Question 1

Which of the following statements concerning neck pain is incorrect:

Explanation

Choices A, B, D, and E are correct and are important considerations with managing a patient with neck pain. Rest and physical therapy are important and effective in treating neck pain. Prolonged immobilization of the neck with a collar, however, can result in deconditioning of the cervical paraspinal musculature, which can increase the patientâ s risk for further neck injury.

Question 2

Schmorlâ s nodes may be seen on radiographic studies in all of the following disorders except:

Explanation

Schmorls nodes are seen in association with several disorders including Scheuermanns kyphosis, degenerative disk disease, trauma, and osteoporosis. Schmorlâ s nodes are not commonly seen in patients with spina bifida.

Question 3

All of the following are possible treatments for congenital or acquired torticollis except:

Explanation

Several treatment options exist for congenital and acquired torticollis. In very mild cases of congenital torticollis, the deformity may be self-limited and no therapy needs to be administered. Sometimes active and passive stretching of the neck can work well if performed before 1 year of life. Parents may hold the babys head so that the chin is rotated toward the affected side. Acquired torticollis can also be managed by physical therapy using NSAIDs and a soft collar. The use of botulinum toxin or braces can be a form of therapy in recalcitrant cases.

Question 4

What is the incidence of congenital torticollis in the general population:

Explanation

Epidemiological studies have shown that the incidence of congenital torticollis is approximately 0.3% to 1.9% in the general population.

Question 5

Which of the following is a contraindication to kyphoplasty:

Explanation

It is important to properly evaluate a patient prior to any surgical procedure. If a patient presents with osteomyelitis, osteoblastic lesions, sepsis, or bleeding diathesis, then surgery should be postponed until the underlying condition is corrected.

Question 6

Approximately how many vertebral compression fractures occur in the United States annually:

Explanation

There are approximately 700,000 reported vertebral compression fractures annually in the United States.

Question 7

It is important to distinguish between acute or subacute vertebral compression fractures and old healed fractures radiographically. Which of the following can help distinguish an acute fracture from a chronic fracture:

Explanation

One can distinguish an acute or subacute vertebral compression fracture from an old, healed fracture by evaluating the fatsuppressed T2-weighted MRI or short tau inversion recovery (STIR) images. These images will show increased signal intensity suggesting an acute fracture. All of the other forms of imaging mentioned may also be used to evaluate the patient but are not the best techniques for differentiating an acute from a subacute fracture. DEXA scans are used to evaluate for osteoporosis. Although CT imaging provides excellent osseous detail, it may not allow for differentiation of an acute from a chronic fracture unless evidence of fracture healing is seen. Another method for evaluating the acuity of a vertebral compression fracture is a threephase bone scan, which will demonstrate increased radiotracer activity at the site of an acute or subacute fracture.

Question 8

What is the prevalence of Schmorls nodes in the general population:

Explanation

Approximately 10% of the population has Schmorlâ s nodes, which are often completely benign.

Question 9

A 34-year-old man presents to the emergency department after sustaining a low-velocity gunshot wound to the upper back. Radiologic studies reveal bullet fragments scattered throughout the T6 to T8 levels. No evidence of instability is present on conventional radiographs and computed tomography. The patient was stabilized and a full neurologic examination was performed, revealing no major neurologic deficits. Management of this patient should consist of:

Explanation

Removal of the bullet fragments from the T6 to T8 levels is not indicated because the patient does not have neurologic deficits and therefore does not require spinal cord decompression via bullet removal. Decompression via bullet removal for neural deficits in the thoracic spine has been shown to result in higher rates of complications compared with nonoperative management. High-dose steroid administration is not indicated in patients with gunshot wounds to the spine because the benefits of steroids are outweighed by the risks. The administration of broad-spectrum antibiotics is not indicated in this patient because the bullet did not pass through the gastrointestinal tract. Nonoperative management and regular observation for progression of neurologic deficits is important in this patient because of the localization of the bullet fragments to the thoracic spine, the lack of neurologic deficits, and the lack of instability.

