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 1721
Topic: 6. Spine
On MRI, a spinal epidural abscess typically appears as what on T2-weighted images?
Correct Answer & Explanation
. Hyperintense with a peripheral hypointense rim
Explanation
Correct Answer: CSpinal epidural abscesses typically appear hyperintense on T2-weighted images due to the high fluid content of pus. They are often surrounded by a peripheral hypointense rim (representing granulation tissue or inflammatory changes) that shows significant enhancement after gadolinium administration. Homogenously hypointense or isointense to CSF are incorrect. Hyperintense without significant contrast enhancement would be atypical for an active abscess, which typically enhances due to inflammation and vascularity of the capsule.
Question 1722
Topic: 6. Spine
Which of the following conditions is LEAST likely to mimic a spinal epidural abscess on initial presentation, considering its typical clinical picture?
Correct Answer & Explanation
. Vertebral compression fracture due to osteoporosis
Explanation
A spinal epidural abscess commonly presents with back pain, fever, and neurological deficits. A simple osteoporotic vertebral compression fracture, while causing back pain, typically does not present with fever or progressive neurological deficits unless there is associated cord compression, which would be atypical for the initial presentation of an uncomplicated osteoporotic fracture.
Question 1723
Topic: 6. Spine
What is the typical recommended duration of intravenous antibiotic therapy for an uncomplicated pyogenic spinal epidural abscess managed non-surgically, assuming cultures are positive for a sensitive organism?
Correct Answer & Explanation
. 6-8 weeks
Explanation
Correct Answer: CFor pyogenic spinal epidural abscesses (SEA), especially those managed non-surgically or those that have undergone successful debridement, a prolonged course of antibiotics is crucial to prevent recurrence and ensure eradication. A typical duration is 6-8 weeks of intravenous antibiotics, often followed by a transition to oral antibiotics for a similar duration, or sometimes 8-12 weeks total with IV transitioning to oral. The total duration depends on the pathogen, host factors, and resolution of inflammatory markers, but 6-8 weeks IV is a standard starting point for uncomplicated cases. 2-4 weeks is generally too short for eradication of established spinal infection, while 3-6 months is more typical for complicated osteomyelitis or prosthetic joint infections.
Question 1724
Topic: 6. Spine
A 45-year-old male presents with right flank pain, limping, and an inability to fully extend his right hip. He has a history of Crohn's disease. On examination, he has tenderness in the right iliac fossa and a positive psoas sign. What is the most appropriate imaging study to confirm the diagnosis and assess for a potential spinal origin?
Correct Answer & Explanation
. MRI of the lumbar spine and pelvis with contrast
Explanation
Correct Answer: CWhile CT abdomen/pelvis with IV contrast is excellent for visualizing psoas abscesses, MRI of the lumbar spine and pelvis with contrast offers superior soft tissue resolution, allowing for better identification of the primary source (e.g., discitis, vertebral osteomyelitis), the extent of the abscess, and any intraspinal involvement. Given that psoas abscesses can often originate from spinal infections (or in Crohn's disease, directly from the bowel), MRI provides a more comprehensive assessment of both spinal and psoas pathology. The psoas sign is classic for psoas irritation/abscess.
Question 1725
Topic: 6. Spine
A patient from an endemic area presents with chronic back pain, night sweats, and weight loss. Imaging reveals destruction of multiple contiguous vertebral bodies with associated large paraspinal abscesses and severe kyphotic deformity. Which pathogen is most likely responsible?
Correct Answer & Explanation
. Mycobacterium tuberculosis
Explanation
Correct Answer: CThis clinical presentation, including chronic symptoms, systemic signs (night sweats, weight loss), destruction of multiple contiguous vertebral bodies (often with relative disc sparing initially but progressing to disc and multiple levels), large paraspinal 'cold' abscesses, and progressive kyphotic deformity (Pott's kyphosis), is classic for spinal tuberculosis (Pott's disease). It is more common in endemic areas and immunocompromised individuals. The other pathogens typically cause pyogenic infections with a more acute course.
