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 861
Topic: 6. Spine
A 60-year-old man with diabetes presents with severe, progressive back pain, a low-grade fever, and bilateral lower extremity weakness that began 24 hours ago. His ESR and CRP are markedly elevated. Which of the following is the most appropriate definitive treatment?
Correct Answer & Explanation
. Intravenous antibiotics alone for 6 weeks
Explanation
The patient's presentation is highly suspicious for a spinal epidural abscess with developing neurological deficits. Emergent surgical decompression combined with targeted antibiotics is the standard of care to prevent irreversible paraplegia.
Question 862
Topic: Cervical Spine
A 75-year-old man sustains a Type II odontoid fracture after a fall. Which of the following factors is most predictive of nonunion if treated conservatively with a halo vest?
Correct Answer & Explanation
. Fracture displacement of 2 mm
Explanation
Risk factors for nonunion of a Type II odontoid fracture include age greater than 50 years, fracture displacement greater than 5 mm, and posterior displacement. Due to poor outcomes with halo immobilization in the elderly, surgical fixation is often preferred.
Question 863
Topic: 6. Spine
When placing a pedicle screw in the lumbar spine, which anatomical landmarks are primarily used to identify the optimal starting point?
Correct Answer & Explanation
. The base of the spinous process and the superior articular facet
Explanation
The standard starting point for a lumbar pedicle screw is located at the intersection of a vertical line tangential to the lateral border of the superior articular facet and a horizontal line bisecting the transverse process.
Question 864
Topic: 6. Spine
Among the incomplete spinal cord injury syndromes, which one classically carries the worst prognosis for functional motor recovery?
Correct Answer & Explanation
. Central cord syndrome
Explanation
Anterior cord syndrome results from injury to the anterior two-thirds of the spinal cord, leading to loss of motor function and pain/temperature sensation. It has the poorest prognosis for functional recovery, with fewer than 20% of patients regaining significant motor function.
Question 865
Topic: Thoracolumbar Spine & Deformity
A 12-year-old girl presents to the clinic with scoliosis detected by school screening. Her past medical history includes ophthalmologic observation for Lisch nodules of the iris. She has just started her menstrual periods. On physical exam, she has axillary freckles and normal neurological function. Standing radiographs of the spine illustrate a 32° right thoracic curve from T4 to T10 and rib pencilling. In the sagittal plane, she has a thoracic kyphosis of 30°. The most likely diagnosis is:
Correct Answer & Explanation
. Neurofibromatosis-1 (NF-1)
Explanation
Neurofibromatosis (von Recklinghausen disease) is an autosomal dominant disorder that affects connective tissue. The most common type is NF-1, and is associated with primary skeletal disorders such as scoliosis, cortical thinning and pseudarthrosis of the tibia. It is the result of an abnormality on chromosome 17, and is also associated with: Café au lait spots, Neurofibromas, Axillary or inguinal freckling, Iris hamartomata (Lisch nodules). Scoliosis in NF-1 can occur in 2 patterns. The first is similar to idiopathic scoliosis. The second, or dystrophic type is marked by short, sharper deformities, scalloping of the vertebral bodies, rib pencilling, enlarged foramina and severe apical vertebral body rotation. Some authors have demonstrated that curves characterized as idiopathic in childhood can take on dystrophic characteristics later in life and progress rapidly. Treatment is usually surgical.
Question 866
Topic: 6. Spine
A 10-year-old boy with Down syndrome presents with his parents who have noticed that his endurance for walking seems to have decreased, and he seems clumsier. Your physical examination reveals generalized ligamentous laxity, but no other musculoskeletal abnormalities. His neurological examination is normal. His flexion/extension cervical spine radiographs are abnormal. The most likely pathophysiology is:
Correct Answer & Explanation
. Os odontoideum
Explanation
Children with Down syndrome (trisomy 21) have a higher incidence of hypothroidism, congenital heart disease, leukemia, and slipped capital femoral epiphysis. About 20% of children with Down syndrome develop atlantoaxial instability due to incompetence of the transverse atlantal ligament, and fortunately, most are asymptomatic. Patients with Down syndrome should be screened for atlantoaxial instability with routine flexion/extension lateral cervical radiographs, especially prior to athletic participation. An atlanto-dens interval (ADI) of >5 mm should be treated with activity restriction in the absence of myelopathy. With symptoms of cervical myelopathy or an ADI >7 mm, an atlantoaxial arthrodesis is indicated.
