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6. Spine MCQs

Practice Set 56 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 1101

Topic: Thoracolumbar Spine & Deformity

A 12-year-old girl is involved in a severe motor vehicle accident wearing a lap belt. Radiographs demonstrate the injury shown.

What associated injury must be urgently ruled out?

. Aortic dissection
. Splenic laceration
. Hollow viscus injury
. Diaphragmatic rupture
. Renal contusion

Correct Answer & Explanation

. Hollow viscus injury

Explanation

The image represents a Chance fracture, a flexion-distraction injury highly associated with lap belt use. Approximately 40-50% of these pediatric patients have concurrent intra-abdominal injuries, most commonly hollow viscus perforations.

Question 1102

Topic: 6. Spine

A 45-year-old man dives into a shallow pool and sustains an axial load injury to his cervical spine. CT reveals a burst fracture of C1. According to the Rule of Spence, what radiographic finding indicates incompetence of the transverse atlantal ligament?

. Combined lateral mass displacement of >6.9 mm on an open-mouth view
. Predental space of 2 mm on lateral view
. Atlantodental interval (ADI) of 2.5 mm
. Retropharyngeal space >5 mm at C2
. Basion-dental interval >8 mm

Correct Answer & Explanation

. Combined lateral mass displacement of >6.9 mm on an open-mouth view

Explanation

The Rule of Spence dictates that if the combined lateral mass overhang of C1 on C2 is greater than 6.9 mm on an AP open-mouth odontoid view, the transverse atlantal ligament is likely ruptured.

Question 1103

Topic: 6. Spine

A 65-year-old man with pre-existing cervical spondylosis falls forward, striking his chin. He presents with profound motor weakness in his upper extremities but can move his legs against gravity. Proprioception and pain sensation are diminished but present. What is the most likely diagnosis?

. Anterior cord syndrome
. Brown-Sequard syndrome
. Central cord syndrome
. Posterior cord syndrome
. Conus medullaris syndrome

Correct Answer & Explanation

. Central cord syndrome

Explanation

Central cord syndrome typically occurs after a hyperextension injury in a stenotic cervical spine. It causes disproportionately greater motor impairment in the upper extremities compared to the lower extremities because cervical motor tracts are located more centrally.

Question 1104

Topic: 6. Spine

A 50-year-old man with longstanding Ankylosing Spondylitis suffers a low-energy fall. He complains of severe back pain but is neurologically intact. Initial plain radiographs of the spine are inconclusive. What is the most appropriate next step in management?

. Discharge with NSAIDs and physical therapy
. Dynamic flexion-extension radiographs
. CT or MRI of the entire spine
. Prescription of a Thoracolumbosacral orthosis (TLSO)
. Bone scintigraphy (bone scan)

Correct Answer & Explanation

. CT or MRI of the entire spine

Explanation

Patients with Ankylosing Spondylitis are at high risk for highly unstable, occult spinal fractures even from minor trauma. CT or MRI of the whole spine is mandatory to rule out a fracture and prevent delayed catastrophic neurological decline.

Question 1105

Topic: Thoracolumbar Spine & Deformity

In a neurologically intact patient with a thoracolumbar burst fracture, which of the following features most strongly indicates the need for operative stabilization?

. 10 degrees of focal kyphosis
. 20% loss of anterior vertebral body height
. Disruption of the posterior ligamentous complex (PLC)
. Isolated fracture of the spinous process
. 15% spinal canal compromise by retropulsed bone

Correct Answer & Explanation

. Disruption of the posterior ligamentous complex (PLC)

Explanation

In the Thoracolumbar Injury Classification and Severity Score (TLICS), a disrupted posterior ligamentous complex (PLC) indicates a highly unstable injury. This structural failure typically requires operative stabilization even without neurological deficits.

Question 1106

Topic: 6. Spine
A 12-year-old pedestrian is struck by a car. Lateral cervical radiograph shows a basion-dental interval (BDI) of 14 mm. Which of the following interventions is absolutely contraindicated in the initial management of this patient?
. Placement in a rigid cervical collar
. Application of longitudinal cervical traction
. MRI of the cervical spine
. CT angiography of the neck
. Neurosurgical or orthopedic spine consultation

Correct Answer & Explanation

. Application of longitudinal cervical traction

Explanation

The patient has atlanto-occipital dissociation (AOD), representing complete cranio-cervical instability. Cervical traction is strictly contraindicated as it can cause catastrophic over-distraction and brainstem injury.

Question 1107

Topic: 6. Spine

A 14-year-old boy presents with a 6-month history of worsening mid-back pain that is particularly severe at night and relieved by ibuprofen. Examination reveals a painful structural scoliosis. What is the most likely anatomic location of the primary pathology?

