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6. Spine MCQs

Practice Set 363 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 7241

Topic: 6. Spine

A 65-year-old female presents with worsening clumsiness in her hands and frequent tripping. On examination, flicking the nail of the middle finger results in reflexive flexion of the thumb and index finger. This clinical sign indicates pathology involving which of the following structures?

. Anterior horn cells at the C5-C6 level
. Corticospinal tract above the C5 level
. Spinothalamic tract in the cervical cord
. Dorsal columns of the cervical spine
. Peripheral median nerve at the carpal tunnel

Correct Answer & Explanation

. Corticospinal tract above the C5 level

Explanation

The Hoffmann sign indicates an upper motor neuron lesion resulting from compression of the corticospinal tract in the cervical spine. It is a hallmark finding in cervical spondylotic myelopathy.

Question 7242

Topic: 6. Spine

A 14-year-old gymnast presents with severe mechanical back pain and radiculopathy. Radiographs show a Grade II L5-S1 isthmic spondylolisthesis. She has failed 6 months of physical therapy and bracing. What is the most appropriate surgical intervention?

. L5 pars interarticularis direct repair
. L5-S1 posterior spinal fusion with instrumentation
. L4-S1 posterior spinal fusion without instrumentation
. Lumbar microdiscectomy at L5-S1
. Anterior lumbar interbody fusion at L4-L5

Correct Answer & Explanation

. L5-S1 posterior spinal fusion with instrumentation

Explanation

For progressive or symptomatic Grade II isthmic spondylolisthesis in adolescents failing conservative care, L5-S1 posterior spinal fusion with instrumentation is the gold standard. Direct pars repair is reserved for Grade 0 or very mild Grade I slips in young athletes.

Question 7243

Topic: 6. Spine

A 65-year-old man presents with progressive hand clumsiness and frequent falls. Examination reveals hyperreflexia and a positive Hoffman's sign. MRI of the cervical spine demonstrates severe C5-C6 stenosis with focal T1 hypointensity within the spinal cord. What does this MRI finding indicate regarding surgical intervention?

. Excellent potential for complete neurologic recovery
. Acute spinal cord edema requiring immediate steroids
. Myelomalacia, predicting a poor prognosis for neurologic recovery
. An underlying demyelinating process such as multiple sclerosis
. Active intramedullary hemorrhage

Correct Answer & Explanation

. Myelomalacia, predicting a poor prognosis for neurologic recovery

Explanation

T1 hypointensity within the spinal cord indicates myelomalacia, which represents permanent spinal cord damage and cystic necrosis. This finding is the most reliable predictor of poor neurologic recovery following surgical decompression.

Question 7244

Topic: Thoracolumbar Spine & Deformity

A 14-year-old female gymnast complains of chronic lower back pain exacerbated by extension. Radiographs reveal a grade 1 isthmic spondylolisthesis at L5-S1. Her neurologic examination is normal. After failing 6 months of rigorous physical therapy and activity modification, what is the most appropriate surgical treatment?

. L5 pars interarticularis repair
. L5-S1 posterior lumbar interbody fusion (PLIF)
. L5-S1 posterolateral fusion in situ
. L5 laminectomy without fusion
. Anterior lumbar interbody fusion (ALIF) alone

Correct Answer & Explanation

. L5-S1 posterolateral fusion in situ

Explanation

For adolescents with a low-grade isthmic spondylolisthesis at L5-S1 who fail nonoperative treatment, L5-S1 posterolateral fusion in situ is the gold standard. Pars repair is typically reserved for L1-L4 defects or L5 defects without significant slip.

Question 7245

Topic: 6. Spine

A 68-year-old woman presents with bilateral buttock and leg pain that worsens with walking and improves when leaning over a shopping cart. MRI shows severe L4-L5 central canal stenosis and a grade 1 degenerative spondylolisthesis. After failing 6 months of nonoperative management, which surgical intervention provides the lowest risk of future reoperation for instability?

