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 1561
Topic: Thoracolumbar Spine & Deformity
The Gaines procedure is a salvage operation reserved for severe cases of spondyloptosis (Grade V spondylolisthesis). Which of the following best describes the surgical sequence of the Gaines procedure?
Correct Answer & Explanation
. Anterior L5 corpectomy followed by posterior reduction and fusion of L4 onto S1
Explanation
The Gaines procedure is a two-stage technique for spondyloptosis. It involves an anterior L5 vertebrectomy (corpectomy), followed by a posterior procedure to resect the posterior elements of L5 and reduce/fuse L4 directly onto S1.
Question 1562
Topic: 6. Spine
What is the optimal starting point for a traditional infrapatellar intramedullary nail in the tibia on an anteroposterior (AP) and lateral radiograph?
Correct Answer & Explanation
. AP: just medial to the lateral tibial spine; Lateral: immediately anterior to the anterior articular margin
Explanation
The optimal starting point for a tibial IM nail is on the medial edge of the lateral tibial spine on the AP view. On the lateral view, it should be just anterior to the articular surface (the anterior safe zone) to prevent intra-articular damage and ensure correct trajectory.
Question 1563
Topic: 6. Spine
A 72-year-old male presents with severe lower back pain, fever, and progressive bilateral leg weakness. He has a history of poorly controlled diabetes and a recent urinary tract infection. MRI of the lumbar spine reveals an epidural abscess extending from L2 to L4 with significant spinal cord compression. What is the most appropriate definitive management strategy?
Correct Answer & Explanation
. Urgent surgical decompression and debridement with intravenous antibiotics.
Explanation
Correct Answer: CGiven the patient's progressive neurological deficits (bilateral leg weakness) and evidence of significant spinal cord compression from an epidural abscess, urgent surgical decompression and debridement are indicated to prevent irreversible neurological damage. Intravenous antibiotics are crucial but insufficient alone due to the mass effect. Percutaneous drainage may be considered for smaller, non-compressive abscesses, but with neurological compromise, surgical decompression is paramount. Corticosteroids are generally not recommended in spinal epidural abscesses as they can mask symptoms and potentially worsen infection. Brace immobilization and observation are inappropriate for a rapidly progressing neurological deficit.
Question 1564
Topic: Thoracolumbar Spine & Deformity
A 16-year-old female presents with progressive scoliosis, exhibiting a 55-degree thoracic curve (T5-T12). Her pulmonary function tests show a forced vital capacity (FVC) of 60% of predicted. What is the primary concern regarding her respiratory function in the long term without intervention?
Correct Answer & Explanation
. Restrictive lung disease and respiratory insufficiency.
Explanation
Correct Answer: CSevere scoliosis, particularly thoracic curves exceeding 50-60 degrees, can significantly restrict chest wall and lung expansion. This leads to a restrictive ventilatory defect, characterized by reduced lung volumes (like FVC). Over time, this can progress to chronic respiratory insufficiency and, in severe cases, pulmonary hypertension and cor pulmonale (right heart failure due to lung disease). While pulmonary hypertension can be a late complication, restrictive lung disease is the primary and direct impact on lung function. Asthma is not directly caused by scoliosis. Diaphragmatic paralysis is unrelated. Obstructive lung disease involves airflow limitation, which is not the primary issue in scoliosis.
Question 1565
Topic: 6. Spine
A 50-year-old male with a T6 complete spinal cord injury (SCI) develops a pounding headache, profuse sweating above the level of injury, and severe hypertension during routine bladder catheterization. What is the most likely diagnosis?
Correct Answer & Explanation
. Autonomic dysreflexia.
Explanation
Correct Answer: CThis constellation of symptoms (pounding headache, sweating above injury, severe hypertension) in an SCI patient, especially from T6 and above, triggered by a noxious stimulus below the level of injury (bladder catheterization in this case), is classic for autonomic dysreflexia. This is a medical emergency that can lead to stroke, myocardial infarction, or seizure. Vasovagal syncope involves bradycardia and hypotension. Spinal shock is a transient physiological state immediately following SCI, characterized by flaccid paralysis and loss of reflexes. Malignant hyperthermia is a rare anesthetic complication. Pulmonary embolism has different clinical features.