. Anterior vertebral body
. Intervertebral disc space
. Pedicle or posterior elements
. Anterior longitudinal ligament
. Vertebral endplate

Correct Answer & Explanation

. Pedicle or posterior elements

Explanation

The clinical presentation is classic for an osteoid osteoma of the spine. These lesions typically arise in the posterior elements (pedicles, facets, lamina) and frequently cause a secondary painful, rigid scoliosis.

Question 1108

Topic: 6. Spine

A 30-year-old man is involved in a high-speed MVC. Cervical spine CT demonstrates 25% anterior translation of C5 on C6. What is the most likely mechanism that produced this specific injury pattern?

. Flexion-distraction
. Axial loading
. Flexion-rotation
. Hyperextension
. Lateral bending

Correct Answer & Explanation

. Flexion-rotation

Explanation

The radiographic finding of 25% anterior translation is classic for a unilateral facet dislocation. This injury is typically caused by a flexion-rotation mechanism, whereas bilateral facet dislocations (usually >50% translation) result from hyperflexion.

Question 1109

Topic: Cervical Spine

A 40-year-old laborer complains of lower neck pain after forcefully shoveling dirt. Radiographs reveal an isolated avulsion fracture of the C7 spinous process. What is the recommended treatment?

. Anterior cervical discectomy and fusion (ACDF)
. Halo vest immobilization for 6 weeks
. Posterior cervical wiring
. Symptomatic treatment with analgesia and a soft collar
. Rigid cervical orthosis for 12 weeks

Correct Answer & Explanation

. Symptomatic treatment with analgesia and a soft collar

Explanation

A Clay Shoveler's fracture is a stable avulsion fracture of a lower cervical spinous process. It does not compromise the structural stability of the cervical spine and is treated symptomatically.

Question 1110

Topic: Thoracolumbar Spine & Deformity

A 15-year-old male gymnast complains of chronic low back pain worsened by extension. Oblique radiographs demonstrate a 'collar on the Scottie dog' sign at L5. What anatomical structure is defective?

. Superior articular facet
. Pars interarticularis
. Pedicle
. Transverse process
. Lamina

Correct Answer & Explanation

. Pars interarticularis

Explanation

The 'collar on the Scottie dog' sign seen on oblique lumbar radiographs represents a defect or fracture in the pars interarticularis, which is the hallmark of isthmic spondylolysis.

Question 1111

Topic: Cervical Spine

When interpreting pediatric cervical spine radiographs, it is important to distinguish fractures from normal development. At what age does the basilar synchondrosis (between the odontoid process and the body of C2) typically fuse?

. 1-2 years
. 3-4 years
. 5-7 years
. 9-11 years
. 12-14 years

Correct Answer & Explanation

. 5-7 years

Explanation

The basilar synchondrosis separates the dens from the body of C2 and typically fuses between 5 and 7 years of age. Before it fuses, this normal anatomical feature can easily be mistaken for a Type II odontoid fracture.

Question 1112

Topic: Cervical Spine

A 6-year-old girl presents with persistent torticollis for two weeks following severe pharyngitis. Radiographs and CT scan confirm atlantoaxial rotatory subluxation (AARS) without neurologic deficits. What is the most appropriate initial management?

. Immediate posterior C1-C2 fusion
. Halo vest application
. Soft cervical collar and NSAIDs
. Cervical traction followed by bracing
. Anterior cervical discectomy and fusion

Correct Answer & Explanation

. Cervical traction followed by bracing

Explanation

Grisel's syndrome is a non-traumatic atlantoaxial rotatory subluxation associated with head or neck infections. For AARS present for 1-4 weeks, initial management typically involves cervical traction to achieve reduction followed by rigid bracing.

Question 1113

Topic: 6. Spine

An 8-year-old boy is brought to the trauma bay after a motor vehicle collision. He was wearing a lap-only seatbelt. Lateral lumbar spine radiograph reveals a fracture line propagating horizontally through the spinous process, pedicles, and posterior vertebral body of L2. What is the most commonly associated concomitant injury?

. Spinal cord transection
. Aortic tear
. Intra-abdominal hollow viscus injury
. Renal avulsion
. Diaphragmatic rupture

Correct Answer & Explanation

. Intra-abdominal hollow viscus injury

Explanation

Chance fractures (flexion-distraction injuries) in children wearing lap belts have a very high association with intra-abdominal hollow viscus injuries. A thorough abdominal evaluation is mandatory in these patients.

Question 1114

Topic: 6. Spine

A 3-year-old child sustains a neck injury after falling from a playground structure. Radiographs show a displaced fracture through the base of the dens. This fracture typically occurs through which of the following structures?