Question 10

A patient with slipped capital femoral epiphysis (SC FE) should have an endocrine workup if presenting with which of the following features:

Explanation

Endocrine workup is only indicated for age ,10 or .15 years, or stature less than the 10th percentile. Bilaterality, obesity, and negative family history are common findings in idiopathic SC FE. Although SC FE is more common in males, it is not uncommon in females.

Question 11

Occipitocervical fusion is often technically difficult in patients with rheumatoid arthritis due to all of the following reasons except:

Explanation

Reduced bone quality is common in patients with rheumatoid arthritis. Steroid use may contribute to poor bone quality, impair bony fusion, and impede wound healing. The combination of occipitocervical deformity and subaxial subluxation may make individual patient constructs more extensive.

Question 12

The majority of studies confirm the presence of atlanto-axial subluxation (AAS) when:

Explanation

As described by Puttlitz and colleagues, AAS is defined as an AADI greater than 3 mm or a PADI less than 14 mm.

Question 13

The most common traumatic indications for occipitocervical fusion include type III occipital condyle fractures and:

Explanation

Basilar invagination and atlanto-axial subluxation are more commonly present in degenerative disorders and less in trauma. Odontoid fractures are usually treated via C 1-C 2 fusion or odontoid screw fixation, although less commonly occipitocervical fusion is required. C 1-C 2 instability, similarly, is usually treated via C 1-C 2 stabilization. A more common traumatic indication for occipitocervical fusion is atlanto-axial dissociation.

Question 14

Occipitocervical fusion is indicated in all of the following situations except:

Explanation

An unstable C 1-C 2 segment, with intact posterior elements, may be treated via a C 1-C 2 fusion. If decompression is necessary or the posterior elements at C 1-C 2 are involved, then extension to the occiput may be necessary.

Question 15

Approximately what percentage of individuals with rheumatoid arthritis will develop basilar invagination:

Explanation

As per Sandhu and researchers, approximately 11% of patients with rheumatoid arthritis will eventually develop basilar invagination.

Question 16

Which approach(es) will provide access to the middle and anterior columns of the thoracic spine:

Explanation

The anterior and posterolateral approaches provide access to the vertebral body (the anterior and middle columns of the spine) for performance of a corpectomy procedure, for example.

Question 17

A 30-year-old man underwent an anterior lumbar discectomy and fusion at L4-L5 and L5-S1 through an anterior retroperitoneal approach 1 month ago. He now reports that he is unable to obtain and maintain an erection. The most likely cause of this condition is:

Explanation

Sexual dysfunction is a common condition after extensive anterior lumbar surgical dissection. Erectile dysfunction is often nonorganic but may be related to parasympathetic injury. The parasympathetic nerves are deep in the pelvis at the level of S2-S3 and S3-S4 and are not usually involved in the surgical field for anterior L4-L5 and L5-S1 procedures. Retrograde ejaculation is the result of injury to the sympathetic chain on the anterior surface of the major vessels crossing the L4-L5 level and at the L5-S1 interspace. Erectile function and orgasm are not affected by sympathetic injury. The pudendal nerve is primarily a somatic nerve and is not located in the surgical field.

Question 18

What percentage of patients with cervical myelopathy living in North America exhibit ossification of the posterior longitudinal ligament:

Explanation

Although ossification of the posterior longitudinal ligament is considered most common in the Japanese population, 25% of North Americans with cervical myelopathy exhibit signs of this condition.

Question 19

A 46-year-old patient with cervical myelopathy undergoes a multilevel posterior cervical laminectomy from C 3 to C 7. The risk of post laminectomy kyphosis is greatest with removal of which of the following structures:

Explanation

Post laminectomy kyphosis is often seen in patients who have removal of more than 50% of each facet joint or 100% of one facet joint. It is not commonly seen with removal of the ligamentum flavum or interspinous ligament. Less frequently, post laminectomy kyphosis is seen with removal of more than 80% of the lamina or excision of the facet joint capsules.

