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6. Spine MCQs

Practice Set 4 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 61

Topic: 6. Spine

A 12-year-old gymnast presents with progressive neck pain and clumsy hands. Imaging reveals an os odontoideum with 6 mm of instability on dynamic flexion-extension views and early myelopathic signal on MRI. What is the most appropriate management?

. Observation and restriction from gymnastics
. Cervical orthosis for 3 months
. Posterior C1-C2 instrumental fusion
. Transoral odontoidectomy without fusion
. Anterior odontoid screw fixation

Correct Answer & Explanation

. Posterior C1-C2 instrumental fusion

Explanation

Surgical stabilization, most commonly a posterior C1-C2 fusion, is indicated for os odontoideum when there is significant atlantoaxial instability associated with neurological deficits or myelopathy.

Question 62

Topic: 6. Spine

A 45-year-old intravenous drug user presents with a 3-day history of severe, localized back pain, low-grade fever, and acute bilateral lower extremity weakness. MRI reveals a spinal epidural abscess. What is the most likely causative organism?

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

Correct Answer & Explanation

. Staphylococcus aureus

Explanation

Staphylococcus aureus is the most common organism isolated in spinal epidural abscesses. The classic presentation includes the triad of severe back pain, fever, and progressive neurological deficits.

Question 63

Topic: 6. Spine

Which of the following radiographic criteria is traditionally required to formally establish the diagnosis of classic Scheuermann's kyphosis (Sorensen criteria)?

. At least three adjacent vertebrae demonstrating anterior wedging of 5 degrees or more
. A single vertebra demonstrating 10 degrees of anterior wedging
. The presence of Schmorl's nodes in at least two adjacent vertebrae
. Disc space narrowing without structural vertebral wedging
. A measured thoracic kyphosis greater than 30 degrees only

Correct Answer & Explanation

. At least three adjacent vertebrae demonstrating anterior wedging of 5 degrees or more

Explanation

The Sorensen criteria for defining classic Scheuermann's disease requires anterior wedging of 5 degrees or more in at least three adjacent vertebral bodies. It is also associated with Schmorl's nodes and endplate irregularities, but the wedging criteria are strictly required.

Question 64

Topic: 6. Spine

A 14-year-old boy presents with progressive mid-back pain and clinical hyperkyphosis. Radiographs reveal a thoracic kyphosis of 65 degrees with anterior wedging of 4 adjacent vertebrae. His Risser stage is 1. What is the most appropriate management?

. Observation with annual radiographs
. Physical therapy for core strengthening without bracing
. Milwaukee brace (extension orthosis) treatment
. Posterior spinal fusion
. Combined anterior and posterior spinal fusion

Correct Answer & Explanation

. Milwaukee brace (extension orthosis) treatment

Explanation

In a skeletally immature patient (Risser 0-2) with progressive Scheuermann's kyphosis between 50 and 75 degrees, extension bracing (such as a Milwaukee brace) is the recommended treatment. Surgery is generally reserved for curves greater than 75 degrees or those refractory to bracing.

Question 65

Topic: 6. Spine

During the evaluation of a 65-year-old male with progressive bilateral hand clumsiness and gait imbalance, the examiner rapidly extends or "flicks" the patient's middle finger, eliciting an involuntary flexion of the thumb and index finger. What is the name of this clinical sign?

. Lhermitte sign
. Hoffmann sign
. Babinski sign
. Wartenberg sign
. Spurling sign

Correct Answer & Explanation

. Hoffmann sign

Explanation

The Hoffmann sign is elicited by flicking the distal phalanx of the middle finger, leading to flexion of the thumb and index finger. It indicates upper motor neuron dysfunction, commonly seen in cervical spondylotic myelopathy.

Question 66

Topic: 6. Spine

A 25-year-old male sustains a Type IIA Hangman's fracture (traumatic spondylolisthesis of the axis) showing severe angulation but minimal translation. Which of the following treatments is specifically contraindicated in the initial management of this specific fracture pattern?

. Halo vest immobilization
. Application of cervical traction
. Surgical stabilization
. Application of a rigid cervical collar
. Reduction with gentle extension and compression

Correct Answer & Explanation

. Application of cervical traction

Explanation

Type IIA Hangman's fractures feature severe angulation with minimal translation and denote a highly unstable injury with posterior longitudinal ligament disruption. Cervical traction is strictly contraindicated as it can cause severe over-distraction and neurologic injury.

Question 67

Topic: 6. Spine

A 45-year-old female complains of neck pain radiating into her right arm. Physical examination reveals weakness in wrist extension, a diminished brachioradialis reflex, and decreased sensation over the dorsal aspect of the thumb and index finger. Which cervical nerve root is most likely compressed?

. C5
. C6
. C7
. C8
. T1

Correct Answer & Explanation

. C6

Explanation

A C6 radiculopathy typically presents with weakness in wrist extension and elbow flexion, an abnormal brachioradialis reflex, and sensory deficits in the thumb and index finger.

