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6. Spine MCQs

Practice Set 48 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 941

Topic: 6. Spine

A 15-year-old boy with adolescent idiopathic scoliosis has a right thoracic curve from T5 to T11 measuring 45° and a left thoracolumbar curve from L1 to L4 measuring 32°. He is Risser stage 2 and has a hypokyphotic thoracic spine. Bending films demonstrate moderate flexibility in the lumbar curve. He was prescribed a thoracolumbosacral orthosis since age 14, but his scoliosis has progressed. His physical exam reveals a prominent right rib hump and mild right shoulder elevation. His head is centered above his pelvis. His neurological examination is normal. You recommend:

. Continued full-time use of the orthosis until skeletal maturity
. Discontinuation of the orthosis due to failure
. Repeat evaluation in 6 months
. Posterior spinal fusion T5-L4 with instrumentation
. Posterior spinal fusion of the thoracic curve only with instrumentation

Correct Answer & Explanation

. Posterior spinal fusion of the thoracic curve only with instrumentation

Explanation

This patient has a right thoracic curve with a compensatory left lumbar curve pattern of adolescent idiopathic scoliosis. There has been documented progression into the surgical range despite bracing, and he still has some growth remaining. Surgical intervention is indicated. This curve pattern (King II, Lenke D) can be approached posteriorly with thoracic fusion alone to the neutral and stable vertebra and instrumentation to obtain and maintain correction. The unfused lumbar curve will spontaneously correct to balance the fused thoracic curve. Care must be taken to avoid fusion into the lower lumbar spine and preserve motion segments.

Question 942

Topic: 6. Spine

A 1-year-old male infant is referred by his pediatrician for evaluation of possible scoliosis. Otherwise, he is healthy. His physical exam reveals normal neurologic function, plagiocephaly and a flexible thoracic curve. Radiographs reveal a left thoracic curve with a C obb angle of 36° and no vertebral anomalies. The apical ribs are in Phase I, and the rib-vertebral angle difference is 18°. At this time, management should include:

. Observation
. Serial body casting to obtain correction
. Full-time use of a thoracolumbosacral orthosis
. Posterior spinal fusion
. Spinal instrumentation without fusion

Correct Answer & Explanation

. Observation

Explanation

Infantile idiopathic scoliosis is rare in this country and not well understood. It is more common in Europe, occurs more frequently in boys, and left thoracic curves predominate. Plagiocephaly, or a flattening of the posterior skull on the convex side of the spinal curvature, is frequently found in these patients, suggesting a postural cause of both. There are 2 types of infantile idiopathic scoliosis: resolving and progressive. Distinguishing between the 2 types has obvious consequences regarding prognosis and treatment. Prior to Mehtas work, identification of the type of infantile idiopathic scoliosis was difficult, because it was not related to curve magnitude, age at onset, rate of progression, or degree of rotation. Mehta showed that the 2 groups were distinguishable by the relationship of the ribs to the apical vertebral body on the posteroanterior radiograph. Ribs that do not overlap the vertebral body are in Phase I, and ribs that do overlap the vertebral body on the convexity of the curve are in Phase II. The rib- vertebral angle is constructed by the intersection of a line perpendicular to the apical vertebral endplate with a line drawn along the long axis of the corresponding rib. The rib-vertebral angle (RVA) difference is the difference of the RVA of the concave and convex ribs of the apical vertebra. In scoliosis, the convex ribs form a more acute angle than the concave ribs, so this difference is >0. Mehta concluded that curves in which the ribs are in Phase I and the RVA difference is < 20° have a better prognosis (resolving type) and require just observation. Treatment for progressive curves includes serial body casts, orthoses, or surgery for severe curves. Various surgical approaches include posterior spinal fusion, instrumentation without fusion to allow spinal growth, or anterior convex hemiepiphysiodesis with posterior hemiarthrodesis.

