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6. Spine MCQs

Practice Set 38 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 741

Topic: 6. Spine

In the surgical planning for thoracic disc herniations, a "giant" thoracic disc is typically defined as one that occupies what percentage of the spinal canal cross-sectional area?

. > 10%
. > 20%
. > 30%
. > 40%
. > 60%

Correct Answer & Explanation

. > 40%

Explanation

A giant thoracic disc herniation is classically defined in the literature as one that occupies greater than 40% of the spinal canal volume. These lesions are technically demanding to resect and carry a higher risk of perioperative neurological injury.

Question 742

Topic: 6. Spine

A 42-year-old man is diagnosed with a symptomatic T1-T2 thoracic disc herniation. In addition to radicular pain, which of the following autonomic findings is most likely to be present on physical examination?

. Anhidrosis of the ipsilateral lower extremity
. Ipsilateral ptosis and miosis
. Contralateral mydriasis and exophthalmos
. Hyperhidrosis of the lower trunk
. Paroxysmal systemic hypertension

Correct Answer & Explanation

. Ipsilateral ptosis and miosis

Explanation

A T1-T2 disc herniation can compress the T1 sympathetic roots. This disruption of the sympathetic chain can result in an ipsilateral Horner's syndrome, characterized by ptosis, miosis, and anhidrosis.

Question 743

Topic: 6. Spine

Thoracic disc herniations in the adolescent population are most frequently associated with which underlying spinal pathology?

. Idiopathic scoliosis
. Isthmic spondylolisthesis
. Scheuermann's kyphosis
. Achondroplasia
. Marfan syndrome

Correct Answer & Explanation

. Scheuermann's kyphosis

Explanation

Adolescent thoracic disc herniations are relatively rare but are highly associated with Scheuermann's kyphosis. The altered biomechanics and vertebral endplate irregularities (Schmorl's nodes) predispose these patients to disc herniations.

Question 744

Topic: 6. Spine

A 55-year-old asymptomatic woman undergoes an MRI of the thoracic spine for a research study. Based on current epidemiological data, what is the approximate probability of finding an incidental, asymptomatic thoracic disc herniation?

. Less than 1%
. 5% to 10%
. 15% to 20%
. 30% to 40%
. Greater than 75%

Correct Answer & Explanation

. 30% to 40%

Explanation

MRI studies of asymptomatic volunteers reveal a high prevalence of incidental thoracic disc herniations, generally reported between 30% and 40%. The vast majority of these lesions remain completely asymptomatic and follow a benign natural history.

Question 745

Topic: 6. Spine

A patient with a central T6-T7 disc herniation exhibits severe myelopathy. During a physical examination to distinguish this from cervical myelopathy, which of the following findings would specifically point toward a thoracic etiology?

. Presence of a positive Hoffmann's sign
. Hyperreflexia in the biceps and triceps tendons
. Normal upper extremity reflexes with hyperreflexic patellar tendons
. Atrophy of the intrinsic hand muscles
. A positive Lhermitte's sign upon cervical flexion

Correct Answer & Explanation

. Normal upper extremity reflexes with hyperreflexic patellar tendons

Explanation

A thoracic lesion causes upper motor neuron signs (hyperreflexia, spasticity) exclusively in the lower extremities. The upper extremities remain neurologically intact, which helps clinically differentiate thoracic myelopathy from cervical myelopathy.

Question 746

Topic: Thoracolumbar Spine & Deformity

An 18-year-old man comes to the office with a grade IV isthmic spondylolisthesis and severe left lower extremity discomfort. Which imaging study would best help identify the site of potential nerve root compression:

. Computed tomography scan
. Magnetic resonance imaging (MRI) scan
. Plain myelography
. Bone scan
. Positron emission tomography (PET)

Correct Answer & Explanation

. Magnetic resonance imaging (MRI) scan

Explanation

An MRI scan would be the imaging study of choice to best identify the site of nerve root compression because it provides parasagittal views that can help determine the degree of narrowing of the neural foramina. Plain myelography may not accurately identify lateral recess compression. A C T scan would produce images perpendicular to the plane of nerve root compression. Bone scan and PET scan would be of little or no help in identifying nerve root compression.

Question 747

Topic: 6. Spine

When considering surgical intervention in the management of low back pain, it is crucial to try and identify the possible offending agent or pain generator. Based on awake anatomical stimulation studies, what percentage of patients should report significant discomfort when a nerve root is either compressed or stretched in an attempt to elicit pain:

. 99%
. 60%
. 40%
. 20%
. 1%

Correct Answer & Explanation

. 99%

Explanation

Studies have reported on diskectomies in awake patients performed under local anesthesia. Anatomic spinal structures were stimulated prior to additional local anesthesia placed into these deeper areas and patients were asked to report any pain. Compression or stretching of nerve roots caused significant pain 100% of the time. Stimulation of the posterior dura caused significant pain only 1% of the time.