Question 68

Topic: 6. Spine

A patient presents with neck pain and arm radiculopathy. Examination demonstrates weakness in triceps extension and wrist flexion, with an absent triceps reflex and numbness primarily in the middle finger. The most likely level of cervical disc herniation is:

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

Correct Answer & Explanation

. C6-C7

Explanation

A herniated disc at the C6-C7 level primarily compresses the C7 nerve root. C7 radiculopathy is characterized by weakness in triceps extension and wrist flexion, diminished triceps reflex, and sensory changes in the middle finger.

Question 69

Topic: 6. Spine

A 60-year-old female with advanced rheumatoid arthritis presents with progressive myelopathy. Radiographs reveal severe atlantoaxial instability. Which of the following radiographic measurements is the most reliable predictor of neurologic recovery following surgical stabilization?

. Anterior atlantodental interval (ADI) greater than 9 mm
. Posterior atlantodental interval (PADI) less than 14 mm
. Ranawat line measurement less than 13 mm
. Clivus-canal angle less than 150 degrees
. Subaxial translation greater than 4 mm

Correct Answer & Explanation

. Posterior atlantodental interval (PADI) less than 14 mm

Explanation

The Posterior Atlantodental Interval (PADI) directly reflects the space available for the spinal cord (SAC). A PADI of less than 14 mm is the most reliable predictor of neurologic deficit and the potential for recovery in rheumatoid cervical spine instability.

Question 70

Topic: 6. Spine

A 65-year-old male presents with severe neck stiffness and mild dysphagia. Lateral radiographs of the cervical spine demonstrate flowing, continuous ossification along the anterior aspect of 5 contiguous vertebral bodies with preservation of the intervertebral disc spaces. The sacroiliac joints are normal. What is the most likely diagnosis?

. Ankylosing spondylitis
. Rheumatoid arthritis
. Diffuse idiopathic skeletal hyperostosis (DISH)
. Cervical spondylosis
. Ossification of the posterior longitudinal ligament (OPLL)

Correct Answer & Explanation

. Diffuse idiopathic skeletal hyperostosis (DISH)

Explanation

DISH is characterized by flowing anterior ossification involving at least 4 contiguous vertebrae, preserved disc heights, and an absence of sacroiliac or apophyseal joint ankylosis. It commonly presents with stiffness and occasionally dysphagia due to anterior osteophytes.

Question 71

Topic: 6. Spine

A 70-year-old male with pre-existing cervical spondylosis sustains a hyperextension injury to his neck in a low-speed motor vehicle collision. He presents with severe motor weakness in his upper extremities but retains functional, albeit weakened, motor strength in his lower extremities. Which incomplete spinal cord syndrome does this patient exhibit?

. Anterior cord syndrome
. Brown-Sequard syndrome
. Central cord syndrome
. Posterior cord syndrome
. Conus medullaris syndrome

Correct Answer & Explanation

. Central cord syndrome

Explanation

Central cord syndrome often occurs after hyperextension injuries in older patients with spondylosis. It affects the centrally located cervical tracts of the upper extremities more severely than the peripherally located tracts of the lower extremities.

Question 72

Topic: 6. Spine

A 5-year-old boy undergoes a lateral cervical spine radiograph after a minor fall. The radiograph shows 3 mm of anterior displacement of C2 on C3. To distinguish physiologic pseudosubluxation from true traumatic instability, which of the following radiographic lines should be evaluated?

. Chamberlain line
. McRae line
. Swischuk line
. Wackenheim clivus line
. McGregor line

Correct Answer & Explanation

. Swischuk line

Explanation

Swischuk's line connects the anterior aspect of the posterior arches of C1 and C3. In physiologic pseudosubluxation, the anterior aspect of the posterior arch of C2 should lie within 1-2 mm of this line. Deviation greater than 2 mm suggests true structural injury.

Question 73

Topic: 6. Spine

A 45-year-old male presents with progressive myelopathy and is found to have a large, calcified central disc herniation at T8-T9 causing severe spinal cord compression. What is the safest and most appropriate surgical approach for decompression?

. Standard posterior laminectomy and discectomy
. Anterior transthoracic or costotransversectomy approach
. Posterior interlaminar endoscopic discectomy
. Transforaminal lumbar interbody fusion (TLIF) approach
. Bilateral laminotomy

Correct Answer & Explanation

. Anterior transthoracic or costotransversectomy approach

Explanation

Standard posterior laminectomy for central, calcified thoracic disc herniations is strictly contraindicated due to a highly unacceptable rate of iatrogenic paraplegia. Anterior transthoracic, lateral, or costotransversectomy approaches are required to decompress the cord without retraction.

Question 74

Topic: 6. Spine
A 28-year-old female is brought to the emergency department after a high-speed motor vehicle collision. She has bilateral upper extremity radicular pain but intact motor function. A lateral cervical spine radiograph reveals 25% anterior translation of C5 on C6. What is the most likely underlying structural injury?
. Unilateral facet dislocation
. Bilateral facet dislocation
. Hangman fracture
. Odontoid type III fracture
. Burst fracture of C5

Correct Answer & Explanation

. Unilateral facet dislocation

Explanation

Anterior translation of one vertebral body on another of approximately 25% (or less than 50%) is the classic radiographic hallmark of a unilateral facet dislocation. Bilateral facet dislocations typically present with greater than 50% translation.