. L4-L5 laminectomy alone
. L4-L5 laminectomy and instrumented posterolateral fusion
. Interspinous spacer placement
. L4-L5 microdiscectomy
. Minimally invasive unilateral laminotomy for bilateral decompression

Correct Answer & Explanation

. L4-L5 laminectomy and instrumented posterolateral fusion

Explanation

In patients with lumbar spinal stenosis and concomitant degenerative spondylolisthesis, adding an instrumented fusion to the decompression (laminectomy) yields lower reoperation rates for iatrogenic instability and better long-term functional outcomes compared to laminectomy alone.

Question 7246

Topic: 6. Spine

An infant with achondroplasia presents with central apnea, hypotonia, and hyperreflexia. What is the most critical anatomical abnormality to evaluate on MRI?

. Thoracolumbar kyphosis
. Foramen magnum stenosis
. Lumbar spinal stenosis
. Cervical instability
. Atlantoaxial rotatory subluxation

Correct Answer & Explanation

. Foramen magnum stenosis

Explanation

Foramen magnum stenosis is a life-threatening complication in infants with achondroplasia, potentially causing cervicomedullary compression, central apnea, hypotonia, and sudden death. Urgent decompression is required if severely symptomatic.

Question 7247

Topic: 6. Spine

A 7-year-old child with spondyloepiphyseal dysplasia congenita (SEDC) presents with increasing fatigue and hyperreflexia. Radiographs show significant platyspondyly. Which of the following conditions must be urgently ruled out?

. Scoliosis curve progression
. Odontoid hypoplasia causing atlantoaxial instability
. Thoracic disc herniation
. Lumbar spondylolisthesis
. Basilar invagination

Correct Answer & Explanation

. Odontoid hypoplasia causing atlantoaxial instability

Explanation

Children with SEDC frequently have odontoid hypoplasia, which can lead to severe atlantoaxial instability and subsequent cervical myelopathy. This requires urgent evaluation with flexion-extension radiographs or MRI.

Question 7248

Topic: 6. Spine

Which of the following clinical or radiographic features best distinguishes Spondyloepiphyseal Dysplasia (SED) from Multiple Epiphyseal Dysplasia (MED)?

. Involvement of the hands and feet
. Presence of platyspondyly and short trunk dwarfism
. Early-onset hip osteoarthritis
. Mutation in the COMP gene
. Autosomal dominant inheritance pattern

Correct Answer & Explanation

. Presence of platyspondyly and short trunk dwarfism

Explanation

SED is characterized by significant spinal involvement (platyspondyly) leading to short-trunk disproportionate dwarfism. MED typically involves minimal or no spinal abnormalities and presents as normal or mildly short stature.

Question 7249

Topic: Thoracolumbar Spine & Deformity

A 12-year-old girl is evaluated for progressive scoliosis. She has a history of a retinal detachment and a cleft palate repair as an infant. Radiographs show mild epiphyseal dysplasia and platyspondyly. Which of the following is the most likely diagnosis?

. Stickler syndrome
. Marfan syndrome
. Ehlers-Danlos syndrome
. Cleidocranial dysplasia
. Multiple epiphyseal dysplasia

Correct Answer & Explanation

. Stickler syndrome

Explanation

Stickler syndrome (hereditary arthro-ophthalmopathy) is a COL2A1 mutation disorder characterized by ocular issues (retinal detachment), cleft palate, hearing loss, and spondyloepiphyseal dysplasia.

Question 7250

Topic: 6. Spine

A 4-year-old boy with a history of disproportionate short stature, a barrel-shaped chest, and severe myopia is diagnosed with spondyloepiphyseal dysplasia (SED) congenita. Which of the following spinal complications must be ruled out with radiographic screening before he undergoes general anesthesia?

. Subaxial cervical stenosis
. Atlantoaxial instability
. Thoracic scoliosis
. Lumbar spondylolisthesis
. Sacral agenesis

Correct Answer & Explanation

. Atlantoaxial instability

Explanation

Spondyloepiphyseal dysplasia congenita frequently involves delayed ossification or hypoplasia of the odontoid. This leads to a high risk of atlantoaxial instability, necessitating flexion-extension cervical radiographs prior to intubation.

