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6. Spine MCQs

Practice Set 57 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 1121

Topic: Thoracolumbar Spine & Deformity

A 14-year-old boy has grade 1 isthmic L5-S1 spondylolisthesis. He has no back pain and wants to play football. The patient should be advised to:

. Play football if his condition is treated by grafting and wiring
. Play football if he has a L5-S1 fusion
. Play football if he wears a lumbosacral orthosis during all games
. Not play football at all
. Play football as desired

Correct Answer & Explanation

. Play football as desired

Explanation

Asymptomatic spondylolisthesis occurs in approximately 5% of the pediatric population. Slips of up to grade 1 develop in at least one third of patients with asymptomatic spondylolisthesis. Most patients with asymptomatic spondylolisthesis are minimally symptomatic or asymptomatic. The patient presented in this scenario may be allowed to play football as long as he understands that he may develop symptoms.

Question 1122

Topic: 6. Spine

Patients with high-grade spondylolisthesis develop a vertical position of the sacrum in response to which condition:

. Lumbar lordosis
. Tight hamstrings
. Olisthetic scoliosis
. Lumbar kyphosis
. Lumbosacral kyphosis

Correct Answer & Explanation

. Lumbosacral kyphosis

Explanation

As spondylolisthesis progresses to a high grade, the fifth lumbar vertebra shifts forward into a kyphotic position termed a slip angle. The slip angle can reach a value of more than 30° and results in verticalization of a patients sacrum to decrease force on the involved vertebra.

Question 1123

Topic: Thoracolumbar Spine & Deformity

What is the primary indication for initiating Milwaukee brace treatment in a patient with Scheuermann's kyphosis?

. A rigid curve of >75 degrees in a skeletally mature patient
. A progressive curve of 55 to 75 degrees in a skeletally immature patient (Risser 0-2)
. A flexible curve of <50 degrees in a skeletally mature patient
. Any kyphotic curve with documented multiple Schmorl's nodes
. Lumbar hyperlordosis compensatory to a 40-degree thoracic kyphosis

Correct Answer & Explanation

. A progressive curve of 55 to 75 degrees in a skeletally immature patient (Risser 0-2)

Explanation

Bracing is typically indicated for progressive Scheuermann's kyphosis between 50 and 75 degrees in skeletally immature patients with significant remaining growth.

Question 1124

Topic: 6. Spine

A 16-year-old boy presents with progressive back pain and cosmetic deformity. Radiographs show a rigid thoracic Scheuermann's kyphosis of 85 degrees. His Risser sign is 4. What is the most appropriate management?

. Milwaukee brace for 23 hours a day
. Physical therapy focusing exclusively on hamstring stretching
. Posterior spinal fusion with pedicle screw instrumentation
. Anterior spinal fusion alone
. Observation with serial radiographs every 6 months

Correct Answer & Explanation

. Posterior spinal fusion with pedicle screw instrumentation

Explanation

Operative treatment, typically a posterior spinal fusion, is indicated for Scheuermann's kyphosis >75 degrees, especially in skeletally mature patients or those with intractable pain.

Question 1125

Topic: Thoracolumbar Spine & Deformity

Which clinical maneuver is most useful in differentiating Scheuermann's kyphosis from a postural roundback deformity?

. Adam's forward bend test
. Thomas test
. Hyperextension test (prone or supine)
. Straight leg raise test
. Ober test

Correct Answer & Explanation

. Hyperextension test (prone or supine)

Explanation

Scheuermann's kyphosis is characterized by a structural, rigid deformity that does not correct upon hyperextension, whereas postural kyphosis is flexible and will fully correct.

Question 1126

Topic: 6. Spine

Type II (atypical) Scheuermann's disease usually affects the thoracolumbar or lumbar spine. It is most commonly associated with which of the following patient profiles?

. Sedentary adolescent females with poor posture
. Athletic adolescents subjected to heavy physical stress or weightlifting
. Children with underlying collagen disorders such as Marfan syndrome
. Infants with failure of vertebral formation
. Skeletally mature adults with osteoporotic compression fractures

Correct Answer & Explanation

. Athletic adolescents subjected to heavy physical stress or weightlifting

Explanation

Type II Scheuermann's involves the thoracolumbar or lumbar spine, frequently lacking the classic cosmetic deformity, and is often seen in athletic adolescents subjected to heavy axial loading.

Question 1127

Topic: 6. Spine

A lateral spine radiograph of a 14-year-old boy with thoracic kyphosis reveals herniations of the intervertebral disc material through the vertebral endplates into the spongiosa. What is the proper term for this finding?

. Limbus vertebra
. Schmorl's nodes
. Cobb's nodes
. Modic type 1 changes
. Syndesmophytes

Correct Answer & Explanation

. Schmorl's nodes

Explanation

Schmorl's nodes are intraosseous disc herniations commonly seen in Scheuermann's disease due to weakened vertebral endplates and disordered ossification.

