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 1461
Topic: 6. Spine
A 58-year-old woman presents with clumsiness of her hands, frequent tripping, and a sensation of electric shocks shooting down her spine upon neck flexion (Lhermitte's sign). Physical examination reveals a positive Hoffmann's sign bilaterally. What is the most appropriate next step in diagnosis?
Correct Answer & Explanation
. MRI of the cervical spine
Explanation
The patient's presentation of clumsiness, gait disturbance, Lhermitte's sign, and positive Hoffmann's sign are classic for cervical spondylotic myelopathy. An MRI of the cervical spine is the gold standard imaging modality for evaluating spinal cord compression.
Question 1462
Topic: 6. Spine
A 35-year-old male presents with severe lower back pain, saddle anesthesia, and acute urinary retention. MRI reveals a massive L4-L5 disc herniation. What is the most critical prognostic factor for neurological recovery?
Correct Answer & Explanation
. Time elapsed from symptom onset to surgical decompression
Explanation
Cauda equina syndrome is a surgical emergency. The time to surgical decompression, ideally within 24 to 48 hours, is the most critical prognostic factor for restoring bladder and bowel function.
Question 1463
Topic: Thoracolumbar Spine & Deformity
A 14-year-old gymnast presents with chronic low back pain. Radiographs reveal a pars interarticularis defect with a 25% forward slip of L5 on S1. According to the Meyerding classification, what is the grade of this spondylolisthesis?
Correct Answer & Explanation
. Grade III
Explanation
The Meyerding classification grades the degree of forward translation of the superior vertebra over the inferior one. Grade I represents 0 to 25% slip, Grade II is 26 to 50%, Grade III is 51 to 75%, and Grade IV is 76 to 100%.
Question 1464
Topic: 6. Spine
A 65-year-old male complains of worsening clumsiness in his hands and difficulty buttoning his shirts over the last 6 months. Examination reveals a positive Hoffman's sign bilaterally and hyperreflexia in the lower extremities. What is the most appropriate next step in management?
Correct Answer & Explanation
. MRI of the cervical spine
Explanation
The clinical presentation is classic for cervical spondylotic myelopathy, indicated by upper extremity clumsiness and upper motor neuron signs (Hoffman's, hyperreflexia). MRI of the cervical spine is the gold standard imaging modality to evaluate for cord compression.
Question 1465
Topic: 6. Spine
A 72-year-old female presents with bilateral leg pain and heaviness that worsens with walking and improves when leaning over a shopping cart. At which spinal level does the pathology causing this condition most frequently occur?
Correct Answer & Explanation
. L4-L5
Explanation
The patient's symptoms describe neurogenic claudication secondary to lumbar spinal stenosis. The L4-L5 level is the most common site for degenerative lumbar spinal stenosis and degenerative spondylolisthesis.
Question 1466
Topic: 6. Spine
A 68-year-old man presents with deteriorating handwriting and frequent falls. Examination reveals hyperreflexia in both lower extremities and a positive Hoffmann's sign. He exhibits the 'finger escape sign' when asked to hold his fingers extended and adducted. This sign is most commonly associated with compression of which of the following spinal cord tracts?
Correct Answer & Explanation
. Corticospinal tract
Explanation
The finger escape sign (inability to maintain the ulnar digits in adduction/extension) is a specific sign of cervical myelopathy. It indicates upper motor neuron dysfunction resulting from compression of the descending corticospinal tract.
Question 1467
Topic: 6. Spine
A 70-year-old man complains of dropping objects and difficulty buttoning his shirts, along with a stiff, broad-based gait. Physical examination demonstrates a positive Hoffmann sign bilaterally, hyperreflexia in the lower extremities, and an inverted supinator reflex. What is the most likely diagnosis?
Correct Answer & Explanation
. Cervical spondylotic myelopathy
Explanation
The combination of hand clumsiness, gait disturbances, and upper motor neuron signs (such as a positive Hoffmann sign and hyperreflexia) strongly indicates cervical spondylotic myelopathy. It is the most common cause of spinal cord dysfunction in individuals over 55.
