Orthopedic Spine 2026 MCQs: Board Review Questions & Answers (Part 1)

The transverse diameter of the pedicle is most narrow at which of the following levels?

Subluxation caused by rheumatoid arthritis is most commonly seen at what level of the cervical spine?

During a transperitoneal approach to the L5-S1 interspace, care must be taken to protect the superior hypogastric plexus from injury. Which of the following techniques reduces the risk of neurologic injury?

When treating thoracolumbar spine fractures, which of the following is considered the major advantage of using a thoracolumbosacral orthosis (TLSO) when compared to a three-point fixation brace (Jewett)?

Injury to which of the following structures has been reported following iliac crest bone graft harvest?

A 44-year-old woman has had lower extremity dysesthesias, urinary incontinence, and has been unable to walk for the past 2 days. She reports no pain or history of trauma. She notes that 3 weeks ago she missed work for 2 days because of back pain, but it resolved with rest. Examination shows decreased or absent sensation below the knees, no motor function below the knees, and decreased rectal tone. Catheterization results in a postvoid residual of 2,000 mL. Plain radiographs and MRI scans without contrast are shown in Figures 1a through 1d. What is the next most appropriate step in management?

During anterior surgery on the cervical spine, at what level would the lateral dissection of the longus coli muscle most likely cause Horner's syndrome?

When compared with cobalt-chromium and stainless steel implants, a titanium implant has what biomechanical properties?

A 22-year-old college basketball player who was hit from behind while going up for a rebound is rendered immediately quadraparetic for approximately 10 minutes, followed by complete resolution of motor loss and return of full sensation. The radiograph and MRI scan of the cervical spine shown in Figures 2a and 2b reveal a canal diameter of 13 mm, loss of cerebrospinal fluid space about the spinal cord, and no signal change within the cord. What is the best course of action?

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?

A patient who sustained injuries in a motorcycle accident 30 minutes ago has significant motor and sensory deficits corresponding to a C6 level of injury. A lateral radiograph obtained during the initial on-scene evaluation reveals bilateral jumped facets at C5-C6; this appears to be an isolated injury. The patient is awake and alert. The next step in management of the dislocation should consist of

Figure 4 shows the MRI scan of a patient who has had bilateral leg pain, weakness, diffuse numbness, and urinary retention for the past week. Examination reveals that motor strength is diffusely decreased, although it may be secondary to pain. The patient is numb throughout both legs, and reflexes in the lower extremities are absent. Rectal examination shows decreased tone, but voluntary tightening is present. Management should consist of

A 62-year-old man has cervical myelopathy with no evidence of cervical radiculopathy. MRI reveals stenosis at C4-5 and C5-6 with severe cord compression. Examination will most likely reveal which of the following findings?

A patient who has had neck pain radiating down the arm for the past 4 weeks reports that the pain was excruciating during the first week. Management consisting of anti-inflammatory drugs and physical therapy has decreased the neck and arm symptoms from 10/10 to 3/10. He remains neurologically intact. MRI and CT scans are shown in Figures 5a and 5b. The best course of action should be

Examination of a supine patient in which the hip is abducted, externally rotated, and flexed is referred to as

During the evaluation of a patient suspected of having a lumbar disk herniation, T1- and T2-weighted MRI scans reveal a hyperintence lobular, well-defined lesion in the L2 vertebral body. What is the most likely diagnosis?

A 32-year-old man notes increasing back pain and progressive paraparesis over the past few weeks. He is febrile, and laboratory studies show a WBC of 12,500/mm3. MRI scans are shown in Figures 6a and 6b. Management should consist of

A 21-year-old woman with Marfan syndrome is seeking evaluation of her scoliosis. She reports no back or leg pain, and the neurologic examination is normal. Lateral and bending radiographs are shown in Figures 7a through 7e. Management should consist of

Which of the following substances is least likely to affect the success of bone union after lumbar arthrodesis?

A 33-year-old woman sustains a C6 burst fracture diving into a swimming pool, resulting in a complete spinal cord injury. The canal compromise is shown in Figures 8a and 8b. Functional recovery would be maximized with

In the upright standing position, approximately what percent of the vertical load is borne by the lumbar spine facet joints?

