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6. Spine MCQs

Practice Set 69 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 1361

Topic: 6. Spine

Aneurysmal bone cyst of the spine is most common in which of the following regions:

. C ervical
. Upper thoracic
. Lower thoracic
. Lumbar
. Sacral

Correct Answer & Explanation

. Lumbar

Explanation

Aneurysmal bone cyst of the spine is most common in the lumbar spine, followed by the cervical spine. Aneurysmal bone cyst most commonly involves the anterior elements but later may expand into the posterior elements.

Question 1362

Topic: 6. Spine

A posterior spine fusion with segmental hook fixation from T4-L4 is performed for idiopathic scoliosis in a 15-year-old girl. Somatosensory evoked potential monitoring is normal throughout the procedure. The patient awakens and is unable to move either lower extremity, but she does have some sensation in the lower extremities. Recommended treatment includes:

. Removal of instrumentation
. Myelogram
. Laminectomy above the conus medullaris
. Administration of corticosteroids and observation for 6 hours
. Full heparinization of the patient

Correct Answer & Explanation

. Removal of instrumentation

Explanation

Spinal cord injury occurs in approximately 0.1% of patients operated upon for idiopathic scoliosis. In some cases, sensory spinal cord monitoring may be unchanged, especially if the injury preserves the dorsal columns. The instrumentation should be removed as soon as possible in case spinal traction or derotation or implant protrusion is producing effects on the cord or its blood supply. Corticosteroids should be administered at spinal cord injury doses, but this should not be the only measure. Obtaining a myelogram may delay the removal of instrumentation and should not be the first step. Heparinization has no proven effect.

Question 1363

Topic: 6. Spine
A 12-year-old boy with achondroplasia has a gradual 40° thoracolumbar kyphosis. He is unable to walk more than two blocks. MRI reveals spinal stenosis, and the patient is scheduled to undergo posterior decompression from T12-S1. In addition to this procedure, you recommend:
. Observation with serial radiographs every 4 months
. Postoperative brace for 6 months
. In situ fusion with bone graft
. Posterior fusion across the kyphosis with instrumentation
. Anterior corpectomy and fusion of T12

Correct Answer & Explanation

. Posterior fusion across the kyphosis with instrumentation

Explanation

Extensive posterior decompression poses a high risk of postoperative increase in kyphosis because of both the patient's age and pre-existing kyphosis. Observation would not be a good idea because the risk is already known to be high. Neither a brace nor an uninstrumented fusion would prevent the deformity from developing. Corpectomy is not indicated because the kyphosis is not focal. Posterior instrumented fusion at the time of decompression is indicated.

Question 1364

Topic: Thoracolumbar Spine & Deformity
Which of the following is true regarding brace treatment for Scheuermann kyphosis?
. The Milwaukee brace is not indicated.
. Permanent correction is usually obtainable.
. Bracing is effective in curves over 75°.
. Bracing is ineffective in curves having an apex at or above T8.
. The brace should be worn for 1 year after starting brace treatment.

Correct Answer & Explanation

. Permanent correction is usually obtainable.

Explanation

Brace treatment is effective for Scheuermann kyphosis. Unlike idiopathic scoliosis, permanent correction of the deformity is the goal. The Milwaukee brace is often indicated. Brace treatment is ineffective for curves over 74°. The brace should be worn until skeletal maturity.

Question 1365

Topic: 6. Spine

A magnetic resonance image of a 7-year-old girl shows a line of high-signal intensity within the cord on T2 sequences that parallels the ventral surface of the cord and appears as a syrinx. However, on the axial images and on the T1 sequences, this finding is not evident. The most likely diagnosis is:

. C ollapsing syrinx
. Gibbs artifact
. Motion artifact
. Ependymoma
. Astrocytoma

Correct Answer & Explanation

. Gibbs artifact

Explanation

A Gibbs artifact is a linear focus in the cord on T2-weighted images that parallels the ventral aspect of the cord and mimics a syrinx. The Gibbs artifact is due to the linear interface between two tissues of differing signal intensity. It is not seen on axial images or T1-weighted images. Motion artifact is a blurring of the image due to patient motion, respiration, or cerebral spinal fluid pulsation. Ependymoma and astrocytoma are seen on both the axial and the sagittal images.

Question 1366

Topic: 6. Spine

The conus medullaris is always termed abnormal if it terminates below this level:

. L1
. L1-2 disk
. L2
. L2-3 disk
. L3

Correct Answer & Explanation

. L3

Explanation

The vertebral bodies grow faster than the spinal cord. A more caudal placement of the conus medullaris is considered normal in an older patient. However, a conus medullaris below L3 at any age is abnormal and may represent a tethered and/or dysplastic cord.

Question 1367

Topic: 6. Spine

A 65-year-old male with progressive hand clumsiness and gait instability is diagnosed with cervical spondylotic myelopathy. Magnetic resonance imaging (MRI) of the cervical spine reveals severe cord compression at C4-C5. Which of the following MRI findings correlates most strongly with a poor potential for neurological recovery postoperatively?

