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6. Spine MCQs

Practice Set 71 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 1401

Topic: Thoracolumbar Spine & Deformity

A 16-year-old gymnast presents with severe mechanical back pain. Radiographs show a grade II isthmic spondylolisthesis at L5-S1. Non-operative management has failed after 6 months. What is the most appropriate surgical treatment?

. L5-S1 anterior lumbar interbody fusion only
. L5 laminectomy without fusion
. L5-S1 posterior lateral fusion with instrumentation
. In situ fusion of L4-L5
. Pars repair using a lag screw

Correct Answer & Explanation

. L5-S1 posterior lateral fusion with instrumentation

Explanation

For a symptomatic grade II isthmic spondylolisthesis failing conservative care, an L5-S1 posterolateral fusion with pedicle screw instrumentation is the standard procedure. Direct pars repair is generally reserved for younger patients with pars defects but no significant slip (Grade 0 or very mild Grade I).

Question 1402

Topic: Cervical Spine

During an anterior cervical discectomy and fusion (ACDF) at C5-C6 using a left-sided approach, a retractor is placed medially to protect the visceral structures. Which nerve is most at risk of neuropraxia due to prolonged retractor compression?

. Vagus nerve
. Hypoglossal nerve
. Recurrent laryngeal nerve
. Superior laryngeal nerve
. Phrenic nerve

Correct Answer & Explanation

. Recurrent laryngeal nerve

Explanation

The recurrent laryngeal nerve courses in the tracheoesophageal groove and is highly vulnerable to stretch or compression from prolonged medial retractor placement during an anterior cervical approach, which can result in postoperative hoarseness.

Question 1403

Topic: 6. Spine

A 65-year-old male complains of bilateral hand clumsiness, difficulty buttoning his shirt, and a wide-based gait. Examination shows hyperreflexia in the lower extremities and a positive Hoffmann's sign. He can ambulate but requires the use of a single cane. What is his Nurick classification grade?

. Grade 1
. Grade 2
. Grade 3
. Grade 4
. Grade 5

Correct Answer & Explanation

. Grade 3

Explanation

The Nurick classification evaluates the ambulatory status of patients with cervical spondylotic myelopathy. Grade 3 corresponds to difficulty walking that requires assistance or a cane, while the patient is not yet wheelchair-bound or bedridden.

Question 1404

Topic: 6. Spine

A 30-year-old man is involved in a motor vehicle accident. Cervical spine CT reveals a fracture through the pars interarticularis of C2 bilaterally. Flexion-extension radiographs show severe angulation with minimal translation, and the angulation increases upon application of traction. What is the recommended treatment for this specific fracture pattern?

. Standard cervical traction with 15 lbs of weight
. Application of halo vest with initial slight compression and extension
. Rigid cervical collar for 12 weeks
. Application of halo vest in slight flexion
. Immediate posterior C1-C2 fusion

Correct Answer & Explanation

. Application of halo vest with initial slight compression and extension

Explanation

A Levine-Edwards Type IIa Hangman's fracture is characterized by severe angulation with minimal translation and is caused by flexion-distraction. Traction is contraindicated as it exacerbates the deformity; treatment requires gentle reduction with slight compression and extension followed by halo vest immobilization.

Question 1405

Topic: 6. Spine

Which of the following statements is true regarding ankylosing spondylitis:

. Radiographic changes present early.
. Characteristic features make it easy to diagnose.
. It is a common inflammatory disorder affecting children < 8 years of age.
. It is an inflammation of ligament insertions associated with HLA-B27.
. Long-term prognosis is poor.

Correct Answer & Explanation

. It is an inflammation of ligament insertions associated with HLA-B27.

Explanation

Ankylosing spondylitis is an inflammatory enthesopathy that rarely affects children. Diagnosis is often difficult because the features may be similar to pauciarticular juvenile rheumatoid arthritis. It typically affects males >8 years of age. It is associated with haplotype HLA-B27. The long-term prognosis in these children is generally good.