Question 1726
Topic: 6. Spine
Which of the following criteria would NOT typically favor non-operative management of a spinal epidural abscess?
Correct Answer: EProgressive neurological deficit, especially despite appropriate antibiotic therapy, is a strong absolute indication for urgent surgical decompression of a spinal epidural abscess. This represents failure of medical management and an increasing threat of irreversible neurological damage. The other options (no or minimal neurological deficit, small abscess, responsive infection, and severe comorbidities precluding surgery) are factors that would favor an attempt at non-operative management with close monitoring.
Question 1727
Topic: 6. Spine
A 70-year-old male with a history of prostate cancer presents with new onset of severe mid-thoracic back pain, bilateral lower extremity weakness, and urinary retention. Neurological exam reveals a T8 sensory level and paraparesis (motor grade 2/5 bilaterally). What is the MOST appropriate initial management step?
Correct Answer & Explanation
. Administer IV Dexamethasone and obtain emergent MRI spine.
Explanation
Correct Answer: AThis patient presents with signs and symptoms of acute spinal cord compression due to suspected metastatic disease. The priority is to prevent further neurological deterioration. High-dose IV corticosteroids (Dexamethasone) should be administered immediately to reduce edema around the spinal cord, and an emergent MRI of the entire spine is crucial to delineate the extent of compression, identify instability, and guide definitive treatment. Surgical decompression or radiation therapy will be considered after imaging and patient assessment, but steroids and imaging are the initial, most time-sensitive steps. Plain radiographs are insufficient for diagnosing spinal cord compression.
Question 1728
Topic: 6. Spine
A 68-year-old male presents with difficulty buttoning his shirt and a progressive change in his gait. Examination reveals an inverted brachioradialis reflex. This finding is most indicative of compressive pathology at which of the following spinal levels?
Correct Answer & Explanation
. C5-C6
Explanation
An inverted brachioradialis reflex indicates a lower motor neuron lesion at C5-C6 and an upper motor neuron lesion below this level. It is a classic localizing sign of cervical spondylotic myelopathy at the C5-C6 spinal segment.
Question 1729
Topic: 6. Spine
A 60-year-old female presents with severe neurogenic claudication. Imaging shows a grade I degenerative spondylolisthesis at L4-L5. If conservative management fails, which nerve root is most likely compressed within the lateral recess at this level?
Correct Answer & Explanation
. L5
Explanation
In degenerative spondylolisthesis at L4-L5, the traversing L5 nerve root is most commonly compressed within the lateral recess. The exiting L4 root may be affected by a far lateral disc herniation, but lateral recess stenosis primarily affects the traversing root.
Question 1730
Topic: Cervical Spine
An 82-year-old male sustains a Type II odontoid fracture. He has severe medical comorbidities making surgery high risk. If treated non-operatively with a rigid cervical collar, which factor is most highly associated with an increased risk of non-union?
Correct Answer & Explanation
. Displacement greater than 5 mm
Explanation
Risk factors for non-union of Type II odontoid fractures include initial displacement > 5 mm, angulation > 10 degrees, age > 65 years, and delayed treatment. Displacement > 5 mm is one of the strongest independent predictors of non-union.
Question 1731
Topic: 6. Spine
A 54-year-old intravenous drug user presents with mid-back pain, a low-grade fever, and progressive bilateral lower extremity weakness over the past 48 hours. MRI of the thoracic spine reveals a ventral epidural abscess spanning T6-T8 with severe anterior spinal cord compression. What is the most appropriate surgical approach for this patient?
Correct Answer & Explanation
. Anterior corpectomy, debridement, and structural fusion
Explanation
Anterior epidural abscesses causing severe cord compression require an anterior approach (corpectomy and fusion) to directly decompress the cord. A posterior approach requires dangerous retraction of the already compromised spinal cord to access the ventral pathology.
Question 1732
Topic: Thoracolumbar Spine & Deformity
In the radiographic evaluation of adult spinal deformity, which of the following spinopelvic parameters is most highly correlated with poor health-related quality of life (HRQOL) scores and serves as a primary target during surgical correction?