. T2-weighted hyperintensity within the cord
. T1-weighted hypointensity within the cord
. Loss of normal cervical lordosis
. Multi-level disc osteophyte complexes
. Ligamentum flavum hypertrophy

Correct Answer & Explanation

. T1-weighted hypointensity within the cord

Explanation

T1-weighted hypointensity in the spinal cord indicates myelomalacia and irreversible cord necrosis, serving as a strong predictor of poor postoperative clinical recovery. While T2 hyperintensity shows edema, T1 hypointensity confirms permanent damage.

Question 1368

Topic: 6. Spine

A 68-year-old male presents with bilateral buttock and calf pain that worsens after walking two blocks. Which of the following clinical features is most useful in differentiating neurogenic claudication secondary to lumbar spinal stenosis from vascular claudication?

. Pain is relieved by standing upright and remaining completely still
. Pain is exacerbated by walking uphill
. Pain is rapidly relieved by sitting or lumbar flexion
. Peripheral pulses are symmetrically absent
. Symptoms begin immediately upon standing from a seated position

Correct Answer & Explanation

. Pain is rapidly relieved by sitting or lumbar flexion

Explanation

Neurogenic claudication is characteristically relieved by lumbar flexion (such as sitting or leaning on a shopping cart), which increases the cross-sectional area of the spinal canal. Vascular claudication is typically relieved simply by resting, regardless of spinal posture.

Question 1369

Topic: 6. Spine

A 68-year-old man complains of bilateral leg pain when walking. Which of the following clinical findings best differentiates neurogenic claudication (due to lumbar spinal stenosis) from vascular claudication?

. Relief of pain with standing stationary
. Absent distal pulses
. Pain relief when walking uphill compared to downhill
. Cramping pain in the calves alone
. Skin trophic changes

Correct Answer & Explanation

. Pain relief when walking uphill compared to downhill

Explanation

Walking uphill places the lumbar spine in slight flexion, which increases the spinal canal cross-sectional area and relieves symptoms of neurogenic claudication. Conversely, walking downhill extends the spine, exacerbating neurogenic symptoms.

Question 1370

Topic: Cervical Spine
A 30-year-old male is involved in a motor vehicle accident and sustains a Levine-Edwards Type II traumatic spondylolisthesis of the axis (Hangman's fracture). The mechanism of injury typically involves hyperextension followed by axial loading and flexion. What is the most appropriate definitive management for this specific injury pattern?
. Rigid cervical collar for 6 weeks
. Halo vest immobilization
. Anterior cervical discectomy and fusion (ACDF) of C2-C3
. Posterior C1-C2 transarticular screw fixation
. Observation and conservative care

Correct Answer & Explanation

. Halo vest immobilization

Explanation

A Levine-Edwards Type II Hangman's fracture involves significant translation and angulation but is primarily treated with non-operative management using Halo vest immobilization. Operative management is typically reserved for Type IIa (with severe angulation requiring compression) or Type III (with bilateral facet dislocations).

Question 1371

Topic: 6. Spine

Which of the following problems is most common in achondroplasia:

. Atlantoaxial instability
. Basilar invagination
. Symptomatic kyphosis
. Thoracolumbar stenosis
. Spondylolisthesis

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 1372

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 conditions is:

. Severe scoliosis of the thoracic spine
. Foramen magnum stenosis
. Lumbar stenosis
. Thoracolumbar kyphosis
. Atlantoaxial instability

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 1373

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:

. Exercise program for the trunk extensor muscles
. Thoracolumbar orthosis
. Halo traction followed by orthosis
. Posterior spinal fusion
. Anterior and posterior spinal fusion

Correct Answer & Explanation

. Anterior and posterior spinal fusion

Explanation

Anterior and posterior fusion will correct the translation, instability, and ensure a solid fusion. 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. Posterior fusion alone is not enough to control this focal instability if the patient is well enough to tolerate a more involved procedure.

Question 1374

Topic: 6. Spine

A 14-year-old girl is examined because of a pain in her left flank. The radiographs of the lumbar spine show loss of the pedicle with expansion of the lateral wall of the third lumbar vertebral body. Magnetic resonance imaging shows multiple fluid levels in the vertebral body with no additional areas of involvement. She is neurologically normal. The least invasive, effective treatment is which?

. Observation
. Radiation therapy
. Selective arterial embolization
. Radical en bloc resection
. C urettage plus radiation therapy

Correct Answer & Explanation

. Selective arterial embolization

Explanation

This patient has an aneurysmal bone cyst of the vertebra. Selective arterial embolization is a minimally invasive treatment that often succeeds in arresting the lesions. Many times it is the only treatment needed. Selective arterial embolization can also be used as part of a strategy to be followed by curettage and reconstruction to decrease operative bleeding. This lesion will continue to expand and might cause neurologic compromise or mechanical instability. Radiation therapy poses risks of later malignant degeneration. There are other ways of treating this lesion. Radical en bloc resection may unnecessarily injure neurologic structures. While curettage is often necessary, there is no reason to introduce the risk of radiation therapy.

