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6. Spine MCQs

Practice Set 65 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 1281

Topic: 6. Spine

A 60-year-old diabetic male with a history of intravenous drug use presents with worsening back pain, fevers, and new-onset bilateral lower extremity weakness. MRI reveals a large ventral epidural abscess at T8-T10 causing severe cord compression. What is the best definitive management?

. Intravenous antibiotics for 6 weeks
. CT-guided percutaneous aspiration
. Anterior corpectomy and decompression with stabilization
. Posterior laminectomy alone
. Corticosteroid administration followed by radiation therapy

Correct Answer & Explanation

. Anterior corpectomy and decompression with stabilization

Explanation

A ventral epidural abscess with neurologic deficit requires urgent anterior decompression to directly remove the pathology and decompress the spinal cord. Posterior laminectomy alone for a ventral thoracic lesion often fails to adequately decompress the cord and can cause instability.

Question 1282

Topic: 6. Spine

A 62-year-old male presents with progressive hand clumsiness and difficulty walking. Examination reveals a positive Hoffmann's sign bilaterally, hyperreflexia in the lower extremities, and an inverted brachioradialis reflex. MRI demonstrates multilevel cervical spondylosis with severe cord compression from C3 to C6 and neutral cervical sagittal alignment. Which of the following surgical approaches is most appropriate?

. C3-C6 anterior cervical discectomy and fusion (ACDF)
. C3-C6 cervical laminectomy without fusion
. C3-C6 cervical laminoplasty
. Anterior cervical corpectomy of C4 and C5
. Posterior cervical foraminotomy

Correct Answer & Explanation

. C3-C6 cervical laminoplasty

Explanation

In multilevel cervical myelopathy (>3 levels) with neutral or lordotic sagittal alignment, posterior decompression via laminoplasty avoids the morbidity and pseudarthrosis risks of multilevel anterior approaches. Laminectomy without fusion in an adult risks progressive post-laminectomy kyphosis.

Question 1283

Topic: 6. Spine
Which of the following is most likely to cause upper-lobe fibrosis on chest X-ray?
. Ankylosing spondylitis
. Idiopathic pulmonary fibrosis
. Rheumatoid arthritis
. Scleroderma
. Systemic lupus erythematosus

Correct Answer & Explanation

. Ankylosing spondylitis

Explanation

Ankylosing spondylitis is the correct answer. Causes of upper-lobe fibrosis on a chest X-ray include: Ankylosing spondylitis (affects the apices), tuberculosis, sarcoidosis, extrinsic allergic alveolitis, silicosis, allergic bronchopulmonary aspergillosis (ABPA), and post-radiotherapy. Idiopathic pulmonary fibrosis, rheumatoid arthritis, scleroderma, and systemic lupus erythematosus are more likely to be associated with lower-lobe fibrosis.

Question 1284

Topic: 6. Spine

A 42-year-old man presents with severe lower back pain, bilateral sciatica, saddle anesthesia, and urinary retention with overflow incontinence. MRI confirms a massive L4-L5 central disc herniation. What is the maximum generally accepted timeframe for surgical decompression to optimize sphincter recovery?

. 12 hours
. 24 hours
. 48 hours
. 72 hours
. 96 hours

Correct Answer & Explanation

. 48 hours

Explanation

Cauda equina syndrome is an absolute surgical emergency. Decompression within 48 hours is widely accepted to offer the best chance for optimal recovery of urinary and bowel sphincter function.

Question 1285

Topic: 6. Spine

A 25-year-old man presents with chronic inflammatory back pain and stiffness that improves with exercise. Radiographs show squaring of the vertebral bodies and syndesmophyte formation. What is the most common extraskeletal manifestation of this condition?

. Aortic regurgitation
. Anterior uveitis
. Pulmonary apical fibrosis
. Inflammatory bowel disease
. IgA nephropathy

Correct Answer & Explanation

. Anterior uveitis

Explanation

Ankylosing spondylitis is an HLA-B27 associated seronegative spondyloarthropathy. Anterior uveitis is its most common extraskeletal manifestation, affecting approximately 25-30% of patients.

Question 1286

Topic: 6. Spine

A 70-year-old female presents with neck pain, clumsiness in her hands, and difficulty with balance. Examination reveals a positive Hoffmann's sign and hyperreflexia in the lower extremities. What is the most likely diagnosis?

. Cervical radiculopathy
. Cervical myelopathy
. Amyotrophic lateral sclerosis
. Syringomyelia
. Multiple sclerosis

Correct Answer & Explanation

. Cervical myelopathy

Explanation

Cervical myelopathy presents with upper motor neuron signs (hyperreflexia, Hoffmann's sign, positive Babinski) due to spinal cord compression. Hand clumsiness and gait disturbances are classic clinical manifestations.

