Menu

6. Spine MCQs

Practice Set 75 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 1481

Topic: Thoracolumbar Spine & Deformity

A 30-year-old male undergoes posterior pedicle screw fixation for an unstable T12 burst fracture. Postoperatively, he develops a cerebrospinal fluid (CSF) leak from the incision site. The surgical team suspects an incidental durotomy occurred during decompression. Based on the complications and management section of the case, what is the most appropriate initial management strategy for this complication?

. Immediate return to the operating room for hardware removal and dural repair.
. Placement of a continuous lumbar drain to divert CSF flow.
. Primary repair using 4-0 or 5-0 non-absorbable suture, augmented closure with muscle/fascia patches, dural substitutes, and fibrin sealants, and bed rest.
. Observation with serial neurological exams and wound care.
. Administration of broad-spectrum antibiotics and placement of a subfascial drain to suction.

Correct Answer & Explanation

. Primary repair using 4-0 or 5-0 non-absorbable suture, augmented closure with muscle/fascia patches, dural substitutes, and fibrin sealants, and bed rest.

Explanation

Correct Answer: CThe case explicitly details the management of incidental durotomies: 'Primary repair using 4-0 or 5-0 non-absorbable suture is the gold standard. If primary repair is impossible, augmented closure with muscle/fascia patches, dural substitutes, and fibrin sealants is utilized. A subfascial drain is generally avoided or placed to gravity rather than suction to prevent a continuous cerebrospinal fluid fistula.' Post-operative bed rest is also a common adjunct to allow dural healing.Option A is incorrectbecause hardware removal is not typically indicated for an incidental durotomy unless the hardware itself is causing the leak or preventing repair. The primary goal is dural repair and sealing.Option B is incorrectbecause while lumbar drains can be used in some CSF leak scenarios, the primary management for an intraoperative durotomy is direct repair and sealing at the time of surgery, or if discovered post-op, re-exploration for repair. A lumbar drain is a secondary measure.Option D is incorrectbecause a persistent CSF leak from the incision site carries a high risk of infection (meningitis) and requires active management, not just observation.Option E is incorrectbecause while antibiotics might be considered if infection is suspected, the primary issue is the dural defect. The case specifically advises against placing a subfascial drain to suction, as it can perpetuate the fistula.

Question 1482

Topic: 6. Spine

A 25-year-old male presents with a T12 burst fracture with significant kyphotic deformity and an incomplete neurological deficit. Preoperative imaging includes standard radiographs and CT. The surgical team is considering the need for MRI. Based on the preoperative planning section, in which of the following scenarios is MRI considered indispensable or strictly indicated?

. In all thoracolumbar spine injuries, regardless of neurological status or fracture type.
. Only in neurologically intact patients to rule out occult disc herniation.
. Strictly indicated in any patient with a neurological deficit, suspected tension-band injury not clearly visible on CT, or when the TLICS score is equivocal.
. Primarily for evaluating bony anatomy and facet subluxation, which CT cannot adequately visualize.
. Only if the patient is unable to undergo CT due to contrast allergy or renal insufficiency.

Correct Answer & Explanation

. Strictly indicated in any patient with a neurological deficit, suspected tension-band injury not clearly visible on CT, or when the TLICS score is equivocal.

Explanation

Correct Answer: CThe case states under 'Advanced Imaging Modalities': 'Magnetic Resonance Imaging is indispensable for evaluating the integrity of the Posterior Ligamentous Complex, intervertebral discs, and the spinal cord itself. Short Tau Inversion Recovery sequences are particularly sensitive for detecting ligamentous edema and epidural hematomas. MRI is strictly indicated in any patient with a neurological deficit, suspected tension-band injury not clearly visible on CT, or when the TLICS score is equivocal.'Option A is incorrectbecause MRI is not indicated inallthoracolumbar spine injuries. For example, stable compression fractures in neurologically intact patients with clear CT findings may not require MRI.Option B is incorrectbecause while MRI can show disc herniation, its primary indications extend beyond this, especially for neurological deficits and PLC assessment. It's more critical for neurologically compromised patients.Option D is incorrectbecause CT is the gold standard for defining bony anatomy and facet subluxation. MRI is superior for soft tissue structures like ligaments, discs, and the spinal cord.Option E is incorrectbecause while CT contraindications might lead to alternative imaging, the strict indications for MRI are based on specific clinical and injury characteristics, not just CT contraindications.

Question 1483

Topic: Thoracolumbar Spine & Deformity

A 35-year-old male falls from a height. CT of the thoracolumbar spine reveals a T12 burst fracture. MRI shows an intact posterior ligamentous complex. Neurological examination is completely normal. According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the score and the recommended management?

