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 1341
Topic: 6. Spine
A 55-year-old diabetic patient presents with progressive back pain, fever, and lower extremity weakness. MRI reveals a spinal epidural abscess. What is the most common causative organism and the most frequent mechanism of spread?
Correct Answer & Explanation
. Staphylococcus aureus via hematogenous spread
Explanation
Staphylococcus aureus is the most common organism responsible for spinal epidural abscesses. The most frequent mechanism of infection is hematogenous dissemination from a distant source, such as skin, respiratory, or urinary tract infections.
Question 1342
Topic: 6. Spine
Which of the following statements is true concerning atlanto-occipital dislocations in children:
Correct Answer & Explanation
. No single plain radiographic finding is always diagnostic.
Explanation
Pediatric atlanto-occipital dislocation is increasing in frequency due to improved emergency care. Although the injuries are sometimes fatal and are often accompanied by severe spinal cord injury, this is not always the case. Although the dens-basion distance should be less than 10 mm and the power ratio should be less than 1 in normals, these are not always abnormal in children with such injuries. Clinical and radiographic correlation, with computer tomography or magnetic resonance imaging if needed, are called for to maximize diagnosis.
Question 1343
Topic: Thoracolumbar Spine & Deformity
Emery-Dreifuss muscular dystrophy is unique among the dystrophies because of the development of which deformity:
Correct Answer & Explanation
. Neck extension contracture
Explanation
Emery-Dreifuss muscular dystrophy is an x-linked disorder of emerin, which is a cell-membrane protein. Symptoms and signs develop within the first decade in most cases. A unique deformity, neck extension contracture, develops, in addition to elbow flexion contractures and peroneal wasting. The other deformities listed above are common in many dystrophies.
Question 1344
Topic: 6. Spine
Which of the following is found less often in children with lumbosacral agenesis as compared to controls:
Correct Answer & Explanation
. Genu recurvatum
Explanation
Patients with lumbosacral agenesis often have knee flexion contractures as compared with controls. All of the other features listed are common in patients with lumbosacral agenesis.
Question 1345
Topic: Thoracolumbar Spine & Deformity
Which of the following figures most closely approximates the prevalence of defects in the L5 pars interarticularis in a newborn:
Correct Answer & Explanation
. 5%
Explanation
Pars interarticularis defects are not found in newborns, whereas the incidence is 5% in patients who are in the first grade. It remains close to this figure throughout later life.
Question 1346
Topic: 6. Spine
A 65-year-old man with progressive cervical spondylotic myelopathy presents with difficulty buttoning his shirts and a wide-based gait. Examination reveals hyperreflexia. Which of the following physical exam findings is most specific for cervical myelopathy at the C5-C6 level?
Correct Answer & Explanation
. Inverted radial reflex
Explanation
The inverted radial reflex (finger flexion upon tapping the brachioradialis tendon) is a highly specific sign of cervical spondylotic myelopathy at C5-C6. It indicates a lower motor neuron lesion at C5 and an upper motor neuron lesion below that level.
Question 1347
Topic: 6. Spine
A 45-year-old man is involved in a motor vehicle accident. CT scan shows a bilateral fracture of the C2 pars interarticularis with 2 mm of displacement and no angulation. Neurological examination is normal. What is the most appropriate management?
Correct Answer & Explanation
. Rigid cervical collar
Explanation
A Levine-Edwards Type I Hangman's fracture involves bilateral pars interarticularis fractures with less than 3 mm of displacement and no angulation. It is a stable injury that is appropriately managed non-operatively with a rigid cervical collar.
Question 1348
Topic: Thoracolumbar Spine & Deformity
A 15-year-old male presents with persistent low back pain due to a grade II L5-S1 isthmic spondylolisthesis. Conservative management with physical therapy and bracing has failed over the past 6 months. What is the most appropriate surgical treatment?
Correct Answer & Explanation
. L5-S1 posterior in situ posterolateral fusion
Explanation
Posterior in situ posterolateral fusion is the gold standard for symptomatic, low-grade (Grade 1 and 2) isthmic spondylolisthesis that fails conservative care. Pars repair is typically reserved for younger patients with a pars defect but no significant slip (Grade 0).