. Apical odontoid epiphysis
. Dentocentral synchondrosis
. Neurocentral synchondrosis
. Pars interarticularis of C2
. Transverse ligament avulsion

Correct Answer & Explanation

. Dentocentral synchondrosis

Explanation

In children under 7 years of age, odontoid fractures typically occur through the dentocentral synchondrosis, which is the cartilaginous junction between the dens and the body of C2. It generally fuses between ages 5 and 7.

Question 1115

Topic: 6. Spine

A 14-year-old high school football player experiences transient bilateral upper and lower extremity weakness lasting 15 minutes after making a spear tackle. Radiographs show no fracture, but the Torg-Pavlov ratio is measured at 0.7. What is the most appropriate next step in management?

. Immediate return to play
. Cervical spine MRI
. Flexion-extension radiographs
. Electromyography (EMG)
. Posterior cervical laminectomy

Correct Answer & Explanation

. Cervical spine MRI

Explanation

Transient quadriparesis with a low Torg-Pavlov ratio (< 0.8) indicates congenital cervical stenosis. An MRI is required to evaluate the spinal cord for contusion, edema, or disc herniation before considering clearance to return to play.

Question 1116

Topic: 6. Spine
Which of the following is not a typical characteristic of Scheuermann's kyphosis?
. Endplate irregularity
. Wedging of three vertebrae
. Narrowing of disk space
. Schmorl's nodes
. Curve apex at or above T8

Correct Answer & Explanation

. Curve apex at or above T8

Explanation

Scheuermann's kyphosis may affect any region of the thoracic spine; it also may affect the thoracolumbar junction or the lumbar spine. Endplate irregularity, wedging of three vertebrae, narrowing of disk space, and Schmorl's nodes are characteristic of Scheuermann's kyphosis.

Question 1117

Topic: 6. Spine

A 17-year-old boy presents with thoracic kyphosis. He has minimal discomfort in his back. Radiographs show a 62° Scheuermanns kyphosis, with wedging of T8-T10. His Risser sign is 4, and his Tanner stage is 4. He states that he is not cosmetically aware of his kyphosis. Recommended treatment includes:

. A Milwaukee brace
. A Boston brace
. A posterior spine fusion
. An anterior and posterior spine fusion
. Observation

Correct Answer & Explanation

. Observation

Explanation

This patient is too skeletally mature to benefit from bracing. Bracing is not likely to change the natural history of the curve at maturity. Surgery is indicated if a patient experiences pain or dissatisfaction with the appearance of the back. Otherwise, the natural history is benign and observation is indicated.

Question 1118

Topic: Thoracolumbar Spine & Deformity
Adults with untreated Scheuermann's kyphosis do not differ from controls in terms of this parameter:
. Pulmonary function
. Severity of back pain
. Activity levels in job
. Location of greatest backache
. Presence of scoliosis

Correct Answer & Explanation

. Pulmonary function

Explanation

Patients with Scheuermann's kyphosis have no decrease in pulmonary function compared to controls; however, they have increased severity of back pain, seek jobs with lower activity levels, and have more thoracic back pain and less trunk extension. They also have a 30% incidence of scoliosis of less than 35°.

Question 1119

Topic: 6. Spine
Correction of Scheuermann's kyphosis from a posterior approach involves this mechanical principle:
. Compression of the posterior column of the spine
. Distraction of the posterior column
. Transverse approximation
. Rod rotation
. Hemiepiphyseodesis

Correct Answer & Explanation

. Compression of the posterior column of the spine

Explanation

Compression of the posterior column is the principal method of correcting Scheuermann's kyphosis. Compression is usually achieved by resecting portions of the elongation.

Question 1120

Topic: 6. Spine
A 13-year-old boy has a Scheuermann's kyphosis of 68°, apex at T8. His Risser sign is 1. His mother is concerned about his appearance and possible future progression. Recommended treatment includes:
. A Milwaukee brace
. Exercise
. A posterior spine fusion
. An anterior and posterior spine fusion
. Observation

Correct Answer & Explanation

. A Milwaukee brace

Explanation

Brace treatment for Scheuermann's kyphosis is successful in decreasing the kyphosis, usually permanently, by 10° to 20° if worn properly. A patient's Risser sign must be below 3. Because this patient has a Risser sign of 1, bracing is appropriate treatment. The Milwaukee brace is the most effective type of brace for kyphosis. However, the Boston brace is also somewhat effective in treating patients with Scheuermann's kyphosis because it corrects the compensatory lordosis and stimulates active correction of the thoracic curve.

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