Question 943

Topic: 6. Spine

The most appropriate indication, after scoliosis curve progression, for a posterior spinal fusion with segmental instrumentation to the pelvis in a severely involved spastic quadriplegic child with cerebral palsy is:

. Pelvic obliquity
. Deterioration in function
. Poor nutritional status
. Normal pulmonary function
. Non-ambulatory status

Correct Answer & Explanation

. Pelvic obliquity

Explanation

Patients with a spastic quadriplegic pattern of cerebral palsy have higher than 25% incidence of scoliosis. This neuromuscular scoliosis differs from that of idiopathic scoliosis in that it is usually a long C -shaped thoracolumbar curve that may involve the pelvis. Frequently, posterior spinal fusion from T1 to the sacrum is required with rigid segmental instrumentation with stabilization to the pelvis (a unit rod). Indications for fusion in these patients include curve progression and loss of function. This can include loss of sitting ability, poor pulmonary function due to poor pulmonary toiletting, and recurrent infection such as decubitus ulcers. These children are most often non-ambulators and are dependent on wheelchair sitting supports for postural control.

Question 944

Topic: 6. Spine

A 12-year-old boy with Duchenne muscular dystrophy has a 25° curve in the thoracolumbar spine with moderate pelvic obliquity. His pulmonary function tests are 70% of predicted function. He uses a wheelchair for ambulation, but is able to stand for transfers. Management should include:

. Observation, with repeat radiograph and pulmonary function tests in 6 months
. Thoracolumbosacral orthosis
. Wheelchair seat pressure mapping and lateral trunk support modifications
. Posterior spinal fusion with instrumentation
. Anterior spinal release and posterior spinal fusion with instrumentation

Correct Answer & Explanation

. Posterior spinal fusion with instrumentation

Explanation

Scoliosis in patients with Duchenne muscular dystrophy typically becomes progressive when ambulation ceases. For curves >20°, posterior spinal fusion with instrumentation is indicated. Fixation to the pelvis is necessary to improve sitting if pelvic obliquity is present. Severe, collapsing scoliosis can result without operative intervention and can result in diminishing pulmonary function and loss of sitting ability. Surgery can be safely undertaken if pulmonary function remains >40% of predicted function, but anterior surgery causes morbidity on an already compromised pulmonary system. Nonoperative treatment such as orthoses or trunk supports offer little in the way of controlling progression and are generally not well tolerated by these patients.

Question 945

Topic: 6. Spine

A 6-year-old girl with a lumbar level paraplegia secondary to myelomenigocele presents with a rapidly progressive thoracolumbar scoliosis. The most accurate test to determine the etiology of the spinal deformity is:

. Bone scan
. Lumbar puncture and cerebrospinal fluid analysis
. Magnetic resonance imaging of the brain and spinal cord
. Lateral flexion/extension radiographs of the cervical spine
. C omputerized tomography scan of the spine at the lumbosacral junction

Correct Answer & Explanation

. Magnetic resonance imaging of the brain and spinal cord

Explanation

Children with myelodysplasia are at risk for scoliosis, but a rapidly progressive curve should alert the physician to aggressively investigate the etiology. Causes include: Tethered cord Syringomyelia Shunt failure Progressive hydromyelia Arnold-C hiari malformation All of these conditions can be readily diagnosed by a magnetic resonance imaging scan of the brain and spinal cord. Radiologic imaging such as radiographs, computerized tomography scans, or bone scans for bony lesions is rarely helpful. Cerebrospinal fluid analysis is unlikely to reveal an answer regarding scoliosis. In the presence of a working ventriculoperitoneal shunt, the most likely etiology in this child is a tethered cord. Increased lumbar lordosis, back pain, or an increase in lower root level spasticity should alert the clinician to the possible presence of a tethered cord.

Question 946

Topic: 6. Spine
An 11-year-old girl presents with low back pain for 2 months' duration. She is an elite gymnast and has missed 2 meets because of the pain. Physical exam reveals pain with hyperextension of the lumbar spine. Her neurological exam is normal. Radiographs of the lumbar spine, including oblique views, are normal. The recommendation is:
. Rest, with slow return to training in 4 weeks
. Custom lumbosacral orthosis
. Magnetic resonance imaging of the spinal cord
. Physical therapy exercises
. Bone scan with single photon emission computed tomography imaging