. Score 2; non-operative management
. Score 4; operative management
. Score 5; operative management
. Score 2; operative management
. Score 4; non-operative management

Correct Answer & Explanation

. Score 2; non-operative management

Explanation

The TLICS score is calculated as: burst fracture morphology (2 points), intact PLC (0 points), and normal neurologic status (0 points). A total score of 2 points strongly indicates non-operative management.

Question 1484

Topic: Thoracolumbar Spine & Deformity

A 22-year-old female presents after a high-speed motor vehicle collision wearing a lap belt. She has severe abdominal bruising. Radiographs show a flexion-distraction injury (Chance fracture) at L2. Which of the following associated injuries must be aggressively ruled out?

. Diaphragmatic rupture
. Thoracic aortic aneurysm
. Gastrointestinal hollow viscus injury
. Renal artery thrombosis
. Splenic rupture

Correct Answer & Explanation

. Gastrointestinal hollow viscus injury

Explanation

Chance fractures (flexion-distraction injuries) are highly associated with intra-abdominal injuries. Hollow viscus injuries (e.g., bowel perforation) occur in up to 40-50% of these cases and must be excluded.

Question 1485

Topic: 6. Spine
A 45-year-old male sustains an L1 burst fracture with 60% canal compromise. He has saddle anesthesia, bowel/bladder incontinence, and bilateral lower extremity weakness. What is the clinical syndrome and appropriate management?
. Conus medullaris syndrome; routine non-operative management
. Cauda equina syndrome; emergent surgical decompression
. Brown-Sรฉquard syndrome; intravenous steroids
. Anterior cord syndrome; emergent surgical decompression
. Central cord syndrome; delayed surgical decompression

Correct Answer & Explanation

. Cauda equina syndrome; emergent surgical decompression

Explanation

The clinical presentation of saddle anesthesia, bowel/bladder incontinence, and lower extremity weakness indicates cauda equina syndrome. This is a surgical emergency requiring immediate decompression.

Question 1486

Topic: 6. Spine

A 60-year-old female sustains a stable compression fracture at T8. She is prescribed a Thoracolumbosacral orthosis (TLSO). To be biomechanically effective in preventing further flexion at T8, a TLSO must extend superiorly to control which anatomical landmark?

. Sternal notch
. Clavicle
. Xiphoid process
. Costal margin
. Symphysis pubis

Correct Answer & Explanation

. Sternal notch

Explanation

For a TLSO to effectively control flexion at the midthoracic spine (T8), the anterior superior trimline must reach the sternal notch. This provides an adequate lever arm to resist forward bending.

Question 1487

Topic: 6. Spine

Which type of Denis burst fracture involves both the superior and inferior endplates, typically occurs in the mid-lumbar spine, and is the result of a pure axial load?

. Type A (fracture of both endplates)
. Type B (fracture of superior endplate)
. Type C (fracture of inferior endplate)
. Type D (burst rotation)
. Type E (lateral burst)

Correct Answer & Explanation

. Type A (fracture of both endplates)

Explanation

According to the Denis classification, a Type A burst fracture involves both the superior and inferior endplates resulting from a pure axial load. Type B involves only the superior endplate.

Question 1488

Topic: Thoracolumbar Spine & Deformity

A 35-year-old male falls from a height. Imaging reveals an L1 burst fracture with disruption of the posterior ligamentous complex. He has an incomplete lower extremity motor deficit. According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is his total score and recommended treatment?

. Score 4; non-operative management with a TLSO
. Score 5; surgical intervention
. Score 7; non-operative management
. Score 8; surgical intervention
. Score 9; surgical intervention

Correct Answer & Explanation

. Score 8; surgical intervention

Explanation

The TLICS score is 8 (Burst fracture morphology = 2, PLC disrupted = 3, incomplete neurological deficit = 3). A score greater than 4 is a strong indication for surgical intervention.

Question 1489

Topic: 6. Spine

A 24-year-old female is involved in a high-speed motor vehicle collision while wearing a lap belt. She sustains a flexion-distraction injury of the L2 vertebra. Which of the following associated injuries is MOST commonly seen with this specific spinal fracture pattern?

. Blunt cardiac injury
. Aortic transection
. Hollow viscus gastrointestinal injury
. Renal laceration
. Splenic rupture

Correct Answer & Explanation

. Hollow viscus gastrointestinal injury

Explanation

Flexion-distraction (Chance) fractures often occur with lap-belt use and are highly associated with intra-abdominal injuries, particularly hollow viscus injuries like small bowel perforations, occurring in up to 40% of cases.

Question 1490

Topic: Thoracolumbar Spine & Deformity

A 40-year-old female sustains a T12 burst fracture. Imaging shows 25% loss of anterior vertebral body height, 10 degrees of focal kyphosis, and 20% canal compromise. The posterior ligamentous complex is intact on MRI, and she is neurologically intact. What is the most appropriate management?

