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6. Spine MCQs

Practice Set 66 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 1301

Topic: 6. Spine

A 70-year-old male complains of frequent clumsiness and dropping objects. Examination reveals a wide-based gait and generalized hyperreflexia. Flicking the distal phalanx of his middle finger results in an involuntary flexion of his thumb and index finger. What does this specific clinical sign indicate?

. A positive Babinski sign indicating lumbar stenosis
. A positive Hoffmann sign indicating upper motor neuron dysfunction
. A positive Spurling sign indicating cervical radiculopathy
. A positive Lhermitte sign indicating multiple sclerosis
. A positive Phalen test indicating severe carpal tunnel syndrome

Correct Answer & Explanation

. A positive Hoffmann sign indicating upper motor neuron dysfunction

Explanation

The Hoffmann sign is elicited by flicking the middle finger nail; a reflexive flexion of the thumb and index finger is a positive result. It signifies upper motor neuron dysfunction, which is classically seen in cervical spondylotic myelopathy.

Question 1302

Topic: 6. Spine

A 45-year-old male is involved in a high-speed motor vehicle collision. Cervical radiographs demonstrate an anterior displacement of C5 on C6 by exactly 50% of the vertebral body width. What is the most likely mechanism of this specific injury?

. Pure axial loading
. Hyperextension and rotation
. Hyperflexion and distraction
. Hyperextension and compression
. Pure lateral bending

Correct Answer & Explanation

. Hyperflexion and distraction

Explanation

Anterior displacement of a cervical vertebra by 50% or more typically indicates bilateral facet dislocation. The classic mechanism of injury for a bilateral facet dislocation is severe hyperflexion combined with distraction.

Question 1303

Topic: 6. Spine

A 45-year-old male with a long history of ankylosing spondylitis and severe restrictive lung disease presents after a minor mechanical fall. He complains of severe neck pain but denies neurological deficits. Initial cervical radiographs appear unremarkable. What is the most appropriate next step?

. Reassurance and NSAIDs
. Physical therapy
. Cervical spine CT or MRI
. Corticosteroid injection
. Flexion-extension radiographs

Correct Answer & Explanation

. Cervical spine CT or MRI

Explanation

Patients with ankylosing spondylitis have highly rigid, brittle spines and are at severe risk for unstable fractures even from low-energy trauma. A CT or MRI is mandatory as conventional radiographs easily miss these potentially devastating fractures.

Question 1304

Topic: 6. Spine

A 42-year-old male presents to the emergency department with severe lower back pain, bilateral sciatica, and new-onset urinary incontinence. Examination reveals perineal numbness. Which of the following is the most appropriate next step in management?

. Administer high-dose intravenous methylprednisolone
. Obtain an emergent MRI of the lumbar spine
. Schedule an elective lumbar laminectomy within 1 week
. Perform an emergency diagnostic lumbar puncture
. Prescribe a 7-day course of oral corticosteroids and re-evaluate

Correct Answer & Explanation

. Obtain an emergent MRI of the lumbar spine

Explanation

This patient presents with classic signs of cauda equina syndrome, an orthopedic and neurosurgical emergency. The most appropriate immediate step is to obtain an emergent MRI of the lumbar spine to confirm the diagnosis and level of compression prior to urgent surgical decompression.

Question 1305

Topic: 6. Spine

A 25-year-old male sustains a C1 ring fracture. On the open-mouth odontoid view, the sum of the lateral mass overhang of C1 on C2 is 8 mm. Which of the following statements regarding his injury is most accurate?

. The transverse ligament is likely intact.
. It is considered a stable injury requiring only a hard collar.
. Halo vest immobilization or C1-C2 fusion is indicated.
. This injury is typically associated with a complete spinal cord injury.
. Traction should be applied immediately to reduce the fracture.

Correct Answer & Explanation

. Halo vest immobilization or C1-C2 fusion is indicated.

Explanation

The Rule of Spence states that a combined C1 lateral mass overhang on C2 of greater than 6.9 mm indicates a rupture of the transverse alar ligament. This renders the C1 ring fracture unstable, necessitating rigid immobilization with a halo vest or surgical stabilization.