A 40-year-old patient who has a type II odontoid fracture is placed in a halo vest for 12 weeks; however, current radiographs show no evidence of healing. The next most appropriate step in management should consist of

In the initial evaluation of acute low back pain (duration of less than 4 weeks), plain radiographs are recommended in which of the following situations?

Figure 9 shows a cross-sectional view of the spinal cord at the lower cervical level. Injury to the structure indicated by the black arrow will lead to what neurologic deficit?

A 26-year-old woman who noted right-sided lumbosacral pain 10 days ago while vacuuming now reports that the pain has intensified. She denies any history of back problems. No radicular component is present, and her neurologic examination is normal. The next most appropriate step in management should consist of

A 75-year-old male sustains a Type II odontoid fracture with 3 mm of posterior displacement following a low-energy fall. He is neurologically intact. Which of the following is the most appropriate initial management?

During an anterior cervical discectomy and fusion (ACDF) at C6-C7, the surgeon uses electrocautery near the lateral border of the longus colli muscle. Postoperatively, the patient develops ipsilateral ptosis and miosis. Injury to which of the following structures is most likely responsible?

A 68-year-old male with a long-standing history of ankylosing spondylitis presents to the emergency department with severe neck pain after a minor fall. Plain radiographs of the cervical spine are unremarkable, and he is neurologically intact. What is the most appropriate next step in management?

In a patient with symptomatic L5-S1 isthmic spondylolisthesis, which nerve root is most commonly compressed, and where does the compression typically occur?

A 35-year-old male sustains an L1 burst fracture. He is neurologically intact. MRI demonstrates an intact posterior ligamentous complex. According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the most appropriate treatment?

A 55-year-old male presents with difficulty buttoning his shirts and a clumsy gait. Examination reveals hyperreflexia in the lower extremities and a positive Hoffmann's sign. Radiographs show severe cervical spondylosis. The earliest clinical presentation of this condition is most commonly associated with dysfunction of which spinal tract?

A 70-year-old male with pre-existing cervical stenosis sustains a hyperextension injury to his neck. He presents with profound weakness in his upper extremities and relatively preserved motor function in his lower extremities. What is the most likely diagnosis?

A 45-year-old intravenous drug user presents with severe lower back pain, fever, and progressive bilateral leg weakness over the past 48 hours. He has urinary retention and decreased perianal sensation. MRI reveals an L3-L4 epidural abscess. What is the most appropriate definitive management?

A 25-year-old male sustains a Type IIa Hangman's fracture following a motor vehicle collision. Radiographs show severe anterior angulation of C2 on C3 without significant translation. What is the most appropriate non-operative management?

A patient presents with acute, severe right-sided radicular leg pain. MRI demonstrates a far-lateral (extraforaminal) disc herniation at the L4-L5 level on the right. Which nerve root is most likely compressed?

In the assessment of spinopelvic parameters, which of the following is considered a fixed morphological parameter of the pelvis that is unaffected by the patient's posture?

During the application of a halo vest in an adult, the anterior pins are placed 1 cm superior to the lateral one-third of the eyebrow. This specific placement is designed to minimize the risk of injury to branches of which cranial nerve?

A 60-year-old male presents with a solitary lytic lesion in the L3 vertebral body, confirmed as metastatic renal cell carcinoma. Before proceeding with a palliative surgical decompression and stabilization, which adjunctive procedure is highly recommended?

What is the primary advantage of cervical disc arthroplasty over anterior cervical discectomy and fusion (ACDF) based on long-term randomized trials?

A 65-year-old man presents with bilateral upper extremity weakness (distal greater than proximal) and mild lower extremity weakness following a hyperextension injury to his neck. Which specific spinal cord region injury is primarily responsible for his upper extremity deficits?

Which of the following is the most consistent radiographic predictor of failure of nonoperative management in patients with degenerative lumbar spondylolisthesis and spinal stenosis?

A 6-year-old child presents with torticollis 10 days after an upper respiratory infection. Dynamic CT scan reveals C1-C2 rotatory subluxation with 4 mm of anterior displacement of C1 on C2. According to the Fielding and Hawkins classification, what type is this and what is the status of the transverse ligament?

In the Lenke classification of Adolescent Idiopathic Scoliosis, a structural curve is determined by side-bending radiographs. Which of the following defines a structural proximal thoracic curve?

Which of the following clinical findings has the highest sensitivity for the diagnosis of cauda equina syndrome?