Question 1128

Topic: 6. Spine

A 15-year-old boy presents with mid-back pain. Evaluate the provided radiograph.

Based on the typical radiographic signs associated with this condition, including endplate irregularities and wedging, what is the most likely diagnosis?

. Congenital kyphosis type I
. Scheuermann's kyphosis
. Postural kyphosis
. Ankylosing spondylitis
. Spondylolisthesis

Correct Answer & Explanation

. Scheuermann's kyphosis

Explanation

The image highlights anterior wedging of multiple vertebral bodies and endplate irregularities, which are the hallmark radiographic features of Scheuermann's kyphosis.

Question 1129

Topic: 6. Spine

When performing a posterior spinal fusion for Scheuermann's kyphosis, what is the most critical factor in choosing the lower instrumented vertebra (LIV) to prevent distal junctional kyphosis?

. Including all wedged vertebrae regardless of sagittal alignment
. Including the first lordotic disc space (the sagittal stable vertebra)
. Stopping exactly at the apex of the lumbar lordosis
. Always extending the fusion to L4 or L5
. Stopping at the first vertebra below the lowest Schmorl's node

Correct Answer & Explanation

. Including the first lordotic disc space (the sagittal stable vertebra)

Explanation

To minimize the risk of distal junctional kyphosis, the lower instrumented vertebra (LIV) must include the first lordotic disc space, ensuring it is the sagittal stable vertebra.

Question 1130

Topic: 6. Spine

What is considered the most common major complication following posterior spinal fusion for the correction of Scheuermann's kyphosis?

. Complete spinal cord injury
. Deep surgical site infection
. Junctional kyphosis (proximal or distal)
. Symptomatic pseudarthrosis
. Superior mesenteric artery syndrome

Correct Answer & Explanation

. Junctional kyphosis (proximal or distal)

Explanation

Junctional kyphosis, either proximal or distal to the construct, is the most common complication and is frequently related to improper selection of fusion levels.

Question 1131

Topic: 6. Spine

Histological analysis of the vertebral endplates in classic Scheuermann's disease typically demonstrates which of the following abnormalities?

. Avascular necrosis of the entire vertebral body
. Extensive osteoclastic resorption of the posterior elements
. Disorganized endplate cartilage with defective ossification
. Hypertrophy of the posterior longitudinal ligament
. Malignant infiltration of the marrow space

Correct Answer & Explanation

. Disorganized endplate cartilage with defective ossification

Explanation

Histologically, Scheuermann's disease is characterized by disorganized endplate cartilage and defective ossification, predisposing the spine to disc herniation and wedging.

Question 1132

Topic: 6. Spine

To minimize the risk of proximal junctional kyphosis (PJK) following corrective surgery for Scheuermann's kyphosis, the upper instrumented vertebra (UIV) should typically be selected as:

. The apex of the kyphotic curve
. The exact center of the measured Cobb angle
. Always the T1 vertebra
. The proximal end vertebra or one level above it
. The most proximal wedged vertebra only

Correct Answer & Explanation

. The proximal end vertebra or one level above it

Explanation

Extending the fusion construct to include the proximal end vertebra of the kyphotic curve, or one level proximal to it, is a standard strategy to prevent proximal junctional kyphosis.

Question 1133

Topic: Thoracolumbar Spine & Deformity

In an adolescent patient with untreated Scheuermann's kyphosis who reports pain, where is the pain most typically located?

. At the cervicothoracic junction
. Directly over the apex of the kyphotic deformity
. At the lumbosacral junction radiating to the buttocks
. Radiating down the bilateral lower extremities
. Anteriorly in the chest wall mimicking costochondritis

Correct Answer & Explanation

. Directly over the apex of the kyphotic deformity

Explanation

Pain in Scheuermann's disease is typically described as a non-radiating, dull ache located directly over the apex of the thoracic or thoracolumbar kyphosis.

Question 1134

Topic: 6. Spine

Which of the following spinal deformities is most frequently associated as a concurrent finding with Scheuermann's kyphosis?

. High-grade isthmic spondylolisthesis
. Mild idiopathic-like scoliosis
. Congenital block vertebra
. Basilar invagination
. Klippel-Feil anomaly

Correct Answer & Explanation

. Mild idiopathic-like scoliosis

Explanation

Mild scoliosis, usually measuring 10 to 20 degrees, is observed in approximately 20% to 30% of patients presenting with Scheuermann's kyphosis.

Question 1135

Topic: 6. Spine

When utilizing a Milwaukee brace for Scheuermann's kyphosis, optimal curve correction relies on a three-point bending principle. Where should these forces be directed?

