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6. Spine MCQs

Practice Set 6 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 101

Topic: 6. Spine

Which of the following statements regarding radiographic evaluation of patients with burners and stingers is correct:

. A Torg ratio > 0.8 indicates that cervical spinal stenosis may be present.
. A Torg ratio , 0.8 indicates that cervical spinal stenosis may be present.
. An extension lateral cervical conventional radiograph is used to determine the Torg ratio.
. A Torg ratio > 0.8 indicates that cervical spinal stenosis may be present, and an extension lateral cervical conventional radiograph is used to determine the Torg ratio.
. A Torg ratio , 0.8 indicates that cervical spinal stenosis may be present, and an extension lateral cervical conventional radiograph is used to determine the Torg ratio.

Correct Answer & Explanation

. A Torg ratio , 0.8 indicates that cervical spinal stenosis may be present, and an extension lateral cervical conventional radiograph is used to determine the Torg ratio.

Explanation

The Torg ratio is calculated using an extension lateral cervical radiograph. To calculate the Torg ratio, divide the distance between the midpoint of the posterior aspect of the vertebral body to the nearest point on the corresponding spinolaminar line by the anteroposterior width of the vertebral body. A Torg ratio , 0.8 is associated with cervical spinal stenosis and sustained burners and stingers in athletes with cervical spine-extension- compression type injuries.C orrect Answer: A Torg ratio , 0.8 indicates that cervical spinal stenosis may be present, and an extension lateral cervical conventional radiograph is used to determine the Torg ratio.

Question 102

Topic: 6. Spine
A 26-year-old man with HIV presents to your office with symptoms of lower back pain, difficulty with ambulation, loss of appetite, mild fever, and malaise for 2 weeks. The patient states that he has had difficulty with compliance to his medical management. You suspect that he has a low CD4 count, which is confirmed by laboratory tests. Physical examination reveals tenderness at the L4-L5 level. The patient has abnormal gait. Ankle dorsiflexion and plantarflexion are 1 out of 5 bilaterally. The Achilles tendon reflex is absent bilaterally; all other reflexes are normal. A T2-weighted MRI study shows slightly increased intensity of the disk at the L4-L5 level and an obvious epidural abscess. Conventional radiographs of the lumbar region are normal. Management of this patient should consist of:
. Admission to the intensive care unit (ICU) and intravenous administration of broad-spectrum antibiotics
. Consideration of urgent surgical intervention and evacuation of the epidural abscess
. Counseling the patient on the importance of compliance with medical management
. Surveillance for signs of further neurologic deterioration
. All of the above

Correct Answer & Explanation

. All of the above

Explanation

All of the above answer choices are correct. The patient described above has HIV and is severely immunocompromised. Because of the severity of the patient's condition, immediate admission to the ICU and intravenous administration of a broad-spectrum antibiotic regimen is indicated. Biopsy and drainage of the infected regions should be performed. It is important in this case to monitor the patient for any signs of neurologic deterioration. Finally, to prevent recurrent cases of diskitis, or other infections, it is important to counsel the patient on compliance with medical management.

Question 103

Topic: 6. Spine

Which of the following statements regarding diskitis is correct:

. Signs and symptoms of diskitis generally progress rapidly.
. Intravenous drug use and immunocompromise are not generally considered risk factors for diskitis.
. Diskitis commonly occurs in the thoracic region of the spine.
. Blood cultures are generally positive in up to 70% of patients with diskitis.
. All of the above

Correct Answer & Explanation

. Blood cultures are generally positive in up to 70% of patients with diskitis.

Explanation

Diskitis is usually indolent, and patients live with symptoms for several months before seeking treatment. Intravenous drug use and immunocompromise are two important risk factors for diskitis, along with surgical procedures involving the spine. Diskitis rarely occurs in the thoracic spine; instead, diskitis usually occurs in the lumbar spine. Blood cultures should be taken in any patient with suspected diskitis.