Question 1306

Topic: Thoracolumbar Spine & Deformity
A 16-year-old gymnast presents with persistent lower back pain. Radiographs reveal an L5-S1 isthmic spondylolisthesis with 65% forward translation of L5 on S1. According to the Meyerding classification, what grade is this slip?
. Grade I
. Grade II
. Grade III
. Grade IV
. Spondyloptosis

Correct Answer & Explanation

. Grade III

Explanation

The Meyerding classification grades spondylolisthesis based on the percentage of vertebral translation: Grade I (0-25%), Grade II (26-50%), Grade III (51-75%), Grade IV (76-100%), and Grade V (>100% or spondyloptosis). A 65% slip is Grade III.

Question 1307

Topic: 6. Spine

A 45-year-old male presents to the emergency department with a 24-hour history of severe lower back pain, bilateral leg weakness, and numbness in the perineal region. Bladder ultrasound reveals a post-void residual volume of 500 mL. What is the best initial step in management?

. Urgent MRI of the lumbar spine
. Immediate decompressive laminectomy without imaging
. Administration of 30 mg/kg of methylprednisolone
. CT myelography of the cervical and lumbar spine
. Referral for physical therapy and NSAIDs

Correct Answer & Explanation

. Urgent MRI of the lumbar spine

Explanation

The patient is presenting with classic signs of cauda equina syndrome, including saddle anesthesia and urinary retention. Urgent MRI of the lumbar spine is the gold standard diagnostic step prior to surgical decompression.

Question 1308

Topic: Thoracolumbar Spine & Deformity

A 14-year-old female gymnast complains of mechanical lower back pain for 8 months that limits her sports participation. Lateral lumbar radiographs reveal a bilateral pars interarticularis defect at L5 with a 40% anterior translation of L5 on S1 (Grade II isthmic spondylolisthesis). She has failed 6 months of structured physical therapy. What is the most appropriate surgical treatment?

. L5-S1 in situ posterolateral fusion
. L4-S1 decompressive laminectomy without fusion
. Anterior lumbar interbody fusion (ALIF) at L4-L5
. Insertion of an interspinous process distraction device
. Transforaminal epidural steroid injections followed by bracing

Correct Answer & Explanation

. L5-S1 in situ posterolateral fusion

Explanation

For a symptomatic, low-grade (Grade I or II) isthmic spondylolisthesis in an adolescent who has failed conservative treatment, an L5-S1 in situ posterolateral arthrodesis is the surgical treatment of choice.

Question 1309

Topic: 6. Spine

A 45-year-old man presents with acute bilateral lower extremity radiculopathy, perianal numbness, and urinary retention following a heavy lifting injury. Which of the following is the most appropriate initial diagnostic imaging modality?

. CT scan of the lumbar spine
. Radiographs of the lumbar spine
. Ultrasound of the bladder
. MRI of the lumbar spine
. CT myelogram

Correct Answer & Explanation

. MRI of the lumbar spine

Explanation

This patient exhibits classic signs of cauda equina syndrome, a surgical emergency. An urgent MRI of the lumbar spine is the gold standard imaging modality to identify the level and extent of neural compression.

Question 1310

Topic: 6. Spine

Which of the following investigations is most specific to allergic bronchopulmonary aspergillosis (ABPA)?

. An early positive skinprick test for Aspergillus fumigatus
. Computed tomographic (CT) evidence of proximal bronchiectasis
. Positive history of exposure to Aspergillus
. Positive precipitins for Aspergillus
. Upper-zone fibrosis

Correct Answer & Explanation

. An early positive skinprick test for Aspergillus fumigatus

Explanation

Correct Answer: A- An early positive skinprick test for Aspergillus fumigatus Explanation An early positive skinprick test for Aspergillus fumigatus Positive skinprick tests reflect antigen-specific IgE. Computed tomographic (CT) evidence of proximal bronchiectasis Computed tomographic (CT) evidence of proximal bronchiectasis is incorrect. Proximal bronchiectasis is a feature of classical ABPA but it is not pathognomic and other causes of bronchiectasis should be considered. Positive history of exposure to Aspergillus Positive history of exposure to Aspergillus is incorrect. A specific exposure history is very difficult to elicit. Most people are exposed to small amounts of Aspergillus regularly and inhale spores in the air. However, only a minority become sensitised to Aspergillus and develop ABPA. Positive precipitins for Aspergillus Positive precipitins for Aspergillus is incorrect. Precipitins (IgG) are more usual with an aspergilloma, but may be positive in ABPA or in up to 10% of patients with asthma. Upper-zone fibrosis Upper-zone fibrosis is incorrect. Allergic bronchopulmonary aspergillosis is characterised by wheezy breathlessness, serum eosinophilia and pulmonary infiltrates on X-ray. Lobar collapse can also occur, due to mucus plugging. ABPA can cause apical fibrosis in its most severe form; however, there are many other causes of upper-lobe fibrosis, including tuberculosis, extrinsic allergic alveolitis, sarcoidosis and ankylosing spondylitis.

