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6. Spine MCQs

Practice Set 8 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 141

Topic: 6. Spine

In a patient suspected of having Cauda Equina Syndrome, which of the following is considered the most sensitive early clinical sign or symptom?

. Complete lower extremity paralysis
. Fecal incontinence
. Urinary retention
. Bilateral absent Achilles reflexes
. Positive Babinski sign

Correct Answer & Explanation

. Urinary retention

Explanation

Urinary retention is the most sensitive early clinical finding in cauda equina syndrome. A normal post-void residual volume (typically <100-200 mL) makes the diagnosis of cauda equina syndrome highly unlikely.

Question 142

Topic: Thoracolumbar Spine & Deformity
Using the Thoracolumbar Injury Classification and Severity (TLICS) score, which of the following clinical scenarios most definitively indicates the need for surgical intervention (score > 4)?
. Compression fracture (morphology) with an intact posterior ligamentous complex (PLC)
. Burst fracture with an intact PLC and no neurologic deficit
. Translational/rotational injury with a complete neurologic deficit
. Isolated transverse process fractures
. Isolated spinous process fracture

Correct Answer & Explanation

. Translational/rotational injury with a complete neurologic deficit

Explanation

In the TLICS system, a translational/rotational injury yields 3 points, a complete neuro deficit yields 2 points, and a ruptured PLC yields 3 points. A total score greater than 4 is a strict indication for surgical stabilization.

Question 143

Topic: 6. Spine

A 65-year-old man with pre-existing cervical spondylosis presents after a hyperextension injury. He has disproportionately greater motor impairment in his upper extremities compared to his lower extremities. Which of the following spinal cord tracts is primarily responsible for the disproportionate upper extremity weakness?

. Lateral corticospinal tract
. Anterior spinothalamic tract
. Dorsal columns
. Fasciculus cuneatus
. Rubrospinal tract

Correct Answer & Explanation

. Lateral corticospinal tract

Explanation

The lateral corticospinal tract has a somatotopic organization where the cervical motor fibers are located more medially. This medial location makes them more susceptible to injury in central cord syndrome.

Question 144

Topic: 6. Spine

A 55-year-old male with a long history of ankylosing spondylitis sustains a seemingly minor fall. Radiographs reveal an extension-distraction fracture through the T8-T9 disc space. What is the most appropriate management?

. Rigid cervicothoracic orthosis for 12 weeks
. Short-segment posterior spinal fusion
. Long-segment posterior spinal instrumentation and fusion
. Anterior plate fixation only
. Physical therapy and early mobilization

Correct Answer & Explanation

. Long-segment posterior spinal instrumentation and fusion

Explanation

Fractures in ankylosing spondylitis are highly unstable due to the altered biomechanics of the fused spine. Long-segment posterior instrumentation (at least three levels above and below) is required to prevent failure.

Question 145

Topic: Thoracolumbar Spine & Deformity

A 30-year-old male falls from a height and sustains an L1 burst fracture. Neurological examination is completely normal. MRI demonstrates an intact posterior ligamentous complex (PLC). What is his Thoracolumbar Injury Classification and Severity (TLICS) score, and what is the recommended treatment?

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

Correct Answer & Explanation

. Score 2; Non-operative management

Explanation

The TLICS score is 2: morphology is burst (2 points), neurological status is intact (0 points), and PLC is intact (0 points). A score of 3 or less indicates non-operative management.

Question 146

Topic: Thoracolumbar Spine & Deformity

A 22-year-old female presents after a high-speed motor vehicle collision where she was wearing a lap belt. She sustains a flexion-distraction injury (Chance fracture) at L2. Which of the following associated injuries must be highly suspected and ruled out?

. Aortic dissection
. Hollow viscus injury
. Renal artery thrombosis
. Diaphragmatic rupture
. Pelvic ring disruption

Correct Answer & Explanation

. Hollow viscus injury

Explanation

Chance fractures (flexion-distraction injuries) in the setting of lap belt use are highly associated with intra-abdominal injuries. Hollow viscus (bowel) injuries occur in up to 50% of these cases.

Question 147

Topic: 6. Spine

A 14-year-old gymnast presents with persistent low back pain exacerbated by extension. Oblique radiographs of the lumbar spine demonstrate a "Scotty dog" with a collar. Which of the following anatomical structures corresponds to the "neck" of the Scotty dog?