Correct Answer & Explanation
. Sagittal vertical axis (SVA)
Explanation
Sagittal vertical axis (SVA) measures global sagittal alignment and is one of the strongest radiographic predictors of pain and disability in adult spinal deformity. Restoration of neutral sagittal alignment is a primary surgical goal.
Question 1733
Topic: Thoracolumbar Spine & Deformity
A 30-year-old male falls from a height of 15 feet, sustaining a T12 burst fracture. He is neurologically intact. Which of the following radiographic findings is most specifically indicative of a posterior ligamentous complex (PLC) injury, necessitating surgical stabilization?
Correct Answer & Explanation
. Widening of the interspinous distance on the AP radiograph
Explanation
Widening of the interspinous distance (splaying of the spinous processes) on an AP radiograph strongly indicates disruption of the posterior ligamentous complex (PLC). A disrupted PLC implies significant biomechanical instability requiring surgical stabilization.
Question 1734
Topic: 6. Spine
A 45-year-old male presents with severe right leg pain radiating to the dorsum of his foot and great toe. Neurological examination reveals 3/5 weakness in extensor hallucis longus (EHL) and decreased sensation over the first dorsal web space. A paracentral disc herniation at which lumbar level is most likely responsible?
Correct Answer & Explanation
. L4-L5
Explanation
A paracentral disc herniation at L4-L5 typically impinges the traversing L5 nerve root. An L5 radiculopathy is classically characterized by weakness in great toe extension (EHL) and numbness in the first dorsal web space.
Question 1735
Topic: 6. Spine
A 12-year-old patient presents with the spinal deformity shown in the radiograph. The examiner identifies a left-sided lumbar scoliosis attributed to a hemivertebra. Which of the following statements regarding the classification and characteristics of this type of scoliosis is most accurate?
Correct Answer & Explanation
. This is a congenital scoliosis, where the vertebral abnormality is present at birth, and the scoliosis develops with subsequent growth.
Explanation
Correct Answer: CThe radiograph clearly shows a hemivertebra in the lumbar spine, which is a congenital vertebral anomaly. The case explicitly states, 'The radiograph shows a congenital scoliosis. There is a hemivertebra within the lumbar spine producing the scoliosis.' Congenital scoliosis is characterized by vertebral abnormalities present at birth, and the resulting spinal curvature (scoliosis) develops as these abnormal vertebrae grow. This aligns perfectly with the image and case description.Option A is incorrectbecause idiopathic scoliosis, while the most common type (70%), has no identifiable cause and typically presents as a right thoracic curve in adolescents. The image shows a clear structural anomaly (hemivertebra) and a left lumbar curve, ruling out idiopathic.Option B is incorrectbecause neuromuscular scoliosis arises from a lack of spinal support due to neuromuscular conditions (e.g., cerebral palsy, Duchenne muscular dystrophy) and typically presents as a long, collapsing 'C' shaped curve. The image shows a localized, angular deformity due to a specific vertebral anomaly, not a generalized collapse.Option D is incorrectbecause while congenital scoliosis can be early-onset, the definition of early-onset scoliosis (EOS) is typically before age 7, and infantile idiopathic scoliosis (0-3 years) is the type that often resolves spontaneously (80-90%). The case describes a congenital etiology, not necessarily an infantile idiopathic one, and the prognosis for congenital scoliosis is highly variable depending on the anomaly.Option E is incorrectbecause miscellaneous scoliosis is associated with systemic conditions like Marfan's syndrome or neurofibromatosis, which are not indicated by the presence of a hemivertebra alone. The primary etiology here is a congenital vertebral malformation.
Question 1736
Topic: 6. Spine
A 16-year-old male presents with a progressive thoracolumbar scoliosis measuring 55 degrees Cobb angle. He has completed his growth spurt and has a Risser sign of 5. He reports increasing difficulty with sitting balance and occasional costo-pelvic impingement pain. Which of the following is the most appropriate initial treatment recommendation?
Correct Answer & Explanation
. Referral to a specialist center for surgical evaluation and possible spinal fusion.