Question 1566
Topic: Cervical Spine
A 72-year-old female presents after a low-energy fall, landing on her head. She complains of severe neck pain. Radiographs show a fracture through the base of the odontoid process, extending into the body of C2, with significant anterior displacement of the odontoid fragment relative to C2. She has no neurological deficits. Given her age and fracture pattern, what is the most appropriate definitive management strategy?
Correct Answer & Explanation
. Posterior C1-C2 fusion.
Explanation
Correct Answer: CRationale:The patient has a Type II odontoid fracture (fracture at the base of the odontoid process). In elderly patients, Type II odontoid fractures have a high rate of non-union with conservative management (e.g., halo vest) due to poor bone quality, decreased healing potential, and difficulty tolerating prolonged immobilization. Anterior odontoid screw fixation is an option for Type II fractures, but its success rate decreases significantly with age, osteoporosis, and significant displacement, making it less reliable in this 72-year-old patient. Posterior C1-C2 fusion (e.g., with C1 lateral mass and C2 pedicle screws) provides rigid fixation and a high fusion rate, making it the most appropriate definitive management for an unstable Type II odontoid fracture in an elderly patient, especially with significant displacement.Why other options are incorrect:A) Halo vest immobilization for 12 weeks:While a halo vest is a common treatment for Type II odontoid fractures in younger patients, it has a high non-union rate (up to 80%) in the elderly due to poor bone quality and intolerance.B) Anterior odontoid screw fixation:This technique is best for Type II fractures with minimal displacement and good bone quality, typically in younger patients. Its success rate is significantly lower in the elderly with osteoporosis and significant displacement.D) Soft cervical collar and observation:This is completely inadequate for an unstable Type II odontoid fracture and would lead to non-union and potential neurological compromise.E) Anterior cervical discectomy and fusion (ACDF) at C2-C3:ACDF is used for disc herniations or degenerative conditions at lower cervical levels. It is not indicated for an odontoid fracture, which involves C1 and C2.
Question 1567
Topic: Thoracolumbar Spine & Deformity
A 45-year-old male presents after a fall from a ladder, sustaining a T10 compression fracture. Imaging reveals a wedge compression fracture with 30% loss of anterior vertebral body height, no posterior wall involvement, and an intact posterior ligamentous complex. Neurological examination is completely normal. Using the Thoracolumbar Injury Classification System (TLICS), what is the most appropriate management recommendation?
Correct Answer & Explanation
. Conservative management with bracing and early mobilization.
Explanation
Correct Answer: BRationale:The Thoracolumbar Injury Classification System (TLICS) assigns points based on three main categories: morphology of the injury, integrity of the posterior ligamentous complex (PLC), and neurological status. A score of 3 or less typically indicates non-operative management, while a score of 5 or more suggests surgical intervention. A score of 4 is equivocal and often depends on surgeon preference or other patient factors.Morphology:Compression fracture = 1 point.Posterior Ligamentous Complex (PLC) Integrity:Intact = 0 points.Neurological Status:Intact = 0 points.Total TLICS score = 1 + 0 + 0 = 1 point. A score of 1 strongly indicates conservative management with bracing and early mobilization.Why other options are incorrect:A) Surgical stabilization due to high TLICS score:The TLICS score is 1, which is low and indicates non-operative management.C) Anterior decompression and fusion:This is indicated for significant anterior canal compromise, which is not present here, or for specific fracture patterns not seen in a simple compression fracture.D) Vertebroplasty or kyphoplasty:These procedures are primarily for pain relief in osteoporotic compression fractures, not typically for traumatic compression fractures in a 45-year-old, especially when conservative management is indicated by TLICS.E) Immediate halo vest immobilization:Halo vests are used for cervical spine injuries, not thoracolumbar fractures.
Question 1568
Topic: 6. Spine
A 10-year-old boy is involved in a bicycle accident, sustaining a high-energy injury to his neck. He presents with transient quadriparesis that resolved within minutes. Initial plain radiographs and CT scan of the cervical spine are normal. Despite the resolution of symptoms, what is the most appropriate next diagnostic step?
Correct Answer & Explanation
. Perform an MRI of the entire spine.