Question 20

Which of the following variables is the most reliable predictor of poor outcome following arthroscopic debridement of an arthritic knee:

Explanation

The presence of mechanical symptoms is a reliable predictor of successful outcome. Age has not been shown to reliably predict outcome following knee debridement. Although a prolonged duration of symptoms correlates with poor outcome, the presence of varus malalignment has a far more dismal prognosis.

Question 21

A 6-year-old presents with torticollis following an upper respiratory infection. Radiographs reveal atlantoaxial rotatory subluxation. According to the Fielding and Hawkins classification, which describes a Type II injury?

Explanation

Fielding Type II is characterized by rotatory displacement with anterior translation of 3 to 5 mm. This indicates one lateral mass is displaced anteriorly with a deficient or ruptured transverse ligament.

Question 22

A 65-year-old male presents with deteriorating handwriting and difficulty buttoning his shirt. Examination reveals a positive inverted brachioradialis reflex. This sign indicates a spinal cord lesion at which specific cervical level?

Explanation

The inverted brachioradialis reflex localizes a compressive lesion to the C5-C6 spinal level. It manifests as paradoxical finger flexion instead of normal elbow flexion and supination when the brachioradialis tendon is tapped.

Question 23

According to Sorensen's criteria, the radiographic diagnosis of classic Scheuermann's kyphosis requires which of the following?

Explanation

Sorensen's criteria define Scheuermann's kyphosis as structural thoracic kyphosis > 40 degrees with anterior wedging of at least 5 degrees in three or more consecutive vertebrae. Endplate irregularities and Schmorl's nodes are common but not strict diagnostic criteria.

Question 24

Which of the following pathophysiologic mechanisms best describes Grisel's syndrome?

Explanation

Grisel's syndrome is non-traumatic atlantoaxial subluxation caused by inflammatory hyperemia of the retropharyngeal space. This typically occurs following a head or neck infection, leading to laxity of the transverse ligament.

Question 25

A 5-year-old girl is diagnosed with Klippel-Feil syndrome. Which of the following associated conditions must be screened for routinely due to its high incidence and potential severity?

Explanation

Klippel-Feil syndrome involves congenital fusion of cervical vertebrae and is highly associated with multiple systemic anomalies. Screening should include renal ultrasound, echocardiogram, and audiometry due to the high incidence of renal, cardiac, and otic abnormalities.

Question 26

In an infant with congenital muscular torticollis resistant to conservative stretching by 18 months of age, surgical release is typically targeted at which of the following structures?

Explanation

Congenital muscular torticollis is caused by unilateral fibrosis and contracture of the sternocleidomastoid (SCM) muscle. If a prolonged trial of conservative stretching fails, unipolar or bipolar surgical release of the SCM is indicated.

Question 27

A 45-year-old patient presents with neck pain radiating down the right arm. Examination shows weakness in triceps extension and wrist flexion, with numbness isolated to the middle finger. Which nerve root is most likely compressed?

Explanation

A C7 radiculopathy classically presents with weakness in the triceps (elbow extension) and wrist flexors. It is also associated with an absent or diminished triceps reflex and sensory changes in the middle finger.

Question 28

Which radiographic finding is essential to confirm the diagnosis of Diffuse Idiopathic Skeletal Hyperostosis (DISH) according to Resnick's criteria?

Explanation

Resnick's criteria for DISH require flowing ossification of at least four contiguous vertebral bodies. It also requires the preservation of disc height and the absence of sacroiliac joint or apophyseal joint ankylosis.

Question 29

In the Levine-Edwards classification of traumatic spondylolisthesis of the axis (Hangman's fracture), a Type IIA fracture is characterized by which of the following?

Explanation

A Type IIA Hangman's fracture represents a flexion-distraction injury characterized by severe angulation with minimal anterior translation. Traction is strictly contraindicated in Type IIA injuries as it will exacerbate the deformity.

Question 30

A 75-year-old male sustains a Type II odontoid fracture with 6 mm of posterior displacement. Because of multiple medical comorbidities, he is treated non-operatively in a halo vest. What is his most likely clinical outcome?

Explanation

Type II odontoid fractures in the elderly, particularly those with displacement greater than 5 mm, have an extremely high nonunion rate (often > 50%) when treated non-operatively. Surgical stabilization is generally preferred if the patient can tolerate anesthesia.