. Posterior pedicle screw fixation one level above and below
. Anterior corpectomy and fusion
. Thoracolumbosacral orthosis (TLSO) bracing and early mobilization
. Strict bed rest for 6 weeks without bracing
. Laminectomy and posterolateral fusion

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing and early mobilization

Explanation

This is a stable thoracolumbar burst fracture with intact neurology, intact PLC, and minimal deformity (TLICS score 2). It is best treated conservatively with a TLSO brace and early mobilization.

Question 1491

Topic: 6. Spine

A 65-year-old male with a long-standing history of ankylosing spondylitis presents after a low-energy fall. He reports severe back pain but is neurologically intact. Radiographs reveal a transverse fracture through the T10-T11 disc space. What is the most appropriate definitive management?

. Non-operative management with a custom TLSO
. Short-segment posterior instrumentation (one level above and below)
. Long-segment posterior instrumentation (at least three levels above and below)
. Anterior interbody fusion alone
. Vertebroplasty of T10 and T11

Correct Answer & Explanation

. Long-segment posterior instrumentation (at least three levels above and below)

Explanation

Fractures in the ankylosed spine are highly unstable and behave like long bone fractures. Due to the long lever arms, long-segment posterior fixation (often three levels above and below) is required to prevent secondary displacement and neurological injury.

Question 1492

Topic: 6. Spine
A patient falls from a ladder, sustaining a severe L1 fracture-dislocation. They present with symmetrical saddle anesthesia, early bowel and bladder dysfunction, and a mixture of upper and lower motor neuron signs in the lower extremities. Which neurological syndrome does this represent?
. Cauda Equina Syndrome
. Conus Medullaris Syndrome
. Brown-Sรฉquard Syndrome
. Anterior Cord Syndrome
. Central Cord Syndrome

Correct Answer & Explanation

. Conus Medullaris Syndrome

Explanation

Conus medullaris syndrome typically occurs with injuries at the T12-L1 level. It is characterized by early sphincter dysfunction, symmetrical saddle anesthesia, and mixed upper/lower motor neuron signs, distinguishing it from cauda equina syndrome.

Question 1493

Topic: 6. Spine

According to the Denis three-column theory of the spine, which of the following injuries is the hallmark of a burst fracture?

. Isolated failure of the anterior column under compression
. Failure of the anterior and middle columns under axial loading
. Failure of the posterior column alone under tension
. Failure of all three columns with translation
. Isolated failure of the middle column under rotation

Correct Answer & Explanation

. Failure of the anterior and middle columns under axial loading

Explanation

The Denis classification defines a burst fracture by the failure of the anterior and middle columns under axial loading. The involvement of the middle column differentiates a burst fracture from a simple compression fracture.

Question 1494

Topic: Thoracolumbar Spine & Deformity

A 35-year-old male sustains a T12 burst fracture after a fall. On exam, he has 4/5 strength in hip flexion, 5/5 in lower muscle groups, and normal bowel/bladder function. CT shows a burst fracture with 40% canal compromise. MRI shows an intact posterior ligamentous complex (PLC). What is his Thoracolumbar Injury Classification and Severity Score (TLICS), and what is the recommended management?

. 2; nonoperative management
. 3; nonoperative management
. 4; surgeon's choice
. 5; operative management
. 7; operative management

Correct Answer & Explanation

. 5; operative management

Explanation

Burst fracture morphology gets 2 points, an intact PLC gets 0 points, and an incomplete neurologic deficit gets 3 points, totaling 5 points. A TLICS score greater than 4 is a strong indication for operative stabilization.

Question 1495

Topic: Thoracolumbar Spine & Deformity

A 30-year-old male falls from a height. CT shows an L1 burst fracture with 40% loss of vertebral body height. MRI confirms an intact posterior ligamentous complex (PLC). The patient is neurologically intact. According to the Thoracolumbar Injury Classification and Severity Score (TLICS), what is his score and the recommended management?

. Score 2; Non-operative management
. Score 3; Operative management
. Score 4; Operative or non-operative management
. Score 5; Operative management
. Score 7; Operative management

Correct Answer & Explanation

. Score 2; Non-operative management

Explanation

The TLICS score is calculated as: Morphology (Burst = 2), PLC (Intact = 0), and Neurologic status (Intact = 0), for a total score of 2. A score of less than 4 warrants non-operative management.

Question 1496

Topic: Thoracolumbar Spine & Deformity

A 24-year-old female sustains a seatbelt-type flexion-distraction injury at T12 (bony Chance fracture) in a motor vehicle collision. She is neurologically intact. Which of the following is the most commonly associated concomitant injury in this specific clinical scenario?

