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6. Spine MCQs

Practice Set 85 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 1681

Topic: 6. Spine

A 60-year-old diabetic patient is being evaluated for surgical reconstruction of a Charcot foot deformity. During preoperative vascular assessment, which of the following findings would be most predictive of successful wound healing post-surgery?

. An Ankle-Brachial Index (ABI) of 1.2.
. A palpable dorsalis pedis pulse.
. A Toe-Brachial Index (TBI) of 0.4.
. A transcutaneous oxygen measurement (TcPO2) of 45 mmHg.
. Absence of claudication symptoms.

Correct Answer & Explanation

. A transcutaneous oxygen measurement (TcPO2) of 45 mmHg.

Explanation

Correct Answer: DThe case emphasizes the paramount importance of vascular assessment. It states: 'Non-invasive vascular studies, including Ankle-Brachial Indices (ABIs) and Toe-Brachial Indices (TBIs), should be obtained. In diabetic patients with calcified vessels, ABIs may be falsely elevated; therefore, transcutaneous oxygen measurements (TcPO2) or arterial duplex ultrasonography are often required. A TcPO2 greater than 40 mmHg is generally predictive of successful wound healing.' An ABI of 1.2 (Option A) could be falsely elevated in a diabetic patient due to vessel calcification. A palpable pulse (Option B) does not rule out microvascular disease. A TBI of 0.4 (Option C) is generally considered poor vascularity. Absence of claudication (Option E) is a symptom assessment, not a direct measure of healing potential.

Question 1682

Topic: 6. Spine

A 45-year-old man presents with a painless, massively swollen left shoulder. Radiographs show severe destruction of the humeral head, massive joint debris, and dislocation. Neurological examination reveals a loss of pain and temperature sensation in a "cape-like" distribution over his shoulders and upper extremities. What is the most appropriate next diagnostic step to determine the underlying etiology?

. Fluoroscopically guided joint aspiration.
. MRI of the cervical spine.
. Serum VDRL and RPR testing.
. Electromyography (EMG) of the upper extremities.
. Fasting blood glucose and HbA1c.

Correct Answer & Explanation

. MRI of the cervical spine.

Explanation

The patient has a neuropathic (Charcot) arthropathy of the shoulder, which in the upper extremity is classic for syringomyelia. The "cape-like" distribution of sensory loss indicates a central cord lesion, which is best evaluated with an MRI of the cervical spine.

Question 1683

Topic: 6. Spine

What is the primary role of the annulus fibrosus in the intervertebral disc?

. Bear axial load
. Permit spinal flexibility
. Contain the nucleus pulposus
. Produce collagen and proteoglycans
. Serve as a shock absorber

Correct Answer & Explanation

. Contain the nucleus pulposus

Explanation

Correct Answer: CThe annulus fibrosus, composed of concentric lamellae of collagen fibers, primarily functions to contain the nucleus pulposus and resist tensile forces during spinal movements. While it contributes to bearing axial load and spinal flexibility, its most critical role is to encapsulate the highly hydrated nucleus pulposus. The nucleus pulposus itself acts more as the shock absorber, and the annulus maintains its position. Fibroblasts within the annulus produce collagen and proteoglycans, but this is a cellular function, not the primary structural role.

Question 1684

Topic: 6. Spine

A 65-year-old male presents with bilateral lower extremity pain and cramping that worsens with walking and prolonged standing. He notes the symptoms are reliably relieved when leaning forward on a shopping cart. Which of the following differentiates neurogenic claudication from vascular claudication?

. Symptoms start distally and spread proximally
. Symptoms are completely relieved by simply stopping and standing still
. Pulses are symmetrically diminished
. Symptoms are relieved by lumbar flexion
. Skin shows trophic changes and hair loss

Correct Answer & Explanation

. Symptoms are relieved by lumbar flexion

Explanation

Neurogenic claudication is classically relieved by lumbar flexion (e.g., leaning on a shopping cart), which increases the cross-sectional area of the spinal canal. Vascular claudication is typically relieved simply by resting or standing still, without a change in posture.