Question 31

A 55-year-old male with long-standing ankylosing spondylitis presents after a minor fall with neck pain but intact neurology. CT reveals a fracture through the C5-C6 disc space extending into the posterior elements. What is the most appropriate definitive management?

Explanation

Cervical spine fractures in ankylosing spondylitis often act as long-bone fractures and are highly unstable, carrying a significant risk of delayed neurologic deterioration. Long-segment posterior instrumented fusion is the gold standard for robust stabilization.

Question 32

An 80-year-old male with severe cervical spondylotic myelopathy has multi-level compression from C3 to C6 predominantly due to ossification of the posterior longitudinal ligament (OPLL). Radiographs show a fixed, rigid kyphotic deformity of 15 degrees. Which surgical approach is generally indicated?

Explanation

In the presence of a rigid kyphotic deformity, posterior indirect decompression (laminectomy or laminoplasty) is contraindicated because the spinal cord will not drift backward. An anterior or combined approach is required to correct the kyphosis and directly decompress the OPLL.

Question 33

Which radiographic finding best differentiates an os odontoideum from an acute Type II odontoid fracture?

Explanation

Os odontoideum presents with smooth, rounded, sclerotic borders of the ossicle and an associated hypertrophic anterior arch of the atlas. This indicates a chronic, long-standing process, unlike the sharp, irregular fracture lines seen in an acute injury.

Question 34

In a patient with severe rheumatoid arthritis, what measurement of the anterior atlantodens interval (ADI) is generally considered an absolute indication for surgical stabilization, even if the patient is asymptomatic?

Explanation

In rheumatoid arthritis, an ADI greater than 9 to 10 mm signifies failure of the alar ligaments and apical ligaments in addition to the transverse ligament. This places the spinal cord at significant risk, warranting prophylactic surgical stabilization.

Question 35

A trauma patient presents with complete loss of motor and sensory function below T4 following a motorcycle accident. The bulbocavernosus reflex is absent. Which of the following statements regarding the patient's prognosis is most accurate?

Explanation

The absence of the bulbocavernosus reflex indicates the patient is in a state of spinal shock. A definitive diagnosis of complete versus incomplete spinal cord injury cannot be established until spinal shock resolves.

Question 36

A 4-year-old child presents with a persistent head tilt to the right and chin rotation to the left following an upper respiratory infection. Imaging reveals anterior displacement of the atlas of 4 mm with one lateral mass acting as a pivot. According to the Fielding and Hawkins classification, what type of atlantoaxial rotatory subluxation is this?

Explanation

Fielding and Hawkins Type II involves anterior displacement of 3 to 5 mm with one lateral mass acting as the pivot point. It implies a deficiency of the transverse ligament.

Question 37

A 65-year-old man with cervical spondylotic myelopathy exhibits a positive inverted supinator reflex on examination. This abnormal reflex is characterized by a diminished brachioradialis response accompanied by which of the following simultaneous actions?

Explanation

The inverted supinator reflex occurs when tapping the brachioradialis tendon produces finger flexion rather than the normal reflex, indicating an upper motor neuron lesion at the C5-C6 level.

Question 38

Klippel-Feil syndrome is characterized by the congenital fusion of two or more cervical vertebrae. Which of the following systemic anomalies is most commonly associated with this syndrome and requires routine screening?

Explanation

Up to 30% of patients with Klippel-Feil syndrome have genitourinary anomalies, with unilateral renal agenesis being the most common. Renal ultrasound is a mandatory screening test in these patients.

Question 39

In a 3-week-old infant presenting with a palpable, firm mass in the sternocleidomastoid muscle and a clinical diagnosis of congenital muscular torticollis, what is the expected natural history of this sternomastoid tumor?

Explanation

A sternocleidomastoid tumor of infancy typically becomes palpable at 2 to 3 weeks of age, peaks in size at 1 to 2 months, and resolves spontaneously by 4 to 8 months with conservative stretching.