Question 7251

Topic: 6. Spine

A 10-year-old child presents with waddling gait, bilateral knee pain, and early-onset hip osteoarthritis. Radiographs demonstrate delayed ossification of the epiphyses but normal spine alignment. A lateral knee radiograph reveals a pathognomonic finding. Which of the following is most likely observed?

. Double-layered patella
. Stippled epiphyses
. Erlenmeyer flask deformity
. Ollier disease-like enchondromas
. Bipartite patella at the superolateral pole

Correct Answer & Explanation

. Double-layered patella

Explanation

Multiple epiphyseal dysplasia (MED) is primarily caused by mutations in the COMP gene and frequently presents with a double-layered patella on lateral radiographs. Patients typically develop early-onset osteoarthritis with relatively normal spinal alignment.

Question 7252

Topic: 6. Spine

A 6-year-old boy with a known type II collagen mutation (COL2A1) has a short trunk, barrel chest, and coxa vara. He is scheduled for elective lower extremity osteotomies. Which of the following preoperative screening evaluations is most critical for preventing a catastrophic complication in this patient?

. Echocardiogram
. Renal ultrasound
. Flexion-extension cervical spine radiographs
. Pulmonary function tests
. Dual-energy X-ray absorptiometry (DEXA) scan

Correct Answer & Explanation

. Flexion-extension cervical spine radiographs

Explanation

This patient has Spondyloepiphyseal Dysplasia Congenita (SEDc). These patients are at high risk for atlantoaxial instability due to odontoid hypoplasia, making preoperative flexion-extension cervical spine radiographs mandatory before any intubation or anesthesia.

Question 7253

Topic: 6. Spine

A 25-year-old female with known rheumatoid arthritis presents with worsening neck pain and myelopathic symptoms. Radiographs of the cervical spine reveal an anterior atlanto-dens interval (ADI) of 11 mm. Which of the following radiographic measurements is the most reliable predictor of neurologic recovery after surgical decompression and stabilization?

. Anterior atlanto-dens interval (ADI)
. Posterior atlanto-dens interval (PADI) / Space Available for the Cord (SAC)
. Cervical lordosis angle
. Ranawat line measurement
. McGregor's line measurement

Correct Answer & Explanation

. Posterior atlanto-dens interval (PADI) / Space Available for the Cord (SAC)

Explanation

The Space Available for the Cord (SAC), also known as the posterior atlanto-dens interval (PADI), is the most reliable predictor of neurologic deficit and recovery in RA cervical subluxation. A SAC of less than 14 mm is an indication for surgery.

Question 7254

Topic: 6. Spine

A 30-year-old male with known ankylosing spondylitis presents to the emergency department with severe back pain after a low-speed motor vehicle collision. Neurological exam is intact. Radiographs are difficult to interpret due to extensive ossification. What is the most appropriate next step in management?

. Discharge with NSAIDs and physical therapy
. Flexion-extension radiographs of the cervical spine
. CT scan of the entire spine
. Immediate administration of high-dose corticosteroids
. DEXA scan to evaluate bone density

Correct Answer & Explanation

. CT scan of the entire spine

Explanation

Patients with ankylosing spondylitis are at a high risk for highly unstable, three-column spinal fractures even with minor trauma. A CT scan or MRI of the entire spine is mandatory if a fracture is suspected, as these fractures are easily missed on plain radiographs.

Question 7255

Topic: 6. Spine

A 4-year-old child with achondroplasia presents with progressively worsening lower extremity weakness, apnea, and hyperreflexia. What is the most likely anatomic cause of these symptoms?

. Atlantoaxial instability
. Foramen magnum stenosis
. Thoracolumbar kyphosis
. Lumbar spinal stenosis
. Tethered spinal cord

Correct Answer & Explanation

. Foramen magnum stenosis

Explanation

Infants and young children with achondroplasia are at high risk for cervicomedullary compression due to foramen magnum stenosis, leading to hyperreflexia, weakness, and central apnea. Lumbar stenosis typically presents later in adulthood.

Question 7256

Topic: Cervical Spine

In a patient with advanced rheumatoid arthritis evaluating the cervical spine, which radiographic parameter indicates the highest risk for progressive neurologic deficit and dictates the need for surgical stabilization?

