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6. Spine MCQs

Practice Set 5 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 81

Topic: 6. Spine

An infant presents with intermittent torticollis, dystonic posturing of the neck, and back arching that tends to occur after feeding. Neurological exam is otherwise normal. What is the most appropriate next step in management?

. MRI of the posterior fossa
. Cervical spine radiographs
. Referral for gastrointestinal evaluation
. Surgical release of the sternocleidomastoid
. Botulinum toxin injection

Correct Answer & Explanation

. Referral for gastrointestinal evaluation

Explanation

The clinical picture is characteristic of Sandifer syndrome, which consists of spasmodic torsional dystonia with arching of the back and rigid opisthotonic posturing associated with gastroesophageal reflux. The best next step is evaluating and treating the reflux.

Question 82

Topic: 6. Spine

A patient with advanced rheumatoid arthritis is undergoing evaluation of the cervical spine prior to total knee arthroplasty. Which of the following radiographic measurements represents the most critical indication for prophylactic cervical spine stabilization?

. Anterior atlanto-dental interval (ADI) > 5 mm
. Posterior atlanto-dental interval (PADI) < 14 mm
. Cervical kyphosis > 10 degrees
. Subaxial subluxation > 2 mm
. Cranial settling with the dens 2 mm above McGregor's line

Correct Answer & Explanation

. Posterior atlanto-dental interval (PADI) < 14 mm

Explanation

In rheumatoid cervical spine involvement, the posterior atlanto-dental interval (PADI) is the most reliable indicator of the available space for the spinal cord. A PADI of less than 14 mm is considered a critical threshold and an absolute indication for surgical stabilization to prevent paralysis.

Question 83

Topic: 6. Spine
A 55-year-old male with pre-existing cervical spondylosis suffers a hyperextension injury in a motor vehicle collision. He presents with profound bilateral upper extremity weakness but relatively preserved lower extremity strength. What is the most likely diagnosis?
. Anterior cord syndrome
. Brown-Sรฉquard syndrome
. Central cord syndrome
. Posterior cord syndrome
. Complete spinal cord injury

Correct Answer & Explanation

. Central cord syndrome

Explanation

Central cord syndrome typically occurs following a hyperextension injury in patients with pre-existing cervical canal stenosis. It is characterized by disproportionately greater motor impairment in the upper extremities compared to the lower extremities.

Question 84

Topic: Cervical Spine

Which of the following explains the high rate of non-union seen in Anderson and D'Alonzo Type II odontoid fractures?

. Disruption of the apical ligament leading to instability
. Presence of a vascular watershed zone at the base of the dens
. Interposition of the transverse ligament in the fracture site
. Constant motion from the adjacent C2-C3 facet joints
. Involvement of the highly avascular cortical bone of the dens tip

Correct Answer & Explanation

. Presence of a vascular watershed zone at the base of the dens

Explanation

Type II odontoid fractures occur at the junction of the dens and the body of C2. This region represents a vascular watershed zone, predisposing these fractures to a high rate of non-union, especially when displaced or in older patients.

Question 85

Topic: 6. Spine

Ossification of the posterior longitudinal ligament (OPLL) is characterized by heterotopic ossification of the spinal ligaments. Which demographic and spinal region is most classically associated with this condition?

. Caucasian females; Lumbar spine
. African American males; Thoracic spine
. Asian males; Cervical spine
. Hispanic females; Thoracic spine
. Asian females; Lumbar spine

Correct Answer & Explanation

. Asian males; Cervical spine

Explanation

OPLL is most prevalent in Asian males, particularly of Japanese descent. It predominantly affects the cervical spine and can present with progressive cervical myelopathy due to canal stenosis.

Question 86

Topic: 6. Spine

A 24-year-old male is involved in a high-speed motor vehicle accident. Radiographs reveal bilateral pars interarticularis fractures of C2 (Hangman's fracture). What is the primary mechanism of injury for this specific fracture pattern?

. Hyperflexion and rotation
. Hyperextension and axial loading
. Vertical compression
. Lateral bending and distraction
. Direct direct impact to the occiput

Correct Answer & Explanation

. Hyperextension and axial loading

Explanation

A Hangman's fracture (traumatic spondylolisthesis of the axis) is typically caused by a forceful hyperextension of the neck combined with axial loading, often seen in motor vehicle accidents or diving injuries.