Question 748

Topic: 6. Spine

Which disorder does not represent a rheumatologic/inflammatory condition associated with causing low back pain:

. Rheumatoid arthritis
. Reiter syndrome
. Psoriatic arthritis
. Ankylosing spondylitis
. Osteoarthritis

Correct Answer & Explanation

. Osteoarthritis

Explanation

Although osteoarthritis is the most common arthritic disorder associated with low back pain, it is not a rheumatologic condition. Rheumatoid arthritis, Reiter syndrome, psoriatic arthritis, and ankylosing spondylitis are all rheumatologic or inflammatory conditions associated with the development of low back pain.

Question 749

Topic: 6. Spine

A 57-year-old man with known lung cancer and metastatic disease complains of increasing low back pain. How often is the lumbar spine involved when a patient has known spinal metastasis:

. 5%
. 15%
. 50%
. 85%
. 99%

Correct Answer & Explanation

. 85%

Explanation

In 85 % of patients with metastatic disease to the spine, the lumbar region vertebral body is involved. If operable, the vertebral body lesion can be managed via an anterior approach with a corpectomy, as opposed to a posterior approach with laminectomy and removal of all involved posterior elements (if they are involved).

Question 750

Topic: 6. Spine

Which orthopedic test, designed to apply tension to the spinal cord producing pain, involves having the patient lie supine while the examiner flexes the patient's head to his chest:

. Kernig sign
. Hoover test
. Milgram test
. Naffziger test
. Gaenslen test

Correct Answer & Explanation

. Kernig sign

Explanation

The Kernig test involves the patient lying supine while the examiner forcibly flexes the head to the chest applying tension to the spinal cord. The test is positive if pain is elicited and indicates meningeal irritation in conditions such as meningitis. The Hoover test can help identify a patient who is malingering. This test involves having the patient lie supine with the examiner's hands placed under both of the patient's heels. The patient is asked to lift the affected leg. If a true effort is made, the examiner should feel downward pressure in the patient's opposite foot as he attempts to lift the affected leg. If no downward pressure is felt, the patient purposely may not be trying and might be malingering. The Milgram test may be used in conditions with suspected intrathecal pathology. While lying supine, the patient is asked to perform bilateral straight leg lifts. If the patient can sustain his feet 2 inches off the ground for more 30 seconds, intrathecal pathology is less likely. The Naffziger test is designed to increase intrathecal pressure and thus pain by compressing the jugular veins. The Gaenslen test is used to determine sacroiliac joint pathology.

Question 751

Topic: 6. Spine

A 52-year-old man sustained an L1 burst fracture after falling from a ladder 3 weeks ago. He was found neurologically intact after initial examination. He has been treated with conservative management since the accident, but he now complains of an inability to void along with numbness and tingling in both of his legs. Computed tomography scan shows worsening conus compression. On physical examination, you discover that he has weak anal sphincter tone. Your next step in the treatment of this patient should be:

. Anterior decompression and fusion with grafting with or without instrumentation
. High-dose steroids
. Laminectomy
. Posterior fusion with instrumentation
. C ontinue conservative management with follow-up in 1 month

Correct Answer & Explanation

. Anterior decompression and fusion with grafting with or without instrumentation

Explanation

This patient has deteriorating neurological findings involving the cauda equina; therefore, surgical decompression is indicated. An anterior approach will directly decompress the neural structures. Performing a laminectomy alone is actually contraindicated as it may increase potential spinal instability. A posterior approach to achieve a fusion with instrumentation may not fully decompress the neural structures, although this is somewhat controversial.

Question 752

Topic: 6. Spine

A 27-year-old man comes in for examination. He complains of worsening pain in his lower back. He states that the pain started 4 days ago after lifting a heavy box. The patient's neurological exam is completely nonfocal. The initial management of this patient should include:

. Computed tomography scan of the lumbar spine with contrast
. Epidural steroid injection
. Magnetic resonance image of the lumber spine
. Bed rest of short duration along with nonsteroidal anti-inflammatory medications
. Computed tomography scan of the lumbar spine without contrast

Correct Answer & Explanation

. Bed rest of short duration along with nonsteroidal anti-inflammatory medications

Explanation

This patient's neurological exam is normal and his injury was recent; this is most likely a soft tissue injury to his low back. Due to the patient's age and the fact that this is most likely not a serious injury, an initial conservative approach would be most appropriate. Epidural steroids or a selective nerve root block would be indicated if this patient developed worsening low back complaints or radicular pain in association with his low back pain.

Question 753

Topic: 6. Spine

A 42-year-old man sustained a twisting injury to his low back 5 months ago. Since the injury, he has persistent low back pain that radiates into his right thigh and down to his posterior calf. The patient underwent a magnetic resonance imaging of his lumbar spine revealing a small posterolateral lumbar disk herniation at the L4L5 level. Over the past month, the patient states that his leg pain has been getting progressively better and has almost disappeared over the past week with the use of nonsteroidal anti- inflammatory medications and occasional bed rest. The next step in the management of this patient should be:

. A lumbar computed tomography scan
. Repeat magnetic resonance image
. Surgical excision of the herniated disk
. C ontinued conservative management
. Epidural steroid injection

Correct Answer & Explanation

. C ontinued conservative management

Explanation

The patient has shown continued improvement of his symptoms including the leg pain with conservative treatment. Epidural steroids would be indicated if this patient had continued or worsening leg pain and/or low back pain.

