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6. Spine MCQs

Practice Set 99 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 1961

Topic: 6. Spine
Figure 45 shows the radiograph of a 2-year-old patient who has progressive lumbar scoliosis as the result of hemivertebra. Examination reveals no associated cutaneous lesions, and an MRI scan shows no associated intraspinal anomalies. Treatment should consist of
. hemivertebra excision.
. anterior and posterior spinal fusion with instrumentation from T4 to L4.
. convex anterior hemiepiphyseodesis.
. convex posterior hemiarthrodesis.
. an orthosis.

Correct Answer & Explanation

. hemivertebra excision.

Explanation

DISCUSSION: In a retrospective review of 10 patients treated with hemivertebra excision for hemivertebra in the levels of T12 to L3, the procedure was found to be safe and effective. The procedure provided an average curve correction of 67° and was greatest in patients who were younger than age 4 years at the time of surgery. Long anterior and posterior fusion with instrumentation is not the treatment of choice at this age. Either anterior hemiepiphyseodesis or posterior hemiarthrodesis in this isolated hemivertebra setting would be inadequate. Brace treatment is ineffective in management of the primary curvature. REFERENCE: Callahan BC, Georgopoulos G, Eilert RE: Hemivertebral excision for congenital scoliosis. J Pediatr Orthop 1997;17:96-99.

Question 1962

Topic: 6. Spine

A 70-year-old male with severe ankylosing spondylitis and a fused lumbar spine to the sacrum (L1-S1) is undergoing total hip arthroplasty. Spinopelvic assessment reveals that his pelvic tilt does not change when moving from a standing to a seated position. Compared to a patient with normal spinopelvic mobility, how should the acetabular component be positioned to minimize the risk of impingement and dislocation?

. Increased anteversion and increased inclination
. Decreased anteversion and decreased inclination
. Increased retroversion and decreased inclination
. Standard safe zone positioning (15 degrees anteversion, 40 degrees inclination)
. Decreased anteversion and increased inclination

Correct Answer & Explanation

. Increased anteversion and increased inclination

Explanation

In a patient with a stiff spino-pelvic junction (stuck standing), the pelvis fails to roll backward (posterior pelvic tilt) when the patient sits. Because the pelvis remains relatively anteriorly tilted in flexion, there is a high risk of anterior femoral neck impingement on the anterior rim of the cup during sitting, leading to posterior dislocation. To compensate for this lack of dynamic functional anteversion, the surgeon must place the acetabular cup in greater anteversion and inclination than the standard safe zone.

Question 1963

Topic: 6. Spine
A 40-year-old woman has local back pain and intense burning pain in her perianal region after being shot twice in the back. Motor and sensory examination of her lower extremities reveals no apparent deficit. She has present but decreased sensation in her perianal region, an intact anal wink, good rectal tone, and an intact bulbocavernosus reflex. Radiographs and CT scans are shown in Figures 3a through 3d. What is the next most appropriate step in management?
. Initiation of spinal cord injury steroid protocol
. MRI of the lumbar spine
. Immobilization in a thoracolumbosacral orthosis
. Removal of the metallic fragments via laminectomy
. Removal of the metallic fragments and posterior fusion with instrumentation

Correct Answer & Explanation

. Removal of the metallic fragments via laminectomy

Explanation

Because the patient has an apparent compressive neuropathy secondary to the metallic fragments, removal of the fragments in this incomplete lesion at the cauda equina level can be expected to improve her sensory dysesthesias and pain. Steroids are not indicated in a root lesion secondary to a penetrating injury. MRI will have significant artifact effect and will not provide much additional information. The posterior bony elements are not significantly injured; therefore, stabilization is not indicated.

