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6. Spine MCQs

Practice Set 43 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 841

Topic: 6. Spine

According to the Denis three-column theory of the spine, which of the following structures is considered part of the middle column?

. Anterior longitudinal ligament
. Anterior half of the vertebral body
. Posterior longitudinal ligament
. Pedicles
. Ligamentum flavum

Correct Answer & Explanation

. Posterior longitudinal ligament

Explanation

The middle column in the Denis classification consists of the posterior half of the vertebral body, the posterior annulus fibrosus, and the posterior longitudinal ligament. Disruption of the middle column is the defining hallmark of a burst fracture.

Question 842

Topic: 6. Spine

A 28-year-old male presents with chronic lower back pain and morning stiffness lasting longer than an hour. Radiographs show squaring of the lumbar vertebrae and syndesmophyte formation. He is at increased risk for which of the following cervical spine complications even with minor trauma?

. Hangman's fracture
. Jefferson fracture
. Epidural hematoma extending across multiple segments
. Odontoid nonunion
. Syringomyelia

Correct Answer & Explanation

. Epidural hematoma extending across multiple segments

Explanation

Patients with ankylosing spondylitis have a rigid, osteopenic spine that acts like a long bone, making it highly susceptible to fracture even from minor trauma. These fractures are frequently accompanied by extensive epidural hematomas due to the altered dural-bone relationship.

Question 843

Topic: 6. Spine

A 45-year-old man presents with neck pain radiating down his right arm. Examination reveals weakness in right wrist extension and a diminished brachioradialis reflex. Which cervical nerve root is most likely compressed?

. C4
. C5
. C6
. C7
. C8

Correct Answer & Explanation

. C6

Explanation

A C5-C6 disc herniation compresses the C6 nerve root. This results in weakness of wrist extension and elbow flexion, along with a diminished brachioradialis reflex and numbness in the thumb and index finger.

Question 844

Topic: 6. Spine

A 32-year-old weightlifter presents with acute lower back pain radiating to the dorsum of his left foot. He exhibits weakness in great toe extension but normal ankle plantar flexion and knee extension. A paracentral disc herniation at which level is most likely responsible?

. L3-L4
. L4-L5
. L5-S1
. L2-L3
. S1-S2

Correct Answer & Explanation

. L4-L5

Explanation

A paracentral disc herniation at L4-L5 typically compresses the traversing L5 nerve root. This manifests as weakness in extensor hallucis longus (EHL) and sensory deficits over the dorsum of the foot.

Question 845

Topic: 6. Spine

A 68-year-old man complains of deteriorating handwriting and a feeling of imbalance when walking. Physical examination reveals a positive Hoffmann sign bilaterally and hyperreflexia in the lower extremities. What is the most appropriate initial diagnostic modality?

. Electromyography (EMG)
. CT scan of the brain
. MRI of the cervical spine
. Somatosensory evoked potentials (SSEP)
. Radiographs of the thoracic spine

Correct Answer & Explanation

. Electromyography (EMG)

Explanation

The patient exhibits signs of cervical spondylotic myelopathy, including upper extremity clumsiness and upper motor neuron signs. An MRI of the cervical spine is the gold standard to evaluate spinal cord compression and signal changes.

Question 846

Topic: 6. Spine

A 22-year-old woman is brought to the trauma bay after a high-speed motor vehicle collision where she was wearing a lap belt. She has severe localized back pain and an ecchymotic band across her abdomen.

What is the primary mechanism of injury for the suspected spinal fracture?

. Axial loading
. Flexion-distraction
. Hyperextension
. Lateral compression
. Torsional shear

Correct Answer & Explanation

. Axial loading

Explanation

A lap belt injury classically causes a flexion-distraction injury (Chance fracture) of the thoracolumbar spine. It involves tension failure of the anterior, middle, and posterior columns, requiring careful evaluation for associated visceral abdominal injuries.

Question 847

Topic: Thoracolumbar Spine & Deformity

A 15-year-old female gymnast complains of persistent mechanical lower back pain. Lateral radiographs show a grade 1 anterolisthesis of L5 on S1. Oblique views demonstrate a 'Scotty dog with a collar' appearance. What is the initial treatment of choice?

. L5-S1 anterior lumbar interbody fusion
. Pars repair using pedicle screws and hooks
. Rigid bracing and activity modification
. Laminectomy and decompression
. Epidural steroid injections

Correct Answer & Explanation

. L5-S1 anterior lumbar interbody fusion

Explanation

The patient has a symptomatic isthmic spondylolisthesis secondary to a pars interarticularis defect, common in adolescent athletes. Initial management for low-grade slips is non-operative, focusing on activity modification, physical therapy, and bracing.