Question 40

According to the Sorensen criteria, classic Scheuermann's kyphosis is defined radiographically by a thoracic kyphosis greater than 40 degrees accompanied by which of the following?

Explanation

The Sorensen criteria strictly define classic Scheuermann's disease as thoracic kyphosis > 40 degrees with anterior wedging of at least 5 degrees in three or more consecutive vertebrae.

Question 41

A 7-year-old child presents with torticollis and severe neck stiffness one week after undergoing an adenotonsillectomy. Radiographs demonstrate atlantoaxial subluxation without evidence of trauma. What is the most likely diagnosis?

Explanation

Grisel's syndrome is a non-traumatic atlantoaxial subluxation most commonly seen in children following upper respiratory tract infections or head and neck surgeries due to inflammatory ligamentous laxity.

Question 42

According to the Levine-Edwards classification, a Type II Hangman's fracture (traumatic spondylolisthesis of the axis) is generated by which specific mechanism of injury?

Explanation

A Type II Hangman's fracture involves an initial hyperextension force that fractures the pars, followed by severe axial loading and a secondary flexion rebound causing displacement.

Question 43

An 80-year-old patient sustains a Type II odontoid fracture after a low-energy fall. If treated non-operatively with a hard collar, which of the following factors is most strongly associated with an increased risk of fracture nonunion?

Explanation

Risk factors for nonunion of Type II odontoid fractures include patient age > 50 years, initial displacement > 5 mm, posterior displacement, and a delay in diagnosis or treatment.

Question 44

When evaluating a Jefferson burst fracture on an AP open-mouth radiograph, what combined lateral mass overhang measurement (Rule of Spence) is historically used to indicate a high probability of transverse ligament rupture?

Explanation

The Rule of Spence states that a combined lateral mass overhang of C1 on C2 of greater than 6.9 mm on an AP open-mouth radiograph suggests an incompetent transverse alar ligament.

Question 45

A 45-year-old man presents with sharp, radiating neck pain. Neurological examination reveals weakness in triceps extension, a diminished triceps reflex, and numbness over the dorsal aspect of the middle finger. Which cervical nerve root is most likely compressed?

Explanation

C7 radiculopathy is the most common cervical radiculopathy and typically presents with weakness in the triceps and wrist flexors, diminished triceps reflex, and paresthesias in the middle finger.

Question 46

A 55-year-old male with a long history of Ankylosing Spondylitis suffers a mechanical fall from a standing height. He complains of moderate lower neck pain. Initial plain radiographs of the cervical spine appear unremarkable. What is the most appropriate next step in management?

Explanation

Patients with Ankylosing Spondylitis have rigid, osteopenic spines highly susceptible to unstable fractures from minor trauma. A CT scan is mandatory if plain films are negative but clinical suspicion remains.

Question 47

During an anterior cervical discectomy and fusion (ACDF), the surgeon retracts the longus colli muscles laterally to expose the vertebral bodies. Vigorous or prolonged lateral retraction of this muscle places which of the following structures at highest risk of injury?

Explanation

The cervical sympathetic chain runs vertically along the lateral border of the longus colli muscle. Lateral retraction can compress it, potentially causing an ipsilateral Horner's syndrome.

Question 48

A high school linebacker experiences a "stinger" resulting in transient right-sided arm weakness and burning pain after making a tackle. He is evaluated on the sidelines. According to current guidelines, when is he safely allowed to return to play?

Explanation

Athletes who suffer a transient brachial plexopathy (stinger) may return to play only after all neurological symptoms have resolved, strength has returned to normal, and they demonstrate full, painless cervical range of motion.

Question 49

In a 5-year-old trauma patient, a lateral cervical spine radiograph shows apparent anterior subluxation of C2 on C3. To differentiate physiologic pseudosubluxation from true traumatic injury, which radiographic line should be drawn to assess the alignment of the posterior arches?

Explanation

Swischuk's line is drawn from the anterior aspect of the posterior arch of C1 to C3. If the anterior border of the posterior arch of C2 misses this line by >= 2 mm, it indicates a true pathologic subluxation.