Question 1964

Topic: 6. Spine
A 46-year-old man has incomplete paraplegia after being involved in a motor vehicle accident. The CT scan shown in Figure 5 reveals marked canal compromise. What is the most appropriate management to improve neurologic status?
. Postural reduction and application of a hyperextension cast
. Posterior laminectomy alone
. Laminectomy and posterior stabilization
. Bed rest for 6 weeks
. Anterior L2 corpectomy and iliac crest strut grafting, with or without posterior instrumentation and fusion from L1 to L3

Correct Answer & Explanation

. Anterior L2 corpectomy and iliac crest strut grafting, with or without posterior instrumentation and fusion from L1 to L3

Explanation

DISCUSSION: According to a study by the Scoliosis Research Society, the use of anterior decompression is most predictable for improving neurologic status. This is particularly true of bowel and bladder functional loss. Laminectomy is contraindicated because it further destabilizes the spine. Posterior instrumentation and indirect reduction through distraction and ligamentotaxis only incompletely decompress the compromised canal and are successful only if performed within 48 hours of injury. While some improvement may occur with closed management, the amount of recovery is less than that achieved with surgical decompression. A posterior approach and instrumentation may be added to the anterior decompression based on the characteristics of associated injuries to the posterior element. REFERENCES: Gertzbein SD: Scoliosis Research Society multicenter spine fracture study. Spine 1992;17:528-540. Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 197-215. Cammisa FP Jr, Eismont FJ, Green BA: Dural laceration occurring with burst fractures and associated laminar fractures. J Bone Joint Surg Am 1989;71:1044-1052.

Question 1965

Topic: 6. Spine
What is the most appropriate initial diagnostic imaging study for a patient with presumed diskogenic low-back pain?
. MRI
. Discography
. CT discography
. Radiography

Correct Answer & Explanation

. Radiography

Explanation

DISCUSSION: Radiography is the best initial study. Vacuum phenomenon may be found within the disk space. Other possible sources for back pain such as osteoporotic collapse, osteolytic collapse, and deformity also can be evaluated. The other tests may be beneficial and are more appropriate as later imaging options. RECOMMENDED READINGS: Yu WD, Williams SL. Spinal imaging: Radiographs, computed tomography, and magnetic resonance imaging. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine.

Question 1966

Topic: 6. Spine
Figures 1a and 1b are the MR images of a 69-year-old woman with bilateral leg pain that is worse with ambulation. She feels better when she is sitting down or leaning on a grocery cart. Which condition or structure is indicated by the arrows?
. Disk herniation
. Synovial cyst
. Arachnoid cyst
. Epidural lipomatosis

Correct Answer & Explanation

. Synovial cyst

Explanation

DISCUSSION: This patient has neurogenic claudication as demonstrated by her “shopping cart” sign. Typically, spinal stenosis is attributable to bony spurs and/or a thick ligamentum flavum. However, for this patient, a large synovial cyst is the main contributing factor to stenosis. A cyst typically is filled with gelatinous material. If symptomatic, surgical excision is typically recommended because success with aspiration is unreliable. The need for fusion is debatable. A disk herniation is not bright on T2. An arachnoid cyst is a sac filled with cerebrospinal fluid. Spinal arachnoid cysts are relatively uncommon, and typically are intradural, but they also can be extradural. Epidural lipomatosis is a condition caused by excessive accumulation of fat within the epidural space. It is not well circumscribed as seen with this lesion. RECOMMENDED READINGS: Epstein NE, Baisden J. The diagnosis and management of synovial cysts: Efficacy of surgery versus cyst aspiration. Surg Neurol Int. 2012;3(Suppl 3):S157-66. doi: 10.4103/2152-7806.98576. Epub 2012 Jul 17. PubMed PMID: 22905322. Xu R, McGirt MJ, Parker SL, Bydon M, Olivi A, Wolinsky JP, Witham TF, Gokaslan ZL, Bydon A. Factors associated with recurrent back pain and cyst recurrence after surgical resection of one hundred ninety-five spinal synovial cysts: analysis of one hundred sixty-seven consecutive cases. Spine (Phila Pa 1976). 2010 May 1;35(10):1044-53. PubMed PMID: 20173680.

Question 1967

Topic: 6. Spine
A 12-year-old girl has had lower back pain for the past 6 months that interferes with her ability to participate in sports. She denies any history of radicular symptoms, sensory changes, or bowel or bladder dysfunction. Examination reveals a shuffling gait, restriction of forward bending, and tight hamstrings. Radiographs show a grade III spondylolisthesis of L5 on S1, with a slip angle of 20°. Management should consist of
. brace treatment.
. laminectomy, nerve root decompression, and in situ fusion of L4 to the sacrum.
. in situ fusion of L4 to the sacrum.
. excision of the L5 lamina.
. physical therapy.