Question 104

Topic: 6. Spine

Which of the following statements regarding lesions of the spinal cord caused by bullet wounds is true:

. Twenty-five percent of patients with complete lesions recover one motor level after 1 year.
. Thirty-three percent of patients with incomplete lesions usually have a partial or complete recovery after 1 year.
. Complete lesions occur in more than 50% of all gunshot wounds to the spine.
. Seventy-five percent of patients in whom the bullet has passed through the spinal canal will experience a complete lesion.
. All of the above

Correct Answer & Explanation

. All of the above

Explanation

All of the statements are true. Knowledge of these facts is important in decision-making and management of patients who are victims of gunshot wounds to the spine.

Question 105

Topic: 6. Spine
An 18-year-old man presents to the emergency department after sustaining a high-velocity gunshot wound to the umbilical region of the abdomen. An exit wound is found at the L3-L5 region of the lower back. Neurological examination shows grade 0/5 strength in his tibialis anterior muscles, gastrocnemius/soleus muscles, and extensor hallucis longus muscles bilaterally. His quadriceps and hamstrings strength is grade 2/5 bilaterally. A bullet fragment was seen at L4 within the spinal canal on CT imaging. The patient sustained significant gastrointestinal trauma as a result of the bullet traversing his body. Management should consist of:
. Administration of a broad-spectrum antibiotic for 14 days
. Removal of the bullet fragment at L4
. Continued serial neurologic examinations
. Intravenous administration of dexamethasone for 24 hours
. A, B, and C

Correct Answer & Explanation

. A, B, and C

Explanation

Because the bullet entered the patient's umbilical region of the abdomen, significant gastrointestinal damage is suspected. When this occurs, administration of a broad-spectrum antibiotic for 7 to 14 days is indicated to prevent infection and sepsis from gastrointestinal flora. The bullet fragment at L4 should be removed because studies have shown that removal of a bullet from a patient with complete or incomplete neural deficits at T12 to L4 is associated with statistically significant increases in motor recovery as compared to nonoperative management. Intravenous administration of dexamethasone is not indicated for gunshot wounds to the spine because the benefits of steroids do not outweigh the risks.

Question 106

Topic: 6. Spine

Magnetic resonance imaging (MRI) is appropriate in which of the following circumstances:

. Malignancy is suspected as a cause of kyphosis
. Neurologic deficit is suspected as a result of kyphosis
. Patient with congenital kyphosis
. Patient with back pain and a history of osteoporosis
. All of the above

Correct Answer & Explanation

. All of the above

Explanation

It is appropriate to obtain an MRI in all of the above circumstances. Magnetic resonance imaging allows a physician to evaluate the cerebrospinal fluid and spinal cord to localize the cause of a neurologic deficit. The presence of back pain in a patient with kyphosis and osteoporosis suggests the possibility of a vertebral compression fracture; these fractures may not always be seen with conventional radiographs. The use of MRI is recommended for the evaluation of a patient with congenital kyphosis to evaluate the morphology of the malformed segment and to rule out associated pathology.

Question 107

Topic: Thoracolumbar Spine & Deformity

What percentage of women with osteoporotic fractures develop kyphosis:

. 10%
. 15%
. 25%
. 30%
. 60%

Correct Answer & Explanation

. 10%

Explanation

Approximately 15% of women with osteoporotic fractures develop kyphosis. This is often due to the presence of multiple vertebral compression fractures with segmental kyphosis at each level.

Question 108

Topic: 6. Spine

In a patient presenting with an acute L4-L5 far-lateral (extraforaminal) disc herniation, which nerve root is most likely compressed?

. L3 traversing root
. L4 exiting root
. L4 traversing root
. L5 exiting root
. L5 traversing root

Correct Answer & Explanation

. L3 traversing root

Explanation

A far-lateral or extraforaminal disc herniation at L4-L5 compresses the exiting L4 nerve root. This contrasts with a paracentral herniation at the same level, which would compress the traversing L5 root.