Question 75

Topic: Cervical Spine

A 35-year-old manual laborer presents with sudden severe lower neck pain after forcefully shoveling heavy, wet snow. Radiographs reveal an avulsion fracture of the spinous process of C7. What is the recommended management for this injury?

. Immediate halo vest immobilization
. Anterior cervical discectomy and fusion (ACDF)
. Posterior cervical wiring and fusion
. Symptomatic care with a soft collar and gradual return to activity
. Closed reduction and rigid casting

Correct Answer & Explanation

. Symptomatic care with a soft collar and gradual return to activity

Explanation

A Clay Shoveler's fracture is a stable avulsion fracture of a lower cervical spinous process (often C6 or C7). Treatment is primarily symptomatic, involving temporary immobilization for comfort and early range of motion.

Question 76

Topic: Cervical Spine

A 7-year-old boy presents with progressive torticollis following a severe upper respiratory tract infection. Radiographs reveal atlantoaxial rotatory subluxation. What is the most likely diagnosis?

. Sandifer syndrome
. Grisel syndrome
. Klippel-Feil syndrome
. Juvenile idiopathic arthritis
. Posterior fossa tumor

Correct Answer & Explanation

. Grisel syndrome

Explanation

Grisel syndrome is a non-traumatic atlantoaxial subluxation caused by inflammation of the adjacent cervical tissues, often following an upper respiratory infection or head and neck surgery. The inflammation leads to laxity of the transverse ligament.

Question 77

Topic: 6. Spine

When evaluating a 3-year-old child following a cervical spine trauma, the Swischuk line is utilized to differentiate physiological pseudosubluxation of C2 on C3 from a true traumatic subluxation. How is this line correctly drawn?

. From the anterior cortex of the C1 spinous process to the anterior cortex of the C3 spinous process.
. From the posterior cortex of the C1 arch to the posterior cortex of the C3 arch.
. From the anterior tip of the dens to the anterior-inferior body of C3.
. From the posterior tip of the dens to the posterior body of C3.
. From the basion to the posterior aspect of the C2 spinous process.

Correct Answer & Explanation

. From the anterior cortex of the C1 spinous process to the anterior cortex of the C3 spinous process.

Explanation

The Swischuk line (posterior cervical line) is drawn from the anterior aspect of the C1 spinous process to the anterior aspect of the C3 spinous process. If the anterior cortex of the C2 spinous process misses this line by more than 2 mm, a true subluxation is suspected.

Question 78

Topic: Thoracolumbar Spine & Deformity

According to the Sorensen criteria, what is the strict radiographic requirement for the diagnosis of classic Scheuermann's kyphosis?

. Anterior wedging of greater than 5 degrees in at least two consecutive vertebrae.
. Anterior wedging of greater than 5 degrees in at least three consecutive vertebrae.
. Anterior wedging of greater than 10 degrees in at least two consecutive vertebrae.
. Anterior wedging of greater than 10 degrees in at least three consecutive vertebrae.
. Presence of multiple Schmorl's nodes with endplate irregularities only.

Correct Answer & Explanation

. Anterior wedging of greater than 10 degrees in at least three consecutive vertebrae.

Explanation

Sorensen classically defined Scheuermann's disease as a thoracic kyphosis featuring greater than 5 degrees of anterior wedging in at least three consecutive vertebrae. Endplate irregularities and Schmorl's nodes are supportive but not sufficient alone for the classic definition.

Question 79

Topic: 6. Spine

A 65-year-old male presents with difficulty buttoning his shirts and a broad-based gait. Physical examination reveals an inverted supinator reflex. This specific clinical sign strongly suggests pathology at which spinal level?

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

Correct Answer & Explanation

. C5-C6

Explanation

The inverted supinator reflex consists of finger flexion when the brachioradialis reflex is tested. It indicates an upper motor neuron lesion below C5 and a lower motor neuron lesion at C5-C6, heavily pointing to cervical spondylotic myelopathy at the C5-C6 level.

Question 80

Topic: Cervical Spine

In a patient with a suspected Jefferson burst fracture of C1, an open-mouth odontoid radiograph is obtained. According to the Rule of Spence, what radiographic finding indicates a high likelihood of a ruptured transverse ligament?

. Combined lateral overhang of the C1 lateral masses on C2 greater than 3 mm.
. Combined lateral overhang of the C1 lateral masses on C2 greater than 6.9 mm.
. Anterior atlanto-dental interval (ADI) greater than 3 mm.
. Anterior atlanto-dental interval (ADI) greater than 5 mm.
. Asymmetry of the atlantoaxial joints.

Correct Answer & Explanation

. Combined lateral overhang of the C1 lateral masses on C2 greater than 6.9 mm.

Explanation

The Rule of Spence dictates that if the combined overhang of the lateral masses of C1 on C2 exceeds 6.9 mm on an AP open-mouth radiograph, it implies an incompetent transverse ligament. This indicates a highly unstable Jefferson fracture requiring rigid stabilization.

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