Correct Answer & Explanation

. laminectomy, nerve root decompression, and in situ fusion of L4 to the sacrum.

Explanation

DISCUSSION: Indications for surgical treatment of spondylolisthesis include pain and/or progression of deformity. Specifically, surgery is necessary when there is persistent pain or a neurologic deficit that fails to respond to nonsurgical therapy, there is significant slip progression, or the slip is greater than 50%. For patients with mild spondylolisthesis, in situ posterolateral L5-S1 fusion is adequate. In patients with more severe slips (greater than 50%), extension of the fusion to L4 offers better mechanical advantage. Postoperative immobilization may be achieved with instrumentation, casting, or both. In patients with a slip angle of greater than 45°, reduction of the lumbosacral kyphosis with instrumentation or casting is desirable to prevent slip progression. Laminectomy alone is contraindicated in a child. Nerve root decompression is indicated if radiculopathy is present clinically. REFERENCES: Seitsalo S, Osterman K, Hyvarinen H, Tallroth K, Schlenzka D, Poussa M: Progression of spondylolisthesis in children and adolescents: A long-term follow-up of 272 patients. Spine 1991;16:417-421. Newton PO, Johnston CE II: Analysis and treatment of poor outcomes following in situ arthrodesis in adolescent spondylolisthesis. J Pediatr Orthop 1997;17:754-761.

Question 1968

Topic: 6. Spine
A 28-year-old man sustained a fracture-dislocation of T8 in a motor vehicle accident 1 week ago. The injury resulted in complete paraplegia. Management should consist of
. mobilization in a kinetic therapy bed for 8 weeks.
. initiation of a steroid protocol.
. immediate laminectomy of T7, T8, and T9.
. application of a total contact orthosis.
. open reduction and posterior segmental stabilization and grafting.

Correct Answer & Explanation

. open reduction and posterior segmental stabilization and grafting.

Explanation

DISCUSSION: With a complete injury in the thoracic spinal cord, the likelihood of neurologic recovery is small. If possible, treatment should be planned to allow rapid mobilization and rehabilitation without the use of braces and their associated skin problems. The use of long segment fixation provides for rapid mobilization without having to use braces postoperatively. The use of steroid protocol is controversial and should be considered only if it can be started within 8 hours of the injury. Laminectomy is contraindicated because it will increase instability. REFERENCE: Tasdemiroglu E, Tibbs PA: Long-term follow-up results of thoracolumbar fractures after posterior instrumentation. Spine 1995;20:1704-1708.

Question 1969

Topic: Thoracolumbar Spine & Deformity

When comparing the overall outcomes of surgical versus nonsurgical treatment of stable thoracolumbar burst fractures in patients without neurologic injury, 5 years following injury, the principle differences lie in Review Topic

. fracture kyphosis.
. reduction of retropulsed bone.
. pain reduction.
. incidence of complications.
. return to work.

Correct Answer & Explanation

. fracture kyphosis.

Explanation

When patients are compared at 5 years follow-up, there are no statistically significant differences between the two groups with respect to kyphosis, the degree of retropulsed bone resorption, pain and function levels, or the ability to return to work. Nonsurgical management of stable neurologically intact burst fractures has a very low incidence of complications.

Question 1970

Topic: 6. Spine

Figure 31 shows the radiograph of a 64-year-old woman who is seen in the emergency department following a motor vehicle accident. She has no

. continued rapid fluid infusion.
. administration of broad-spectrum antibiotics.
. administration of 30/mg/kg methylprednisolone over 1 hour.
. administration of pressors.
. cardioversion and implantation of a pacemaker.

Correct Answer & Explanation

. administration of pressors.

Explanation

The hallmark of neurogenic shock is hypotension without tachycardia. It is associated most commonly with high cervical spinal cord injuries and results from loss of function of the sympathetic nervous system. Because the peripheral vasculature is dilated due to loss of its sympathetic tone, continued rapid administration of fluid corrects the hypotension and can quickly lead to fluid overload and congestive heart failure. Therefore, neurogenic shock is best treated by the use of pressors. Cardioversion or administration of antibiotics or systemic steroids is not appropriate treatment for this patient’s hypotension.