A 20-year-old male presents with slowly progressive, unilateral upper extremity weakness and atrophy involving the hand and forearm, sparing the brachioradialis. MRI of the cervical spine with neck flexion reveals anterior displacement of the posterior dura compressing the cervical cord. What is the most likely diagnosis?

According to the Levine and Edwards classification of traumatic spondylolisthesis of the axis (Hangman's fracture), what is the mechanism of injury and recommended treatment for a Type IIA fracture?

Which of the following intraoperative factors is most strongly associated with the development of ischemic optic neuropathy following posterior instrumented spinal fusion?

In the preoperative planning for adult spinal deformity correction, which of the following formulas represents the normal morphological relationship between Pelvic Incidence (PI), Sacral Slope (SS), and Pelvic Tilt (PT)?

A 24-year-old male sustains a bony flexion-distraction injury (Chance fracture) of L2 in a motor vehicle collision. Neurologic examination is intact. What is the most appropriate initial management?

A 55-year-old diabetic patient presents with back pain, fever, and progressive lower extremity weakness. MRI confirms a large dorsal epidural abscess at T8-T10. Which of the following factors most strongly indicates the need for emergent surgical decompression rather than medical management alone?

A patient presents with severe right-sided anterior thigh pain, weakness in knee extension, and a diminished right patellar reflex. MRI of the lumbar spine reveals a far lateral (extraforaminal) disc herniation at the L4-L5 level. Which nerve root is most likely compressed?

A 78-year-old male sustains a Type II odontoid fracture after a ground-level fall. He has no neurologic deficits but has a history of severe COPD and congestive heart failure. Which of the following treatments is associated with the highest morbidity and mortality in this specific patient population?

A 30-year-old female sustains a U-shaped sacral fracture following a fall from height. She presents with perineal numbness and urinary retention. What mechanism is typically responsible for this injury pattern?

A 60-year-old male presents with dull, aching lower back pain and bowel/bladder dysfunction. Imaging shows a destructive midline sacral mass with a large pre-sacral soft tissue component. Biopsy reveals physaliferous cells in a myxoid stroma. What is the most appropriate definitive surgical management?

A 45-year-old male presents with acute severe leg pain. MRI demonstrates a large far-lateral (extraforaminal) disc herniation at the L4-L5 level.

Which of the following physical examination findings is most expected in this patient?

A 62-year-old male undergoes an anterior cervical discectomy and fusion (ACDF). The surgeon chooses a right-sided approach to the lower cervical spine. To avoid postoperative hoarseness, the surgeon must be mindful of the recurrent laryngeal nerve (RLN). Which of the following best describes its anatomic course on the right side compared to the left?

A 65-year-old female with long-standing rheumatoid arthritis presents with progressive clumsiness in her hands and difficulty walking. Flexion-extension radiographs reveal an anterior atlantodental interval (ADI) of 11 mm. What is the most critical parameter to evaluate on imaging to determine her risk of impending severe neurologic deficit?

In the emergency evaluation of a patient with spinal trauma, examination reveals preserved proprioception and light touch sensation in the lower extremities but a complete loss of bilateral motor function and pain/temperature sensation below the umbilicus. Which of the following vascular territories is most likely compromised?

A 70-year-old male presents with bilateral lower extremity pain and cramping that worsens with standing and walking but improves when leaning forward on a shopping cart. He is being evaluated for lumbar spinal stenosis. Which of the following differentiates neurogenic claudication from vascular claudication?

A 35-year-old male falls from a height and sustains a burst fracture of L1. His neurologic examination is completely normal. The Thoracolumbar Injury Classification and Severity (TLICS) score is calculated to be 2. What is the most appropriate management?

A 42-year-old female underwent a posterior spinal fusion for adolescent idiopathic scoliosis extending down to L5 when she was a teenager. She now presents with severe lower back pain and radicular symptoms. Radiographs demonstrate advanced degenerative disc disease, facet arthropathy, and listhesis at the L5-S1 level. What is this specific phenomenon termed?

During a posterior lumbar decompression and interbody fusion (PLIF) at L4-L5, the surgeon inadvertently tears the dura, resulting in a cerebrospinal fluid leak. A primary, watertight dural repair is successfully achieved. What is the standard post-operative management to minimize the risk of a persistent CSF fistula?