Question 1287

Topic: 6. Spine

During a surgical approach to the anterior cervical spine (Smith-Robinson approach), the dissection interval is between the carotid sheath and which of the following structures medially?

. Sternocleidomastoid muscle
. Trachea and esophagus
. Longus colli muscle
. Omohyoid muscle
. Platysma

Correct Answer & Explanation

. Trachea and esophagus

Explanation

The standard anterior approach to the cervical spine utilizes an internervous and intermuscular plane. The interval is between the carotid sheath contents laterally and the midline visceral structures (trachea and esophagus) medially.

Question 1288

Topic: 6. Spine

A 30-year-old immigrant presents with chronic back pain, night sweats, and a kyphotic deformity of the thoracic spine. Imaging reveals destruction of the T8-T9 intervertebral disc and adjacent vertebral endplates, along with a paraspinal soft tissue mass. Which of the following is the most likely causative organism?

. Staphylococcus aureus
. Mycobacterium tuberculosis
. Pseudomonas aeruginosa
. Brucella melitensis
. Salmonella typhi

Correct Answer & Explanation

. Mycobacterium tuberculosis

Explanation

This is a classic presentation of spinal tuberculosis (Pott's disease), characterized by indolent infection, anterior wedging/kyphosis, disc space destruction, and cold abscesses.

Question 1289

Topic: Cervical Spine

A 60-year-old female with long-standing, poorly controlled rheumatoid arthritis presents with progressive neck pain, clumsiness in her hands, and hyperreflexia in all four extremities. Flexion-extension radiographs demonstrate an atlanto-dens interval (ADI) of 9 mm. What is the primary pathophysiological cause of this specific upper cervical instability?

. Rupture of the apical ligament
. Pannus destruction of the transverse ligament
. Erosion of the C1-C2 facet joints
. Pathologic fracture of the odontoid process
. Ossification of the posterior longitudinal ligament

Correct Answer & Explanation

. Pannus destruction of the transverse ligament

Explanation

Atlantoaxial subluxation in rheumatoid arthritis is primarily caused by inflammatory pannus eroding and destroying the transverse ligament of the atlas, which normally stabilizes the odontoid process against the anterior arch of C1.

Question 1290

Topic: 6. Spine

A 64-year-old mechanic and lifelong smoker noticed haemoptysis a few days after he had a cold. Clinical examination is unremarkable. His chest X-ray shows predominantly left-sided hilar enlargement and mediastinal widening. What is the most likely diagnosis?

. Bronchial carcinoma
. Hilar metastases
. Lung abscess
. Lymphoma
. Tuberculosis

Correct Answer & Explanation

. Bronchial carcinoma

Explanation

Correct Answer: A- Bronchial carcinoma Explanation Bronchial carcinoma The value of the chest X-ray in the diagnosis and management of pulmonary neoplasm needs no emphasis. No initial examination is complete without a lateral film. Coned views of the ribs can help where rib invasion is suspected clinically. However, the finding of a normal X- ray of the chest does not exclude bronchial carcinoma, as patients presenting with haemoptysis and a normal chest X-ray are sometimes found to have a central tumour on bronchoscopy. The common appearance of a tumour arising from the main central airways (70% of all cases) is enlargement of one or other hilum. Even experienced observers sometimes have difficulty in deciding whether or not a hilar shadow is enlarged; if there is any suspicion,investigation by bronchoscopy and/or computed tomography (CT) should be pursued. Consolidation and collapse distal to the tumour might have occurred by the time the patient presents, with the tumour itself often being obscured in the process. Collapse of the left lower lobe is often hard to identify, as is a tumour situated behind the heart. Apically located masses or superior sulcus tumours (Pancoast tumours) can be misdiagnosed as pleural caps, and patients often have a long history of pain in the distribution of the brachial nerve roots. Loss of the head of the first, second or third rib is not unusual. The mediastinum might be widened by enlarged nodes. Involvement of the phrenic nerve can lead to paralysis and elevation of the hemidiaphragm, which then moves paradoxically on sniffing. Tumour spread to the pleura causes effusion, but such an abnormality can also be secondary to infection beyond obstruction caused by a central tumour. The ribs and spine should be carefully examined for the presence of metastases. Spread of tumour from mediastinal nodes peripherally along the lymphatics gives the characteristic appearance of lymphangitis carcinomatosa โ€“ bilateral hilar enlargement with streaky shadows fanning out into the lung fields on either side. Rarely, localised obstructive emphysema is observed. Hilar metastases Hilar metastases is incorrect. Hilar metastases from an extrapulmonary primary malignancy is a reasonable differential diagnosis in this case. However, given the gentlemanโ€™s lifelong smoking status, absence of extrapulmonary symptoms, normal clinical examination and chest radiograph showing a hilar mass rather than multiple pulmonary lesions, a primary lung carcinoma is the most likely diagnosis of the options listed. Lung abscess Lung abscess is incorrect. Lung abscesses are seen on chest radiographs as cavities with an air/fluid level. Patients would usually have symptoms suggestive of pulmonary infection such as fevers, sweats and purulent sputum. Lymphoma Lymphoma is incorrect. Lymphoma is also a reasonable differential diagnosis in this case. However, hilar enlargenment would usually be bilateral on the chest radiograph, clinical examination would be likely to reveal lymphadenopathy +/- hepatoslenomegaly. This, combined with the lack of history of night sweats and weight loss, means that lymphoma is a less likely diagnosis than bronchial carcinoma. Tuberculosis Tuberculosis is incorrect. Tuberculosis would usually cause bilateral hilar lymphadenopathy and one would expect a history suggestive of potential contact with tuberculosis or presence of risk factors such as immunosuppression, malnutrition or alcoholism. There are no features in this history to suggest infection as the cause of lymphadenopathy.