Question 1406

Topic: 6. Spine

A previously healthy 3-year-old girl presents with 3 weeks of painful torticollis and facial asymmetry. A birth history reveals a normal vaginal delivery with no perinatal complications. The girl has no history of esophagitis or gastrointestinal problems. Her mother reports that approximately 1 month ago, the young girl had an upper respiratory tract infection that has since resolved. The most likely diagnosis is:

. Muscular torticollis
. Os odontoideum
. Grisel syndrome
. Sandifer syndrome
. Pseudosubluxation of C 2 on C 3

Correct Answer & Explanation

. Grisel syndrome

Explanation

Grisel syndrome is an abnormal rotation of the atlantoaxial joint that produces painful torticollis and often follows an upper respiratory tract infection. Muscular torticollis is unlikely in this patient because this condition is usually attributed to a difficult delivery, breech presentation, or some type of in utero positioning problem. Furthermore, muscular torticollis usually presents itself within the first 4-6 weeks and has no association with respiratory infections. Symptoms associated with os odontoideum consist of neck pain, paresthesia, transient paresis, or myelopathy. Patients with os odontoideum do not have torticollis. Sandifer syndrome is a painful torticollis and the abnormal trunk rotation is associated with gastroesophageal reflux disease. Pseudosubluxation does not produce painful torticollis.

Question 1407

Topic: Cervical Spine

A computerized tomography (C T) scan of the neck reveals an atlantoaxial rotatory displacement with 6 mm of anterior translation. The most likely associated anatomic defect is:

. Disruption of both the transverse ligament of C 1 and the alar ligaments
. Odontoid fracture
. Disruption of the anterior and posterior longitudinal ligaments
. Disruption of the ligamentum flavum between C 1 and C 2
. Ossiculum terminale

Correct Answer & Explanation

. Disruption of both the transverse ligament of C 1 and the alar ligaments

Explanation

In order to have anterior displacement of C 1 on C 2 >5 mm, there must be disruption of both the transverse ligament of C 1 and the alar ligaments. Odontoid fracture does not disrupt the articulation between the dens and the atlas, therefore, there would be no abnormal diastasis between the atlas and the dens. The anterior and posterior longitudinal ligaments attach to the anterior and posterior aspects of the vertebral bodies respectively. Insufficiency does not affect the atlantoaxial articulation. Disruption of the ligamentum flavum alone is not thought to result in translation of C 1 on C 2. An ossiculum terminale is a persistent growth center at the tip of the odontoid, but is not indicative of any pathological condition.

Question 1408

Topic: 6. Spine

A 15-year-old basketball player has mild scoliosis, pes planus, pectus carinatum, and long slender fingers. In order to help determine if he has Marfan syndrome and should be allowed to continue playing basketball, it is most useful to order a:

. C ardiac echo
. Magnetic resonance image of the lumbosacral spine
. Slit lamp examination
. C hest radiograph
. Dermal fibroblast assay

Correct Answer & Explanation

. C ardiac echo

Explanation

A cardiac echo will give information about enlargement of the ascending aorta, as well as the valves. This is the most important information for activity recommendations and patient prognosis. A magnetic resonance image (MRI) of the lumbosacral spine will either rule in or out dural ectasia, but a MRI has no clinical importance for activity recommendations. A slit lamp examination is not as important as a cardiac echo in making sport recommendations. A chest radiograph may be helpful, if the patient is suspected of having a pneumothorax. A dermal fibroblast assay is useful in assessing collagen, such as in osteogenesis imperfecta, but it is not helpful in diagnosing Marfan syndrome.

Question 1409

Topic: Thoracolumbar Spine & Deformity

The following skeletal feature helps to establish a diagnostic level of major skeletal involvement in Marfan syndrome:

. Hyperextensible knees
. Atlantoaxial subluxation
. Standing height over 2 m
. Increased thoracic kyphosis
. Pectus carinatum

Correct Answer & Explanation

. Pectus carinatum

Explanation

Pectus carinatum has a high diagnostic value for Marfan syndrome. Hyperextension of the knees is not common in patients with Marfan syndrome. This skeletal feature is seen in many other conditions; therefore, it has low diagnostic specificity. Atlantoaxial subluxation is rare in Marfan syndrome, but is common in some of the skeletal dysplasias. Although patients with Marfan syndrome are generally tall, height is too nonspecific to be a helpful diagnostic criterion. Kyphosis is not a skeletal diagnostic criterion.

