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 1821
Topic: 6. Spine
A 30-year-old male presents with a bilateral C5-C6 facet dislocation following a rugby tackle. He is awake, cooperative, and his neurological examination is completely intact. What is the most appropriate next step in his acute management?
Correct Answer & Explanation
. Awake closed reduction with progressive cranial traction
Explanation
In an awake, cooperative, and neurologically intact patient with a cervical facet dislocation, rapid awake closed reduction with cranial traction is indicated before an MRI. Serial neurological exams are crucial; if the patient's neurologic status worsens during traction, the reduction attempt must be immediately aborted, and an emergent MRI should be obtained.
Question 1822
Topic: 6. Spine
A 45-year-old male sustains a traumatic spondylolisthesis of the axis (Hangman's fracture). Radiographs reveal severe angulation without significant translation of C2 on C3, consistent with a Levine-Edwards Type IIa fracture. Which of the following acute management strategies is strictly contraindicated?
Correct Answer & Explanation
. Surgical stabilization via C1-C3 posterior fusion
Explanation
A Levine-Edwards Type IIa Hangman's fracture is characterized by severe angulation with minimal translation, resulting from a flexion-distraction injury. Cervical traction is strictly contraindicated as it will further distract the already disrupted C2-C3 intervertebral disc, potentially leading to catastrophic neurological compromise.
Question 1823
Topic: 6. Spine
A 25-year-old male sustains a C4 complete spinal cord injury. On arrival in the trauma bay, his blood pressure is 80/50 mmHg and his heart rate is 50 bpm. His extremities are warm to the touch. Which of the following is the most appropriate initial pharmacological treatment for his hemodynamic instability?
Correct Answer & Explanation
. Norepinephrine
Explanation
The patient is presenting with neurogenic shock, characterized by hypotension and bradycardia secondary to a loss of sympathetic tone. Norepinephrine is typically the first-line vasopressor because it provides both alpha-1 (vasoconstriction) and beta-1 (inotropy/chronotropy) adrenergic stimulation to effectively counteract the unopposed parasympathetic tone.
Question 1824
Topic: Cervical Spine
A 35-year-old male is evaluated after being struck by a high-speed vehicle. Lateral cervical spine radiographs are obtained to evaluate for craniocervical junction injury. Which of the following radiographic measurements is most sensitive for diagnosing atlanto-occipital dissociation (AOD)?
Correct Answer & Explanation
. Basion-dental interval (BDI) > 12 mm
Explanation
The Harris measurements, which include the basion-dental interval (BDI) and basion-axial interval (BAI), are considered highly sensitive for evaluating atlanto-occipital dissociation (AOD). A BDI > 12 mm on plain radiographs (or > 8.5 mm on CT scan) is highly indicative of AOD.
Question 1825
Topic: 6. Spine
A 25-year-old male is brought to the trauma bay after a diving accident. He is awake, alert, and cooperative. Neurologic examination reveals an ASIA A complete spinal cord injury at the C5 level. Lateral radiographs demonstrate a bilateral C4-C5 facet dislocation. What is the most appropriate next step in management?
Correct Answer & Explanation
. Immediate closed reduction using cranial traction
Explanation
In an awake, alert, and cooperative patient with a cervical facet dislocation and neurologic deficit, immediate closed reduction with cranial traction is indicated without delaying for an MRI. An MRI is required prior to reduction only if the patient is obtunded or cannot reliably participate in a serial neurologic examination.
Question 1826
Topic: Cervical Spine
A 35-year-old male is involved in a high-speed motor vehicle collision. Cervical spine imaging reveals a C1 ring fracture. Open-mouth odontoid view demonstrates lateral displacement of the C1 lateral masses relative to C2. According to the Rule of Spence, what combined lateral overhang measurement strongly suggests a ruptured transverse ligament?
Correct Answer & Explanation
. Greater than 6.9 mm
Explanation
The Rule of Spence dictates that a combined lateral mass overhang of C1 on C2 greater than 6.9 mm on an open-mouth odontoid radiograph indicates a highly probable transverse ligament rupture. This dictates an unstable Jefferson fracture pattern requiring rigid immobilization or surgical fusion.
Question 1827
Topic: 6. Spine
A 55-year-old male sustains a hyperextension injury to his cervical spine. He presents with profound weakness in his bilateral upper extremities, with trace movement in his hands, but retains 4/5 strength in his bilateral lower extremities. Proprioception and pain sensation are diminished but present globally. What is the most likely long-term functional prognosis for this patient?
Correct Answer & Explanation
. Good potential for ambulatory recovery but persistent deficits in upper extremity fine motor skills
Explanation
This patient has Central Cord Syndrome, characterized by motor deficits more severe in the upper extremities (especially distally) than the lower extremities. Prognosis for ambulation is generally good, but patients often suffer from permanent deficits in fine motor hand function.
Question 1828
Topic: 6. Spine
A 40-year-old male falls 15 feet, sustaining a traumatic spondylolisthesis of the axis (Hangman's fracture). Imaging shows severe angulation and >5 mm of translation of C2 on C3. What is the classic mechanism of injury for this specific fracture pattern?