Question 848

Topic: 6. Spine

A 55-year-old man with long-standing ankylosing spondylitis experiences a mechanical fall from a standing height. He complains of new-onset severe lower neck pain but has no neurological deficits. Radiographs are obscured by his severe kyphotic deformity. What is the most appropriate next step?

. Discharge with a soft cervical collar
. Prescribe high-dose NSAIDs and schedule physical therapy
. Perform a dynamic flexion-extension radiograph
. Obtain a thin-slice CT scan of the entire cervical spine
. Perform a diagnostic facet block

Correct Answer & Explanation

. Discharge with a soft cervical collar

Explanation

Patients with ankylosing spondylitis have rigid, osteopenic spines that are highly susceptible to unstable fractures even from minor trauma. A CT scan of the entire cervical spine is mandatory to detect occult fractures, as standard radiographs are frequently inadequate.

Question 849

Topic: 6. Spine

A 72-year-old woman complains of bilateral leg cramping and heaviness after walking 2 blocks. The pain is rapidly relieved when she sits down or leans forward over a shopping cart, but it persists if she stands upright while stationary. Her pedal pulses are palpable. What is the most likely diagnosis?

. Peripheral arterial disease
. Deep vein thrombosis
. Lumbar spinal stenosis
. Diabetic peripheral neuropathy
. Cauda equina syndrome

Correct Answer & Explanation

. Peripheral arterial disease

Explanation

Neurogenic claudication secondary to lumbar spinal stenosis is classically exacerbated by lumbar extension (standing, walking) and relieved by flexion (sitting, leaning forward). The persistence of symptoms while standing stationary distinguishes it from vascular claudication.

Question 850

Topic: 6. Spine

A 48-year-old intravenous drug user presents with a 1-week history of severe mid-back pain, fever, and progressive bilateral leg weakness. Examination reveals an elevated ESR and CRP. What is the most sensitive and specific imaging modality for the suspected diagnosis?

. Plain radiographs of the thoracic spine
. Non-contrast CT of the thoracic spine
. MRI of the whole spine with gadolinium contrast
. Technetium-99m bone scan
. Gallium-67 scan

Correct Answer & Explanation

. Plain radiographs of the thoracic spine

Explanation

The clinical presentation strongly suggests a spinal epidural abscess. MRI with gadolinium contrast is the gold standard imaging modality, providing excellent detail of the spinal cord, epidural space, and any loculated fluid collections.

Question 851

Topic: 6. Spine
A 29-year-old man is stabbed in the back at the T8 level. Neurological examination reveals loss of motor function and proprioception in his right leg, and loss of pain and temperature sensation in his left leg. What spinal cord syndrome does this represent?
. Anterior cord syndrome
. Central 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, often due to penetrating trauma. It manifests as ipsilateral loss of motor function (corticospinal tract) and proprioception (dorsal columns), with contralateral loss of pain and temperature (spinothalamic tract).

Question 852

Topic: 6. Spine

A 65-year-old man presents with bilateral leg pain and cramping that worsens with walking and prolonged standing. The pain is relieved by sitting or leaning forward over a shopping cart. Physical examination is unremarkable at rest. Which of the following is the most likely diagnosis?

. Lumbar disc herniation
. Lumbar spinal stenosis
. Peripheral arterial disease
. Isthmic spondylolisthesis
. Cauda equina syndrome

Correct Answer & Explanation

. Lumbar disc herniation

Explanation

The patient's symptoms are classic for neurogenic claudication caused by lumbar spinal stenosis. The pain is typically relieved by lumbar flexion, which increases the cross-sectional area of the spinal canal.

Question 853

Topic: 6. Spine

A 45-year-old man presents with acute onset of right-sided sciatica and weakness in his right foot. Examination reveals 3/5 strength in the extensor hallucis longus and decreased sensation over the dorsal aspect of the right foot. Which intervertebral disc level is most likely herniated?

. L2-L3
. L3-L4
. L4-L5
. L5-S1
. S1-S2

Correct Answer & Explanation

. L2-L3

Explanation

The L5 nerve root is compressed by a paracentral disc herniation at the L4-L5 level. This results in weakness of the extensor hallucis longus and sensory loss over the dorsum of the foot.

Question 854

Topic: 6. Spine

A 72-year-old woman with pre-existing cervical spondylosis falls forward and strikes her chin on a table, causing sudden hyperextension of her neck. She presents with bilateral upper extremity weakness, greater in the hands than the shoulders, and relatively preserved lower extremity function. What is the most likely diagnosis?