Question 1971

Topic: Cervical Spine

An 80-year-old man with a history of chronic obstructive pulmonary disease (COPD) and dementia is involved in a fall from standing height, striking his forehead. He is seen in the emergency department with predominantly mechanical neck pain but no obvious neurologic deficits. Radiographs reveal a nondisplaced type II odontoid fracture. What is the most appropriate treatment? Review Topic

. Immobilization in a rigid cervical orthosis for 6 to 8 weeks
. Posterior occipital-cervical fusion with iliac crest bone graft
. Open reduction and internal fixation of the odontoid process with an anterior odontoid screw
. Resection of the odontoid process through a transoral approach
. Halo skeletal fixation

Correct Answer & Explanation

. Immobilization in a rigid cervical orthosis for 6 to 8 weeks

Explanation

The treatment options for a type II odontoid fracture include halo immobilization, odontoid screw fixation, and posterior atlantoaxial arthrodesis. However, surgical care at this time without attempting nonsurgical management is not warranted; therefore, the most appropriate management at this time is immobilization in a rigid cervical orthosis for 6 to 8 weeks. Halo vest fixation can lead to high healing rates but is generally contraindicated in elderly patients, especially one with COPD and dementia. Posterior surgical fusion techniques provide high fusion rates, but do so at the expense of loss of cervical rotation and surgical complications. Resection of a nondisplaced odontoid fracture without cord compression via a transoral approach is not necessary.

Question 1972

Topic: 6. Spine
Figures 11a and 11b show the T2-weighted MRI scans of the lumbar spine of a 53-year-old woman who has low back and right lower extremity pain. What structure is the arrow pointing to in Figure 11a?
. Ligamentum flavum
. Lumbar synovial cyst
. Tarlov cyst
. Pseudomeningocele
. Herniated nucleus pulposus

Correct Answer & Explanation

. Lumbar synovial cyst

Explanation

DISCUSSION: The arrow is pointing to a cystic-appearing structure with high signal intensity on T2-weighted image sequencing. It appears to be contiguous with the hypertrophied right facet joint, which appears to also have high signal intensity. The mass significantly narrows the right lateral recess. The high signal intensity suggests that this is a fluid-filled mass. In addition, the facet joints are degenerative and there is a very mild degree of anterolisthesis on the sagittal image. These findings make a lumbar synovial cyst the most likely diagnosis. Most lumbar juxtafacet cysts are observed at the L4-5 level, extradurally and adjacent to the degenerative facet joint. They may contain synovial fluid and/or extruded synovium. Presentation is indistinguishable from that of a herniated disk. The etiology of spinal cysts remains unclear, but there appears to be a strong association between their formation and worsening spinal instability. They occasionally regress spontaneously and may respond to aspiration and injection of corticosteroids, though there is a high recurrence rate with nonsurgical management. Synovial cysts resistant to nonsurgical management should be treated surgically. If the patient’s symptoms can be attributable to radicular findings, a microsurgical decompression that limits further destabilization should suffice. However, if there is significant low back pain attributable to spinal instability, decompression and fusion remains an appropriate option. REFERENCES: Banning CS, Thorell WE, Leibrock LG: Patient outcome after resection of lumbar juxtafacet cysts. Spine 2001;26:969-972. Deinsberger R, Kinn E, Ungersbock K: Microsurgical treatment of juxta facet cysts of the lumbar spine. J Spinal Disord Tech 2006;19:155-160. Khan AM, Synnot K, Cammisa FP, et al: Lumbar synovial cysts of the spine: An evaluation of surgical outcome. J Spinal Disord Tech 2005;18:127-131.

Question 1973

Topic: Thoracolumbar Spine & Deformity

Figures 2a and 2b show the radiograph and MRI scan of a 56-year-old woman who has low back pain and right leg pain. She has grade 3/5 toe and ankle dorsiflexion strength on the right side. Nonsurgical management has failed to provide relief; therefore, surgery should include Review Topic

. L5 pars repair.
. L5 laminectomy alone.
. L5 laminectomy and fusion.
. stand-alone anterior lumbar interbody fusion.
. L5-S1 total disk replacement.