Correct Answer & Explanation
. Hyperextension with axial loading
Explanation
A typical Hangman's fracture (traumatic spondylolisthesis of C2) is caused by hyperextension and axial loading, commonly seen in motor vehicle accidents or falls. However, Levine-Edwards Type IIA fractures uniquely involve flexion-distraction and require avoidance of traction during treatment.
Question 1829
Topic: Cervical Spine
An 82-year-old male presents with a Type II odontoid fracture after a ground-level fall. He has multiple medical comorbidities, including severe COPD and heart failure. What is the most appropriate management, considering the highest risk of morbidity and mortality?
Correct Answer & Explanation
. Rigid cervical collar for 6-12 weeks
Explanation
In elderly patients with Type II odontoid fractures, halo vest immobilization is associated with high morbidity and mortality (up to 40% complication rate). Nonoperative management with a rigid cervical collar is generally preferred for stable patterns in frail elderly patients, accepting a higher nonunion rate for survival.
Question 1830
Topic: 6. Spine
A 45-year-old female presents with a unilateral facet dislocation of C5 on C6 after an athletic injury. She complains of radicular pain but has normal motor function. On a lateral cervical radiograph, which classic sign is pathognomonic for a unilateral facet dislocation?
Correct Answer & Explanation
. The "Bow-tie" or "Bat-wing" sign
Explanation
The "Bow-tie" or "Bat-wing" sign on a lateral cervical radiograph indicates rotational deformity characteristic of a unilateral facet dislocation. It represents the non-superimposed visual profiles of the right and left articular pillars.
Question 1831
Topic: 6. Spine
A 50-year-old polytrauma patient remains obtunded in the ICU. A high-quality 64-slice CT scan of the cervical spine with sagittal and coronal reconstructions demonstrates no acute fracture or malalignment. According to the current EAST (Eastern Association for the Surgery of Trauma) guidelines, what is the appropriate next step for cervical spine clearance?
Correct Answer & Explanation
. Remove the cervical collar as the CT scan is sufficient for clearance
Explanation
Current EAST guidelines support the removal of the cervical collar in obtunded trauma patients following a negative high-quality, fine-cut CT scan. MRI or dynamic radiographs are no longer routinely required for clearance in this specific scenario if the CT is pristine.
Question 1832
Topic: 6. Spine
A 30-year-old male arrives in the emergency department following a motorcycle collision. He is diagnosed with neurogenic shock. Which of the following clinical profiles best differentiates neurogenic shock from hypovolemic shock?
Correct Answer & Explanation
. Bradycardia and hypotension with warm, well-perfused extremities
Explanation
Neurogenic shock occurs due to the loss of sympathetic tone following severe spinal cord injury, leading to unopposed parasympathetic activity. This presents classically as hypotension, bradycardia, and warm, peripherally vasodilated extremities.
Question 1833
Topic: 6. Spine
A 35-year-old female undergoes closed reduction for a bilateral cervical facet dislocation. Post-reduction MRI reveals a massive, extruded intervertebral disc herniation compressing the ventral spinal cord. Her neurologic exam shows progressive weakness. Which of the following is the most appropriate surgical approach?
Correct Answer & Explanation
. Anterior cervical discectomy and fusion (ACDF)
Explanation
In the presence of an extruded disc compressing the ventral cord following a facet dislocation, an anterior approach (ACDF) is mandatory. A direct posterior reduction maneuver in this setting can pull the herniated disc further into the spinal canal, causing iatrogenic cord injury.
Question 1834
Topic: Cervical Spine
An 82-year-old male sustains a Type II odontoid fracture after a ground-level fall. He is neurologically intact. Given his age and injury type, which of the following is the most appropriate management with the lowest morbidity?
Correct Answer & Explanation
. Rigid cervical collar immobilization for 6-12 weeks
Explanation
In elderly patients with Type II odontoid fractures, rigid cervical collar immobilization is often preferred due to the high morbidity and mortality associated with halo vests and surgical intervention. Although nonunion rates are high with a collar, a stable fibrous nonunion is typically well-tolerated in this population.
Question 1835
Topic: Cervical Spine
A 45-year-old male is involved in a rollover motor vehicle accident and sustains a burst fracture of the C1 ring (Jefferson fracture). Which radiographic finding best indicates a rupture of the transverse ligament and need for surgical stabilization?
Correct Answer & Explanation
. Combined lateral mass overhang greater than 6.9 mm on open-mouth odontoid view
Explanation
According to Spence's rule, a combined lateral mass overhang of the C1 masses on C2 greater than 6.9 mm on an open-mouth odontoid radiograph indicates a competent transverse ligament rupture. MRI is often used today for confirmation, but 6.9 mm remains the classic threshold for instability.
Question 1836
Topic: 6. Spine
A 30-year-old female sustains a cervical spine injury following a high-speed collision. Which of the following specific fracture patterns is most strongly associated with a vertebral artery injury requiring computed tomography angiography (CTA) screening?