Question 1291

Topic: Thoracolumbar Spine & Deformity

A 45-year-old man falls from a height and sustains an L1 burst fracture. His neurological examination is normal. A CT scan demonstrates 30% canal compromise, and MRI confirms an intact posterior ligamentous complex. His Thoracolumbar Injury Classification and Severity (TLICS) score is calculated as 2. What is the most appropriate management?

. Anterior corpectomy and fusion
. Posterior spinal fusion
. Short segment pedicle screw fixation
. Thoracolumbosacral orthosis (TLSO)
. Laminectomy alone

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO)

Explanation

A burst fracture with intact neurological status and an intact posterior ligamentous complex typically scores a 2 on the TLICS system. The standard of care for a neurologically intact patient with a stable burst fracture is nonoperative management with a TLSO.

Question 1292

Topic: 6. Spine

A 42-year-old woman presents with acute onset severe lower back pain, bilateral sciatica, and perineal numbness. Which of the following clinical findings is considered the most sensitive indicator for the diagnosis of cauda equina syndrome?

. Loss of Achilles tendon reflexes
. Bilateral foot drop
. Urinary retention
. Fecal incontinence
. Decreased rectal tone

Correct Answer & Explanation

. Urinary retention

Explanation

Urinary retention (often with post-void residual > 100-200 mL) is the most sensitive symptom and sign of cauda equina syndrome. If a patient does not have urinary retention, a complete cauda equina syndrome is highly unlikely.

Question 1293

Topic: 6. Spine

A 42-year-old female presents to the Emergency Department with severe low back pain, bilateral sciatica, and perineal numbness. She reports difficulty initiating micturition. A post-void residual bladder volume is measured. What residual volume threshold is most indicative of early Cauda Equina Syndrome?

. Less than 50 mL
. 50 to 100 mL
. 100 to 200 mL
. Greater than 200 mL
. Greater than 500 mL only

Correct Answer & Explanation

. Greater than 200 mL

Explanation

In the context of suspected Cauda Equina Syndrome, a post-void residual (PVR) bladder volume greater than 200 mL is highly sensitive for urinary retention secondary to sacral root compression. Urgent MRI and surgical decompression are indicated.

Question 1294

Topic: 6. Spine

A 65-year-old man presents with progressive hand clumsiness, difficulty buttoning his shirts, and a broad-based, unsteady gait. Physical examination reveals a positive Hoffmann sign bilaterally and hyperreflexia. MRI shows multilevel cervical spondylosis. What is the most likely diagnosis?

. Amyotrophic lateral sclerosis
. Cervical spondylotic myelopathy
. Syringomyelia
. Multiple sclerosis
. Guillain-Barre syndrome

Correct Answer & Explanation

. Cervical spondylotic myelopathy

Explanation

Cervical spondylotic myelopathy classically presents with upper motor neuron signs (Hoffmann sign, hyperreflexia) and progressive upper extremity clumsiness due to cord compression.