Correct Answer & Explanation

. L5 laminectomy and fusion.

Explanation

The lateral radiograph and MRI scan demonstrate a grade 2 isthmic spondylolisthesis of L5 on S1. The radiograph shows a pars defect of L5. Isthmic spondylolistheses are most common at L5-S1. Degenerative spondylolistheses rarely progress beyond a grade 1 slip. The patient has frank neurologic weakness on the right side and nonsurgical management has failed to provide relief. In patients with significant motor weakness, neurologic decompression is indicated. An L5 pars repair is not recommended in patients with more than a grade 1 slip. Laminectomy alone can destabilize the spine and lead to further slippage and thus it is recommended to fuse the segment. A stand-alone anterior lumbar interbody fusion has a high failure rate with isthmic spondylolisthesis. Isthmic spondylolisthesis is a contraindication for lumbar total disk replacement. While there is some literature that supports fusion without laminectomy or decompression for patients with isthmic slips and radicular pain without neurologic deficit, this patient does not fulfill these criteria.

Question 1974

Topic: 6. Spine
A 50-year-old woman undergoes an L4-S1 laminectomy and noninstrumented fusion for degenerative spondylolisthesis. Which of the following is a common complication of this procedure?
. Postoperative deep surgical site infection
. Proximal junctional kyphosis
. Pedicle screw cut-out
. Pseudarthrosis
. Sagittal imbalance

Correct Answer & Explanation

. Sagittal imbalance

Explanation

DISCUSSION: Complications are numerous in adult spinal deformity surgery. Many complications are related to the patient's sagittal balance following surgery and recognition of the potential to develop sagittal imbalance or flat-back syndrome following spinal fusion. The quality of bone density is important in spinal instrumented fusions, especially among older patients. Patients with osteopenia or osteoporosis have a higher incidence of proximal-level screw cut-out through the vertebral body into the cephalad disk space. Proximal junctional kyphosis is common in longer instrumented fusions, especially when instrumented to the sacrum/pelvis; when the spine is fixed in a "flat" or hypolordotic position; when the thoracic spine is hyperkyphotic (i.e., Scheuermann kyphosis); when the end instrumented vertebrae is kyphotic; or when the sagittal plumb line (measured from C7) is more than 4 cm forward of the posterior corner of the sacrum. Sagittal imbalance is a common complication when the spine is instrumented in a hypolordotic position. This can occur with degenerative conditions that necessitate multilevel fusions or fusions to sacrum without recognition of the degree of lordosis the patient should have. Pelvic incidence (PI) is a spinopelvic measurement that is a constant that measures an angle from the hips to the midpoint of the sacral end plate. PI correlates to the amount of lumbar lordosis that a patient would typically have in an upright position (+/-10 degrees). If a patient has significant sagittal imbalance, he or she will have a forward lean and lack the ability to extend the spine to stand upright. In an attempt to stand upright, the patient may bend his or her knees or hips in a crouched position. When extending their knees, they again lean forward. Pseudarthrosis is common with noninstrumented fusions. Deep surgical-site infections are uncommon but can be major complications that are difficult to treat, necessitating formal irrigation and debridement and long-term antibiotics. Patients with diabetes have a higher incidence of infection. RECOMMENDED READINGS: Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976). 2005 Sep 15;30(18):2024-.

Question 1975

Topic: 6. Spine
Examination of a 13-year-old boy with asymptomatic poor posture reveals increased thoracic kyphosis that is fairly rigid and accentuates during forward bending. The neurologic examination is normal. Spinal radiographs show 10 degrees of scoliosis at Risser stage 2, and there is no evidence of spondylolisthesis. A standing lateral view of the thoracic spine is shown in Figure 41. The kyphosis corrects to 50 degrees. Management should consist of
. electrical stimulation.
. a Charleston bending brace at night.
. an extension-type spinal orthosis.
. posterior spinal fusion with instrumentation.
. anterior spinal release and posterior spinal instrumentation.

Correct Answer & Explanation

. an extension-type spinal orthosis.