Question 50

A 70-year-old male with type 2 diabetes presents with neck stiffness. Radiographs show flowing ossification along the anterolateral aspect of the cervical spine. To meet Resnick's strict radiographic criteria for Diffuse Idiopathic Skeletal Hyperostosis (DISH), how many contiguous vertebral bodies must be involved?

Explanation

Resnick's criteria for DISH require flowing ossification along the anterolateral aspect of at least four contiguous vertebral bodies, preservation of disc height, and the absence of facet ankylosis or sacroiliitis.

Question 51

Ossification of the posterior longitudinal ligament (OPLL) is a progressive condition that can lead to severe cervical myelopathy. Which of the following demographic groups has the highest prevalence of OPLL?

Explanation

OPLL is notably endemic in East Asian populations, particularly among Japanese men over the age of 50. It often presents with progressive myelopathy due to central canal stenosis.

Question 52

A bilateral cervical facet dislocation is a highly unstable injury. What is the primary mechanism of injury responsible for producing this specific pathologic lesion?

Explanation

Bilateral facet dislocations result from severe hyperflexion and distraction forces, leading to complete disruption of the posterior ligamentous complex, facet capsules, and often the posterior annulus.

Question 53

A 12-year-old gymnast presents with progressive neck pain and clumsy hands. Imaging reveals an os odontoideum with 6 mm of instability on dynamic flexion-extension views and early myelopathic signal on MRI. What is the most appropriate management?

Explanation

Surgical stabilization, most commonly a posterior C1-C2 fusion, is indicated for os odontoideum when there is significant atlantoaxial instability associated with neurological deficits or myelopathy.

Question 54

Which of the following describes the underlying embryological failure that results in Klippel-Feil syndrome?

Explanation

Klippel-Feil syndrome results from the failure of normal segmentation and cleavage of the cervical somites during the third to eighth weeks of embryogenesis, leading to congenital vertebral fusion.

Question 55

A 45-year-old intravenous drug user presents with a 3-day history of severe, localized back pain, low-grade fever, and acute bilateral lower extremity weakness. MRI reveals a spinal epidural abscess. What is the most likely causative organism?

Explanation

Staphylococcus aureus is the most common organism isolated in spinal epidural abscesses. The classic presentation includes the triad of severe back pain, fever, and progressive neurological deficits.

Question 56

A 6-year-old child presents with new-onset torticollis following a recent upper respiratory infection. The head is tilted to the right and rotated to the left. Dynamic CT imaging confirms atlantoaxial rotatory subluxation (AARS). According to the Fielding and Hawkins classification, which type is characterized by anterior displacement of the atlas greater than 5 mm with both lateral masses displaced anteriorly?

Explanation

Fielding and Hawkins Type III AARS involves anterior displacement of the atlas greater than 5 mm, indicating deficiency of both the transverse and alar ligaments. Type I has no anterior displacement, and Type II has 3 to 5 mm of anterior displacement.

Question 57

A 4-week-old infant is evaluated for a head tilt to the left and chin rotation to the right. Ultrasound confirms a dense, fibromatous mass in the left sternocleidomastoid muscle. What is the most appropriate initial management for this patient?

Explanation

The initial treatment for congenital muscular torticollis (CMT) is a supervised physical therapy program involving passive stretching and positioning. Surgery is typically reserved for cases that fail to resolve after 1 year of conservative management.

Question 58

Which of the following radiographic criteria is traditionally required to formally establish the diagnosis of classic Scheuermann's kyphosis (Sorensen criteria)?

Explanation

The Sorensen criteria for defining classic Scheuermann's disease requires anterior wedging of 5 degrees or more in at least three adjacent vertebral bodies. It is also associated with Schmorl's nodes and endplate irregularities, but the wedging criteria are strictly required.

Question 59

A 14-year-old boy presents with progressive mid-back pain and clinical hyperkyphosis. Radiographs reveal a thoracic kyphosis of 65 degrees with anterior wedging of 4 adjacent vertebrae. His Risser stage is 1. What is the most appropriate management?