. Anterior cord syndrome
. Central cord syndrome
. Brown-Sequard syndrome
. Posterior cord syndrome
. Complete spinal cord injury

Correct Answer & Explanation

. Anterior cord syndrome

Explanation

Central cord syndrome classically occurs in elderly patients with cervical spondylosis following a hyperextension injury. It affects the medially located cervical motor tracts more than the laterally located lumbar and sacral tracts.

Question 855

Topic: 6. Spine

A 30-year-old immigrant presents with back pain, low-grade fever, and night sweats for 3 months. Imaging shows destruction of the anterior vertebral bodies of T10 and T11 with a paravertebral mass.

What is the primary route of dissemination for this pathogen to the spine?

. Direct extension from a pulmonary source
. Lymphatic spread from the gastrointestinal tract
. Hematogenous spread via Batson's plexus
. Direct inoculation from previous trauma
. Ascending infection from the urinary tract

Correct Answer & Explanation

. Direct extension from a pulmonary source

Explanation

Spinal tuberculosis (Pott's disease) most commonly spreads to the spine hematogenously. The venous plexus of Batson allows retrograde flow of infected blood to the vertebral bodies.

Question 856

Topic: 6. Spine

A 50-year-old man with a long history of ankylosing spondylitis presents to the emergency department after a minor fall. He complains of severe lower cervical neck pain but has no neurological deficits. Initial plain radiographs of the cervical spine are read as normal. What is the most appropriate next step in management?

. Discharge with a soft cervical collar and NSAIDs
. Perform flexion-extension cervical radiographs
. Obtain a CT scan of the cervical spine
. Administer high-dose intravenous steroids
. Schedule an outpatient MRI in 2 weeks

Correct Answer & Explanation

. Discharge with a soft cervical collar and NSAIDs

Explanation

Patients with ankylosing spondylitis have highly rigid, osteopenic spines that are extremely susceptible to fractures even from trivial trauma. A CT scan or MRI is mandatory as occult fractures are common and can lead to devastating neurological compromise.

Question 857

Topic: 6. Spine

An 18-year-old gymnast complains of chronic lower back pain that is exacerbated by spinal extension. Oblique lumbar radiographs demonstrate a "Scotty dog with a collar" sign. At which vertebral level does this pathology most commonly occur?

. L2
. L3
. L4
. L5
. S1

Correct Answer & Explanation

. L2

Explanation

The patient has an isthmic spondylolysis (pars interarticularis defect), which is most commonly seen at the L5 vertebral level. It typically presents with mechanical low back pain exacerbated by extension activities.

Question 858

Topic: Thoracolumbar Spine & Deformity

A 68-year-old woman presents with severe low back pain and neurogenic claudication. Plain radiographs reveal a grade 1 spondylolisthesis at L4-L5. Which of the following best describes the pathogenesis of this specific condition?

. Bilateral defects in the pars interarticularis
. Facet joint osteoarthritis and ligamentum flavum hypertrophy
. A congenital defect in the superior articular facet
. Traumatic fracture of the pedicles
. Pathologic destruction by a metastatic lesion

Correct Answer & Explanation

. Bilateral defects in the pars interarticularis

Explanation

Degenerative spondylolisthesis most commonly occurs at L4-L5 due to facet joint incompetence and degenerative changes. Unlike isthmic spondylolisthesis, the pars interarticularis remains intact.

Question 859

Topic: 6. Spine

A patient sustains a penetrating knife wound to the right side of his thoracic spine. Neurological examination reveals loss of motor function and proprioception in his right leg, and loss of pain and temperature sensation in his left leg. What is the name of this spinal cord syndrome?

. Anterior cord syndrome
. Central cord syndrome
. Brown-Sequard syndrome
. Conus medullaris syndrome
. Cauda equina syndrome

Correct Answer & Explanation

. Anterior cord syndrome

Explanation

Brown-Sequard syndrome results from spinal cord hemisection. It is characterized by ipsilateral loss of motor function and dorsal column function, and contralateral loss of spinothalamic function.

Question 860

Topic: 6. Spine

A 70-year-old man is evaluated for progressive dysphagia and mild neck stiffness. Lateral cervical spine radiographs show flowing ossification along the anterolateral aspect of four contiguous vertebral bodies with preserved disc heights.

What is the most likely diagnosis?

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

Correct Answer & Explanation

. Ankylosing spondylitis

Explanation

DISH is characterized by flowing anterior ossification across at least four contiguous vertebral bodies with preserved intervertebral disc spaces. In the cervical spine, large anterior osteophytes can cause mechanical dysphagia.

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