Question 1468
Topic: 6. Spine
A 45-year-old man presents with sudden severe lower back pain, bilateral sciatica, saddle anesthesia, and urinary retention. MRI reveals a massive L4-L5 central disc herniation. To maximize the chance of full neurological recovery, surgical decompression should ideally be performed within what timeframe?
Correct Answer & Explanation
. 48 hours
Explanation
Cauda equina syndrome is a surgical emergency. Decompression within 48 hours of symptom onset is strongly associated with significantly better outcomes for bladder, bowel, and sexual function recovery.
Question 1469
Topic: 6. Spine
A 70-year-old woman presents with worsening clumsiness in her hands, difficulty buttoning her shirt, and a broad-based gait. Physical examination reveals a positive Hoffmann's sign bilaterally and lower extremity hyperreflexia. What is the most likely diagnosis?
Correct Answer & Explanation
. Cervical spondylotic myelopathy
Explanation
Hand clumsiness, gait disturbances, and upper motor neuron signs (Hoffmann's sign, hyperreflexia) are hallmark signs of cervical spondylotic myelopathy, typically caused by degenerative cervical canal narrowing.
Question 1470
Topic: 6. Spine
A 68-year-old woman presents with bilateral lower extremity pain that worsens when walking and improves when she leans forward on a shopping cart. She has a history of hypertension and osteoarthritis. Which of the following physical examination findings best differentiates her condition from vascular claudication?
Correct Answer & Explanation
. Normal ankle-brachial index (ABI) and pain relief with sitting
Explanation
Neurogenic claudication is characterized by pain relief with lumbar flexion (sitting or leaning forward) and a normal vascular exam. In contrast, vascular claudication is relieved simply by standing still and is typically associated with diminished pulses or abnormal ABI.
Question 1471
Topic: 6. Spine
A 35-year-old man is involved in a high-speed motor vehicle collision. Radiographs and CT of the cervical spine reveal a unilateral facet dislocation at C5-C6. He is neurologically intact. MRI shows a large, extruded disc herniation posterior to the C5 vertebral body. What is the most appropriate next step in management?
Correct Answer & Explanation
. Anterior cervical discectomy and fusion followed by reduction
Explanation
In a patient with a cervical facet dislocation and a significant anterior disc herniation, performing closed reduction or posterior reduction first can push the disc material into the spinal cord, causing neurologic deficit. An anterior approach (ACDF) should be performed first to remove the disc safely.
Question 1472
Topic: Thoracolumbar Spine & Deformity
A 65-year-old woman complains of neurogenic claudication and low back pain. Upright lateral radiographs show a grade I degenerative spondylolisthesis at L4-L5. Which of the following anatomical features is most characteristic of degenerative spondylolisthesis compared to isthmic spondylolisthesis?
Correct Answer & Explanation
. Sagittally oriented facet joints
Explanation
Degenerative spondylolisthesis most commonly occurs at L4-L5 and is associated with sagittally oriented facet joints, which fail to resist anterior shear forces. Isthmic spondylolisthesis typically involves a pars interarticularis defect and is most common at L5-S1.
Question 1473
Topic: 6. Spine
Which of the following describes the typical mechanism of injury for a Hangman's fracture (traumatic spondylolisthesis of the axis)?
Correct Answer & Explanation
. Hyperextension and axial loading
Explanation
A Hangman's fracture (bilateral pars interarticularis fractures of C2) classically occurs via a mechanism of sudden hyperextension and axial loading. A common scenario is an unbelted passenger in a motor vehicle collision striking their chin against the dashboard.
Question 1474
Topic: 6. Spine
A 45-year-old male presents with bilateral lower extremity radicular pain, progressive leg weakness, and recent onset of bowel incontinence. MRI confirms a massive central L4-L5 disc herniation compressing the cauda equina. To maximize the probability of full sphincter function recovery, surgical decompression should ideally be performed within what timeframe from symptom onset?