Correct Answer & Explanation

. Bone scan with single photon emission computed tomography imaging

Explanation

Athletes involved in sports requiring repetitive hyperextension or rotation of the lumbar spine are susceptible to stress fractures of the pars interarticularis or spondylolysis. Two months of insidious back pain warrants a diagnostic work up, and radiographs may be nondiagnostic in the early period. A bone scan with single photon emission computed tomography will confirm the diagnosis in a patient with a history and physical findings of spondylolysis. Magnetic resonance imaging is rarely helpful in the diagnosis of this bony lesion, but it may be the next diagnostic modality if the bone scan was negative and the pain continued. Rest with immobilization is usually the first line of treatment for spondylolysis. In cases of refractory pain, controversy exists in the surgical management of this condition. Some authors favor repair of the lytic defect and others prefer a posterolateral fusion.

Question 947

Topic: 6. Spine
An 8-year-old girl presents with back pain and an abnormal gait. She walks with externally rotated feet and limited hip flexion. She has a palpable step-off at the lumbosacral junction and hamstring tightness. Radiographs of the lumbosacral spine demonstrate a dysplastic spondylolisthesis with a slip angle of 55° and slippage of 60% of L5 on S1. The recommended course of treatment is:
. Posterolateral spinal fusion
. Epidural steroid injection
. Physical therapy
. Lumbosacral orthosis
. Observation with repeat radiographs in 6 months

Correct Answer & Explanation

. Posterolateral spinal fusion

Explanation

Spondylolisthesis is the forward slipping of 1 vertebra on the next caudal vertebra. Spondylolisthesis in children can be classified into 2 types: isthmic and dysplastic. Isthmic spondylolisthesis is an entity in which there is a lesion in the pars interarticularis that permits forward slippage; the articular facets are normal. Dysplastic or congenital spondylolisthesis implies that there is a congenital deficiency in the L5-S1 facet that allows forward slipping. There is no defect or elongation in the pars. Growing children, particularly females, with dysplastic spondylolisthesis are at risk for further progression. This patient's abnormal gait is due to hamstring tightness, probably due to the lumbosacral instability and nerve root irritation. With a grade III slip, back pain, and an abnormal gait, this patient is a candidate for an in situ posterolateral spinal fusion. Use of instrumentation is controversial, especially because the long-term results of in situ noninstrumented fusions are superior.

Question 948

Topic: Thoracolumbar Spine & Deformity
The following can be found in the examination and radiographs of a child with Scheuermann disease:
. Schmorl nodes
. Back pain
. Anterior wedging 3 or more vertebrae
. Thoracic kyphosis
. All of the above

Correct Answer & Explanation

. All of the above

Explanation

Scheuermann disease is increased thoracic kyphosis, usually rigid, occurring in adolescent males. The etiology is unknown, but has included theories dealing with avascular necrosis of the ring apophysis, growth plate abnormalities, biologic and mechanical causes. The classic definition is increased thoracic kyphosis (>45°) with 5° or more of anterior wedging at 3 sequential vertebrae. Other radiographic abnormalities include: Endplate irregularities, Spondylolysis, Compensatory lumbar hyperlordosis, Schmorl's nodes. Hamstring tightness and rigid thoracic kyphosis is noted on physical examination, and neurological function is normal. Treatment consists of bracing in skeletally immature patients with a thoracolumbosacral orthosis, but many adolescent male patients are noncompliant with bracing. In the skeletally mature patient with pain and severe deformity (>65° of kyphosis), posterior spinal fusion with instrumentation is indicated. Occasionally, anterior diskectomy and interbody fusion with posterior fusion and instrumentation are required for severe deformity correction. Postural kyphosis is also common in adolescent males, but the vertebral changes are not present, and the deformities are usually more supple. Treatment is hyperextension exercises.

Question 949

Topic: 6. Spine

The natural history of which of the following spinal deformities in children carries with it the highest risk of paraplegia?