Question 1410

Topic: 6. Spine
A 12-year-old girl has a scoliosis of 36° from T2-T7 and 15° from T7-L1. She is premenarchal. The following treatment is recommended:
. Charleston bending brace
. Boston overlap brace
. Milwaukee brace
. Lateral electrical spinal stimulation
. Posterior spinal fusion

Correct Answer & Explanation

. Milwaukee brace

Explanation

The Milwaukee brace offers the best chance of controlling this curve. Charleston bending braces are not effective for curves larger than 35°. Boston overlap braces are not effective for curves with an apex above T8. Lateral electrical spinal stimulation has been proven ineffective for scoliosis. This curve is not large enough to pose a recommend fusion.

Question 1411

Topic: Thoracolumbar Spine & Deformity

All of these findings are features of patients with Scheuermann kyphosis, except:

. Vertebral wedging
. Endplate irregularity
. Schmorl nodes
. Truncal obesity
. Back pain

Correct Answer & Explanation

. Truncal obesity

Explanation

Obesity is not any more common in patients with Scheuermann kyphosis than in the general population. Vertebral wedging is a common feature of Scheuermann kyphosis. Endplate irregularity is a common feature of Scheuermann kyphosis. Schmorl nodes are a manifestation of the disordered behavior of the vertebral endplates under load. Back pain is common in Scheuermann kyphosis.

Question 1412

Topic: 6. Spine
An 18-year-old man is seen in the office because of back pain in the thoracic region. He has a kyphosis of 65°, a slight wedging in the midthoracic spine, and a Risser sign of 4. Recommended treatment includes:
. A program of strengthening and stretching exercises
. A Milwaukee brace
. A Boston brace
. A posterior spinal fusion
. An anterior and posterior spinal fusion

Correct Answer & Explanation

. A program of strengthening and stretching exercises

Explanation

Exercises must be the first treatment for this patient because he is too mature for brace treatment. Brace treatment is not indicated for someone of this skeletal maturity. Surgery is not indicated unless the patient fails conservative treatment.

Question 1413

Topic: 6. Spine

A 55-year-old male presents with bilateral hand clumsiness and a broad-based gait. MRI demonstrates severe cervical canal stenosis. Which of the following physical exam findings is an upper motor neuron sign highly indicative of cervical myelopathy?

. Decreased grip strength with thenar atrophy
. Absent biceps reflex
. Inverted radial reflex
. Fasciculations in the deltoid
. Positive Tinel's sign at the wrist

Correct Answer & Explanation

. Inverted radial reflex

Explanation

The inverted radial (or supinator) reflex is a classic upper motor neuron sign of cervical myelopathy. It occurs when striking the brachioradialis tendon produces paradoxical finger flexion due to loss of upper motor neuron inhibition.

Question 1414

Topic: 6. Spine

Which of the following historical features most reliably distinguishes neurogenic claudication (due to lumbar spinal stenosis) from vascular claudication?

. Pain is rapidly relieved by standing still
. Pain is consistently worsened by stationary cycling
. Pain is relieved by lumbar flexion such as sitting or leaning forward on a shopping cart
. Pain is characterized by completely absent distal pulses
. Pain classically progresses from the toes proximally to the buttocks

Correct Answer & Explanation

. Pain is relieved by lumbar flexion such as sitting or leaning forward on a shopping cart

Explanation

Neurogenic claudication is classically relieved by lumbar flexion (e.g., the 'shopping cart sign'), which increases the cross-sectional area of the spinal canal. Vascular claudication is typically relieved simply by resting or standing still.

Question 1415

Topic: 6. Spine

Which of the following clinical findings most reliably indicates the end of spinal shock?