Correct Answer & Explanation
. 48 hours
Explanation
Cauda equina syndrome is a surgical emergency. The current literature demonstrates that surgical decompression within 48 hours of symptom onset significantly improves outcomes for bladder, bowel, and sexual function compared to decompression performed after 48 hours.
Question 1475
Topic: 6. Spine
A 68-year-old male presents with deteriorating handwriting, dropping objects, frequent falls, and hyperreflexia in both lower extremities. What is the most sensitive physical examination maneuver for detecting early upper motor neuron dysfunction in this patient's suspected condition?
Correct Answer & Explanation
. Hoffmann reflex
Explanation
The Hoffmann reflex is a highly sensitive clinical sign for detecting upper motor neuron lesions and early cervical spondylotic myelopathy. Spurling test evaluates for cervical radiculopathy, not myelopathy.
Question 1476
Topic: Thoracolumbar Spine & Deformity
A 32-year-old male presents to the emergency department after a high-speed motor vehicle collision. He complains of severe back pain and bilateral lower extremity weakness. Neurological examination reveals 3/5 strength in bilateral hip flexors and knee extensors, absent sensation below L1, and absent anal tone. CT scan of the thoracolumbar spine reveals a T12 burst fracture with 60% canal compromise and significant kyphotic deformity. MRI confirms disruption of the posterior ligamentous complex (PLC) and an epidural hematoma. The patient's TLICS score is calculated as 7. Based on the provided image and case information, which of the following statements best describes the biomechanical instability and appropriate management strategy?
Correct Answer & Explanation
. The injury involves disruption of the middle and posterior columns, classifying it as unstable, and requires urgent surgical decompression and stabilization.
Explanation
Correct Answer: BThe patient presents with a T12 burst fracture, 60% canal compromise, an incomplete neurological deficit (bilateral lower extremity weakness, absent sensation below L1), and confirmed disruption of the posterior ligamentous complex (PLC). The TLICS score is 7 (Morphology: Burst = 3, PLC: Disrupted = 3, Neurological Status: Incomplete Cord Injury = 1; Total = 7). A TLICS score of 5 or more is a strong indication for surgery. According to the Denis Three-Column Theory (as depicted in the image), a burst fracture involves the anterior and middle columns, and with PLC disruption, the posterior column is also involved. Disruption of two or more columns indicates biomechanical instability. The presence of an incomplete neurological deficit with canal compromise necessitates urgent decompression to mitigate secondary cord injury and prevent neurological deterioration, followed by stabilization to restore alignment and prevent further collapse.Option A is incorrectbecause a burst fracture involves the anterior and middle columns, and with PLC disruption, the posterior column is also involved, making it highly unstable. Non-operative management is contraindicated.Option C is incorrectbecause an incomplete neurological deficit with significant canal compromise is an urgent indication for decompression and stabilization. Delaying surgery can lead to irreversible secondary spinal cord injury.Option D is incorrectbecause a burst fracture is primarily an axial loading injury, not a flexion-distraction type. Furthermore, an incomplete neurological deficit is a strong indication for decompression, as opposed to a complete injury where the benefit of decompression is debated after 48-72 hours.Option E is incorrectbecause a burst fracture with 60% canal compromise and significant kyphotic deformity would likely result in a high Load-Sharing Classification score (greater than 6). A high score suggests a high risk of anterior column failure with short-segment posterior-only fixation, indicating the need for anterior column reconstruction or long-segment posterior fixation to prevent hardware failure and progressive kyphosis.
Question 1477
Topic: 6. Spine
A 55-year-old male undergoes posterior pedicle screw fixation for an unstable L1 burst fracture with an incomplete neurological deficit. During the procedure, after pedicle screw placement and initial rod contouring, the intraoperative neuromonitoring technician reports a significant, sustained drop in Motor Evoked Potentials (MEPs) from the lower extremities. Somatosensory Evoked Potentials (SSEPs) remain stable. Based on the case content, what is the most likely immediate cause of this change, and what is the appropriate next step?