Question 1311

Topic: 6. Spine

A 55-year-old man presents with bilateral hand clumsiness and frequent tripping. On physical examination, flicking the nail of his middle finger results in involuntary flexion of the thumb and index finger. This clinical sign indicates compression or dysfunction of which neural pathway?

. Spinothalamic tract
. Corticospinal tract
. Posterior columns
. Spinocerebellar tract
. Vestibulospinal tract

Correct Answer & Explanation

. Corticospinal tract

Explanation

The Hoffmann sign indicates an upper motor neuron lesion, specifically identifying dysfunction of the corticospinal tract. It is frequently positive in patients with cervical spondylotic myelopathy.

Question 1312

Topic: 6. Spine

A 72-year-old man presents with bilateral leg pain exacerbated by walking. Which of the following historical findings most reliably differentiates neurogenic claudication from vascular claudication?

. Pain relief with standing still
. Pain relief when riding a stationary bicycle
. Absent lower extremity pulses
. Cramping pain in the calves
. Presence of trophic skin changes

Correct Answer & Explanation

. Pain relief when riding a stationary bicycle

Explanation

Neurogenic claudication caused by spinal stenosis improves with lumbar flexion, such as when riding a bicycle, because it increases the spinal canal diameter. Vascular claudication is exacerbated by any leg exercise regardless of posture.

Question 1313

Topic: 6. Spine

A 34-year-old male presents after a motor vehicle collision with a Levine-Edwards Type II traumatic spondylolisthesis of the axis (Hangman's fracture). Imaging shows 4 mm of translation and significant angulation. What is the most appropriate definitive management?

. Rigid cervical collar for 6 weeks
. Halo vest immobilization
. C1-C2 posterior fusion
. Anterior cervical discectomy and fusion at C2-C3
. Occipitocervical fusion

Correct Answer & Explanation

. Halo vest immobilization

Explanation

Type II Hangman fractures typically have >3mm translation and significant angulation due to disruption of the C2-C3 disc. They are traditionally treated with halo vest immobilization after gentle reduction, though surgery may be indicated if reduction cannot be maintained.

Question 1314

Topic: 6. Spine

A 73-year-old woman presents with weight loss and a chronic cough. Her husband has noticed that her pupil is constricted and her right eyelid is drooping. She has had pain in her right shoulder for some months, which her GP has described as ‘probable rheumatism’. Her chest X- ray reveals a mass in the right lung apex with possible lymphadenopathy at the right hilum. What is the most likely diagnosis in this case?

. Aspergilloma
. Eaton–Lambert syndrome
. Horner syndrome caused by a Pancoast tumour
. Small-cell carcinoma
. Tuberculosis

Correct Answer & Explanation

. Horner syndrome caused by a Pancoast tumour

Explanation

Correct Answer: C- Horner syndrome caused by a Pancoast tumour Explanation Horner syndrome caused by a Pancoast tumour Horner syndrome is caused by an apical (Pancoast) lung tumour, which leads to spinal cord damage between spinal nerve root levels C8 and T1. Symptoms are pupil constriction, ptosis and facial anhidrosis. Aspergilloma Aspergilloma is incorrect. Aspergillomas are fungal balls that develop within a lung cavity. Chest X- ray will show a cavity containing a mass with a visible rim of air surrounding the mass. Eaton–Lambert syndrome Eaton–Lambert syndrome is incorrect. Eaton–Lambert syndrome is a paraneoplastic syndrome associated with proximal myopathy that is related to a deficient action of cholinergic neurones. Small-cell carcinoma Small-cell carcinoma is incorrect. Pancoast tumours are mostly squamous or adenocarcinomas, only 3–5% are said to be owing to small-cell tumours; this is because small-cell carcinoma of the bronchus is more likely to occur centrally and so would not be expected to present like this. Tuberculosis Tuberculosis is incorrect. This lady’s presentation is in keeping with an invasive mass causing Horner syndrome. This in conjuction with a solid mass seen on chest imaging is more in keeping with lung cancer than tuberculosis.

Question 1315

Topic: 6. Spine

A 45-year-old male presents with severe low back pain, bilateral sciatica, and new-onset urinary retention. Post-void residual volume is 400 mL. An emergent MRI reveals a massive L4-L5 disc herniation compressing the thecal sac. What is the maximum recommended time frame for surgical decompression to optimize functional recovery?