Correct Answer & Explanation
. Fracture extending through the foramen transversarium
Explanation
Cervical spine fractures extending into the foramen transversarium, as well as significant subluxations like facet dislocations, pose a highly elevated risk for vertebral artery injury. CTA of the neck is the recommended screening modality for these specific, high-risk injury patterns.
Question 1837
Topic: 6. Spine
A 40-year-old physically active man with isolated medial compartment knee osteoarthritis undergoes a medial opening wedge high tibial osteotomy (HTO). If the anterior gap is opened symmetrically with the posterior gap, what unintended consequence is most likely to occur?
Correct Answer & Explanation
. Increase in the posterior tibial slope
Explanation
During a medial opening wedge HTO, opening the osteotomy gap symmetrically anteriorly and posteriorly tends to inadvertently increase the posterior tibial slope due to the triangular shape of the proximal tibia. To maintain the native slope, the anterior gap must be opened approximately half as much as the posterior gap.
Question 1838
Topic: 6. Spine
A 72-year-old male with known Paget's disease of the lumbar spine presents with progressive bilateral lower extremity weakness and numbness. Physical examination reveals diminished sensation in a stocking-glove distribution and hyperreflexia. Which of the following is the MOST likely cause of his neurological symptoms?
Correct Answer & Explanation
. C. Pagetic spinal stenosis due to expanded pagetic bony tissue.
Explanation
Correct Answer: CThe case describes Pagetic spinal stenosis as a complication, defined as compression of the spinal cord, cauda equina, or spinal nerves by expanded pagetic bony tissue of the spine. It is most common in the lumbar region and typically single level, causing cord or nerve root compression. The patient's symptoms of progressive bilateral lower extremity weakness, numbness, and hyperreflexia are classic signs of spinal cord or cauda equina compression.Option A, compression fractures of the vertebral body, are common complications of spinal Paget's, but while they can cause neurological deficits, the primary mechanism of chronic, progressive compression in Paget's is often the expanded pagetic bone itself, rather than an acute fracture. Option B, high cardiac output, is a rare complication of Paget's due to increased bone vascularity, but it does not directly cause peripheral neuropathy. Option D, malignant transformation to osteosarcoma, is a serious complication, but it typically presents with unrelenting bone pain and radiographic bone destruction, not primarily with progressive bilateral neurological deficits in this manner. Option E, hydrocephalus, is a complication of skull involvement in Paget's disease, leading to increased intracranial pressure and cranial nerve deficits, but it would not cause lower extremity weakness and numbness in a stocking-glove distribution.
Question 1839
Topic: 6. Spine
A 7-year-old child presents after a fall from a trampoline, complaining of neck pain and bilateral lower extremity weakness. Neurological examination reveals 2/5 strength in both lower extremities, normal upper extremity strength, and intact sensation throughout. Reflexes are hyperreflexic in the lower extremities. X-rays of the cervical spine are normal, and a subsequent MRI shows no fracture, dislocation, or spinal cord compression, but reveals subtle signal changes within the cord. What is the most likely diagnosis?
Correct Answer & Explanation
. Spinal cord injury without radiographic abnormality (SCIWORA)
Explanation
The clinical presentation of a child with neurological deficits after trauma, coupled with normal radiographs and absence of bony pathology on MRI, but with signal changes within the cord, is pathognomonic for Spinal Cord Injury Without Radiographic Abnormality (SCIWORA). This condition is more common in children due to increased spinal elasticity and laxity of ligaments, allowing for transient cord stretch or compression without bony injury. Atlantoaxial instability would typically show radiographic evidence. Transient myelopathy and acute transverse myelitis are diagnoses of exclusion often related to inflammatory or idiopathic causes, less likely acutely post-trauma with cord signal changes. An epidural hematoma would be visible on MRI as a mass compressing the cord.
Question 1840
Topic: 6. Spine
A 55-year-old male presents with worsening lower back pain, bilateral leg numbness, and progressive weakness, particularly in his quadriceps muscles. He describes his symptoms as being worse with standing and walking, and relieved by sitting or leaning forward (shopping cart sign). Physical examination reveals diminished patellar reflexes and weak knee extension bilaterally. MRI shows severe degenerative changes at L3-L4 and L4-L5 with significant narrowing of the spinal canal. What is the most appropriate initial management approach?
Correct Answer & Explanation
. Trial of non-steroidal anti-inflammatory drugs (NSAIDs) and physical therapy focusing on flexion exercises
Explanation
Correct Answer: EThe patient's symptoms (neurogenic claudication, 'shopping cart sign,' motor weakness, diminished reflexes) are classic for lumbar spinal stenosis. The initial management for symptomatic lumbar spinal stenosis, especially without acute neurological deficits (e.g., cauda equina syndrome), is typically conservative. This involves a trial of NSAIDs, activity modification, and physical therapy focused on flexion exercises to open the spinal canal, improve posture, and strengthen core muscles. Epidural steroid injections can provide temporary symptomatic relief. Surgical decompression and fusion are reserved for those who fail conservative management or develop progressive neurological deficits. Rigid bracing is generally not effective and can lead to muscle atrophy. Progressive resistance exercises are often part of physical therapy but not a standalone initial approach.
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