Question 1295

Topic: 6. Spine
A 56-year-old man has a chest X-ray performed because he has become breathless on exertion and has inspiratory crackles. The chest X-ray reveals upper-lobe lung fibrosis. Which of the following is the most likely explanation?
. Asbestosis
. Connective tissue disease related interstitial lung disease
. Drug-induced interstitial lung disease
. Idiopathic pulmonary fibrosis
. Langerhans cell histiocytosis

Correct Answer & Explanation

. Langerhans cell histiocytosis

Explanation

Correct Answer: E - Langerhans cell histiocytosis. Explanation: Upper zone fibrosis typically occurs in: Tuberculosis, extrinsic allergic alveolitis, sarcoidosis, ankylosing spondylitis, allergic bronchopulmonary aspergillosis, farmerโ€™s lung, pneumoconiosis, histiocytosis, and silicosis. Asbestosis, connective tissue disease-related interstitial lung disease, drug-induced interstitial lung disease, and idiopathic pulmonary fibrosis typically result in lower-zone fibrosis.

Question 1296

Topic: 6. Spine

A 45-year-old immigrant presents with chronic back pain, low-grade fevers, and an increasing kyphotic deformity of the thoracolumbar spine. Imaging reveals destruction of the T11 and T12 vertebral bodies with a paravertebral abscess. What is the most frequent route of spread for this pathogen to the spine in adults?

. Hematogenous spread via Batson's venous plexus
. Lymphatic spread from thoracic nodes
. Direct extension from pulmonary cavitary lesions
. Retrograde flow through the intercostal arteries
. Cerebrospinal fluid dissemination

Correct Answer & Explanation

. Hematogenous spread via Batson's venous plexus

Explanation

Tuberculous spondylitis (Pott's disease) most commonly spreads to the spine hematogenously. In adults, Batson's valveless venous plexus is the primary route, leading to subchondral bone involvement and subsequent disc space narrowing.

Question 1297

Topic: 6. Spine

A 50-year-old male presents with severe lumbar back pain, saddle anesthesia, and bilateral lower extremity weakness. MRI reveals a massive L4-L5 disc herniation compressing the nerve roots. Which of the following factors is the most reliable early predictor of a favorable functional outcome following surgical decompression?

. Size of the disc herniation on MRI
. Presence of lower extremity motor weakness
. Preoperative urinary continence status
. Severity of presenting back pain
. Duration of preoperative leg numbness

Correct Answer & Explanation

. Preoperative urinary continence status

Explanation

In cauda equina syndrome, preoperative urinary continence status is the most significant predictor of postoperative bladder and bowel function recovery. Patients who are incontinent preoperatively have significantly poorer long-term outcomes.

Question 1298

Topic: 6. Spine

A 40-year-old immigrant presents with chronic back pain, night sweats, and a new kyphotic deformity. MRI of the spine demonstrates marked destruction of two adjacent thoracic vertebral bodies and the intervening intervertebral disc. What is the most likely etiology?

. Pyogenic spondylodiscitis
. Multiple myeloma
. Spinal tuberculosis
. Metastatic carcinoma
. Osteoporotic compression fractures

Correct Answer & Explanation

. Spinal tuberculosis

Explanation

Spinal tuberculosis (Pott's disease) characteristically causes granulomatous destruction of adjacent vertebral bodies and the intervening disc, often leading to a sharp kyphotic deformity (gibbus).

Question 1299

Topic: 6. Spine

A 35-year-old male with a history of ankylosing spondylitis presents to the emergency department after a low-energy fall. He complains of severe lower neck pain. Plain radiographs show a highly rigid, osteopenic bamboo spine. What complication is he at the highest risk for in this scenario?

. Unstable cervical spine fracture
. Aortic root dilation
. High-grade spondylolisthesis
. Acute disc herniation
. Central cord syndrome

Correct Answer & Explanation

. Unstable cervical spine fracture

Explanation

Patients with ankylosing spondylitis have highly rigid, osteopenic spines. They are extremely susceptible to highly unstable spinal fractures (often through the ossified disc space) even from minor, low-energy trauma.

Question 1300

Topic: 6. Spine

A 45-year-old presents with acute, severe lower back pain radiating down both legs, associated with perianal numbness and new-onset urinary retention. What is the most appropriate next step?

. Lumbar epidural steroid injection
. Urgent MRI and emergent surgical decompression
. Electromyography (EMG) of the lower extremities
. Strict bed rest and oral NSAIDs for 2 weeks
. High-dose oral corticosteroids

Correct Answer & Explanation

. Urgent MRI and emergent surgical decompression

Explanation

Cauda equina syndrome is an absolute orthopedic emergency characterized by saddle anesthesia, bilateral sciatica, and bowel or bladder dysfunction. Emergent MRI and surgical decompression are vital to prevent permanent neurological deficits.

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