Question 109

Topic: 6. Spine

An 80-year-old female with long-standing ankylosing spondylitis presents with neck pain after a ground-level fall. Initial plain radiographs are read as normal. What is the most appropriate next step in management?

. Discharge with a soft cervical collar
. Perform flexion-extension radiographs
. Obtain a CT scan of the cervical spine
. Prescribe NSAIDs and physical therapy
. Administer high-dose intravenous steroids

Correct Answer & Explanation

. Discharge with a soft cervical collar

Explanation

Patients with ankylosing spondylitis are at high risk for highly unstable spine fractures even after low-energy trauma. CT scan of the entire cervical spine is mandatory because fractures are frequently missed on plain radiographs.

Question 110

Topic: Cervical Spine

During anterior cervical discectomy and fusion (ACDF), the sympathetic trunk is at risk of injury if dissection strays too far laterally. The sympathetic trunk lies anterior to which of the following structures?

. Longus colli muscle
. Scalenus anterior muscle
. Carotid sheath
. Vertebral artery
. Sternocleidomastoid muscle

Correct Answer & Explanation

. Longus colli muscle

Explanation

The sympathetic trunk rests on the lateral border of the longus colli muscle. Injury to it during an anterior approach to the cervical spine can result in Horner's syndrome.

Question 111

Topic: 6. Spine

Which of the following physical examination findings is most specific for cervical myelopathy?

. Positive Spurling's test
. Diminished biceps reflex
. Positive Lhermitte's sign
. Positive inverted brachioradialis reflex
. Weakness of wrist extension

Correct Answer & Explanation

. Positive Spurling's test

Explanation

The inverted brachioradialis reflex is highly specific for cervical myelopathy, indicating a lower motor neuron lesion at C5-C6 and an upper motor neuron lesion below. Spurling's test is specific for cervical radiculopathy.

Question 112

Topic: 6. Spine

According to the Levine and Edwards classification of traumatic spondylolisthesis of the axis (Hangman's fracture), a Type IIA fracture is best managed by which of the following?

. Rigid cervical collar and immediate full weight-bearing
. Halo vest with initial axial traction to reduce angulation
. Halo vest applied in gentle compression and extension, strictly avoiding traction
. Immediate anterior C2-C3 discectomy and fusion
. Posterior C1-C3 instrumented fusion

Correct Answer & Explanation

. Rigid cervical collar and immediate full weight-bearing

Explanation

Type IIA fractures result from flexion-distraction and feature severe angulation with minimal translation. Axial traction is strictly contraindicated as it will exacerbate the injury; they must be reduced with gentle compression and extension.

Question 113

Topic: 6. Spine

A 65-year-old male with severe cervical spondylosis develops disproportionately greater motor impairment in his upper extremities compared to his lower extremities following a hyperextension injury. Which spinal cord tracts are primarily involved in this classic syndrome?

. Anterior spinothalamic tracts
. Medial portions of the lateral corticospinal tracts
. Fasciculus cuneatus and gracilis
. Vestibulospinal tracts
. Anterior horn cells exclusively

Correct Answer & Explanation

. Anterior spinothalamic tracts

Explanation

This presentation is classic for Central Cord Syndrome. It preferentially damages the medial portion of the lateral corticospinal tracts, which topographically carry motor fibers supplying the upper extremities.

Question 114

Topic: Cervical Spine

In a patient with long-standing rheumatoid arthritis, which of the following radiographic measurements is the most reliable predictor of impending or irreversible neurologic deficit due to atlantoaxial subluxation?

. Anterior atlantodental interval (ADI) > 3 mm
. Anterior atlantodental interval (ADI) > 9 mm
. Posterior atlantodental interval (PADI) < 14 mm
. Subaxial subluxation of 2 mm
. Cranial settling with the odontoid 2 mm above Chamberlain's line

Correct Answer & Explanation

. Anterior atlantodental interval (ADI) > 3 mm

Explanation

The Posterior atlantodental interval (PADI), also known as the space available for the cord (SAC), is the most critical prognostic indicator. A PADI less than 14 mm is associated with a high risk of permanent neurologic deficit.