Question 1349
Topic: 6. Spine
A 5-year-old girl comes into the clinic with back pain. Her family has just moved to the United States from southeastern Asia. A lateral radiograph shows destruction of T11, T12, and L1. Magnetic resonance imaging shows a moderate posterior soft tissue mass. A neurological exam is normal. Biopsy confirms tuberculosis. For the girl's spinal problem, recommended treatment includes:
Correct Answer & Explanation
. Anterior debridement, strut graft, and posterior fusion with instrumentation
Explanation
Anterior debridement, strut graft, and posterior fusion with instrumentation provide the patient with the best chance of a positive result. This procedure minimizes graft dislodgement and posterior overgrowth. A two-drug therapy alone for at least 6 months leaves the patient at a significant risk of progressive kyphosis and neurologic deficit. A two-drug therapy for at least 6 months along with a body cast also leaves the patient with significant risk of progressive kyphosis and neurologic deficit. The lack of anterior support from a two-drug therapy and posterior spinal fusion to prevent deformity leaves the patient with significant risk of kyphosis. Even with an anterior spinal debridement and a rib strut graft, there is a risk of graft dislodgment over this large defect and of posterior growth into kyphosis.
Question 1350
Topic: Thoracolumbar Spine & Deformity
Scoliosis in Marfan syndrome is characterized by which of the following:
Correct Answer & Explanation
. Scoliosis curves are more likely to begin in the juvenile period.
Explanation
Scoliosis curves are much more likely to begin in the juvenile period than idiopathic scoliosis. There is no significant difference in the likelihood of left thoracic curves in Marfan syndrome. Brace treatment is less likely to be successful in Marfan syndrome than in idiopathic scoliosis. Marfan patients with scoliosis are more likely to have back pain. Marfan curves are more likely to progress in adulthood.
Question 1351
Topic: 6. Spine
A 16-year-old boy with type I Ehlers-Danlos syndrome has a spinal curvature that has progressed 18° in the past year. The curve is a double major type with a C obb angle of 60° in each curve. There is no associated kyphosis. The following treatment is recommend:
Correct Answer & Explanation
. Posterior fusion and instrumentation
Explanation
Posterior fusion and instrumentation is the best-documented treatment. Although this form of treatment is followed by an increased incidence of wound healing problems, the problems can be treated. Observation is not recommended because the curve is highly likely to increase and cause a decrease in pulmonary function. Bracing has no role in large curves, and it is not known if bracing is successful in Ehlers-Danlos syndrome. Anterior fusion with instrumentation would be difficult with a double curve. Anterior fusion carries an increased risk due to vascular fragility. It is not necessary because there is no increased risk of crankshaft or pseudarthrosis. There is no particular reason for adding an anterior procedure in this situation in view of the vascular risk.
Question 1352
Topic: Thoracolumbar Spine & Deformity
Scoliosis in osteogenesis imperfecta is characterized by which of the following:
Correct Answer & Explanation
. Scoliosis is due primarily to ligamentous laxity.
Explanation
Scoliosis in osteogenesis imperfecta (OI) is due primarily to ligamentous laxity. Scoliosis in OI is due primarily to ligamentous laxity, not bony fractures. There is no association between brainstem impression and scoliosis. Scoliosis in OI rarely responds to brace treatment. Scoliosis, when present in OI, is a major impairment of quality of life.
Question 1353
Topic: 6. Spine
The spine in familial dysautonomia is characterized by which of the following:
Correct Answer & Explanation
. Increased risk of loss of fixation after surgery
Explanation
There is an increased risk of loss of fixation in familial dysautonomia curves due to decreased bone density and curve rigidity. Scoliosis is common in patients with familial dysautonomia and affects up to one-half of patients with the disorder. The curves in familial dysautonomia are rigid, leading to limited correction. The bone density in familial dysautonomia is decreased. Spinal stenosis is not reported in patients with familial dysautonomia.
Question 1354
Topic: 6. Spine
Which of the following spinal problems is most common in achondroplasia:
Correct Answer & Explanation
. Thoracolumbar stenosis
Explanation
Symptomatic stenosis of the thoracic and lumbar spine is seen in almost half of all achondroplastic patients, although not all patients require surgery. Atlantoaxial instability is rare in achondroplasia, although it is not uncommon in other dysplasias. Basilar invagination is not present in achondroplasia. Kyphosis is often transient in achondroplasia and rarely persists beyond the second year. Kyphosis is rarely symptomatic. Spondylolisthesis is rare in achondroplasia.