. Return of the bulbocavernosus reflex
. Normalization of blood pressure
. Return of deep tendon reflexes in the lower extremities
. Improvement of bradycardia
. Recovery of voluntary sphincter tone

Correct Answer & Explanation

. Return of the bulbocavernosus reflex

Explanation

Spinal shock is a temporary state of flaccid paralysis and areflexia following spinal cord injury. The return of the bulbocavernosus reflex marks the end of spinal shock, allowing accurate determination of the neurologic deficit.

Question 1416

Topic: 6. Spine

A 14-year-old boy presents with scoliosis, pectus excavatum, and a highly arched palate. He is diagnosed with a condition caused by a defect in fibrillin-1. Which of the following cardiovascular anomalies is the leading cause of mortality in this patient population?

. Mitral valve prolapse
. Aortic root dilation
. Ventricular septal defect
. Atrial septal defect
. Pulmonary stenosis

Correct Answer & Explanation

. Aortic root dilation

Explanation

Marfan syndrome is an autosomal dominant connective tissue disorder caused by a mutation in the FBN1 gene affecting fibrillin-1. Aortic root dilation and subsequent dissection is the leading cause of morbidity and mortality in these patients.

Question 1417

Topic: 6. Spine

Morquio syndrome (Mucopolysaccharidosis type IV) is an autosomal recessive disorder characterized by severe skeletal dysplasias. Which of the following cervical spine abnormalities is a hallmark of this condition and requires careful evaluation before any surgical procedure?

. Atlantoaxial instability due to odontoid hypoplasia
. Basilar invagination
. Congenital fusion of C2-C3
. Absent anterior arch of C1
. Cervical kyphosis due to absent facet joints

Correct Answer & Explanation

. Atlantoaxial instability due to odontoid hypoplasia

Explanation

Morquio syndrome typically presents with odontoid hypoplasia leading to severe atlantoaxial instability. Prophylactic cervical spinal fusion is often required early in childhood to prevent fatal spinal cord compression.

Question 1418

Topic: Thoracolumbar Spine & Deformity
A 7-year-old boy with a history of multiple café-au-lait spots and axillary freckling presents with a rapidly progressive spinal deformity. Anteroposterior and lateral radiographs demonstrate a short-segment, sharply angulated thoracic curve. Which of the following is the most likely diagnosis?
. Idiopathic scoliosis
. Congenital scoliosis
. Dystrophic neurofibromatosis scoliosis
. Non-dystrophic neurofibromatosis scoliosis
. Marfan syndrome scoliosis

Correct Answer & Explanation

. Dystrophic neurofibromatosis scoliosis

Explanation

Dystrophic scoliosis in Neurofibromatosis type 1 typically presents as a short-segment, sharply angulated curve with severe vertebral wedging, spindling of transverse processes, and rib penciling. It is prone to rapid progression and often requires early surgical stabilization with combined anterior and posterior fusion.

Question 1419

Topic: Thoracolumbar Spine & Deformity

The most common osseous abnormality in neurofibromatosis 1 (NF1) is:

. Congenital tibial dysplasia
. Scoliosis
. Valgus deformity of the ankle
. Macrodactyly
. Dysplasia of posterior cranial fossa

Correct Answer & Explanation

. Scoliosis

Explanation

Of the many orthopedic manifestations of neurofibromatosis 1 (NF1), including kyphoscoliosis, lordoscoliosis, spondylolisthesis, congenital tibial dysplasia, segmental hypertrophy, cystic bone lesions, and subperiostial bone proliferation, scoliosis is the most common.

Question 1420

Topic: 6. Spine

Which of the following treatments is contraindicated as treatment for kyphoscoliosis in neurofibromatosis 1 (NF1):

. Laminectomy over the apex of the kyphosis
. Halo traction
. Bracing
. Anterior spinal fusion
. Posterior spinal fusion

Correct Answer & Explanation

. Laminectomy over the apex of the kyphosis

Explanation

Laminectomy is contraindicated because the cord is usually compressed anteriorly and resection removes bone necessary for fusion.

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