. Transverse process
. Superior articular process
. Pars interarticularis
. Spinous process
. Pedicle

Correct Answer & Explanation

. Pars interarticularis

Explanation

On an oblique radiograph of the lumbar spine, the pars interarticularis forms the neck of the "Scotty dog." A break in the neck (collar) indicates a pars defect or spondylolysis.

Question 148

Topic: 6. Spine

A 45-year-old male presents with severe lower back pain, bilateral sciatica, and saddle anesthesia. Bladder ultrasound reveals a high post-void residual (PVR) volume. What PVR volume is highly sensitive for diagnosing urinary retention associated with cauda equina syndrome?

. Greater than 50 mL
. Greater than 100 mL
. Greater than 200 mL
. Greater than 500 mL
. Any measurable volume

Correct Answer & Explanation

. Greater than 500 mL

Explanation

A post-void residual (PVR) volume greater than 500 mL indicates significant urinary retention. It is highly sensitive for cauda equina syndrome in the context of saddle anesthesia and sciatica.

Question 149

Topic: 6. Spine

A 60-year-old diabetic patient presents with fever, severe back pain, and progressive paraparesis. MRI confirms a spinal epidural abscess. What is the most common causative organism?

. Streptococcus pneumoniae
. Escherichia coli
. Pseudomonas aeruginosa
. Staphylococcus aureus
. Mycobacterium tuberculosis

Correct Answer & Explanation

. Staphylococcus aureus

Explanation

Staphylococcus aureus is the most common organism responsible for spinal epidural abscesses. It accounts for up to two-thirds of all cases, particularly in diabetic patients and intravenous drug users.

Question 150

Topic: Cervical Spine

A patient sustains an axial load injury resulting in a burst fracture of the C1 ring (Jefferson fracture). Which of the following radiographic measurements on an open-mouth odontoid view suggests rupture of the transverse atlantal ligament?

. Combined lateral mass displacement > 6.9 mm
. Atlantodental interval (ADI) > 3 mm
. Basion-dental interval > 12 mm
. Prevertebral soft tissue > 7 mm at C2
. Space available for the cord (SAC) < 13 mm

Correct Answer & Explanation

. Combined lateral mass displacement > 6.9 mm

Explanation

According to the Rule of Spence, if the sum of the overhang of the C1 lateral masses on C2 is greater than 6.9 mm on an open-mouth view, the transverse ligament is likely ruptured.

Question 151

Topic: 6. Spine

A 5-year-old child presents after a minor fall. Lateral cervical spine radiographs show 3 mm of anterior displacement of C2 on C3. Which of the following radiographic lines is most useful to differentiate physiological pseudosubluxation from true injury?

. McRae line
. Chamberlain line
. Swischuk line
. Wackenheim clivus line
. Harris measurement

Correct Answer & Explanation

. Swischuk line

Explanation

The Swischuk line connects the anterior cortices of the posterior arches of C1 and C3. If the anterior cortex of the C2 posterior arch lies within 1.5 mm of this line, it is considered physiological pseudosubluxation.

Question 152

Topic: 6. Spine
A patient sustains a traumatic spondylolisthesis of the axis (Hangman's fracture) resulting from combined flexion and compression. Radiographs show severe displacement and angulation with unilateral facet dislocation. According to Levine and Edwards, what type of fracture is this?
. Type I
. Type II
. Type IIA
. Type III
. Type IV

Correct Answer & Explanation

. Type III

Explanation

A Levine-Edwards Type III fracture involves a bipedicle fracture of C2 with unilateral or bilateral facet dislocation of C2 on C3. It is caused by a flexion and compression mechanism.

Question 153

Topic: 6. Spine
A 40-year-old male is placed in a halo vest for a cervical spine fracture. He subsequently reports difficulty opening his eyes and lateral gaze diplopia. Which cranial nerve has been injured, likely due to improper pin placement?
. Cranial nerve III
. Cranial nerve IV
. Cranial nerve V
. Cranial nerve VI
. Cranial nerve VII

Correct Answer & Explanation

. Cranial nerve VI

Explanation

The abducens nerve (Cranial nerve VI) is the most commonly injured cranial nerve in halo traction or vest placement. This leads to a lateral rectus palsy and lateral gaze diplopia.