. Anterior atlantodental interval (ADI) of 3mm
. Posterior atlantodental interval (PADI) of less than 14mm
. Subaxial subluxation of 2mm
. Basilar invagination with Clark station 1
. Isolated loss of normal cervical lordosis

Correct Answer & Explanation

. Posterior atlantodental interval (PADI) of less than 14mm

Explanation

The PADI (space available for the cord) is the most reliable predictor of neurologic recovery and risk. A PADI of less than 14 mm is a strong indication for surgical intervention in rheumatoid atlantoaxial subluxation.

Question 7257

Topic: 6. Spine

According to the Budapest criteria for the clinical diagnosis of Complex Regional Pain Syndrome (CRPS), which of the following symptom categories is NOT part of the diagnostic requirement?

. Sensory (hyperesthesia/allodynia)
. Vasomotor (temperature/skin color asymmetry)
. Sudomotor/edema (sweating asymmetry/edema)
. Motor/trophic (decreased range of motion/hair changes)
. Neuropathic (dermatomal sensory loss)

Correct Answer & Explanation

. Neuropathic (dermatomal sensory loss)

Explanation

The Budapest criteria require at least one symptom in 3 of 4 categories: Sensory, Vasomotor, Sudomotor/edema, and Motor/trophic. Dermatomal sensory loss is indicative of a peripheral nerve injury or radiculopathy, not CRPS.

Question 7258

Topic: 6. Spine

A 4-year-old boy with achondroplasia presents with progressively worsening lower extremity weakness, central sleep apnea, and hyperreflexia. Evaluation of which anatomical region is most critical in this scenario?

. Lumbar spine for severe spinal stenosis
. Foramen magnum for cervicomedullary compression
. Thoracic spine for structural kyphosis
. Hips for bilateral dysplasia
. Knees for severe genu varum

Correct Answer & Explanation

. Foramen magnum for cervicomedullary compression

Explanation

In infants and young children with achondroplasia, foramen magnum stenosis causing cervicomedullary compression is a life-threatening complication. It presents with hyperreflexia, weakness, hypotonia, and central sleep apnea, requiring urgent decompression.

Question 7259

Topic: 6. Spine

A 55-year-old female with long-standing rheumatoid arthritis is scheduled for a total knee arthroplasty. Flexion-extension cervical spine radiographs reveal an anterior atlantoaxial subluxation (AAS) of 9 mm and a posterior atlantodental interval (PADI) of 12 mm. What is the most appropriate next step?

. Proceed with surgery using standard endotracheal intubation
. Cancel surgery and place the patient in a halo vest
. Obtain an MRI of the cervical spine
. Schedule immediate occipitocervical fusion
. Perform a diagnostic steroid injection of the C1-C2 joint

Correct Answer & Explanation

. Obtain an MRI of the cervical spine

Explanation

In rheumatoid cervical spine involvement, a PADI of <14 mm is a critical threshold indicating impending cord compression. An MRI is required to evaluate for spinal cord impingement or myelomalacia before proceeding with any other management.

Question 7260

Topic: 6. Spine

A 60-year-old woman with long-standing rheumatoid arthritis presents with neck pain, bilateral hand clumsiness, and hyperreflexia. Lateral flexion-extension radiographs reveal anterior atlantoaxial subluxation. Which of the following radiographic parameters is the most reliable predictor of neurologic deficit and the potential for recovery after surgery?

. Anterior atlantodental interval (AADI) greater than 10 mm
. Space Available for the Cord (SAC) / Posterior atlantodental interval (PADI) less than 14 mm
. Ranawat line less than 13 mm in men
. McGregor line breached by the odontoid greater than 4.5 mm
. Cervical lordotic angle less than 10 degrees

Correct Answer & Explanation

. Space Available for the Cord (SAC) / Posterior atlantodental interval (PADI) less than 14 mm

Explanation

In rheumatoid cervical myelopathy, the Posterior Atlantodental Interval (PADI), also known as the Space Available for the Cord (SAC), is the most critical parameter. A PADI < 14 mm strongly correlates with neurologic deficits and a lower chance of neurological recovery.

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