Question 1355
Topic: 6. Spine
A 2-year-old girl with diastrophic dysplasia is brought into the office for an overall examination. A lateral radiograph of the spine shows a kyphosis of 35° from C 3 to C 6. A neurologic exam is normal, although she does have stiff joints. The patient is not yet walking. For management of this kyphosis, recommended treatment includes:
Correct Answer & Explanation
. Observation
Explanation
Many diastrophic cervical kyphoses will correct spontaneously if the curve does not exceed 50°. In this patient, the lack of walking is most likely due to other skeletal factors. There is no evidence that orthosis will change the natural history of the disorder. There is no need for traction given the high chance of spontaneous resolution and the dangers of traction. Posterior fusion is only indicated if the kyphosis is continually progressive, or if neurologic signs or symptoms develop. Anterior and posterior surgery is only indicated in cases with severe pre- existing neurologic deficit.
Question 1356
Topic: 6. Spine
A baby born with diastrophic dysplasia today may eventually require all of the following orthopedic procedures during childhood or adulthood except:
Correct Answer & Explanation
. C orrection of equinus or varus feet
Explanation
Patients with diastrophic dysplasia rarely have instability of the upper cervical spine. Babies with diastrophic dysplasia often have rigid equinovarus feet that require surgery to become plantigrade and wear normal shoes. A number of patients with diastrophic dysplasia develop progressive scoliosis that requires surgical treatment. Degenerative disease of the hips is common and often requires arthroplasty in early adulthood. Degenerative disease of the knees is common and often requires arthroplasty in early adulthood.
Question 1357
Topic: 6. Spine
A patient with spondyloepiphyseal dysplasia congenita reaches the age of 5 without being able to walk with a walker. She has five beats of clonus in both ankles. Her reflexes are brisk and her toes are upgoing. The most likely problem that accounts for these findings is:
Correct Answer & Explanation
. Atlantoaxial instability
Explanation
Atlantoaxial instability, sometimes combined with stenosis of the atlas, is a frequent cause of myelopathy in spondyloepiphyseal dysplasia congenita. Scoliosis does not account for developmental delay or myelopathy. Foramen magnum stenosis is rare in spondyloepiphyseal dysplasia congenita. Lumbar stenosis is rare with spondyloepiphyseal dysplasia congenita and would not account for myelopathy. Thoracolumbar kyphosis severe enough to cause myelopathy is rare in spondyloepiphyseal dysplasia congenita condition.
Question 1358
Topic: 6. Spine
Scoliosis in cleidocranial dysplasia is frequently associated with which of the following conditions:
Correct Answer & Explanation
. Syringomyelia
Explanation
Scoliosis with cleidocranial dysplasia (C C D) is frequently associated with syringomyelia. Cervical instability is rare in C C D. Spondylolisthesis is rare in C C D. Spinal stenosis is rare in C C D. Spinal decompensation is rare in C C D.
Question 1359
Topic: 6. Spine
A 3-year-old girl with Larsen syndrome is brought into the office for examination. A spinal radiograph demonstrates a 50° kyphosis of the cervical spine. Her neurologic examination is normal. Recommended treatment includes:
Correct Answer & Explanation
. Posterior cervical fusion
Explanation
Posterior cervical fusion has been proven effective in curves of 60° or less in Larsen syndrome, in preventing progression, and allowing correction with anterior growth. This curve is much more likely to worsen than to spontaneously improve, so preventive surgery is indicated. There is no role for halo traction in this situation. Bracing has not been proven effective in helping patients with Larsen syndrome. Addition of anterior fusion is not needed for this degree of curve in a neurologically normal child.
Question 1360
Topic: 6. Spine
A 10-year-old patient with Hurler syndrome has undergone a bone marrow transplant and is currently medically stable. He has developed a painful thoracolumbar kyphosis that measures 50° with 25% subluxation T12 on L1. Recommended treatment includes which of the following:
Correct Answer & Explanation
. Anterior and posterior spinal fusion
Explanation
Anterior and posterior fusion will correct the translation, instability, and ensure a solid fusion. In some cases, posterior fusion alone will suffice if pedicle fixation is good. Exercises will not correct the subluxation, which is the cause of the pain. A thoracolumbar orthosis is not corrective or well tolerated. There is no need for halo traction. Anterior fusion alone is not enough to control this focal instability if the patient is well enough to tolerate a more involved procedure.
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