Explanation

DISCUSSION: The radiograph shows excessive thoracic kyphosis (normal 20 degrees to 50 degrees) with multiple contiguous vertebral wedging and end plate irregularity, all consistent with the diagnosis of Scheuermann’s kyphosis. The patient is skeletally immature; therefore, there is the potential for progression of the kyphotic deformity. Extension bracing has shown efficacy in the treatment of Scheuermann’s kyphosis that measures 50 degrees to 74 degrees, and has actually reduced the curvature permanently in some patients. A thoracolumbosacral orthosis may be used if the apex of kyphosis is at T7 or lower. Indications for surgical treatment are controversial, but spinal fusion most likely should not be considered for a painless kyphosis measuring less than 75 degrees. REFERENCES: Murray PM, Weinstein SL, Spratt KF: The natural history and long-term follow-up of Scheuermann kyphosis. J Bone Joint Surg Am 1993;75:236-248. Wenger DR, Frick SL: Scheuermann kyphosis. Spine 1999;24:2630-2639. Tribus CB: Scheuermann’s kyphosis in adolescents and adults: Diagnosis and management. J Am Acad Orthop Surg 1998;6:36-43.

Question 1976

Topic: 6. Spine
One year after undergoing anterior cervical decompression and fusion, what percentage of patients still have dysphagia?
. 10% to 15%
. 30% to 35%
. 50% to 55%
. 70% to 75%

Correct Answer & Explanation

. 30% to 35%

Explanation

DISCUSSION: Dysphagia after anterior cervical diskectomy and fusion is a common, usually transient finding after anterior cervical approaches to the spine. While it has been reported to occur in up to 70% of patients 2 weeks following surgery, in most cases the symptoms quickly resolve. There is, however, a small subset of patients for whom symptoms of dysphagia will persist. Lee and associates prospectively studied the rate of dysphagia after anterior cervical diskectomy and fusion, reporting a 15% rate of dysphagia at 12 months, and 12% at 24 months. Phillips and associates analyzed the 2-year data from the PCM FDE clinical trial and found a 12.1% incidence of dysphagia in the ACDF arm. RECOMMENDED READINGS: Lee MJ, Bazaz R, Furey CG, Yoo J. Risk factors for dysphagia after anterior cervical spine surgery: a two-year prospective cohort study. Spine J. 2007 Mar-Apr;7(2):141-7. Epub 2007 Jan 22. PubMed PMID: 17321961. Smith-Hammond CA, New KC, Pietrobon R, Curtis DJ, Scharver CH, Turner DA. Prospective analysis of incidence and risk factors of dysphagia in spine surgery patients: comparison of anterior cervical, posterior cervical, and lumbar procedures. Spine (Phila Pa 1976). 2004 Jul 1;29(13):1441-6. PubMed PMID: 15223936. Edwards CC 2nd, Karpitskaya Y, Cha C, Heller JG, Lauryssen C, Yoon ST, Riew KD. Accurate identification of adverse outcomes after cervical spine surgery. J Bone Joint Surg Am. 2004 Feb;86-A(2):251-6. PubMed PMID: 14960668. Phillips FM, Lee JY, Geisler FH, Cappuccino A, Chaput CD, DeVine JG, Reah C, Gilder KM, Howell KM, McAfee PC. A prospective, randomized, controlled clinical investigation comparing PCM cervical disc arthroplasty with anterior cervical discectomy and fusion. 2-year results from the US FDA IDE clinical trial. Spine (Phila Pa 1976). 2013 Jul 1;38(15):E907-18. doi: 10.1097/BRS.0b013e318296232f. Rihn JA, Kane J, Albert TJ, Vaccaro AR, Hilibrand AS. What is the incidence and severity of dysphagia after anterior cervical surgery? Clin Orthop Relat Res. 2011 Mar;469(3):658-65. PMID: 21140251.

Question 1977

Topic: 6. Spine
  • A 25-year-old patient who was wearing a seat belt in the back chair of a car involved in a head-on collision undergoes a laparotomy. During surgery, an injury to the sigmoid colon is identified and treated. Two days later the patient has back pain when sitting in a chair. What is the most likely diagnosis?
. Sacral fracture
. Burst fracture of L5
. Cauda equina syndrome
. Distraction-flexion injury at L3
. Distraction-extension injury at L3

Correct Answer & Explanation

. Distraction-flexion injury at L3

Explanation

Number four is correct because it fits the injury pattern and symptoms of the scenario given above. (Chance/Seat Belt Fracture) Number one is incorrect because it is the most “likely” diagnosis in this injury pattern. It would need more of a direct blow type of injury to be true. Number two is incorrect because it does not fit the injury pattern. The burst fracture is usually an axial/vertical loading injury. Number three is incorrect because the patient is having back pain only and no lower extremity or bowed/bladder complaints that you would typically find in a cauda equina syndrome. Number five is incorrect because it does not fit the injury pattern of the scenario given above with comparison to the number four answer.