Explanation
This is a classic presentation of Spinal Cord Injury Without Radiographic Abnormality (SCIWORA). SCIWORA is more common in children due to the greater elasticity of their spinal columns, which allows significant stretching of the spinal cord without bony injury. Even if neurological symptoms are transient, there can be underlying spinal cord edema, hemorrhage, or ligamentous injury that is not visible on plain radiographs or CT. An MRI of the entire spine is the most appropriate next diagnostic step as it is highly sensitive for detecting soft tissue injuries, spinal cord pathology, and ligamentous disruption.
Question 1569
Topic: 6. Spine
A 68-year-old male presents with severe low back pain and bilateral lower extremity weakness (3/5) that developed acutely over 24 hours. He has a history of intravenous drug use and recent skin infection. On examination, he is febrile (39.2°C) and has tenderness over the L4-L5 spinous processes. Lab tests show leukocytosis and elevated ESR/CRP. What is the most appropriate urgent management strategy?
Correct Answer & Explanation
. Immediate MRI of the lumbar spine and empiric broad-spectrum intravenous antibiotics.
Explanation
Correct Answer: CRationale:This patient presents with a classic picture of acute spinal epidural abscess (SEA) with progressive neurological deficit (bilateral lower extremity weakness). Risk factors include IV drug use and recent infection. SEA is an orthopedic and neurosurgical emergency. The most appropriate urgent management involves:Immediate MRI of the lumbar spine:This is the gold standard for diagnosing SEA, delineating its extent, and assessing for spinal cord or cauda equina compression. It is crucial for surgical planning.Empiric broad-spectrum intravenous antibiotics:These should be initiated immediately after blood cultures are drawn, without waiting for MRI or culture results, to cover common pathogens (e.g., Staphylococcus aureus).Why other options are incorrect:A) Conservative management with bed rest and oral antibiotics:This is inadequate and dangerous for a patient with progressive neurological deficits due to SEA. Oral antibiotics are insufficient, and bed rest does not address the underlying compression.B) Lumbar puncture for CSF analysis:Lumbar puncture is generally contraindicated in suspected SEA due to the risk of spreading the infection into the CSF or causing neurological deterioration from changes in intraspinal pressure.D) Plain radiographs of the lumbar spine and blood cultures:Plain radiographs are often normal in early SEA and will not show the abscess or neural compression. While blood cultures are essential, waiting for plain films is a delay, and they are insufficient for diagnosis.E) Urgent neurosurgical consultation for laminectomy without prior imaging:While surgical decompression is often necessary, it must be guided by precise localization and extent of the abscess, which is provided by MRI. Operating without imaging is not standard practice.
Question 1570
Topic: 6. Spine
A 28-year-old male sustains a high-energy trauma resulting in a C1 burst fracture (Jefferson fracture). CT scan reveals bilateral lateral mass displacement of C1 totaling 8 mm. He has no neurological deficits. What is the most appropriate initial management?
Correct Answer & Explanation
. Halo vest immobilization.
Explanation
Correct Answer: BRationale:A Jefferson fracture is a burst fracture of the C1 ring, typically caused by an axial load. The key to management is assessing the stability of the transverse atlantal ligament (TAL). If the sum of the lateral displacement of the C1 lateral masses on an open-mouth odontoid view (or CT scan) is greater than 7 mm, it indicates rupture of the TAL, rendering the C1 ring unstable. In this case, a total displacement of 8 mm signifies TAL rupture and instability. Given no neurological deficits, halo vest immobilization is the most appropriate initial management for unstable C1 fractures with TAL rupture. It provides rigid external stabilization, allowing for ligamentous healing.Why other options are incorrect:A) Soft cervical collar and observation:This is inadequate for an unstable C1 fracture with TAL rupture and would risk further instability and potential neurological injury.C) C1-C2 posterior fusion:This is a surgical option for unstable C1 fractures, particularly if halo vest fails or is contraindicated, or if there is associated C2 instability. However, halo vest is often the first-line for isolated unstable C1 fractures without neurological deficit.D) Occipitocervical fusion:This is a more extensive fusion, typically reserved for highly unstable upper cervical injuries involving the occiput, C1, and C2, or for failed C1-C2 fusions. It is overkill for an isolated unstable C1 fracture.E) Anterior C1-C2 transarticular screw fixation:This is not a standard approach for C1 fractures. C1-C2 fixation is typically performed posteriorly.