Explanation

In a skeletally immature patient (Risser 0-2) with progressive Scheuermann's kyphosis between 50 and 75 degrees, extension bracing (such as a Milwaukee brace) is the recommended treatment. Surgery is generally reserved for curves greater than 75 degrees or those refractory to bracing.

Question 60

A 7-year-old girl is diagnosed with Klippel-Feil syndrome due to congenital fusion of multiple cervical vertebrae. Aside from a thorough orthopedic and neurologic evaluation, which of the following screening tests is most critical for this patient?

Explanation

Klippel-Feil syndrome has a high association with genitourinary anomalies (up to 30%, including unilateral renal agenesis) and cardiovascular defects. Therefore, a renal ultrasound and echocardiogram are critical screening tests for these patients.

Question 61

During the evaluation of a 65-year-old male with progressive bilateral hand clumsiness and gait imbalance, the examiner rapidly extends or "flicks" the patient's middle finger, eliciting an involuntary flexion of the thumb and index finger. What is the name of this clinical sign?

Explanation

The Hoffmann sign is elicited by flicking the distal phalanx of the middle finger, leading to flexion of the thumb and index finger. It indicates upper motor neuron dysfunction, commonly seen in cervical spondylotic myelopathy.

Question 62

A 25-year-old male sustains a Type IIA Hangman's fracture (traumatic spondylolisthesis of the axis) showing severe angulation but minimal translation. Which of the following treatments is specifically contraindicated in the initial management of this specific fracture pattern?

Explanation

Type IIA Hangman's fractures feature severe angulation with minimal translation and denote a highly unstable injury with posterior longitudinal ligament disruption. Cervical traction is strictly contraindicated as it can cause severe over-distraction and neurologic injury.

Question 63

A 45-year-old female complains of neck pain radiating into her right arm. Physical examination reveals weakness in wrist extension, a diminished brachioradialis reflex, and decreased sensation over the dorsal aspect of the thumb and index finger. Which cervical nerve root is most likely compressed?

Explanation

A C6 radiculopathy typically presents with weakness in wrist extension and elbow flexion, an abnormal brachioradialis reflex, and sensory deficits in the thumb and index finger.

Question 64

A patient presents with neck pain and arm radiculopathy. Examination demonstrates weakness in triceps extension and wrist flexion, with an absent triceps reflex and numbness primarily in the middle finger. The most likely level of cervical disc herniation is:

Explanation

A herniated disc at the C6-C7 level primarily compresses the C7 nerve root. C7 radiculopathy is characterized by weakness in triceps extension and wrist flexion, diminished triceps reflex, and sensory changes in the middle finger.

Question 65

A 60-year-old female with advanced rheumatoid arthritis presents with progressive myelopathy. Radiographs reveal severe atlantoaxial instability. Which of the following radiographic measurements is the most reliable predictor of neurologic recovery following surgical stabilization?

Explanation

The Posterior Atlantodental Interval (PADI) directly reflects the space available for the spinal cord (SAC). A PADI of less than 14 mm is the most reliable predictor of neurologic deficit and the potential for recovery in rheumatoid cervical spine instability.

Question 66

A 65-year-old male presents with severe neck stiffness and mild dysphagia. Lateral radiographs of the cervical spine demonstrate flowing, continuous ossification along the anterior aspect of 5 contiguous vertebral bodies with preservation of the intervertebral disc spaces. The sacroiliac joints are normal. What is the most likely diagnosis?

Explanation

DISH is characterized by flowing anterior ossification involving at least 4 contiguous vertebrae, preserved disc heights, and an absence of sacroiliac or apophyseal joint ankylosis. It commonly presents with stiffness and occasionally dysphagia due to anterior osteophytes.

Question 67

A 70-year-old male with pre-existing cervical spondylosis sustains a hyperextension injury to his neck in a low-speed motor vehicle collision. He presents with severe motor weakness in his upper extremities but retains functional, albeit weakened, motor strength in his lower extremities. Which incomplete spinal cord syndrome does this patient exhibit?