Question 867
Topic: 6. Spine
A 13-year old boy presents to the emergency department with back pain of 5 days duration. The pain is exacerbated by sitting or standing. He has a low- grade fever. He has pain on percussion of the lumbar spine. He has no tension signs. White blood cell count is 8000/mm3 and the erythrocyte sedimentation rate is 40 mm/hr. Plain radiographs of the spine demonstrate a narrowed intervertebral space at L3-L4. The most likely diagnosis is:
Correct Answer & Explanation
. Diskitis
Explanation
The symptoms of diskitis are often vague and insidious. This hematogenous infection of the disk space acts differently than other musculoskeletal infections. The presentation is often that of a patient with low back pain or refusal to ambulate. Fever is usually low or absent. The white blood cell count is usually normal, but the erythrocyte sedimentation rate or C -reactive protein levels may be elevated. Blood cultures are frequently negative. Radiographs of the spine may be normal initially, but may show intervertebral disk space narrowing or end plate irregularities. Bone scan and magnetic resonance imaging are also helpful in the diagnosis. Treatment is usually conservative, and outcomes are aided by the fact that this condition is usually self-limiting. Rest and immobilization provide symptomatic relief, and many authors favor intravenous antibiotics. After an initial response in 72 hours or less, the patient can be switched to oral antibiotics for 3 to 5 weeks. A biopsy is indicated if the patient does not improve quickly, or if a tumor or abscess formation is suspected. Patients with vertebral osteomyelitis or abscesses are typically more ill- appearing, have high fevers and white blood cell counts, and a markedly elevated erythrocyte sedimentation rate. Furthermore, a patient with an epidural abscess may have neurological symptoms or a positive straight leg raising test, due to nerve root irritation or spinal cord compression.
Question 868
Topic: 6. Spine
An 11-year-old boy sustains a fall while jumping on a trampoline. He has moderate back pain, an L-5 radiculopathy, and weakness of the right extensor hallucis longus. Radiographs and a computerized tomography scan of the lumbar spine demonstrate a slipped vertebral apophysis. The recommended treatment is:
Correct Answer & Explanation
. Laminectomy and excision of annulus and vertebral bony margin
Explanation
This patient has a slipped vertebral apophysis as a result of trauma. This is analagous to a Salter-Harris type II fracture. A portion of the apophysis and annulus slip posteriorly and may impinge on the exiting nerve root. These usually do not resolve spontaneously or improve with conservative therapy, and excision is indicated. The disk fragments and retropulsed bone must be removed from the canal with a laminectomy for exposure.
Question 869
Topic: Cervical Spine
Appropriate treatment of a nondisplaced Jefferson fracture is:
Correct Answer & Explanation
. Hard cervical orthosis
Explanation
Fractures involving the C 1 or atlas are generally caused by axial compression with either a flexion or extension force. Generally, fractures involving the C 1 consist of multiple fragments. The classical Jefferson fracture is a 4-part fracture of the atlas and can be unstable. However, in this situation, a nondisplaced fracture represents a relatively stable injury. An open-mouth odontoid anteroposterior radiograph is frequently useful to evaluate unstable patterns. An unstable fracture typically has displacement of the lateral masses greater than 8 mm. If displacement of this amount occurs, generally, the transverse ligament has been disrupted and should be treated by halo vest immobilization. In this nondisplaced situation, a hard Philadelphia collar is the most appropriate form of treatment.