Question 1685

Topic: Thoracolumbar Spine & Deformity

A 16-year-old gymnast complains of chronic low back pain. Radiographs show a Grade II L5-S1 isthmic spondylolisthesis. If the patient develops radicular symptoms, which nerve root is most commonly affected due to foraminal compression?

. L4
. L5
. S1
. S2
. L3

Correct Answer & Explanation

. L5

Explanation

In an L5-S1 isthmic spondylolisthesis, the slip occurs through the pars interarticularis. The exiting L5 nerve root is most commonly compressed within the neural foramen by the fibrocartilaginous mass at the pars defect.

Question 1686

Topic: 6. Spine

A 65-year-old female presents with deteriorating handwriting and difficulty buttoning her shirt. Exam reveals a positive Hoffmann sign and hyperreflexia in the lower extremities. MRI confirms severe cervical stenosis with cord signal changes at C4-C5 and C5-C6. What is the most appropriate next step in management?

. Physical therapy and traction
. Epidural steroid injection
. Anterior cervical discectomy and fusion
. Cervical collar immobilization
. Gabapentin and observation

Correct Answer & Explanation

. Anterior cervical discectomy and fusion

Explanation

This patient presents with progressive cervical spondylotic myelopathy. Surgical decompression and stabilization (e.g., ACDF) is indicated to halt progression, as non-operative management typically leads to stepwise neurologic decline.

Question 1687

Topic: Thoracolumbar Spine & Deformity

A 15-year-old elite gymnast presents with mechanical low back pain. Radiographs demonstrate a Grade 1 isthmic spondylolisthesis at L5-S1. She is neurologically intact. What is the most appropriate initial management?

. Posterior spinal fusion from L5 to S1
. Pars interarticularis repair
. Activity modification, core strengthening, and physical therapy
. Epidural steroid injection
. Full-time thoracolumbosacral orthosis (TLSO) for 1 year

Correct Answer & Explanation

. Activity modification, core strengthening, and physical therapy

Explanation

For low-grade isthmic spondylolisthesis in adolescents without neurologic deficits, initial management should be nonoperative. This includes a temporary cessation of hyperextension activities, bracing if acutely symptomatic, and core-strengthening physical therapy.

Question 1688

Topic: 6. Spine

During the surgical procedure for this patient's Hypothenar Hammer Syndrome, the pathological ulnar artery segment (aneurysm and thrombotic occlusion) is resected. Given the length of the resected segment (approximately 3.5 cm) and the goal of restoring distal arterial flow, what is the most appropriate method for arterial reconstruction?

. Primary end-to-end anastomosis of the ulnar artery.
. Ligation of the ulnar artery without reconstruction.
. Reconstruction with an autogenous vein graft.
. Placement of a synthetic prosthetic graft.
. Embolectomy and patch angioplasty.

Correct Answer & Explanation

. Reconstruction with an autogenous vein graft.

Explanation

Correct Answer: CThe case explicitly states: 'Given the patient's symptomatic digital ischemia and the length of the occluded segment, an interposition graft was deemed the preferred approach to restore distal arterial flow and optimize digital perfusion.' Furthermore, under 'Vein Graft Harvest,' it mentions 'a suitable segment of autogenous vein was harvested.' Autogenous vein grafts are generally preferred for small-diameter arterial reconstructions in the hand due to their superior patency rates compared to synthetic grafts and their biological compatibility.Why other options are incorrect:A. Primary end-to-end anastomosis of the ulnar artery:A 3.5 cm defect is too long for a tension-free primary anastomosis, which would lead to kinking, tension, and likely graft failure.B. Ligation of the ulnar artery without reconstruction:The case clearly states 'inadequate collateral circulation' and 'insufficient collateral flow from the radial artery to adequately perfuse the ulnar digits.' Simple ligation would risk further exacerbating severe, irreversible digital ischemia or necrosis.D. Placement of a synthetic prosthetic graft:While used in larger vessels, synthetic grafts have significantly lower patency rates in small-diameter vessels like the ulnar artery in the hand compared to autogenous vein grafts, and are prone to thrombosis.E. Embolectomy and patch angioplasty:Embolectomy addresses an acute embolus, but this patient has a chronic aneurysm with intraluminal thrombus and occlusion. Patch angioplasty might be used for a short stenosis but is insufficient for a 3.5 cm resected segment with an aneurysm and occlusion.