Explanation
Correct Answer: CThe case states that surgery is 'Usually reserved for curves with a magnitude > 50.' This patient has a 55-degree curve, which exceeds this threshold. Furthermore, the patient is experiencing functional problems like difficulty with sitting balance and costo-pelvic impingement, which are common indications for surgery, particularly in neuromuscular scoliosis (though this patient is not explicitly stated to have neuromuscular scoliosis, these are general indications for surgery in severe curves). Even if the patient is skeletally mature, curves over 50 degrees can still progress at approximately 1 degree per year and cause significant functional impairment.Option A is incorrectbecause while skeletal maturity (Risser 5) does reduce the rate of progression, a 55-degree curve is considered severe and is typically an indication for surgical intervention, not just observation, especially with functional symptoms. Curves over 50 degrees can continue to progress even after skeletal maturity.Option B is incorrectbecause bracing is generally indicated for progressive curves between 25 and 40 degrees in skeletally immature patients to prevent progression. It is not effective for curves over 40-45 degrees or in skeletally mature patients, and certainly not for a 55-degree curve with functional deficits.Option D is incorrectbecause while physical therapy can be beneficial for pain management and muscle balance, it does not correct or prevent the progression of structural scoliosis, especially a severe curve of 55 degrees.Option E is incorrectbecause while MRI is important for atypical curves (e.g., left thoracic, severe pain, rapid progression, short angular deformities) to rule out intraspinal anomalies, a 55-degree thoracolumbar curve in a male, while somewhat atypical for AIS, is primarily an indication for surgical consideration based on magnitude and symptoms, making surgical evaluation the most immediate and appropriate next step. An MRI might be part of the surgical workup, but the primary recommendation is surgical evaluation.
Question 1737
Topic: 6. Spine
The radiograph shows a congenital scoliosis with a hemivertebra. In the context of congenital scoliosis, which of the following vertebral anomalies carries the worst prognosis for curve progression?
Correct Answer & Explanation
. A fully segmented hemivertebra with a contralateral unsegmented bar.
Explanation
Correct Answer: BThe case explicitly states, 'Progression of congenital curves depends on growth potential and whether that growth is balanced. Thus a fully segmented hemivertebra in connection with a contralateral unsegmented bar has the least balanced growth and the worst prognosis.' This combination creates a 'crankshaft' effect, with continuous growth on one side (fully segmented hemivertebra) and no growth on the other (unsegmented bar), leading to severe and rapid progression.Option A is incorrectbecause a block vertebra has a benign prognosis, rarely leading to a curve beyond 20 degrees, as stated in the text.Option C is incorrectbecause a semi-segmented hemivertebra, while having growth potential, is typically less aggressive than a fully segmented hemivertebra with a contralateral unsegmented bar. A semi-segmented hemivertebra is fused to one adjacent vertebra, limiting growth on that side.Option D is incorrectbecause an incarcerated hemivertebra is one that is fully incorporated into the vertebral column, often with minimal growth potential and thus a more benign course compared to a fully segmented hemivertebra.Option E is incorrectbecause a wedge vertebra is a partial failure of formation, but its growth potential and prognosis are generally less severe than the combination of a fully segmented hemivertebra and a contralateral unsegmented bar.
Question 1738
Topic: 6. Spine
A 10-year-old patient with severe cerebral palsy presents with a rapidly progressing 'C' shaped thoracolumbar scoliosis. In addition to the spinal deformity, which of the following is a common problem specifically associated with neuromuscular scoliosis that would influence treatment goals?
Correct Answer & Explanation
. Difficulty with sitting balance, leading to hand-dependent sitting and limited upper limb function.