Question 870
Topic: 6. Spine
The American Spinal Injury Association has developed a classification of spinal cord injuries. Using this classification system, an Asia C injury is best described as:
Correct Answer & Explanation
. Incomplete motor loss with some preservation of motor function with groups with less then grade 3 strength
Explanation
Asia C is an incomplete spinal cord injury with reservation of motor function with < grade 3 motor strength.C orrect Answer: Incomplete motor loss with some preservation of motor function with groups with less then grade 3 strength
Question 871
Topic: 6. Spine
Which of the following incomplete spinal cord injury syndromes has the most potential for recovery:
Correct Answer & Explanation
. Brown-Sequard syndrome
Explanation
Brown-Sequard syndrome is described as ipsilateral loss of motor function and contralateral loss of pain and temperature sensation. This syndrome is caused by penetrating injuries. Generally < 90% of patient who have this injury will recover ambulation.
Question 872
Topic: Cervical Spine
A 6-year-old boy has neck pain and stiffness following an upper respiratory tract infection. He presented with his head tilted to the right and turned to the left 3 weeks ago, but a soft cervical collar has not been beneficial. There is no known history of trauma. A computerized tomography scan shows rotatory subluxation of C1 on C2. The next step in the treatment of this child is:
Correct Answer & Explanation
. Cervical traction
Explanation
This child has torticollis as sequelae of an upper respiratory infection (Grisel syndrome) and rotatory subluxation (fixation) of C1 on C2. Other causes of torticollis include congenital muscular torticollis, neurogenic causes, Sandifer syndrome, Klippel-Feil syndrome, juvenile rheumatoid arthritis, and trauma. The common thread is that all of the etiologies appear to weaken, through inflammation or force, the supporting soft tissue structures of the atlantoaxial articulation. The diagnosis is made by dynamic CT scan. Fielding classified atlantoaxial rotatory subluxation into 4 types: Type I is a simple rotatory displacement without an anterior shift, and is the most common type in children. Type II is rotatory fixation with anterior displacement >3 to 5 mm, and is associated with a deficiency of the transverse ligament and unilateral displacement of one lateral mass of the atlas. Type III rotatory fixation there is anterior displacement >5 mm with bilateral displacement of the lateral mass with one side displaced more than the other. This is caused by a deficiency of both the transverse ligament and secondary ligament. Type IV is rotatory fixation with posterior displacement where the dens allows posterior shift of one or both of the lateral masses, and one shifting more than the other. Types III and IV are rare but have potential for catastrophe and should be recognized to promptly initiate treatment. Children with rotatory fixation of <1 week can be treated with a soft cervical collar and rest for 1 week. Most cases resolve, but close follow-up is necessary. If spontaneous reduction does not occur after 1-2 weeks, aggressive treatment is necessary. Inpatient halter traction with judicious use of muscle relaxants and analgesics is recommended. Halo traction is necessary for reduction of longer standing (2-4 weeks) subluxation. Surgery is indicated in cases of neurological compromise, failure to achieve closed reduction, long-standing deformity (3 months or more), or recurrence following closed treatment. A Gallie-type fusion posteriorly is favored.
Question 873
Topic: 6. Spine
A 40-year-old victim of a car accident was complaining of anterior chest pain. An x-ray of the chest showed no widening of the mediastinum and absence of pneumothorax. Lateral C XR revealed a fractured sternum with the proximal part of the fracture displaced posteriorly. Which of the following is the next step in the management of this patient?
Correct Answer & Explanation
. Lateral x-ray of the thoracic spine with the patient supine
Explanation
N/AC orrect Answer: Lateral x-ray of the thoracic spine with the patient supine
Question 874
Topic: 6. Spine
The patient was diagnosed with spinal stenosis of the lumbosacral spine. In addition to educating the patient about his condition, the most appropriate initial treatment is:
Correct Answer & Explanation
. Nonsteroidal anti-inflammatory drugs
Explanation
Initial treatment begins with patient education, a physical therapy regime (gentle conditioning exercises), judicious activity change, and sometimes spinal support with a corset or light-weight brace. Anti-inflammatory nonsteroidal drugs provide some relief of symptoms for many patients.