Question 1689

Topic: 6. Spine

A 50-year-old construction worker presents with classic symptoms of Hypothenar Hammer Syndrome. If surgical intervention is planned, preoperative imaging is required. Besides conventional angiography, which non-invasive modality is considered highly sensitive and often the first line for vascular mapping?

. Plain radiography of the hand
. Non-contrast MRI of the cervical spine
. Color Duplex Ultrasonography
. Bone scintigraphy (Bone scan)
. Electromyography (EMG)

Correct Answer & Explanation

. Color Duplex Ultrasonography

Explanation

Color Duplex Ultrasonography is a highly sensitive, non-invasive first-line imaging modality for HHS. It can easily identify ulnar artery thrombosis, aneurysm, and the patency of the superficial palmar arch prior to surgical intervention.

Question 1690

Topic: 6. Spine

What characteristic angiographic finding distinguishes hypothenar hammer syndrome from other causes of digital ischemia such as Buerger's disease or Raynaud's phenomenon?

. Bilateral symmetric tapering of digital arteries
. Proximal subclavian artery stenosis
. A "corkscrew" configuration of the ulnar artery near the hamate
. Absence of the deep palmar arch
. Diffuse calcification of the radial and ulnar arteries

Correct Answer & Explanation

. A "corkscrew" configuration of the ulnar artery near the hamate

Explanation

Angiography in HHS typically shows a "corkscrew" appearance, aneurysm, or focal occlusion of the ulnar artery adjacent to the hamate. Systemic conditions like Raynaud's usually present with symmetric, diffuse vasospasm rather than a focal anatomic lesion.

Question 1691

Topic: 6. Spine

A 3-week-old newborn, presenting with a clinical picture consistent with Erb-Duchenne palsy, undergoes an MRI of the cervical spine and brachial plexus. An image similar to the T2-weighted sagittal view shown below is obtained. The finding of T2 hyperintensity and thickening of the C5 and C6 nerve roots, without clear evidence of pseudomeningoceles, as described in the case, most accurately suggests which type of injury?

. Complete preganglionic avulsion of C5 and C6.
. Isolated neurapraxia of the upper trunk.
. Severe postganglionic injury (rupture or neuroma-in-continuity) of C5 and C6.
. Phrenic nerve palsy with associated C5 involvement.
. Spinal cord contusion at the C5-C6 level.

Correct Answer & Explanation

. Severe postganglionic injury (rupture or neuroma-in-continuity) of C5 and C6.

Explanation

Correct Answer: CThe case explicitly states the MRI findings: "Sagittal and Axial T2-weighted images demonstrated T2 hyperintensity and thickening of the right C5 and C6 nerve roots in the supraclavicular fossa, consistent with significant stretch injury and edema, likely representing neuromas-in-continuity or ruptures. No clear evidence of pseudomeningoceles in the cervical spinal canal, which reduces the likelihood of complete preganglionic C5/C6 avulsion, but does not definitively rule it out."T2 hyperintensity and thickening:These are classic MRI signs of nerve injury, indicating edema, inflammation, and scar tissue formation within the nerve, consistent with a neuroma-in-continuity or a complete rupture.Absence of pseudomeningoceles:Pseudomeningoceles (extradural collections of CSF) are highly suggestive of preganglionic root avulsions from the spinal cord. Their absence in this case makes a complete preganglionic avulsion less likely, although it doesn't entirely rule out partial avulsions or avulsions without meningeal tearing.Therefore, the findings point towards a severe postganglionic injury, such as a rupture or neuroma-in-continuity, rather than a preganglionic avulsion or a mild neurapraxia (which would typically not show such significant T2 changes at 3 weeks).