Explanation
Correct Answer: DThe case lists specific problems associated with neuromuscular scoliosis, including 'Problems with sitting balance causing patients to become hand-dependent sitters, which in turn limits upper limb function.' This is a significant functional concern for patients with neuromuscular conditions like cerebral palsy, directly impacting their quality of life and independence.Option A is incorrectbecause severe pain, while a red flag for underlying pathology, is not typically associated with neuromuscular scoliosis in the same way as an osteoid osteoma. Osteoid osteoma is a distinct cause of painful scoliosis, not a common problemassociated withneuromuscular scoliosis.Option B is incorrectbecause while compensatory curves can develop, the text does not highlight rigid cervical curves as acommon problemspecifically associated with neuromuscular scoliosis. The primary curve is typically a long, collapsing 'C' shape.Option C is incorrectbecause while cardiorespiratory compromise is a significant concern, it is primarily highlighted as a risk in 'early-onset scoliosis' (onset before age 7), where the developing heart and lungs may be affected. While severe neuromuscular curves can eventually impact respiratory function, the text specifically links 'progressive cardiorespiratory compromise' to early-onset scoliosis, not neuromuscular scoliosis as itsprimaryunique complication in the same context.Option E is incorrectbecause neuromuscular scoliosis, particularly in severe cerebral palsy, is known for its progressive nature and rarely resolves spontaneously. Spontaneous resolution is more characteristic of infantile idiopathic scoliosis.
Question 1739
Topic: Thoracolumbar Spine & Deformity
An 18-month-old infant is diagnosed with an infantile idiopathic scoliosis measuring 28 degrees. The curve is progressive. Based on the case information, what is the most appropriate initial non-surgical management strategy for this patient?
Correct Answer & Explanation
. Application of serial plaster jackets (localizer casts).
Explanation
Correct Answer: DThe case states under 'Early-onset scoliosis' that 'Patients that present with an idiopathic scoliosis below the age of 3 (infantile scoliosis) have the most heterogeneous prognosis... Treatment is problematic and prolonged. The most common forms of treatment are serial plaster jackets (localizer casts), subsequently bracing and eventually growing rods.'Option A is incorrectbecause immediate surgical fusion, especially with growing rods, is typically reserved for curves that fail to respond to conservative measures or are extremely severe and progressive, not as an initial treatment for an 18-month-old with a 28-degree curve, even if progressive. Growing rods are a later stage treatment.Option B is incorrectbecause while a significant number of infantile curves (80-90%)canresolve, the question states the curve isprogressive. For progressive curves, active intervention is needed, not just observation. The text specifically mentions treatment for those that 'do not resolve'.Option C is incorrectbecause while bracing is a treatment option, the text specifically lists 'serial plaster jackets (localizer casts)' as themost common initial form of treatmentfor infantile idiopathic scoliosis, followed by bracing.Option E is incorrectbecause physical therapy alone is not an effective treatment for correcting or preventing the progression of structural scoliosis in an infant.
Question 1740
Topic: 6. Spine
During the physical examination of a 13-year-old girl suspected of having scoliosis, the Adam's forward bend test is performed. What is the primary purpose of this test in the assessment of spinal deformity?
Correct Answer & Explanation
. To identify rotational deformity of the trunk, often manifesting as a rib hump or lumbar prominence.
Explanation
Correct Answer: DThe Adam's forward bend test is a clinical maneuver used to assess for rotational deformity of the trunk, which is a key component of scoliosis. When a patient bends forward, a structural scoliosis will typically manifest as a prominence on one side of the back (a rib hump in thoracic curves or a lumbar prominence in lumbar curves) due to vertebral rotation. The case lists 'Adam's forward bend test' under 'Examination โ key features', implying its role in assessing the curve's characteristics.Option A is incorrectbecause skeletal maturity is assessed using factors like age, menarcheal status, height, and radiographically with Risser's sign, not the Adam's forward bend test.Option B is incorrectbecause intraspinal anomalies are detected through neurological examination (e.g., abnormal abdominal reflexes) and confirmed with MRI scanning, not the Adam's forward bend test.Option C is incorrectbecause the Cobb angle is a radiographic measurement used to quantify the magnitude of the curve on plain X-rays, not a clinical assessment tool like the Adam's test.Option E is incorrectbecause while spinal flexibility is assessed during the examination, the Adam's forward bend test primarily highlights thestructuralnature of the curve and its rotational component, rather than directly quantifying flexibility. Flexibility is often assessed with lateral bending radiographs.
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