Question 87

Topic: 6. Spine

A 35-year-old manual laborer presents with severe lower neck pain after forcefully shoveling heavy snow. Radiographs show an isolated avulsion fracture of the C7 spinous process. What is this fracture commonly termed?

. Teardrop fracture
. Jefferson fracture
. Hangman's fracture
. Clay Shoveler's fracture
. Chance fracture

Correct Answer & Explanation

. Clay Shoveler's fracture

Explanation

A Clay Shoveler's fracture is an avulsion fracture of the lower cervical or upper thoracic spinous processes (classically C6, C7, or T1). It results from sudden, forceful contraction of the trapezius and rhomboid muscles or hyperflexion.

Question 88

Topic: 6. Spine

A patient presents with radiating right arm pain. Examination reveals a diminished brachioradialis reflex, decreased sensation over the lateral forearm and thumb, and weakness in wrist extension. Which cervical nerve root is most likely compressed?

. C4
. C5
. C6
. C7
. C8

Correct Answer & Explanation

. C6

Explanation

A C6 radiculopathy classically presents with a diminished brachioradialis reflex, sensory deficits over the radial forearm and thumb, and motor weakness in wrist extension (extensor carpi radialis longus/brevis) and elbow flexion.

Question 89

Topic: 6. Spine

A 3-year-old girl refuses to walk and has severe back pain. She is afebrile with normal white blood cell counts, but her ESR and CRP are markedly elevated. Early radiographs are normal. What is the most likely diagnosis?

. Leukemia
. Spinal epidural abscess
. Pediatric discitis
. Spondylolysis
. Osteoid osteoma

Correct Answer & Explanation

. Pediatric discitis

Explanation

Pediatric discitis typically affects children under 5 years old presenting with back pain or refusal to walk. It is characterized by elevated inflammatory markers (ESR, CRP) despite often normal early plain radiographs, though narrowing of the disc space may appear later.

Question 90

Topic: Cervical Spine

According to the Fielding and Hawkins classification of atlantoaxial rotatory subluxation, what defines a Type I injury?

. Rotatory fixation without anterior displacement (intact transverse ligament).
. Rotatory fixation with anterior displacement of 3-5 mm.
. Rotatory fixation with anterior displacement greater than 5 mm.
. Rotatory fixation with posterior displacement of the atlas.
. Rotatory fixation combined with bilateral facet dislocation.

Correct Answer & Explanation

. Rotatory fixation without anterior displacement (intact transverse ligament).

Explanation

Fielding and Hawkins Type I atlantoaxial rotatory subluxation is characterized by unilateral facet subluxation/fixation with an intact transverse ligament, meaning there is no anterior displacement of the atlas (ADI < 3 mm).

Question 91

Topic: 6. Spine

A 45-year-old male with long-standing Ankylosing Spondylitis presents after a minor ground-level fall with severe neck pain. Radiographs reveal a cervical fracture. What is a hallmark characteristic of fractures in the ankylosed spine?

. They are usually stable and require only soft collar immobilization.
. They typically spare the posterior elements of the vertebra.
. They frequently occur through the ossified disc space and are highly unstable.
. They rarely cause epidural hematomas or neurologic deficits.
. They are almost exclusively treated with anterior-only cervical plating.

Correct Answer & Explanation

. They frequently occur through the ossified disc space and are highly unstable.

Explanation

Fractures in an ankylosed spine act like long bone fractures. They typically propagate completely across the anterior, middle, and posterior columns (often transdiscal) and are highly unstable, carrying a high risk of neurologic injury and epidural hematoma.

Question 92

Topic: 6. Spine

Unilateral facet dislocation may be distinguished radiographically from bilateral facet dislocation by which of the following features:

. Misalignment of the spinous processes
. Subluxation >50%
. Subluxation <25%
. Marked angular deformity
. Spinal canal compromise

Correct Answer & Explanation

. Subluxation <25%

Explanation

Unilateral jumped facets typically involve anterolisthesis of the upper vertebral body, which is less than 25%. Misalignment of the spinous processes and spinal canal compromise may be seen with either unilateral or bilateral facet dislocation. Subluxation greater than 50% and marked angular deformity are characteristics of bilateral facet dislocations.