Question 1692

Topic: 6. Spine

A 1-month-old infant presents with a flaccid right upper extremity following a complicated macrosomic delivery. Physical examination reveals an ipsilateral ptosis and miosis. Which of the following is the most appropriate management?

. Observation with physical therapy and reassessment at 3 months
. Immediate MRI of the cervical spine
. Early microsurgical nerve exploration and grafting
. EMG and nerve conduction studies at 6 weeks
. Botulinum toxin injection to the antagonist muscles

Correct Answer & Explanation

. Early microsurgical nerve exploration and grafting

Explanation

Horner's syndrome (ptosis, miosis, anhidrosis) in the setting of neonatal brachial plexus palsy indicates a preganglionic avulsion of the lower roots (C8-T1). This is a poor prognostic sign for spontaneous recovery and is a strong indication for early microsurgical intervention.

Question 1693

Topic: 6. Spine

A 45-year-old male presents with acute, severe, unremitting right shoulder pain that started one week ago without trauma. The pain is now resolving, but he has noted profound weakness in shoulder abduction and external rotation. MRI of the cervical spine and shoulder are unremarkable. What is the most likely diagnosis?

. C5 radiculopathy
. Massive rotator cuff tear
. Parsonage-Turner syndrome
. Quadrilateral space syndrome
. Adhesive capsulitis

Correct Answer & Explanation

. Parsonage-Turner syndrome

Explanation

Parsonage-Turner syndrome (idiopathic brachial neuritis) classically presents with an acute onset of severe shoulder pain lasting days to weeks, followed by patchy muscle weakness as the pain subsides.

Question 1694

Topic: 6. Spine

A 28-year-old male undergoes exploration of the brachial plexus 4 months after a C5-C6 injury. A neuroma-in-continuity is identified at the upper trunk. Intraoperative nerve action potential (NAP) testing across the neuroma yields a positive response. What is the most appropriate next step?

. Resection of the neuroma and sural nerve cable grafting
. External neurolysis alone
. Oberlin nerve transfer
. Spinal accessory to suprascapular nerve transfer
. Amputation of the affected limb

Correct Answer & Explanation

. External neurolysis alone

Explanation

A positive nerve action potential (NAP) across a neuroma-in-continuity indicates viable regenerating axons crossing the lesion. The standard treatment is external neurolysis, leaving the nerve intact to allow continued spontaneous recovery.

Question 1695

Topic: 6. Spine

A 55-year-old male is undergoing a lumbar spinal fusion. During the procedure, the anesthesiologist notes a sudden drop in blood pressure from 120/70 mmHg to 80/40 mmHg, accompanied by an increase in end-tidal CO2 from 35 mmHg to 55 mmHg. The surgical field is dry, and estimated blood loss is minimal. What is the most likely diagnosis?

. Massive hemorrhage
. Pulmonary embolism
. Anaphylaxis to an antibiotic
. Venous air embolism
. Spinal shock

Correct Answer & Explanation

. Venous air embolism

Explanation

Correct Answer: DThe sudden drop in blood pressure and concurrent increase in end-tidal CO2 during a spinal surgery, particularly when the surgical field is dry, is highly suggestive of a venous air embolism (VAE). Air can enter open venous sinuses in the surgical field (especially in elevated positions like prone or sitting), travel to the heart, and obstruct the right ventricular outflow tract, leading to acute right heart failure and circulatory collapse. The increased end-tidal CO2 results from air trapping in the pulmonary vasculature, impairing gas exchange, and then a subsequent decrease as cardiac output falls. Massive hemorrhage would cause hypotension but not typically an acute increase in end-tidal CO2. Pulmonary embolism could cause hypotension, but an acute, significant ETCO2 increase is less typical. Anaphylaxis presents with bronchospasm, rash, and other signs. Spinal shock occurs with acute spinal cord injury and typically involves vasodilation below the level of injury, not an increase in ETCO2.

