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6. Spine MCQs

Practice Set 51 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 1001

Topic: 6. Spine

A 30-year-old man sustains a gunshot wound to the abdomen, with the bullet lodging in the L3 spinal canal. He presents with a partial, progressive cauda equina syndrome. What is the most appropriate management regarding the spinal injury?

. Nonoperative management with intravenous antibiotics
. Immediate bullet extraction and laminectomy
. High-dose methylprednisolone administration
. Debridement of the tract only
. Local wound care and bracing

Correct Answer & Explanation

. Immediate bullet extraction and laminectomy

Explanation

While most spinal gunshot wounds are managed nonoperatively, indications for surgical bullet removal include a bullet lodged in the spinal canal causing a progressive neurologic deficit or an incomplete cauda equina syndrome. Steroids are generally contraindicated in penetrating spinal trauma.

Question 1002

Topic: 6. Spine
A trauma patient sustains a highly comminuted Zone III sacral fracture according to the Denis classification. Which of the following neurologic deficits is most likely to be encountered?
. L4 radiculopathy
. L5 radiculopathy
. S1 radiculopathy
. Bowel and bladder dysfunction
. Intact neurology

Correct Answer & Explanation

. Bowel and bladder dysfunction

Explanation

Denis Zone III sacral fractures involve the central sacral canal. Because the fracture extends through the central canal containing the lower sacral nerve roots, there is a very high incidence (up to 60%) of bowel, bladder, and sexual dysfunction.

Question 1003

Topic: 6. Spine

An awake, alert, and cooperative 35-year-old man presents with a bilateral cervical facet dislocation and an incomplete spinal cord injury following a diving accident. According to standard guidelines, what is the best next step?

. Immediate MRI prior to any reduction attempts
. Awake closed reduction with skeletal traction
. Immediate anterior cervical discectomy and fusion
. Immediate posterior cervical fusion
. Hard collar application and delayed surgery

Correct Answer & Explanation

. Awake closed reduction with skeletal traction

Explanation

In an awake, alert, and cooperative patient with a cervical facet dislocation, urgent awake closed reduction using skeletal traction is indicated. An MRI is not mandatory before reduction in this specific patient population, as immediate realignment is prioritized.

Question 1004

Topic: 6. Spine

In the Thoracolumbar Injury Classification and Severity (TLICS) score, which of the following neurologic statuses contributes the highest number of points?

. Intact neurologic status
. Nerve root injury
. Complete spinal cord injury
. Incomplete spinal cord injury
. Normal bulbocavernosus reflex

Correct Answer & Explanation

. Incomplete spinal cord injury

Explanation

In the TLICS system, an incomplete spinal cord injury (or cauda equina syndrome) receives 3 points, which is the highest neurologic score. A complete cord injury receives 2 points, reflecting the higher potential for recovery and greater indication for urgent surgery in incomplete lesions.

Question 1005

Topic: Cervical Spine

A 5-year-old child falls from a swing. Cervical radiographs reveal 3 mm of anterior displacement of C2 on C3. The Swischuk line passes 1 mm anterior to the anterior cortex of the posterior arch of C3. What is the most likely diagnosis?

. Type II odontoid fracture
. Normal physiologic pseudosubluxation
. Hangman fracture
. C2-C3 bilateral facet dislocation
. Ruptured transverse ligament

Correct Answer & Explanation

. Normal physiologic pseudosubluxation

Explanation

Pseudosubluxation of C2 on C3 is a normal physiologic variant in young children due to horizontal facets and ligamentous laxity. A Swischuk line passing within 1.5 mm of the posterior arch of C3 confirms the alignment is physiologic rather than a true fracture or dislocation.

Question 1006

Topic: Thoracolumbar Spine & Deformity

A 45-year-old man presents with an L1 burst fracture demonstrating 60% canal compromise and progressive weakness in his lower extremities. What is the most appropriate surgical approach?

. Posterior laminectomy without fusion
. Anterior corpectomy and fusion
. Posterior short-segment pedicle screw fixation without decompression
. Translaminar screw fixation
. Stand-alone anterior interbody cage

Correct Answer & Explanation

. Anterior corpectomy and fusion

Explanation

Anterior corpectomy allows direct decompression of retropulsed bone fragments causing neurologic deficits in burst fractures. Laminectomy alone is contraindicated as it further destabilizes an already compromised anterior and middle column, leading to progressive kyphosis.

Question 1007

Topic: 6. Spine

A trauma patient has complete absence of sensory and motor function below the T10 dermatome following a severe crush injury. The bulbocavernosus reflex is present. What does this signify?