Question 1571
Topic: 6. Spine
A 55-year-old male presents with chronic, progressive low back pain and bilateral leg numbness and weakness, worse with standing and walking, and relieved by sitting or leaning forward. MRI reveals severe degenerative changes at L4-L5 with hypertrophy of the ligamentum flavum and facet joints, causing significant central canal stenosis. He has failed extensive conservative management. What is the most appropriate surgical intervention?
Correct Answer & Explanation
. Posterior decompression (laminectomy) and instrumented fusion.
Explanation
Correct Answer: DRationale:The patient's symptoms (neurogenic claudication, relief with flexion) and MRI findings (severe central canal stenosis due to ligamentum flavum and facet hypertrophy) are classic for lumbar spinal stenosis. Given the failure of conservative management and the presence of neurological deficits, surgical intervention is indicated. For severe central canal stenosis, posterior decompression (laminectomy) is necessary to relieve pressure on the neural elements. However, performing a laminectomy alone can destabilize the spine, especially in the presence of significant degenerative changes and facet hypertrophy, potentially leading to iatrogenic instability or spondylolisthesis. Therefore, posterior decompression combined with instrumented fusion (e.g., posterior lumbar interbody fusion - PLIF, or transforaminal lumbar interbody fusion - TLIF) is often the most appropriate approach to provide both decompression and long-term stability.Why other options are incorrect:A) Microdiscectomy:This procedure is primarily for disc herniations causing nerve root compression, not for central canal stenosis due to bony and ligamentous hypertrophy.B) Laminectomy alone without fusion:While it provides decompression, it carries a risk of iatrogenic instability, especially in a degenerated spine. Fusion is often added to maintain stability.C) Anterior lumbar interbody fusion (ALIF) alone:ALIF provides indirect decompression and fusion, but it may not adequately address severe posterior element hypertrophy causing central stenosis. It is often combined with posterior decompression if needed.E) Vertebroplasty:This procedure is for vertebral compression fractures, not for lumbar spinal stenosis.
Question 1572
Topic: 6. Spine
A 4-year-old child presents with a history of a fall from a swing set. He has severe neck pain and is holding his head in a 'cock-robin' position (head tilted to one side, chin rotated to the opposite side). Neurological examination is normal. Plain radiographs show rotation of C1 on C2. What is the most likely diagnosis?
Correct Answer & Explanation
. Atlantoaxial rotatory subluxation (AARS).
Explanation
Correct Answer: BRationale:The classic presentation of a child with a 'cock-robin' head posture (head tilted to one side, chin rotated to the opposite side) following trauma, combined with radiographic evidence of C1-C2 rotation, is highly suggestive of atlantoaxial rotatory subluxation (AARS). This condition is more common in children due to increased ligamentous laxity and the horizontal orientation of the facet joints. It can be traumatic or non-traumatic (e.g., Grisel's syndrome associated with pharyngitis).Why other options are incorrect:A) Cervical disc herniation:While possible in children, it typically presents with radicular pain and neurological deficits, and less commonly with the 'cock-robin' posture.C) Odontoid fracture:An odontoid fracture would cause severe neck pain but typically doesn't present with the specific 'cock-robin' posture unless there's significant C1-C2 instability, which would be evident on radiographs as displacement, not just rotation.D) Congenital muscular torticollis:This is a developmental condition presenting in infancy, usually without acute trauma, and is due to sternocleidomastoid muscle shortening, not C1-C2 subluxation.E) Spinal epidural hematoma:This would cause acute neurological deficits and severe pain, but the 'cock-robin' posture is not its characteristic presentation.
Question 1573
Topic: 6. Spine
A 60-year-old male with a history of ankylosing spondylitis presents after a minor fall, complaining of severe, acute onset back pain. He has no neurological deficits. Given his underlying condition, what is the most critical diagnostic imaging study to perform, even if plain radiographs appear normal or minimally changed?
Correct Answer & Explanation
. MRI of the entire spine.