Question 1696

Topic: 6. Spine

A 70-year-old male with pre-existing cervical spondylosis is brought to the emergency department after falling forward and striking his chin, hyperextending his neck. He presents with profound bilateral upper extremity motor weakness but preserved distal lower extremity strength and intact bowel/bladder function. What is the most likely diagnosis?

. Anterior cord syndrome
. Central cord syndrome
. Brown-Sequard syndrome
. Posterior cord syndrome
. Spinal shock

Correct Answer & Explanation

. Central cord syndrome

Explanation

Central cord syndrome classically occurs in elderly patients with pre-existing cervical spondylosis following hyperextension injuries. It disproportionately affects the medially located cervical motor tracts, leading to upper extremity weakness greater than lower extremity weakness.

Question 1697

Topic: 6. Spine

A 75-year-old female presents with bilateral leg heaviness and pain that worsens with walking and prolonged standing, but improves significantly when she leans forward over a shopping cart. Hypertrophy of which of the following structures is the primary posterior contributor to this specific pathology?

. Posterior longitudinal ligament
. Anterior longitudinal ligament
. Ligamentum flavum
. Interspinous ligament
. Supraspinous ligament

Correct Answer & Explanation

. Ligamentum flavum

Explanation

This patient has classic neurogenic claudication due to lumbar spinal stenosis. The narrowing of the spinal canal is primarily caused by facet joint arthropathy, intervertebral disc bulging, and hypertrophy of the ligamentum flavum posteriorly.

Question 1698

Topic: 6. Spine

A 60-year-old male presents with severe neck pain radiating down his right arm, diagnosed as an isolated C5 radiculopathy due to a foraminal disc herniation. Which of the following neurological deficits is expected on physical examination?

. Weakness in wrist extension and an absent brachioradialis reflex
. Weakness in elbow flexion and shoulder abduction, with an absent biceps reflex
. Weakness in elbow extension and an absent triceps reflex
. Weakness in finger abduction with normal reflexes
. Weakness in thumb extension with an absent triceps reflex

Correct Answer & Explanation

. Weakness in elbow flexion and shoulder abduction, with an absent biceps reflex

Explanation

A C5 radiculopathy affects the deltoid and biceps muscles, resulting in weakness in shoulder abduction and elbow flexion, along with an absent or diminished biceps reflex.

Question 1699

Topic: Thoracolumbar Spine & Deformity

When planning for percutaneous iliosacral screw fixation, which of the following is a classic radiographic hallmark of sacral dysmorphism?

. Sacral kyphosis
. Acute sacral alar slope
. Perfectly circular sacral neural foramina
. A deeply seated (sunken) upper sacrum
. Absence of mammillary bodies

Correct Answer & Explanation

. Acute sacral alar slope

Explanation

Radiographic signs of sacral dysmorphism include an acute (steep) alar slope, residual intervertebral discs, non-circular neural foramina, an elevated upper sacrum, and the presence of mammillary bodies.

Question 1700

Topic: 6. Spine

A 42-year-old male sustains a pelvic ring injury with a sacral fracture passing vertically through the sacral foramina. If the patient develops a neurological deficit, which of the following is the most likely clinical presentation?

. Cauda equina syndrome
. Symmetrical bilateral lower extremity weakness
. Unilateral sciatica or radiculopathy
. Complete paraplegia
. Isolated loss of anal sphincter tone

Correct Answer & Explanation

. Unilateral sciatica or radiculopathy

Explanation

A Denis Zone II fracture passes through the sacral foramina and has an intermediate risk of neurological deficit (approximately 28%). Injuries most commonly cause unilateral radiculopathy (sciatica) due to direct involvement of the exiting nerve roots in the affected foramina.

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