. Anteriorly over the sternum, with a posterior force at the sacrum
. Directly over the apex anteriorly, and posteriorly at the sternum
. Posteriorly at the apex of the curve, countered by anterior forces at the sternum and pelvis
. Exclusively at the lumbar spine to reduce hyperlordosis
. Laterally to derotate the associated mild scoliosis

Correct Answer & Explanation

. Posteriorly at the apex of the curve, countered by anterior forces at the sternum and pelvis

Explanation

The three-point bending principle uses a posterior pad to apply an anteriorly directed force at or slightly below the curve's apex, countered by posteriorly directed forces anteriorly at the sternum and pelvis.

Question 1136

Topic: 6. Spine

Historically, severe Scheuermann's kyphosis was treated with combined anterior-posterior spinal fusion. Today, an all-posterior approach is preferred. What is the primary advantage of modern all-posterior pedicle screw constructs over combined approaches?

. Complete elimination of pseudarthrosis risk
. Avoidance of thoracotomy-related pulmonary morbidity while achieving equivalent correction
. Decreased incidence of distal junctional kyphosis
. Ability to avoid fusing the lumbar spine entirely
. Shorter total construct length

Correct Answer & Explanation

. Avoidance of thoracotomy-related pulmonary morbidity while achieving equivalent correction

Explanation

Modern all-posterior pedicle screw constructs achieve equivalent or superior deformity correction compared to historic methods, avoiding the significant pulmonary morbidity associated with an anterior thoracotomy.

Question 1137

Topic: 6. Spine

When evaluating sagittal balance in a patient with severe Scheuermann's kyphosis, increased cervical and lumbar lordosis are frequently observed. What is the primary physiological reason for these findings?

. Concurrent structural cervical and lumbar disc disease
. Flexible compensatory mechanisms to maintain global sagittal balance and horizontal gaze
. Systemic ligamentous laxity extending throughout the spine
. Neurologic tethering of the spinal cord
. Fixed, non-reversible bony deformities of the facet joints

Correct Answer & Explanation

. Flexible compensatory mechanisms to maintain global sagittal balance and horizontal gaze

Explanation

Hyperlordosis in the cervical and lumbar regions is typically a flexible, compensatory response to the rigid thoracic kyphosis, allowing the patient to maintain their head centered over the pelvis.

Question 1138

Topic: 6. Spine

Although rare, neurologic deficit can occur in severe Scheuermann's kyphosis. When present, it is most commonly caused by which of the following?

. Thoracic disc herniation or an epidural cyst at the apex of the curve
. Thoracic spinal stenosis from severe facet hypertrophy
. Epidural lipomatosis compressing the cauda equina
. Traction on the recurrent laryngeal nerve
. Syrinx formation within the spinal cord

Correct Answer & Explanation

. Thoracic disc herniation or an epidural cyst at the apex of the curve

Explanation

Neurologic compromise is very rare in Scheuermann's disease. When it does happen, it is usually due to a compressive thoracic disc herniation or an epidural cyst located at the apex of the severe kyphosis.

Question 1139

Topic: 6. Spine

A 2-year-old child presents with a sharp, angular thoracic kyphosis. Radiographs reveal a failure of formation of the anterior vertebral body. How does the expected management of this condition differ fundamentally from Scheuermann's kyphosis?

. It responds rapidly to Milwaukee bracing until skeletal maturity
. It frequently requires early surgical intervention due to high risk of severe progression and neurologic deficit
. It typically resolves spontaneously with remaining spinal growth
. It requires isolated physical therapy to strengthen extensor muscles
. It is managed by isolated anterior vertebroplasty

Correct Answer & Explanation

. It frequently requires early surgical intervention due to high risk of severe progression and neurologic deficit

Explanation

Congenital kyphosis (Type I, failure of formation) has a high propensity for severe, rapid progression and neurologic compromise, often requiring early surgical intervention, unlike the more benign course of Scheuermann's.

Question 1140

Topic: Thoracolumbar Spine & Deformity

According to the Sorensen criteria, what is the strict radiographic definition required to diagnose classical Scheuermann's kyphosis?

. Anterior wedging of >5 degrees in at least two adjacent vertebrae
. Anterior wedging of >5 degrees in at least three adjacent vertebrae
. Anterior wedging of >10 degrees in at least two adjacent vertebrae
. Anterior wedging of >10 degrees in at least three adjacent vertebrae
. Thoracic kyphosis >45 degrees with Schmorl's nodes

Correct Answer & Explanation

. Anterior wedging of >5 degrees in at least three adjacent vertebrae

Explanation

The Sorensen criteria for diagnosing Scheuermann's kyphosis require anterior wedging of greater than 5 degrees in at least three consecutive vertebrae. Additional common findings include Schmorl's nodes and endplate irregularities.

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