Question 93

Topic: 6. Spine

The annual incidence of cervical radiculopathy in men is 107.3 per 100,000 and 63.5 per 100,000 in women. The incidence for both groups occurs within which of the following peak age ranges:

. 45-49 years
. 50-54 years
. 55-59 years
. 60-64 years
. 65-69 years

Correct Answer & Explanation

. 50-54 years

Explanation

Although the incidence rate of cervical radiculopathy in men is nearly double the rate found in women, the peak age range is the same (50-54 years).

Question 94

Topic: 6. Spine

Which of the following structures are found within an intervertebral foramen:

. Dorsal root ganglion
. C onnective tissue
. Radicular artery and vein
. Recurrent meningeal nerves
. All of the above

Correct Answer & Explanation

. All of the above

Explanation

In addition to the dorsal root ganglion, connective tissue, radicular artery and vein, and recurrent meningeal nerves, spinal nerve roots and adipose also comprise an intervertebral foramen.

Question 95

Topic: 6. Spine
Most cervical radiculopathy occurs as a result of inflammatory mediators released after mechanical injury, without direct compression of the nerve root(s).
. True
. False

Correct Answer & Explanation

. True

Explanation

Approximately 75% of cervical radiculopathies occur as a result of direct compression of nerve roots, with at least one study noting a pressure of only 10 mm Hg produced significant conduction block, the potential of nerve impulses falling under 60 percent of its initial value in 15 minutes. With higher levels of pressure, we have observed incomplete recovery after many hours of recording. Disk protrusion, with the associative release of inflammatory mediators, is responsible for up to 25% of cervical radiculopathies. One study even suggests chemical release from the nucleus pulposus into the nerve root epidural space, without herniation of the nucleus pulposus and without direct nerve root compression, caused radiculopathic pain in an animal model.

Question 96

Topic: 6. Spine

Typical C 3 reflexes include which of the following:

. Sternocleidomastoid reflex
. Head retraction reflex
. Pectoralis reflex
. Biceps reflex
. None of the above

Correct Answer & Explanation

. None of the above

Explanation

No reflexes are associated with the C3 spinal nerve.

Question 97

Topic: 6. Spine

Which of the following is a distinguishing feature of a C 7 radiculopathy rarely found in C 6 radiculopathies:

. Paresthesia of the middle finger
. Anterior chest pain
. Little to no pain in associated muscles
. Epaulet pain in the associated shoulder and lateral arm
. None of the above

Correct Answer & Explanation

. Paresthesia of the middle finger

Explanation

C 7 radiculopathies classically entail pain and/or sensory changes involving the middle finger. C 6 radicular symptoms generally involve the thumb and first finger. C 8 radiculopathies involve the pinkie and ring fingers.

Question 98

Topic: 6. Spine

Studies suggest that cervical radiculopathy (or related pathology) of which nerve root may partially explain the phenomenon of cervicogenic headaches:

. C 3
. C 4
. C 5
. C 6
. C 7

Correct Answer & Explanation

. C 3

Explanation

Headaches observed with upper cervical pathology may be due, in part, to the convergence of C 1-, C 2-, and C 3-level pain fibers with second-order neurons of the descending sensory tract of cranial nerve V.

Question 99

Topic: 6. Spine

Which of the following diagnostic tests is preferred for suspected cervical radiculopathy:

. C hest radiograph
. Magnetic resonance imaging
. C -reactive protein assay
. Myelogram
. All of the above

Correct Answer & Explanation

. Magnetic resonance imaging

Explanation

Although myelogram and nerve conduction studies are useful tests, they are invasive. Magnetic resonance imaging studies are the most appropriate choice for diagnosis. Most important in the diagnosis of cervical radiculopathy is a thorough history and physical examination.

Question 100

Topic: 6. Spine

What is the preferred treatment method for patients with cervical radiculopathy:

. Physical therapy
. Surgical repair
. Medical management (eg, nonsteroidal anti-inflammatory drugs, opioids, and corticosteroids)
. Bed rest
. None of the above

Correct Answer & Explanation

. Medical management (eg, nonsteroidal anti-inflammatory drugs, opioids, and corticosteroids)

Explanation

Most patients with cervical radiculopathy are best treated medically after the age of 50. In other age groups, based on the history, physical examination, and number of involved nerve roots, a combination of the above methods may be appropriate. Surgical therapy may be necessary in patients refractory to medical management.

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