Question 1375

Topic: Thoracolumbar Spine & Deformity
Which of the following is true regarding brace treatment for Scheuermann kyphosis?
. The Milwaukee brace is not indicated.
. Permanent improvement is usually obtainable if compliant.
. Bracing is effective in curves over 75°.
. Bracing is ineffective in curves having an apex at or above T8.
. The brace should be worn for 1 year after starting brace treatment.

Correct Answer & Explanation

. Permanent improvement is usually obtainable if compliant.

Explanation

Brace treatment is effective for Scheuermann kyphosis. Unlike idiopathic scoliosis, permanent improvement of the deformity is the goal. The Milwaukee brace is often indicated. Brace treatment is ineffective for curves over 74°. The brace should be worn until skeletal maturity.

Question 1376

Topic: Thoracolumbar Spine & Deformity

Which of the following statements is true regarding scoliosis in cerebral palsy (C P):

. Scoliosis is most common in hemiplegic C P because of muscle imbalance.
. A thoracolumbosacral orthosis is usually successful in halting curve progression.
. Scoliotic curves over 50° are likely to worsen even if the children are mature.
. Surgery for scoliosis will prolong life expectancy.
. The surgical complication rate is lower in C P than idiopathic scoliosis.

Correct Answer & Explanation

. Scoliotic curves over 50° are likely to worsen even if the children are mature.

Explanation

Curves greater than 50° usually progress. Scoliosis is most common in totally involved C P patients. Scoliosis is rare in patients with hemiplegia. Braces rarely halt curves in CP. Surgery has no proven effect on prolonging life expectancy. The complication rate is higher in CP.

Question 1377

Topic: 6. Spine

A 12-year-old girl is referred because of a positive school scoliosis screen. She has a curve of 16° from T5 to T12, convex to the right. She incidentally also complains of mild back pain over the region of the curve several times per month. Neurologic examination is normal. Recommended treatment includes:

. Magnetic resonance imaging
. Technetium bone scintigraphy with SPEC T
. Treatment with a thoracolumbosacral orthosis
. Computed tomography of the thoracic spine
. Home exercises and re-examination in follow-up

Correct Answer & Explanation

. Home exercises and re-examination in follow-up

Explanation

Home exercises and re-examination in follow-up is the most appropriate treatment in view of lack of any worrisome features. If this child had severe pain or significant night pain, then further imaging studies would be warranted. The magnetic resonance imaging is not indicated in this situation. The bone scan has a low likelihood of being positive. Bracing is not indicated for the curve or the pain. Computer tomography is unlikely to demonstrate any pathology.

Question 1378

Topic: 6. Spine

A 10-year-old boy undergoes biopsy of a spinal cord tumor through a laminectomy of C7-T2. The most likely complication of this procedure is:

. Progressive cervicothoracic kyphosis
. Progressive cervicothoracic lordosis
. Progressive scoliosis
. Degenerative disk disease
. Progressive C 7 radiculopathy

Correct Answer & Explanation

. Progressive cervicothoracic kyphosis

Explanation

The removal of posterior restraints in the young and growing flexible spine usually leads to cervicothoracic kyphosis.

Question 1379

Topic: Thoracolumbar Spine & Deformity

A patient with neurofibromatosis and a 55° scoliosis may be treated with a posterior fusion and instrumentation alone in which of the following situations:

. He has a kyphosis of 75°.
. He is also undergoing multilevel laminectomy for tumor.
. He has a prior pseudarthrosis.
. He has a kyphosis of 35°.
. He has a bone age of 9.

Correct Answer & Explanation

. He has a kyphosis of 35°.

Explanation

He has a kyphosis of 35°. This degree of kyphosis increases the risk of pseudarthrosis with posterior fusion alone. The laminectomy increases the risk of pseudarthrosis. Anterior fusion should be added when there is a history of pseudarthrosis. A 9-year-old boy has a high risk of crankshift phenomenon with posterior fusion alone.

Question 1380

Topic: Thoracolumbar Spine & Deformity

Which of the following statements is true regarding school screening for scoliosis:

. The American Academy of Orthopaedic Surgeons (AAOS) no longer recommends it.
. The AAOS recommends screening each year.
. The AAOS recommends screening boys and girls at age 9.
. The AAOS recommends screening boys and girls at age 11.
. The AAOS recommends screening only boys at age 16.

Correct Answer & Explanation

. The AAOS recommends screening boys and girls at age 11.

Explanation

All children should be screened at age 11. The AAOS still recommends school screening for scoliosis. The AAOS recognizes that yearly screening is counterproductive. Screening at age 9 is too early.. Screening at age 16 is too late.

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