Question 154

Topic: 6. Spine

A patient complains of anterior thigh pain and weakness in knee extension. Examination reveals a diminished patellar reflex and sensory loss over the medial aspect of the lower leg. Which nerve root is most likely involved?

. L2
. L3
. L4
. L5
. S1

Correct Answer & Explanation

. L4

Explanation

L4 radiculopathy classically involves weakness in knee extension, a diminished patellar reflex, and sensory loss over the medial aspect of the lower leg.

Question 155

Topic: Thoracolumbar Spine & Deformity

Which of the following patient profiles is most strongly associated with the development of degenerative lumbar spondylolisthesis?

. Teenage male athlete
. Young female with a pars interarticularis defect
. Caucasian female over 50 years of age
. Male over 60 years of age with DISH
. Any patient with prior lumbar fusion

Correct Answer & Explanation

. Caucasian female over 50 years of age

Explanation

Degenerative lumbar spondylolisthesis occurs most frequently at the L4-L5 level. It is classically seen in females over the age of 50, particularly those with more sagittally oriented facet joints.

Question 156

Topic: 6. Spine

During an anterior cervical discectomy and fusion, a surgeon considers using recombinant human bone morphogenetic protein-2 (rhBMP-2). Which of the following is a recognized complication specifically associated with the anterior cervical use of rhBMP-2, leading to an FDA warning?

. Malignant transformation
. Severe retroperitoneal fibrosis
. Massive prevertebral soft tissue swelling and dysphagia
. Rapid systemic hypocalcemia
. Irreversible vocal cord paralysis

Correct Answer & Explanation

. Massive prevertebral soft tissue swelling and dysphagia

Explanation

The FDA issued a black box warning regarding the use of rhBMP-2 in the anterior cervical spine. It has been associated with life-threatening complications, including massive prevertebral soft tissue swelling, dysphagia, and airway compromise.

Question 157

Topic: 6. Spine

Which of the following statements is false regarding minimally invasive transperitoneal anterior lumbar interbody fusion:

. This technique may be safely performed at all lumbar levels.
. This technique allows direct access to pathology in the vertebral body.
. Laparoscopy is of great value in the transperitoneal approach to the anterior lumbar spine.
. There is a potential risk of injuring the aorta and its bifurcation with this technique.
. None of the above

Correct Answer & Explanation

. This technique may be safely performed at all lumbar levels.

Explanation

Due to the potential risk of injury to the aorta and its bifurcation, which occurs at the L4 level, this procedure is difficult and may be impossible to perform above the L4 level. Retroperitoneal approaches allow access to more superior lumbar levels due to the more lateral trajectory taken to avoid the aorta and its bifurcation.

Question 158

Topic: 6. Spine

All of the following are elements of the lateral mass of cervical spinal segments except:

. Inferior articulating process
. Superior articulating process
. Spinous process
. Transverse process
. Transverse foramen

Correct Answer & Explanation

. Spinous process

Explanation

The lateral mass of the cervical spinal segments includes the inferior and superior articulating processes, the transverse foramen, and the transverse process. The spinous process is not an element of the lateral mass.

Question 159

Topic: 6. Spine

Which of the following is/are potential complications associated with posterior cervical decompression and placement of lateral mass screws:

. Injury to the vertebral artery
. Compression injury to the spinal cord
. Traction injury to the cervical nerve roots
. Injury to the vertebral artery and traction injury to the cervical nerve roots only
. Injury to the vertebral artery, traction injury to the cervical nerve, and traction injury to the cervical nerve roots

Correct Answer & Explanation

. Injury to the vertebral artery, traction injury to the cervical nerve, and traction injury to the cervical nerve roots

Explanation

All of the above are potential complications associated with posterior cervical decompression and placement of lateral mass screws.

Question 160

Topic: 6. Spine

Which of the following conditions is not associated with cervical fractures:

. Rheumatoid arthritis
. Ossiculum terminale
. Ankylosing spondylitis
. Os odontoideum
. None of the above

Correct Answer & Explanation

. Ossiculum terminale

Explanation

Rheumatoid arthritis, ankylosing spondylitis, and os odontoideum have been associated with fractures as part of their presentation or etiology. Os odontoideum is most likely an old nonunion fracture or injury to vascular supply of the developing odontoid process. However, one has to differentiate true os odontoideum from the more common ossiculum terminale, which describes the nonunion of the apex at the secondary ossification center and is not a fracture.

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