Question 115

Topic: Cervical Spine

During an anterior cervical discectomy and fusion (ACDF) at the C6-C7 level, a right-sided surgical approach is chosen. Which of the following structures is at a higher risk of injury compared to a left-sided approach?

. Thoracic duct
. Recurrent laryngeal nerve
. Sympathetic chain
. Superior laryngeal nerve
. Vertebral artery

Correct Answer & Explanation

. Thoracic duct

Explanation

The right recurrent laryngeal nerve is at higher risk during right-sided lower cervical approaches because it leaves the vagus nerve more proximally and courses at a more oblique, unprotected angle compared to the left nerve.

Question 116

Topic: 6. Spine

A 25-year-old is involved in a severe motor vehicle collision and sustains a Jefferson burst fracture. On the AP open-mouth radiograph, what combined lateral mass overhang measurement indicates disruption of the transverse alar ligament (Rule of Spence)?

. > 3.5 mm
. > 5.0 mm
. > 6.9 mm
. > 8.5 mm
. > 11.0 mm

Correct Answer & Explanation

. > 3.5 mm

Explanation

The Rule of Spence dictates that a combined overhang of the C1 lateral masses on C2 > 6.9 mm on an open-mouth view implies transverse ligament rupture, rendering the C1 ring highly unstable.

Question 117

Topic: 6. Spine

Which of the following physical examination findings is most specific for diagnosing a severe upper motor neuron lesion such as cervical myelopathy?

. Positive Spurling's maneuver
. Absent biceps reflex
. Inverted brachioradialis reflex
. Weakness of elbow extension
. Diminished sensation in the C6 dermatome

Correct Answer & Explanation

. Positive Spurling's maneuver

Explanation

An inverted brachioradialis reflex (finger flexion or triceps extension when the brachioradialis tendon is tapped) strongly indicates cervical myelopathy, representing simultaneous lower motor neuron damage at C5/C6 and upper motor neuron damage below that level.

Question 118

Topic: 6. Spine

A 45-year-old patient presents with neck pain radiating to the thumb and index finger. Examination reveals weakness in wrist extension and a diminished brachioradialis reflex. Which cervical nerve root is most likely compressed?

. C4
. C5
. C6
. C7
. C8

Correct Answer & Explanation

. C6

Explanation

C6 radiculopathy typically manifests with numbness in the thumb and index finger, weakness in wrist extension, and a diminished brachioradialis reflex.

Question 119

Topic: 6. Spine

What is a major indication for utilizing a posterior approach (laminoplasty or laminectomy with fusion) rather than an anterior approach for ossification of the posterior longitudinal ligament (OPLL)?

. Cervical kyphosis greater than 15 degrees
. Single-level focal disease
. Concomitant central disc herniation
. Lordotic cervical alignment with involvement of more than 3 levels
. K-line negative alignment

Correct Answer & Explanation

. Lordotic cervical alignment with involvement of more than 3 levels

Explanation

A posterior approach relies on preserved cervical lordosis to allow the spinal cord to drift posteriorly away from the anterior compressive OPLL mass. Multi-level disease (>3 levels) is better treated posteriorly if lordosis is intact.

Question 120

Topic: 6. Spine

A 60-year-old patient with ankylosing spondylitis sustains a minor fall resulting in an extension-type cervical fracture. Even without immediate neurologic deficit, which of the following life-threatening complications is most frequently associated with this specific injury pattern?

. Vertebral artery aneurysm
. Epidural hematoma
. Syringomyelia
. Esophageal perforation
. Tracheal stenosis

Correct Answer & Explanation

. Epidural hematoma

Explanation

Patients with ankylosing spondylitis have rigid, vascularized bone and altered epidural venous plexus dynamics. Fractures often tear these vessels, predisposing them to rapidly expanding, compressive epidural hematomas.

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