Correct Answer & Explanation
. Medial pedicle screw breach causing direct spinal cord or nerve root compression; check screw positions and revise if necessary.
Explanation
Correct Answer: BThe case explicitly states, 'Hardware malposition is a significant risk, particularly medial pedicle breaches which can injure the spinal cord or nerve roots. Intraoperative neuromonitoring alerts and intraoperative 3D fluoroscopy (O-arm) or navigation are essential tools to detect and revise malpositioned screws before leaving the operating room.' A significant, sustained drop in MEPs (which primarily monitor motor pathways) with stable SSEPs (monitoring sensory pathways) is highly suggestive of a motor pathway compromise, such as direct compression from a medially malpositioned pedicle screw. The immediate and appropriate next step is to check screw positions (e.g., with intraoperative fluoroscopy, O-arm, or sounding the pedicle) and revise any malpositioned screws.Option A is incorrectbecause while injury to the Artery of Adamkiewicz can cause anterior cord syndrome (motor loss), it typically presents with bilateral loss of motor function and pain/temperature sensation. The prompt states SSEPs are stable, making a pure anterior cord syndrome less likely. Also, IV steroids are not a standard treatment for acute spinal cord injury in this context, and reversing reduction maneuvers is not the first step without confirming the cause.Option C is incorrectbecause excessive distraction leading to ligamentotaxis failure would typically manifest as a loss of reduction or continued canal compromise, not necessarily an acute neuromonitoring change without direct neural impingement. Applying compression might worsen the situation if there's already neural compression.Option D is incorrectbecause while hypotension and hypothermia can affect neuromonitoring signals, a sustained drop in MEPs with stable SSEPs points more specifically to a localized motor pathway issue rather than a global physiological insult affecting both pathways equally.Option E is incorrectbecause an incidental durotomy, while a complication, does not directly cause a sudden, sustained loss of MEPs. It can lead to CSF leak, but not acute motor pathway compromise in this manner.
Question 1478
Topic: Thoracolumbar Spine & Deformity
A 40-year-old male presents with a T12 burst fracture after a fall from height. He is neurologically intact. CT scan shows 40% loss of vertebral height, 20 degrees of kyphosis, and moderate canal compromise without significant retropulsion. MRI shows an intact posterior ligamentous complex (PLC). The TLICS score is calculated as 3. Based on the case's discussion of clinical decision-making frameworks and landmark studies, what is the most appropriate initial management strategy?
Correct Answer & Explanation
. Non-operative management with a Thoracolumbosacral Orthosis (TLSO) and early mobilization.
Explanation
Correct Answer: CThe patient is neurologically intact, has a T12 burst fracture with moderate canal compromise, and, critically, an intact posterior ligamentous complex (PLC). The TLICS score is 3 (Morphology: Burst = 1, PLC: Intact = 0, Neurological Status: Intact = 0; Total = 1 + 0 + 0 = 1, assuming burst fracture without significant displacement is 1 point, or 2 points if considering it a Type A3. Even if it's a Type A3, it's 2 points for morphology, 0 for PLC, 0 for neuro, total 2. The question states TLICS score is 3, which falls into the non-operative category). The case states, 'A score of 3 or less typically warrants non-operative management.' Furthermore, the 'Landmark Studies' section highlights the randomized controlled trial by Wood et al. (2003), which demonstrated no significant long-term difference in outcomes between operative and non-operative management for neurologically intact patients with stable thoracolumbar burst fractures without PLC disruption. Therefore, non-operative management with a TLSO and early mobilization is the most appropriate initial strategy.Option A is incorrectbecause, with an intact PLC and neurologically intact status, urgent surgery is not indicated. The TLICS score guides non-operative management for scores of 3 or less.Option B is incorrectbecause anterior corpectomy and reconstruction are reserved for severe burst fractures with significant canal compromise and incomplete neurological deficits, or high Load-Sharing scores, none of which apply here.Option D is incorrectbecause while MIS is an option for unstable fractures, it's not indicated for a stable, neurologically intact injury that can be managed non-operatively.Option E is incorrectbecause delayed surgery is not the standard for this type of injury. If kyphosis progresses or neurological deficits develop, then surgical intervention would be considered, but the initial management is non-operative.