. Spinal shock is ongoing and neurologic status may improve
. The spinal cord injury is definitively complete
. There is a concurrent upper motor neuron lesion above the conus
. There is a massive cauda equina injury
. Recovery of motor function is imminent

Correct Answer & Explanation

. The spinal cord injury is definitively complete

Explanation

The presence of the bulbocavernosus reflex indicates that the period of spinal shock has resolved. If the patient continues to have absent sensory and motor function below the injury level at this stage, the spinal cord injury is classified as complete.

Question 1008

Topic: 6. Spine

A patient with a C5 burst fracture presents with a blood pressure of 80/50 mmHg, a heart rate of 50 beats per minute, and warm, flushed extremities. What is the primary pathophysiology of this presentation?

. Loss of parasympathetic tone
. Loss of sympathetic tone
. Severe hypovolemia
. Pericardial tamponade
. Adrenal insufficiency

Correct Answer & Explanation

. Loss of sympathetic tone

Explanation

Neurogenic shock occurs with high spinal cord injuries (above T6) due to the loss of descending sympathetic pathways. This leaves parasympathetic tone (vagus nerve) unopposed, resulting in the classic triad of hypotension, bradycardia, and peripheral vasodilation (warm extremities).

Question 1009

Topic: 6. Spine

Which of the following syndromes has the highest incidence of scoliosis as a percentage of affected patients:

. Marfan syndrome
. Loeys-Dietz syndrome
. Down syndrome
. Rett syndrome
. Prader-Willi syndrome

Correct Answer & Explanation

. Marfan syndrome

Explanation

Marfan syndrome, due to a mutation in fibrillin-1, causes spinal deformity in two-thirds of patients. Rett syndrome, caused by a mutation in MEC P-2, results in neurological balance disorder and may cause scoliosis in up to half of affected patients. Scoliosis is seen in smaller numbers of patients with Prader-Willi, Down, and Loeys-Dietz syndromes.

Question 1010

Topic: 6. Spine

Acute pain that presents in the lateral arm and shoulder is suggestive of:

. Cervical myelopathy
. Thoracic outlet syndrome
. Radial tunnel syndrome
. Cervical disk herniation
. Diabetic neuropathy

Correct Answer & Explanation

. Cervical disk herniation

Explanation

Acute radiculopathies of the upper extremity are suggestive of soft cervical disk herniations. Three types of soft disk herniations have been described: Intraforaminal is the most common and is often evidenced by radicular symptoms in a dermatomal distribution. Posterolateral herniation results in predominantly motor symptoms. Midline disk herniations may result in myelopathy.

Question 1011

Topic: 6. Spine

A cervical disk herniation that causes weakness in the wrist extensors will likely produce sensory changes in the:

. Lateral arm
. Ulnar forearm
. Radial forearm
. Long finger
. Hypothenar eminance

Correct Answer & Explanation

. Radial forearm

Explanation

The wrist extensors are innervated by C6. Weakness would likely be the result of a C5-C6 cervical disk herniation, thus causing a C 6 radiculopathy. The dermatome of C 6 includes the radial side of the forearm and radial digits.

Question 1012

Topic: 6. Spine

In order to diagnose a disk herniation, the preferred test is:

. Electromyogram
. Flexion-extension roentgenograms
. C omputerized tomography scan
. Magnetic resonance imaging (MRI) with gadolinium
. MRI without gadolinium

Correct Answer & Explanation

. MRI without gadolinium

Explanation

Magnetic resonance imaging (MRI) has become the modality of choice for diagnosis of disk herniation. It is readily available, noninvasive, and has proven as accurate as post-myelogram computerized tomography scans in the evaluation of cervical radiculopathy. An MRI study should include a T1- and T2-weighted image sequence with both sagittal and axial images.

Question 1013

Topic: 6. Spine

Initial management of cervical radiculopathy includes all of the following except:

. Nonsteroidal anti-inflammatory drugs
. Cervical immobilization
. Physical therapy
. Anterior cervical discectomy and fusion
. Home traction

Correct Answer & Explanation

. Anterior cervical discectomy and fusion

Explanation

Initial management of cervical radiculopathy is nonoperative. This includes: Nonsteroidal anti-inflammatory drugs Occasional narcotic analgesic medications Immobilization in a soft collar for 10 to 14 days Physical therapy with emphasis on isometric exercises Home traction Surgical intervention is indicated for patients who fail nonoperative treatment. Motor deficits intertractable pain may serve as indication for early surgical therapy. In addition, patients with intertractable pain or motor deficits may be recommended for early surgery.

