone that runs from the anterior inferior iliac spine (AIIS) to the posterior superior iliac spine (PSIS). Half pins for external fixation frames or screws can be safely inserted into this dense column for robust fixation of pelvic ring fractures.

Question 7134

Topic: 6. Spine

When evaluating an obturator outlet view of the pelvis, the radiographic 'teardrop' represents a thick column of bone that is frequently utilized for the placement of half pins in external fixation. This column of bone extends between which two anatomic landmarks?

. Anterior superior iliac spine (ASIS) to the posterior inferior iliac spine (PIIS)
. Anterior inferior iliac spine (AIIS) to the posterior superior iliac spine (PSIS)
. Ischial tuberosity to the posterior superior iliac spine (PSIS)
. Anterior inferior iliac spine (AIIS) to the ischial spine
. Pubic tubercle to the anterior superior iliac spine (ASIS)

Correct Answer & Explanation

. Anterior inferior iliac spine (AIIS) to the posterior superior iliac spine (PSIS)

Explanation

Correct Answer: BThe radiographic teardrop seen on the obturator outlet view represents the dense column of bone extending from the anterior inferior iliac spine (AIIS) to the posterior superior iliac spine (PSIS). This corridor is an excellent site for supra-acetabular pin placement in pelvic external fixation, providing robust bony purchase for frame stability.

Question 7135

Topic: 6. Spine

A 65-year-old man presents with progressive gait imbalance and deteriorating fine motor skills. Physical examination reveals a positive Hoffmann sign. What maneuver is used to elicit this clinical sign?

. Tapping the volar aspect of the wrist over the median nerve
. Flicking the nail of the middle finger downward
. Forced hyperextension of the neck with lateral rotation
. Scraping the lateral plantar surface of the foot
. Rapid supination and pronation of the forearm

Correct Answer & Explanation

. Flicking the nail of the middle finger downward

Explanation

The Hoffmann sign is elicited by flicking the nail of the middle finger downward, which results in a reflex flexion of the thumb and index finger. It is indicative of an upper motor neuron lesion, such as cervical spondylotic myelopathy.

Question 7136

Topic: 6. Spine

A 60-year-old woman presents with classic neurogenic claudication that has failed 6 months of nonoperative management. Imaging shows an L4-L5 degenerative spondylolisthesis. What is the surgical treatment of choice?

. Laminectomy alone without fusion
. L4-L5 decompression and instrumented posterolateral fusion
. Total disc arthroplasty at L4-L5
. Interspinous process spacer placement
. Anterior lumbar interbody fusion without posterior decompression

Correct Answer & Explanation

. L4-L5 decompression and instrumented posterolateral fusion

Explanation

The classic, evidence-based standard of care for symptomatic degenerative spondylolisthesis failing conservative therapy is neural decompression accompanied by instrumented fusion. Decompression alone has a historically higher rate of subsequent instability and revision.

Question 7137

Topic: 6. Spine

A 14-year-old female gymnast presents with progressive back pain and an L5 radiculopathy that has failed 6 months of conservative management. Standing lateral radiographs demonstrate a grade 3 isthmic spondylolisthesis at L5-S1. What is the most appropriate surgical treatment?

. Direct pars repair with pedicle screw construct
. L4-S1 posterior spinal fusion in situ without reduction
. L5-S1 anterior lumbar interbody fusion (ALIF) alone
. L5-S1 decompression and instrumented posterior spinal fusion
. L5 laminectomy without fusion

Correct Answer & Explanation

. L5-S1 decompression and instrumented posterior spinal fusion

Explanation

High-grade (Grade 3 or 4) symptomatic isthmic spondylolisthesis in adolescents typically requires surgical intervention. Decompression of the L5 nerve root combined with an instrumented L5-S1 fusion (often with partial reduction to improve sagittal balance) is the standard of care.

Question 7138

Topic: 6. Spine

An 8-month-old infant with a known FGFR3 mutation is brought to the clinic. The parents report recent episodes of apnea and generalized hypotonia. Which of the following is the most critical and immediate orthopedic evaluation required for this patient?

. Cervical spine MRI to evaluate for foramen magnum stenosis
. Lumbar spine MRI to evaluate for a tethered cord
. Radiographs of the lower extremities to assess progressive bowing
. Genetic testing for an overlapping secondary mutation
. Thoracic spine radiographs to evaluate for infantile scoliosis

Correct Answer & Explanation

. Cervical spine MRI to evaluate for foramen magnum stenosis

Explanation

Achondroplasia (FGFR3 mutation) can cause life-threatening foramen magnum stenosis in infants, leading to central apnea, sudden death, or severe myelopathy. A cervical MRI is mandatory in infants presenting with apneic episodes or unexplained hypotonia.

Question 7139

Topic: 6. Spine

A 10-year-old girl presents with knee pain and a waddling gait. Radiographs show small, irregular epiphyses in the hips and knees, but her spine appears radiographically normal. A lateral knee radiograph reveals a distinct double-layered patella. What is the most likely diagnosis?

. Spondyloepiphyseal dysplasia congenita
. Multiple epiphyseal dysplasia
. Pseudoachondroplasia
. Cleidocranial dysplasia
. Mucopolysaccharidosis Type IV

Correct Answer & Explanation

. Multiple epiphyseal dysplasia

Explanation

Multiple epiphyseal dysplasia (MED) typically presents with irregular, delayed ossification of the epiphyses with a relatively normal spine. A double-layered patella is a classic, pathognomonic radiographic sign often seen in patients with MED.

Question 7140

Topic: 6. Spine

A 2-year-old boy presents with generalized lower extremity pain, irritability, and bleeding gums. Radiographs show a distinct white line of Frankel and a Pelkan spur at the distal femoral metaphyses. What is the underlying biochemical defect?

. Defective mineralization of osteoid
. Impaired hydroxylation of proline and lysine
. Accumulation of unmineralized osteoid
. Excessive parathyroid hormone secretion
. Defective endochondral ossification in the reserve zone

Correct Answer & Explanation

. Impaired hydroxylation of proline and lysine

Explanation

The clinical picture is classic for scurvy, caused by Vitamin C deficiency. Vitamin C acts as a necessary cofactor for prolyl and lysyl hydroxylase; without it, defective hydroxylation of proline and lysine leads to unstable collagen.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page