Explanation
Correct Answer: CRationale:Patients with ankylosing spondylitis (AS) have a rigid, osteoporotic spine (bamboo spine) that is highly susceptible to fracture, even after minor trauma. These fractures often occur through the fused segments and can be highly unstable, even if minimally displaced on plain radiographs. There is a high risk of neurological injury, even with seemingly benign fractures. Therefore, an MRI of the entire spine is the most critical diagnostic imaging study. It can detect subtle fractures, assess for spinal cord edema or hemorrhage, and identify epidural hematomas, which are common and can cause delayed neurological deficits in AS patients. Plain radiographs and CT scans may underestimate the severity of the injury or miss soft tissue/cord involvement.Why other options are incorrect:A) Bone scan (technetium-99m):While sensitive for metabolic activity, it is not specific for fracture type or stability and does not provide detail on neural elements or soft tissue.B) Flexion-extension radiographs:These are contraindicated in the acute setting of suspected spinal fracture in AS patients due to the high risk of catastrophic neurological injury from an unstable spine.D) CT scan of the affected spinal segment:CT is excellent for bony detail but less sensitive than MRI for detecting spinal cord injury, ligamentous disruption, or epidural hematoma, which are critical concerns in AS fractures.E) Electromyography (EMG):EMG assesses nerve function but is not an acute diagnostic imaging study for fracture or spinal cord injury.
Question 1574
Topic: 6. Spine
A 55-year-old female presents with severe, progressive back pain radiating down both legs, worsening with standing and walking, and relieved by sitting or leaning forward. She also reports bilateral leg numbness and weakness. On examination, she has diminished patellar and Achilles reflexes bilaterally. What is the most likely diagnosis?
Correct Answer & Explanation
. Lumbar spinal stenosis
Explanation
Correct Answer: BThe classic symptoms of neurogenic claudication – bilateral leg pain, numbness, and weakness exacerbated by standing/walking and relieved by sitting/leaning forward (shopping cart sign) – are highly indicative of lumbar spinal stenosis. While a large disc herniation or spondylolisthesis can cause radiculopathy, bilateral symptoms relieved by flexion strongly point towards stenosis. Cauda equina syndrome would involve acute urinary retention, saddle anesthesia, and severe, progressive neurological deficits. Facet arthropathy typically causes axial back pain, potentially referred pain, but not classic neurogenic claudication.
Question 1575
Topic: 6. Spine
A 45-year-old man presents with acute onset of bilateral leg pain, saddle anesthesia, and urinary retention after lifting a heavy box. MRI shows a massive central disc herniation at L4-L5. Which of the following is the most critical factor in predicting full return of bladder function after decompression?
Correct Answer & Explanation
. Preoperative duration of symptoms
Explanation
The duration of symptoms prior to surgical decompression is the most critical prognostic factor for recovery in cauda equina syndrome. Surgery within 48 hours is generally recommended to maximize the likelihood of functional urologic recovery.
Question 1576
Topic: 6. Spine
A 60-year-old male presents with slowly progressive cervical myelopathy. MRI shows significant ossification of the posterior longitudinal ligament (OPLL). Which demographic profile and genetic marker are most strongly associated with this condition?
Correct Answer & Explanation
. Japanese male, COL6A1
Explanation
OPLL has a much higher prevalence in East Asian populations, particularly Japanese males. Genetic predisposition is complex but has been significantly linked to mutations in the COL6A1 gene.
Question 1577
Topic: 6. Spine
A 72-year-old male presents with deteriorating handwriting, frequent falls, and numbness in his hands. Exam reveals a positive Hoffmann sign bilaterally. MRI shows severe cervical stenosis from C3 to C6 with a T2 hyperintense signal and a T1 focal hypointense signal in the cord at C4-C5. Which MRI finding is most strongly associated with a poor prognosis for neurologic recovery following surgical decompression?
Correct Answer & Explanation
. T1 hypointensity in the spinal cord
Explanation
In cervical spondylotic myelopathy, T1 focal hypointensity within the spinal cord indicates myelomalacia (permanent cystic necrosis or gliosis). This finding is a strong predictor of poor neurologic recovery post-operatively compared to T2 hyperintensity alone, which represents potentially reversible edema.
Question 1578
Topic: 6. Spine
A 19-year-old female wearing a lap belt is involved in a head-on collision. Radiographs show a flexion-distraction injury (Chance fracture) through the L2 vertebra. Which concomitant injury must be aggressively ruled out?