Question 1014

Topic: 6. Spine
This patient has a wide-based gait and hyper-reflexia in his lower extremities. His MRI is presented. Other physical findings in this patient would likely include:
. Negative Hoffman sign
. Negative Babinski sign
. Carpal tunnel syndrome
. Hand intrinsic wasting
. Thoracic outlet syndrome

Correct Answer & Explanation

. Hand intrinsic wasting

Explanation

This patient's clinical presentation is suggestive of cervical spondylotic myelopathy. The T2 sagittal MRI shows multiple areas of spinal cord compression due to spondylosis. In this situation, one sees evidence of upper motor neuron dysfunction in the lower extremities such as hyper-reflexia, Hoffman sign, clonus, wide-based gait, and sexual or bladder dysfunction. The upper extremities may demonstrate upper and lower motor neuron findings, hypo-reflexia or hyper-reflexia, crossed radial reflex, Hoffman sign, and hand intrinsic wasting.

Question 1015

Topic: 6. Spine

A useful test to differentiate cervical radiculopathy from diabetic peripheral neuropathy is:

. Hemoglobin A1C
. Magnetic resonance imaging
. Computerized tomography-myelogram
. Electrodiagnostic testing
. Cervical flexion/extension roentgenograms

Correct Answer & Explanation

. Electrodiagnostic testing

Explanation

An electromyogram detects motor changes as a result of nerve compression. It can be used to differentiate cervical radiculopathy from peripheral neuropathy.

Question 1016

Topic: 6. Spine

With a left-sided anterior cervical spine approach, the structure at increased risk for injury is the:

. Recurrent laryngeal nerve
. Superior laryngeal nerve
. Hypoglossal nerve
. Thoracic duct
. Esophagus

Correct Answer & Explanation

. Thoracic duct

Explanation

On the left side of the neck, the thoracic duct ascends lateral to the carotid sheath and is at potential risk for laceration with resulting chylothorax. This potential risk must be avoided by remaining medial to the carotid sheath during the left-sided anterior cervical spine approach.

Question 1017

Topic: 6. Spine

With a right-sided anterior cervical spine approach, the structure at increased risk is the:

. Recurrent laryngeal nerve
. Superior laryngeal nerve
. Hypoglossal nerve
. Thoracic duct
. Esophagus

Correct Answer & Explanation

. Recurrent laryngeal nerve

Explanation

The left recurrent laryngeal nerve enters the thorax within the carotid sheath before looping around the aortic arch and ascending into the neck between the trachea and the esophagus. On the right side, the nerve exits the carotid sheath at a higher level, making the nerve susceptible to injury during the surgical dissection.

Question 1018

Topic: 6. Spine

The structure most at risk during lateral mass screw placement is the:

. Vertebral artery
. Nerve root
. Spinal cord
. Recurrent laryngeal nerve
. Thoracic duct

Correct Answer & Explanation

. Nerve root

Explanation

Lateral mass screws placed in the cervical spine for plate fixation are directed 30° lateral and 15° cephalad from a point 1 mm medial to the mid- portion of the particular pillar. The nerve root exits at the anterolateral portion of the facet joint and is at risk of injury. The vertebral artery may be injured in screws placed too medially. The spinal cord is essentially free of danger with accepted techniques.

Question 1019

Topic: 6. Spine

After undergoing an anterior cervical discectomy and fusion through a left- sided neck incision, the patient is noted to have a drooping eyelid and a right pinpoint pupil. This is likely due to:

. Spinal cord injury
. Nerve root injury
. Retractor placement
. C arotid sheath compression
. Vertebral artery injury

Correct Answer & Explanation

. Retractor placement

Explanation

This patient has postoperative Horner syndrome. The sympathetic chain lies lateral to the longus colli muscles. Retractors must be placed deep into these muscles. Retractors placed ventrally to the longus colli muscles can cause injury to the sympathetic chain, esophagus medially, and carotid sheath contents laterally.

Question 1020

Topic: 6. Spine

After an anterior cervical discectomy and fusion with autogenous iliac crest bone graft, the patient reports numbness in the lateral thigh. This is due to:

. Nerve root injury
. Intraoperative positioning
. Lateral femoral cutaneous nerve injury
. Genitofemoral nerve injury
. Sciatic nerve injury

Correct Answer & Explanation

. Lateral femoral cutaneous nerve injury

Explanation

The lateral femoral cutaneous nerve emerges from the lateral border of the psoas major muscle and crosses the ilium as it runs toward the anterior superior iliac spine. The course of the nerve is variable. The nerve is at risk of injury, with resulting meralgia paresthetica, in approximately 10% of patients.

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