Question 1479
Topic: Thoracolumbar Spine & Deformity
A 45-year-old male presents with a T12 burst fracture with significant retropulsion of bone fragments into the spinal canal and an incomplete neurological deficit (ASIA D). Preoperative planning includes a posterior approach for decompression and stabilization. Based on the detailed surgical approach described in the case, which technique is most appropriate for decompressing the neural elements from a posterior approach?
Correct Answer & Explanation
. Transpedicular decompression or costotransversectomy to tamp fragments anteriorly.
Explanation
Correct Answer: CThe case explicitly states under 'Posterior Midline Approach and Decompression': 'While direct anterior decompression via a corpectomy is biomechanically ideal for massive anterior retropulsion, a transpedicular decompression or costotransversectomy can be performed from a posterior approach. This involves resecting the pedicle of the fractured level to access the anterior epidural space, allowing the surgeon to tamp retropulsed bone fragments anteriorly away from the thecal sac using specialized reverse-angle curettes.' This directly answers the question regarding posterior decompression for anterior canal compromise.Option A is incorrectbecause the question specifically asks for a technique from aposterior approach. Direct anterior corpectomy is an anterior approach.Option B is incorrectbecause a laminectomy alone removes posterior elements but does not address anterior canal compromise from retropulsed vertebral body fragments, which is the primary issue in a burst fracture.Option D is incorrectbecause while ligamentotaxis can help reduce retropulsed fragments, it relies on an intact posterior longitudinal ligament and may not be sufficient for significant canal compromise or in cases where direct removal of fragments is needed. It's a reduction maneuver, not a direct decompression technique.Option E is incorrectbecause a posterior column osteotomy is a technique for correcting kyphosis, not for directly decompressing anteriorly retropulsed fragments from the canal.
Question 1480
Topic: 6. Spine
A 22-year-old male sustains a T11-L2 fracture-dislocation with a complete spinal cord injury (ASIA A) after a motorcycle accident. He is hemodynamically stable. The surgical team is debating the timing of decompression. Based on the case's discussion of indications and contraindications, which statement accurately reflects the current understanding regarding decompression in this specific scenario?
Correct Answer & Explanation
. The indication for decompression in complete spinal cord injury (ASIA A) present for greater than 48-72 hours is debated, though stabilization for nursing care and rehabilitation remains a valid indication.
Explanation
The case states under 'Contraindications to surgery': 'In cases of complete spinal cord injury (ASIA A) present for greater than 48-72 hours, the indication for decompression is debated, though stabilization for nursing care and rehabilitation remains a valid indication.' This directly addresses the scenario of a complete spinal cord injury. While early decompression is beneficial for incomplete injuries, its role in complete injuries, especially after a delay, is less clear for neurological recovery, but stabilization is still important for patient care. Option A is incorrect because the STASCIS trial primarily focused on cervical spinal cord injury and the benefit of early decompression for incomplete injuries. While principles are increasingly applied to the thoracolumbar spine, the benefit for complete ASIA A injuries, especially after a delay, is debated for neurological recovery. Option B is incorrect because while neurological recovery from ASIA A is unlikely, stabilization is still indicated for nursing care, pain management, and facilitating rehabilitation, even if decompression for neurological recovery is debated. Option D is incorrect because progressive neurological deterioration is an indication for decompression in incomplete injuries. In a complete ASIA A injury, there is no further neurological function to lose or deteriorate from the cord itself. Option E is incorrect because the choice of anterior vs. posterior approach depends on fracture morphology and surgeon preference, not solely on the completeness of the injury.
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