Question 875
Topic: 6. Spine
The superior aspect of the iliac crest often bisects this midline spinal structure:
Correct Answer & Explanation
. L4/L5 disk space
Explanation
The L4/L5 intervertebral disk space is located by placing your fingers at the top of a patient's iliac crests, while allowing your thumbs to meet at the midline of the spine between the palpable L4 and L5 spinous processes.
Question 876
Topic: 6. Spine
When palpating the sacral triangle in the posterior aspect of a patient's lower back, if gaps are present between the spinous processes or no lumbar or sacral bony prominences are detected, this is suggestive of:
Correct Answer & Explanation
. Spina bifida
Explanation
When palpating the lumbosacral area (sacral triangle), if palpable gaps are present between the spinous processes or there is an absence of lumbar and/or sacral bony prominences, this is suggestive of spina bifida. A Gibbus deformity is characterized by a sharp kyphosis and is often found in the thoracic spine. Scoliosis is identified by a lateral curvature of the spine A palpable "step-off" of one spinous process relative to the next would be suggestive of a spondylolisthesis. Becs de perroquet is a radiographic feature associated with tuberculosis of the lumbar spine in which bony bridges form across the sides of two adjacent vertebrae.
Question 877
Topic: 6. Spine
Which of the following is not a routinely used imaging technique for the evaluation of lumbar disk disease:
Correct Answer & Explanation
. Positron emission tomography (PET)
Explanation
Positron emission tomography (PET) is a technique that measures brain activity through positron emission from radiolabled glucose. Myelography is an invasive procedure with radio-opaque dye placed into subarachnoid space. It aids in the detection of neural compressive lesions. Computer tomography alone offers better visualization of bony lesions, foraminal spinal stenosis, and lateral disk herniations when compared to plain myelography. C omputer tomography is often combined with myelography. Magnetic resonance imaging (MRI) has an advantage over CAT because it detects soft tissue pathologies, including improved spinal cord imaging in the detection of intraspinal tumors. MRI also examines the entire spine. Bone scanning is a nonspecific but sensitive test. It is useful in detecting neoplastic, infectious, traumatic, and/or arthritic problems in the spine.
Question 878
Topic: 6. Spine
A 28-year-old woman complains of pain and numbness in her lower legs bilaterally for approximately 2 months following strenuous moving of furniture. She now states that she has not voided in the past 48 hours and that her abdomen area is markedly distended. Which is the most likely causative lesion of the patient's symptoms:
Correct Answer & Explanation
. C auda equina syndrome
Explanation
This patient's symptoms are most consistent with cauda equina syndrome. This surgical emergency can present with bowel or bladder dysfunction, and bilateral lower extremity symptoms are also often present.
Question 879
Topic: 6. Spine
A 15-year-old boy with achondroplasia presents with progressive bilateral leg pain and weakness that worsens with walking and improves when he bends forward. His neurological exam reveals mild lower extremity weakness and hyperreflexia. Which of the following radiographic findings is most characteristic of the underlying pathophysiology in this patient?
Correct Answer & Explanation
. Narrowing of the interpedicular distance from L1 to L5
Explanation
Achondroplasia is characterized by a failure of endochondral ossification. In the spine, this classically presents as narrowing of the interpedicular distance from L1 to L5, leading to severe spinal stenosis and neurogenic claudication.
Question 880
Topic: Thoracolumbar Spine & Deformity
A 13-year-old female gymnast presents with progressive lower back pain and a waddling gait. On physical examination, she walks with a peculiar gait with her hips and knees flexed, and she has severe hamstring tightness and a vertical sacrum. Radiographs confirm a high-grade L5-S1 isthmic spondylolisthesis. The gait abnormality described is known as:
Correct Answer & Explanation
. Phalen-Dickson sign
Explanation
The Phalen-Dickson sign is characterized by a waddling gait with flexed knees and hips due to severe hamstring tightness and pelvic retroversion (vertical sacrum). It is a classic clinical finding in high-grade spondylolisthesis.
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