. C ongenital lordosis
. C ongenital kyphosis
. Neuromuscular scoliosis
. Idiopathic scoliosis
. Postlaminectomy kyphosis

Correct Answer & Explanation

. C ongenital kyphosis

Explanation

Congenital kyphosis, if left alone, is the most likely cause of paraplegia of all noninfectious spinal deformities. Defects of formation are more progressive than defects of segmentation, and paraplegia is common with defects that have an apex at T4-T9, the watershed area of spinal cord blood flow. Treatment is usually surgical. There is no evidence of successful nonoperative treatment for congenital kyphosis. An early, limited posterior fusion, coupled with anterior growth, may result in a slow correction of the kyphosis. For kyphosis >55° in children older than 5 years of age, anterior and posterior spinal fusions are necessary. The tethering structures anteriorly must be released (anterior longitudinal ligament, annulus fibrosus) and distraction anteriorly is maintained by autogenous strut grafts. Posteriorly, compression instrumentation is required with fusion. If neurological compromise exists preoperatively, magnetic resonance imaging is necessary to delineate the area of compression so that an anterior cord decompression may be performed successfully.

Question 950

Topic: 6. Spine

A 40-year-old unrestrained driver suffers a Levine-Edwards Type IIA traumatic spondylolisthesis of the axis (Hangman's fracture). What is the most appropriate initial non-operative management?

. Halter traction
. Halo vest application in slight extension with minimal traction
. Halo vest application with heavy longitudinal traction
. Immediate anterior cervical discectomy and fusion
. Immediate posterior C1-C3 fusion

Correct Answer & Explanation

. Halo vest application in slight extension with minimal traction

Explanation

Type IIA Hangman's fractures feature oblique fracture lines and severe angulation with minimal translation. Traction is contraindicated as it exacerbates the distraction; they are treated with mild compression in slight extension.

Question 951

Topic: Thoracolumbar Spine & Deformity

A 19-year-old restrained passenger in a high-speed collision sustains a flexion-distraction injury (Chance fracture) of L2. Which of the following associated injuries must be actively ruled out due to its high incidence?

. Aortic tear
. Renal artery thrombosis
. Hollow viscus injury
. Diaphragmatic rupture
. Pulmonary contusion

Correct Answer & Explanation

. Hollow viscus injury

Explanation

Chance fractures (flexion-distraction injuries) are frequently associated with lap-belt usage. Up to 50% of these patients have an associated hollow viscus or bowel injury that requires urgent general surgery evaluation.

Question 952

Topic: 6. Spine

An 80-year-old male with pre-existing cervical spondylosis falls forward, striking his chin. He presents with profound upper extremity weakness but is able to move his lower extremities against gravity. What is the most likely diagnosis?

. Anterior cord syndrome
. Central cord syndrome
. Brown-Sequard syndrome
. Posterior cord syndrome
. Spinal shock

Correct Answer & Explanation

. Central cord syndrome

Explanation

Central cord syndrome often occurs after hyperextension injuries in elderly patients with stenotic cervical canals. It presents with upper extremity motor deficits that are characteristically more severe than lower extremity deficits.

Question 953

Topic: 6. Spine

Which spinal cord injury syndrome is characterized by loss of motor function and pain/temperature sensation distal to the lesion, while preserving proprioception, and carries the poorest prognosis for functional recovery?

. Central cord syndrome
. Anterior cord syndrome
. Posterior cord syndrome
. Brown-Sequard syndrome
. Cauda equina syndrome

Correct Answer & Explanation

. Anterior cord syndrome

Explanation

Anterior cord syndrome results from injury to the anterior two-thirds of the spinal cord (often vascular), preserving the dorsal columns (proprioception). It carries the worst prognosis for motor recovery.

Question 954

Topic: Thoracolumbar Spine & Deformity

A 30-year-old male falls 15 feet, sustaining an L1 burst fracture. He is neurologically intact. MRI confirms severe disruption of the posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity (TLICS) system, what is his total score and management recommendation?

. Score 2: Non-operative management
. Score 4: Non-operative management
. Score 5: Operative management
. Score 7: Operative management
. Score 3: Surgeon's preference

Correct Answer & Explanation

. Score 5: Operative management

Explanation

The TLICS score is calculated as follows: Burst fracture morphology (2) + Intact neurology (0) + PLC disrupted (3) = Total score of 5. A score of 5 or greater is an indication for operative management.