. Aortic dissection
. Pancreatic pseudocyst
. Hollow viscus gastrointestinal injury
. Diaphragmatic rupture
. Renal artery thrombosis

Correct Answer & Explanation

. Hollow viscus gastrointestinal injury

Explanation

Chance fractures, caused by a flexion-distraction mechanism often from a lap seatbelt, have a high association (30-50%) with intra-abdominal hollow viscus injuries. Prompt general surgery evaluation is critical.

Question 1497

Topic: 6. Spine

A 45-year-old male presents with a T12 burst fracture after a fall. CT shows a retropulsed bone fragment occupying 60% of the spinal canal. He exhibits new-onset lower extremity weakness and bowel/bladder incontinence. What is the preferred surgical approach?

. Bracing in a TLSO for 6 weeks
. Anterior corpectomy without instrumentation
. Posterior decompression with long-segment instrumented fusion
. Posterior laminectomy without fusion
. Administration of high-dose intravenous methylprednisolone alone

Correct Answer & Explanation

. Posterior decompression with long-segment instrumented fusion

Explanation

The patient has a burst fracture with conus medullaris syndrome. Urgent surgical decompression and stabilization (typically via a posterior approach with pedicle screw fixation) are indicated due to the progressive neurologic deficit.

Question 1498

Topic: 6. Spine

A 60-year-old male with long-standing ankylosing spondylitis sustains a low-energy fall. Radiographs show a through-and-through fracture of the T10 vertebral body and posterior elements. He is neurologically intact. What is the most appropriate management?

. Rigid TLSO bracing for 12 weeks
. Short-segment posterior instrumented fusion (1 level above, 1 below)
. Anterior corpectomy and plating
. Long-segment posterior instrumented fusion (multiple levels above and below)
. Percutaneous kyphoplasty

Correct Answer & Explanation

. Long-segment posterior instrumented fusion (multiple levels above and below)

Explanation

Fractures in ankylosing spondylitis are highly unstable 'chalk-stick' fractures. Due to the long lever arms of the fused spine, rigid long-segment posterior instrumented fixation (typically 3 levels above and below) is required.

Question 1499

Topic: 6. Spine

A 60-year-old male with chronic back pain presents for elective lumbar laminectomy. Pre-operatively, his home medications include Lisinopril. On the morning of surgery, his BP is 155/95 mmHg. What is the most appropriate management of his Lisinopril on the day of surgery?

. Instruct him to take his Lisinopril as usual
. Hold Lisinopril and administer a different antihypertensive post-operatively
. Hold Lisinopril and monitor BP, re-initiating post-operatively when stable
. Hold Lisinopril and administer an IV beta-blocker pre-operatively
. Administer a half-dose of Lisinopril

Correct Answer & Explanation

. Hold Lisinopril and monitor BP, re-initiating post-operatively when stable

Explanation

Correct Answer: CACE inhibitors (like Lisinopril) are typically held on the day of surgery due to their potential to cause refractory hypotension under anesthesia, especially with spinal or epidural blocks. While some studies suggest continuing them, the current consensus for elective surgery usually leans towards holding them. The blood pressure should be monitored, and if dangerously high, an alternative short-acting antihypertensive (e.g., IV Labetalol or Hydralazine) can be administered. Re-initiating post-operatively when the patient is stable is generally safe. Taking it as usual carries risk. Administering an IV beta-blocker might be an option for acute hypertension but not the standard management for holding an ACEi. Half-dosing does not eliminate the risk.

Question 1500

Topic: 6. Spine

A 48-year-old male presents to the emergency department with acute onset severe low back pain, bilateral leg weakness, saddle anesthesia, and new-onset urinary retention. He reports a history of chronic low back pain but these symptoms are new and rapidly progressing. What is the most appropriate immediate diagnostic and management step?

. Administer high-dose oral corticosteroids and observe for improvement.
. Order an urgent MRI of the lumbar spine and prepare for emergent surgical decompression.
. Initiate aggressive physical therapy and pain management.
. Perform a lumbar epidural steroid injection.
. Refer for electromyography and nerve conduction studies.

Correct Answer & Explanation

. Order an urgent MRI of the lumbar spine and prepare for emergent surgical decompression.

Explanation

Correct Answer: BThe patient's presentation with acute severe low back pain, bilateral leg weakness, saddle anesthesia, and urinary retention is highly suggestive of Cauda Equina Syndrome (CES). CES is a surgical emergency requiring urgent diagnosis and decompression to prevent permanent neurological deficits, particularly bowel and bladder dysfunction. The most appropriate immediate step is an urgent MRI of the lumbar spine to confirm the diagnosis and identify the level of compression, followed by emergent surgical decompression. Delay in treatment significantly worsens the prognosis. Corticosteroids (A) are not the primary treatment for CES. Physical therapy (C), epidural injections (D), and nerve conduction studies (E) are inappropriate and would cause critical delays in a rapidly progressing neurological emergency.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page