. Within 12 hours
. Within 24 to 48 hours
. Within 72 hours
. Within 1 week
. Conservative management is trialed first

Correct Answer & Explanation

. Within 24 to 48 hours

Explanation

Cauda equina syndrome with urinary retention is a surgical emergency. Decompression should ideally be performed within 24 to 48 hours to maximize the chances of recovery of motor, sensory, and sphincter function.

Question 1316

Topic: 6. Spine

A 14-year-old female with Adolescent Idiopathic Scoliosis is evaluated for spinal fusion. Her curve measures 75 degrees in the thoracic spine. Which of the following pulmonary function test (PFT) parameters is most likely to be decreased and best correlates with her preoperative respiratory status?

. FEV1/FVC ratio
. Residual volume
. Peak expiratory flow rate
. Total lung capacity
. Diffusing capacity of carbon monoxide (DLCO)

Correct Answer & Explanation

. Total lung capacity

Explanation

Severe thoracic scoliosis primarily causes a restrictive lung disease pattern. This is best indicated by a proportional decrease in both FEV1 and FVC with a notably decreased Total Lung Capacity (TLC).

Question 1317

Topic: 6. Spine

A 45-year-old male presents to the clinic with severe low back pain, bilateral sciatica, and new-onset urinary incontinence. Physical examination reveals perianal anesthesia and significantly decreased anal sphincter tone. An urgent MRI confirms a massive L4-L5 central disc herniation. What is the most critical factor influencing the functional recovery of this patient's normal bladder function?

. The use of high-dose intravenous corticosteroids prior to surgery
. The patient's age and baseline metabolic status
. The degree of initial lower extremity motor weakness
. The time interval from onset of symptoms to surgical decompression
. Preoperative administration of gabapentinoids

Correct Answer & Explanation

. The time interval from onset of symptoms to surgical decompression

Explanation

This patient has cauda equina syndrome, which is an absolute surgical emergency. The time to surgical decompression (ideally within 24 to 48 hours of symptom onset) is the most critical prognostic factor for the recovery of bladder and bowel function.

Question 1318

Topic: 6. Spine

A 65-year-old female with long-standing rheumatoid arthritis presents with progressive hand clumsiness and gait instability. Lateral flexion-extension radiographs of the cervical spine demonstrate an anterior atlantodens interval (ADI) of 11 mm. Which of the following is the most likely pathological mechanism for her symptoms?

. Basilar invagination
. Subaxial cervical subluxation
. Transverse ligament incompetence leading to spinal cord compression
. Vertebral artery dissection
. Syringomyelia

Correct Answer & Explanation

. Transverse ligament incompetence leading to spinal cord compression

Explanation

An ADI greater than 9-10 mm in adults indicates disruption of the transverse and accessory ligaments with a high likelihood of spinal cord compression. This manifests clinically as myelopathy, presenting with hand clumsiness and gait instability.

Question 1319

Topic: 6. Spine
A 58-year-old smoker with chronic bronchitis was treated with antibiotics for a right upper-lobe bronchopneumonia by his GP. After 6 weeks he was readmitted to hospital. The chest X-ray shows signs of a pneumonia in the same place. What is the most likely reason?
. Bronchial carcinoma with post-stenotic pneumonia
. Candida pneumonia
. Immunodeficiency
. Sarcoidosis
. Tuberculosis

Correct Answer & Explanation

. Bronchial carcinoma with post-stenotic pneumonia

Explanation

Non-resolving pneumonia is an indication of bronchogenic carcinoma. An ill-defined homogeneous or patchy consolidation in a segmental or non-segmental distribution might be an indication of bronchogenic carcinoma. The lack of response to antibiotic therapy suggests the diagnosis of a malignancy.

Question 1320

Topic: 6. Spine

A 55-year-old man with poorly controlled type 2 diabetes is scheduled for an elective lumbar spinal fusion. He is counseled extensively on the risk of surgical site infection (SSI). What is the generally accepted preoperative HbA1c threshold above which most elective orthopedic surgeries should be delayed?

. 6.0%
. 6.5%
. 7.0%
. 8.0%
. 10.0%

Correct Answer & Explanation

. 8.0%

Explanation

Current orthopedic guidelines recommend delaying elective joint and spine surgeries if the patient's HbA1c is 8.0% or higher. Values above this threshold are independently associated with a significantly increased risk of surgical site infections and poor wound healing.

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