A 55-year-old male with long-standing ankylosing spondylitis sustains a minor fall at home. He presents with new-onset neck pain and bilateral hand tingling. Initial AP and lateral plain radiographs of the cervical spine are interpreted as "normal" with expected autofusion.

What is the most appropriate next step in management?

Which of the following pathologic entities is classically associated with the "winking owl" sign on an anteroposterior (AP) plain radiograph of the thoracic spine?

A 28-year-old male is diagnosed with an L5-S1 isthmic spondylolisthesis (Meyerding Grade II). He has failed 6 months of conservative therapy and continues to have axial back pain and bilateral L5 radiculopathy. What is the underlying anatomical defect characterizing this specific condition?

During an anterior approach to the cervical spine for a C5-C6 discectomy, the surgeon must elevate the longus colli muscles. Care must be taken to avoid aggressive lateral dissection over the anterior surface of the longus colli to prevent injury to which of the following structures?

A 65-year-old male with long-standing ankylosing spondylitis sustains a minor fall. He complains of new-onset neck pain but is neurologically intact. Radiographs reveal a transverse fracture through the C5-C6 disc space extending through the posterior elements. What is the most appropriate management?

A 55-year-old male undergoes a C3-C6 posterior cervical laminectomy and fusion for cervical spondylotic myelopathy. On postoperative day 2, he develops profound, isolated weakness of his bilateral deltoids and biceps (0/5) with preserved lower extremity function. What is the most likely etiology of this complication?

A surgeon plans to use recombinant human bone morphogenetic protein-2 (rhBMP-2) off-label during an anterior cervical discectomy and fusion (ACDF). The patient should be counseled about a significantly increased risk of which of the following complications compared to autograft?

A 30-year-old neurologically intact male presents after a motor vehicle collision. CT imaging demonstrates a burst fracture of L1 with 40% loss of vertebral body height and 15 degrees of local kyphosis. MRI confirms the posterior ligamentous complex (PLC) is completely intact. According to the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the most appropriate management?

In planning corrective surgery for a 62-year-old female with severe adult spinal deformity, achieving optimal sagittal balance is critical. According to the SRS-Schwab classification guidelines, what is the surgical target for the mismatch between pelvic incidence (PI) and lumbar lordosis (LL)?

During the posterior surgical exposure of the C1 posterior arch, the surgeon must exercise extreme caution to avoid catastrophic vascular injury. What is the maximum safe distance for lateral subperiosteal dissection from the posterior midline of C1?

A 14-year-old female presents with severe low back pain, radicular leg symptoms, and a waddling gait. Imaging reveals a Meyerding Grade IV isthmic spondylolisthesis at L5-S1 with a slip angle of 55 degrees. After failed conservative management, what is the most appropriate surgical intervention?

A 52-year-old diabetic male presents with 3 weeks of progressively worsening back pain, low-grade fevers, and new-onset bilateral iliopsoas weakness (3/5). MRI with contrast reveals an extensive anterior epidural abscess from L2-L4 causing severe compression of the thecal sac. The patient is hemodynamically stable. What is the most appropriate next step in management?

A 72-year-old male with known cervical spondylosis falls forward, striking his chin. He presents with severe upper extremity weakness, particularly in his hands, but can ambulate with a walker. Sensation to pinprick and temperature is diminished in a cape-like distribution over his shoulders. What is the primary pathophysiological mechanism of his spinal cord injury?

A 45-year-old female presents to the emergency department with acute onset of severe right-sided radicular leg pain, saddle anesthesia, and urinary retention. MRI confirms a massive L4-L5 disc herniation compressing the cauda equina. Which timeline for surgical decompression is supported by current literature to maximize the potential for urological and neurological recovery?

A 14-year-old female with adolescent idiopathic scoliosis (AIS) has a standing PA radiograph demonstrating a main thoracic curve of 55 degrees and a lumbar curve of 35 degrees. On supine side-bending radiographs, the lumbar curve corrects to 15 degrees. What is her Lenke curve type, and what is the standard surgical strategy?

An 82-year-old male with severe COPD and congestive heart failure falls from standing height. CT of the cervical spine reveals a Type II odontoid fracture with 2 mm of posterior displacement. He is neurologically intact. What is the recommended management strategy that balances fracture care with the lowest morbidity and mortality for this specific patient?