Question 955

Topic: Cervical Spine

A patient presents after a high-speed collision with severe upper cervical pain. Lateral radiographs show a Basion-Dental Interval (BDI) of 14 mm. What is the most appropriate definitive management?

. Halo vest immobilization for 12 weeks
. Hard cervical collar for 6 weeks
. Occipitocervical fusion
. C1-C2 transarticular screw fixation
. Anterior odontoid screw fixation

Correct Answer & Explanation

. Occipitocervical fusion

Explanation

A BDI greater than 10 mm indicates Atlanto-Occipital Dissociation (AOD), a highly unstable ligamentous injury. Definitive management requires surgical stabilization via occipitocervical fusion.

Question 956

Topic: Cervical Spine

In a patient with a suspected C1 (Jefferson) fracture, an open-mouth odontoid radiograph demonstrates a combined lateral mass overhang of 8 mm on C2. What specific structure is presumed incompetent based on this finding?

. Alar ligament
. Transverse atlantal ligament
. Apical ligament
. Tectorial membrane
. Posterior longitudinal ligament

Correct Answer & Explanation

. Transverse atlantal ligament

Explanation

According to the Rule of Spence, a combined lateral mass overhang of C1 on C2 greater than 6.9 mm on an open-mouth radiograph strongly suggests rupture of the transverse atlantal ligament.

Question 957

Topic: 6. Spine
A 6-year-old child presents after an MVC with transient numbness and weakness in all extremities. Cervical radiographs and CT are normal. MRI shows spinal cord edema at C3-C4 without ligamentous injury. What is the appropriate management?
. Immediate surgical decompression
. Rigid cervical collar immobilization and observation
. High-dose methylprednisolone for 48 hours
. Halo vest application
. Reassurance and immediate discharge

Correct Answer & Explanation

. Rigid cervical collar immobilization and observation

Explanation

This is Spinal Cord Injury Without Radiographic Abnormality (SCIWORA), common in pediatric populations due to spinal elasticity. Management is generally conservative with rigid collar immobilization for up to 12 weeks.

Question 958

Topic: 6. Spine

A 55-year-old male sustains an isolated gunshot wound to the abdomen that transverses the bowel and lodges in the L3 vertebral body. He is neurologically intact. What is the recommended management of the spinal injury?

. Urgent laminectomy and bullet retrieval
. Broad-spectrum intravenous antibiotics for 7-14 days
. Posterior spinal instrumentation and fusion
. Anterior corpectomy and strut grafting
. Local wound care and tetanus prophylaxis only

Correct Answer & Explanation

. Broad-spectrum intravenous antibiotics for 7-14 days

Explanation

For trans-abdominal gunshot wounds to the spine without neurologic deficit or structural instability, routine bullet extraction is contraindicated. Treatment focuses on broad-spectrum IV antibiotics to prevent infection from bowel flora.

Question 959

Topic: 6. Spine

A 60-year-old male with long-standing ankylosing spondylitis presents with neck pain after a ground-level fall. Initial plain radiographs of the cervical spine are reported as negative. What is the most appropriate next step?

. Reassurance and discharge with NSAIDs
. Flexion-extension radiographs
. CT scan of the entire cervical spine
. Soft cervical collar for 2 weeks
. Referral for physiotherapy

Correct Answer & Explanation

. CT scan of the entire cervical spine

Explanation

Patients with ankylosing spondylitis have a rigid, brittle spine and are at extremely high risk for occult, highly unstable fractures even from minor trauma. A CT scan or MRI is mandatory regardless of negative plain films.

Question 960

Topic: 6. Spine

A trauma patient presents with hypotension, bradycardia, and warm extremities following a C5 burst fracture with complete paralysis. What is the most likely etiology of his hemodynamic instability?

. Hypovolemic shock
. Spinal shock
. Neurogenic shock
. Cardiogenic shock
. Septic shock

Correct Answer & Explanation

. Neurogenic shock

Explanation

Neurogenic shock is a hemodynamic phenomenon caused by loss of sympathetic vascular tone after high spinal cord injury, leading to hypotension and bradycardia. Spinal shock, by contrast, refers purely to temporary loss of neurologic reflexes.

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