Question 754

Topic: Thoracolumbar Spine & Deformity

This radiograph shows a grade I spondylolisthesis of L5 on S1. This is due to a defect in what anatomical area:

. Superior articular process
. Inferior articular process
. Pars interarticularis
. Pedicle
. Lamina

Correct Answer & Explanation

. Pars interarticularis

Explanation

The anatomical region involved in a spondylolisthesis is the pars interarticularis that is located between the superior and inferior articular processes and is a high stress area of relatively thinner bone.

Question 755

Topic: Thoracolumbar Spine & Deformity

A 16-year-old football lineman develops unrelenting low back pain for the past 3 months. Based on the magnetic resonance image shown, the next step in the management of this patient is:

. Fusion in situ
. Epidural injection therapy
. Excision of a herniated disk
. Restriction of the exacerbating activity
. Observation

Correct Answer & Explanation

. Restriction of the exacerbating activity

Explanation

This patient has a grade I-II spondylolisthesis of L5 on S1. The initial management should include restriction of physical activity. Once the symptoms abate, the athlete can return to the sport. If symptoms return, other interventions are indicated including possible brace wear.C orrect Answer: Restriction of the exacerbating activity

Question 756

Topic: 6. Spine

A 45-year-old construction worker with long standing low back pain now notices bilateral thigh and lower extremity discomfort for the past 6 months. He has undergone conservative treatment with little success including injection therapy. He cannot perform his work duties. Based on the lateral radiograph shown below, the next step in the management of the patient should consist of:

. Laminectomy
. C ontinued conservative treatment
. Posterolateral fusion in situ without instrumentation
. Diskectomy
. Decompression and posterolateral fusion in situ with instrumentation.

Correct Answer & Explanation

. Decompression and posterolateral fusion in situ with instrumentation.

Explanation

This patient has an isthmic L4L5 spondylolisthesis with accompanied neuroforaminal stenosis. He already failed conservative management and would benefit from operative intervention. This should consist of a decompressive procedure to alleviate his lower extremity symptomatology along with a fusion procedure of the L4-L5 level due to the listhesis. If he undergoes a laminectomy alone, he may develop increased low back pain in the future.

Question 757

Topic: Thoracolumbar Spine & Deformity

A 35-year-old woman presents with severe back pain. Radiographic evaluation reveals a thoracic curve of 70° and a loss of thoracic kyphosis. Surgery is recommended to correct the deformity. Which of the following tests must be ordered as part of the preoperative evaluation:

. Electrocardiogram (ECG)
. Pulmonary function tests
. Electromyelogram (EMG)
. Chest radiograph
. Somatosensory evoked potentials (SSEP)

Correct Answer & Explanation

. Pulmonary function tests

Explanation

Thoracic curves greater than 65° may affect pulmonary function, especially when they are combined with thoracic lordosis. This patient displays a thoracic curve of 70° and a loss of the normal thoracic kyphosis; therefore, pulmonary function tests are part of the routine evaluation.

Question 758

Topic: 6. Spine

A calcified thoracic disk in the spinal canal is pathognomonic for:

. Scheuermann disease
. Ankylosing spondylitis
. Thoracic disk herniation
. Vertebral wedging
. Infection

Correct Answer & Explanation

. Thoracic disk herniation

Explanation

Plain radiographs of the spine are helpful in the diagnosis of disk herniation only if they demonstrate disk calcification. However, the calcified disk is not always the disk that is herniated, but it suggests the diagnosis. Detection of a calcified disk on radiograph in the canal is pathognomonic of herniation.

Question 759

Topic: 6. Spine

Surgical treatment of thoracic disk herniation by a laminectomy is contraindicated because this procedure is associated with which of the following:

. Incomplete relief of symptoms
. High incidence of neurologic damage
. Destabilization of the spine
. High incidence of recurrence
. High incidence of post-laminectomy kyphosis

Correct Answer & Explanation

. High incidence of neurologic damage

Explanation

There is a high incidence of spinal cord injury associated with thoracic disks removed by laminectomy. The advent of alternative procedures, such as costotransversectomy and transthoracic decompression, has led to a decrease in spinal cord injury admissions. Also, patients who do not improve after laminectomy are less likely to be helped by later anterior decompression.

Question 760

Topic: 6. Spine

A 68-year-old male presents with bilateral lower extremity aching and cramping that worsens with walking and improves when he leans forward on a shopping cart. Which of the following is the most characteristic clinical feature distinguishing this condition from vascular claudication?

. Exacerbation of symptoms with lumbar flexion
. Relief of symptoms when walking uphill
. Diminished pedal pulses during rest
. Increased pain when riding a stationary bicycle
. Worsening of pain when sitting

Correct Answer & Explanation

. Exacerbation of symptoms with lumbar flexion

Explanation

Neurogenic claudication due to lumbar spinal stenosis is typically relieved by lumbar flexion (e.g., walking uphill or leaning on a cart), which increases the spinal canal diameter. Vascular claudication is exacerbated by walking regardless of posture and is not relieved by spinal flexion.

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