A 45-year-old male presents with right arm pain and weakness. Physical examination reveals a diminished triceps reflex, weakness with elbow extension, and numbness over the middle finger. Which of the following nerve roots is most likely affected?

A 68-year-old male with long-standing ankylosing spondylitis sustains a minor fall. He complains of severe neck pain but is neurologically intact. Standard radiographs are inconclusive. What is the most appropriate next step in management?

Which of the following physical examination findings is most specific for differentiating neurogenic claudication from vascular claudication in a patient with lower extremity pain during walking?

An 82-year-old female presents with a Type II odontoid fracture displaced by 4 mm posteriorly after a ground-level fall. She has significant medical comorbidities. What is the most appropriate management?

According to the Thoracolumbar Injury Classification and Severity Score (TLICS), which of the following isolated findings automatically assigns a score strongly recommending surgical intervention?

A 55-year-old male presents with clumsy hands and a wide-based gait. Tapping the volar aspect of the distal phalanx of the middle finger produces a reflex flexion of the thumb and index finger. This clinical test is known as:

A 65-year-old female presents with worsening back pain and inability to stand up straight. A standing lateral radiograph is obtained.

For optimal surgical correction of her adult spinal deformity, the surgeon should aim for a mismatch between pelvic incidence (PI) and lumbar lordosis (LL) of:

A 38-year-old male acutely develops severe right leg pain radiating down the posterior thigh and calf to the plantar aspect of the foot. He has a weakened Achilles reflex. A paracentral disc herniation at which level is most likely responsible?

A 50-year-old intravenous drug user presents with back pain, fever, and progressive lower extremity weakness. MRI reveals a ventral spinal epidural abscess from L1 to L3 with severe canal stenosis. What is the most appropriate surgical approach?

A 14-year-old gymnast presents with persistent low back pain. Radiographs reveal a Grade 1 L5-S1 isthmic spondylolisthesis. After 6 months of physical therapy and bracing, her pain remains debilitating. What is the recommended surgical management?

When applying a halo vest in an adult patient, the anterior pins must be placed carefully to avoid nerve injury. Which of the following nerves is at greatest risk if the anterior pins are placed too medially?

Which of the following clinical findings is considered the most reliable indicator of urinary retention in a patient suspected of having cauda equina syndrome?

A 25-year-old male sustains a traumatic spondylolisthesis of the axis (Hangman's fracture). Radiographs demonstrate severe angulation without significant translation. Flexion-extension views are contraindicated. Which Levine and Edwards classification does this represent, and what is the recommended treatment?

A 30-year-old male is involved in a high-speed motor vehicle collision. He has 0/5 strength in his lower extremities and a sensory level at the nipple line. A lateral cervical radiograph is obtained.

Assuming an MRI shows a large extruded disc herniation behind the displaced vertebral body, what is the safest sequence of surgical management?

In a patient with known metastatic prostate cancer to the thoracic spine, which of the following primary factors is evaluated in the modified Tokuhashi scoring system to predict survival and guide surgical decision-making?

During an anterior cervical discectomy and fusion (ACDF) at C5-C6, the surgeon utilizes a right-sided approach. Postoperatively, the patient has a hoarse voice but normal swallowing. Injury to which of the following nerves is the most likely cause?

A 70-year-old male with pre-existing cervical stenosis falls forward and strikes his chin. He develops severe weakness in his bilateral hands and arms, but maintains 4/5 strength in his legs. Bowel and bladder functions are intact. What is the most likely diagnosis?

A 65-year-old man undergoes a C3-C6 laminectomy and fusion for cervical spondylotic myelopathy. On postoperative day 2, he develops isolated profound weakness in bilateral deltoid and biceps muscles. Sensation and lower extremity function remain completely intact. An MRI shows adequate decompression with a significant posterior shift of the spinal cord. What is the most likely etiology of this complication?

A 35-year-old male sustains a severe flexion-distraction injury to the thoracolumbar spine resulting in a bony Chance fracture. An anterior surgical approach is chosen for stabilization. To minimize the risk of an iatrogenic anterior spinal cord syndrome, the surgeon must be cautious during mobilization of the aorta and segmental vessels. The artery of Adamkiewicz typically arises at which of the following anatomic locations?