Correct Answer & Explanation
. Hollow viscus intra-abdominal injury
Explanation
Chance fractures (flexion-distraction injuries) are highly associated with intra-abdominal hollow viscus injuries (especially bowel perforations) due to the lap-belt compression mechanism.
Question 1579
Topic: 6. Spine
A 10-year-old premenarchal girl presents with a chief complaint of 'scoliosis'. A PA full spine X-ray, shown below, was performed after a positive forward-bend test. Her curve measures 48 degrees, and she is hyperkyphotic on the lateral X-ray. No neurologic abnormalities, spondylolysis, or spondylolisthesis are detected on physical exam.
What is the most appropriate next step in her evaluation and treatment?
Correct Answer & Explanation
. Order an MRI of the cervical, thoracic, and lumbar spine
Explanation
Correct Answer: EThe correct answer is to order an MRI of the cervical, thoracic, and lumbar spine. This patient, a 10-year-old premenarchal girl, has a large scoliotic curve (48 degrees) with onset before age 10, classifying it as juvenile scoliosis. It is estimated that approximately 20% of children with juvenile scoliosis (onset 3–10 years old) have an intraspinal anomaly. Therefore, obtaining an MRI of the entire spine is crucial to look for conditions such as Chiari malformation, syringomyelia (syrinx), tethered cord, or spinal cord tumors. To thoroughly evaluate for these potential underlying diagnoses, the entire neural axis, including the base of the brain and cervical spine, must be imaged.Option A (Order laboratory tests including a CBC, ANA, and HLA-B27)is incorrect. While a CBC might be considered before potential surgical intervention, ANA and HLA-B27 are not typically indicated in the routine work-up of idiopathic or juvenile scoliosis unless there are specific clinical signs suggestive of inflammatory or rheumatologic conditions, which are not mentioned here.Option B (Order a bone density scan)is incorrect. A bone density scan is not a necessary part of the routine work-up for juvenile scoliosis. It may be considered in selected patients with specific concerns about underlying bone density issues, but not as a primary next step here.Option C (Prescribe a brace)is incorrect. For a curve of 48 degrees, bracing is generally not considered effective, and surgical intervention is often indicated. Even if the curve were smaller and bracing was a consideration, an MRI would still be necessary for a child with juvenile scoliosis to rule out intraspinal anomalies before initiating treatment.Option D (Order an MRI of the thoracic and lumbar spine)is incorrect. While an MRI is the correct imaging modality, it must include the cervical spine and base of the brain to adequately evaluate for Chiari malformation and other potential intraspinal anomalies that can affect the entire neural axis. Limiting the MRI to only the thoracic and lumbar spine would be an incomplete evaluation.
Question 1580
Topic: 6. Spine
A 3-year-old boy presents with his parents, who have noticed his spine 'looks crooked' over the last year and appears to be worsening. On examination, you confirm a spinal curvature and order X-rays, which are shown below.
Based on the X-ray findings, what is the most appropriate diagnosis for this child's spinal condition?
Correct Answer & Explanation
. Congenital scoliosis
Explanation
Correct Answer: CThe correct answer is Congenital scoliosis. The X-ray clearly demonstrates a hemivertebra in the lumbar spine. Congenital scoliosis is defined by structural abnormalities of the vertebrae that are present at birth, such as hemivertebrae, wedge vertebrae, or unilateral bars. These anomalies lead to an imbalance in spinal growth and result in a curvature.Option A (Infantile scoliosis)is incorrect. Infantile scoliosis is typically diagnosed in children from birth to 3 years of age, but it refers to a curve without an underlying structural vertebral anomaly (i.e., idiopathic). This child has a clear structural anomaly.Option B (Juvenile scoliosis)is incorrect. Juvenile scoliosis is diagnosed in children aged 3 to 10 years, but it also refers to idiopathic curves without underlying vertebral malformations.Option D (Idiopathic scoliosis)is incorrect. Idiopathic scoliosis is a diagnosis of exclusion, meaning there is no identifiable cause for the spinal curvature. This child has a clear congenital vertebral anomaly (hemivertebra) as the cause.Option E (A positional curve)is incorrect. A positional curve (or non-structural curve) is typically flexible and corrects with changes in position or bending. The presence of a hemivertebra indicates a fixed, structural abnormality, not merely a positional curve.
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