Question 1978

Topic: Thoracolumbar Spine & Deformity

A 13-year-old girl presents with back pain for 6 months. Figures A and B are SPECT scan and CT images taken at the time of presentation. What is the most likely diagnosis? Review Topic

. Osteoid osteoma
. Bone island
. Spondylolysis
. Osteoblastic metastases
. Aneurysmal bone cyst

Correct Answer & Explanation

. Spondylolysis

Explanation

Thispatienthasspondylolysis.Spondylolysis is a common cause of back pain in children/adolescents. It is common in sports with repetitive hyperextension (gymnasts, weightlifters, football linemen). It is best seen on lateral and oblique radiographs, CT (best study to diagnose and delineate anatomy), and SPECT.Saifuddin et al. reviewed the orientation of the pars fracture. They found that only 32% of defects were oriented within 15° of the 45° lateral oblique plane and would bevisible on oblique radiographs. They thus recommend CT scans for spondylolysis.Cheung et al. reviewed spondylolysis and spondylolisthesis. They advocate pars repair for symptomatic spondylolysis and low-grade, mobile spondylolisthesis with pars defects cephalad to L5 and for those with multiple-level defects.Figure A is a 99mTc-MDP SPECT scan showing increased uptake at the right L5 pars interarticularis. Figure B is an axial helical CT image showing bilateral spondylolysis at L5. Illustration A is a corresponding sagittal reconstruction image demonstrating right pars fracture into the right L5 superior facet. Illustration B shows the appearance of osteoblastic metastasis (green arrow). Illustration C shows the options for pars repair.Incorrect

Question 1979

Topic: 6. Spine
A 40-year-old man sustains a fracture-dislocation of C4-5. Examination reveals no motor or sensory function below the C5 level. All extremities are areflexic. The bulbocavernosus reflex is absent. The prognosis for this patient’s neurologic recovery can be best determined by
. myelography with CT.
. spinal cord-evoked potentials.
. repeat physical examinations.
. MRI.
. electromyography and nerve conduction velocity studies.

Correct Answer & Explanation

. repeat physical examinations.

Explanation

DISCUSSION: The patient has spinal shock. Steroid administration and MRI are appropriate therapeutic and diagnostic procedures. Myelography with CT is of little value unless there is an unusual skeletal variant. Spinal cord-evoked potentials have no value. The best method to determine the patient’s neurologic recovery is repeated physical examinations over the first 48 to 72 hours. REFERENCES: Spivak JM, Connolly PF (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 183-184. Herkowitz HN, Garfin SR, Eismont FJ: Rothman-Simone The Spine, ed 5. Philadelphia, PA, Saunders Elsevier, 2006, pp 1185-1194.

Question 1980

Topic: 6. Spine

A 45-year-old woman awakens with the acute onset of burning left shoulder pain that radiates toward the axilla. She denies any history of trauma. On examination, she is unable to abduct her arm but has full passive shoulder motion. Her sensation is intact. Cervical spine examination reveals full range of motion and a negative Spurling’s test. Radiographs and MRI studies are normal for the cervical spine and shoulder. What is the most likely diagnosis? Review Topic

. Cervical C6-7 radiculopathy
. Impingement
. Rotator cuff tear
. Brachial neuritis
. Adhesive capsulitis

Correct Answer & Explanation

. Brachial neuritis

Explanation

The definition of brachial neuritis or Parsonage-Turner syndrome is a rare disorder of unknown etiology that causes pain or weakness of the shoulder and upper extremity. The loss of active motion excludes cervical C6-7 radiculopathy and impingement. A normal MRI scan and full passive motion exclude a rotator cuff tear and adhesive capsulitis, respectively.

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