Explanation

Central cord syndrome often occurs after hyperextension injuries in older patients with spondylosis. It affects the centrally located cervical tracts of the upper extremities more severely than the peripherally located tracts of the lower extremities.

Question 68

A 32-year-old male sustains a Type II odontoid fracture after a fall. The fracture line passes through the base of the dens and has 6 mm of posterior displacement. He is neurologically intact. Which of the following patient factors represents the highest risk for nonunion if treated non-operatively in a halo vest?

Explanation

Risk factors for nonunion of a Type II odontoid fracture include displacement greater than 5 mm, angulation greater than 10 degrees, age over 50 years, and a fracture gap greater than 2 mm.

Question 69

A 5-year-old boy undergoes a lateral cervical spine radiograph after a minor fall. The radiograph shows 3 mm of anterior displacement of C2 on C3. To distinguish physiologic pseudosubluxation from true traumatic instability, which of the following radiographic lines should be evaluated?

Explanation

Swischuk's line connects the anterior aspect of the posterior arches of C1 and C3. In physiologic pseudosubluxation, the anterior aspect of the posterior arch of C2 should lie within 1-2 mm of this line. Deviation greater than 2 mm suggests true structural injury.

Question 70

A 45-year-old male presents with progressive myelopathy and is found to have a large, calcified central disc herniation at T8-T9 causing severe spinal cord compression. What is the safest and most appropriate surgical approach for decompression?

Explanation

Standard posterior laminectomy for central, calcified thoracic disc herniations is strictly contraindicated due to a highly unacceptable rate of iatrogenic paraplegia. Anterior transthoracic, lateral, or costotransversectomy approaches are required to decompress the cord without retraction.

Question 71

A 19-year-old collegiate football player experiences a sudden, burning pain radiating down his right arm after a tackle where his neck was laterally flexed to the left and his right shoulder was depressed. The symptoms completely resolve within 5 minutes. This "stinger" most commonly involves which of the following nerve roots?

Explanation

Burners or stingers are transient brachial plexus injuries commonly occurring due to traction or compression. They most frequently involve the upper trunk of the brachial plexus or the C5 and C6 nerve roots.

Question 72

A 4-year-old child presents with torticollis, dysphagia, low-grade fever, and significant neck stiffness. Laboratory studies show an elevated WBC count and ESR. Plain lateral neck radiographs demonstrate notable widening of the prevertebral soft tissues. What is the most likely diagnosis?

Explanation

The combination of fever, dysphagia, elevated inflammatory markers, and widening of the prevertebral soft tissues on radiographs strongly suggests a retropharyngeal abscess, which is a life-threatening cause of acquired pediatric torticollis.

Question 73

A 28-year-old female is brought to the emergency department after a high-speed motor vehicle collision. She has bilateral upper extremity radicular pain but intact motor function. A lateral cervical spine radiograph reveals 25% anterior translation of C5 on C6. What is the most likely underlying structural injury?

Explanation

Anterior translation of one vertebral body on another of approximately 25% (or less than 50%) is the classic radiographic hallmark of a unilateral facet dislocation. Bilateral facet dislocations typically present with greater than 50% translation.

Question 74

A 35-year-old manual laborer presents with sudden severe lower neck pain after forcefully shoveling heavy, wet snow. Radiographs reveal an avulsion fracture of the spinous process of C7. What is the recommended management for this injury?

Explanation

A Clay Shoveler's fracture is a stable avulsion fracture of a lower cervical spinous process (often C6 or C7). Treatment is primarily symptomatic, involving temporary immobilization for comfort and early range of motion.

Question 75

A 7-year-old boy presents with progressive torticollis following a severe upper respiratory tract infection. Radiographs reveal atlantoaxial rotatory subluxation. What is the most likely diagnosis?

Explanation

Grisel syndrome is a non-traumatic atlantoaxial subluxation caused by inflammation of the adjacent cervical tissues, often following an upper respiratory infection or head and neck surgery. The inflammation leads to laxity of the transverse ligament.

Question 76

When evaluating a 3-year-old child following a cervical spine trauma, the Swischuk line is utilized to differentiate physiological pseudosubluxation of C2 on C3 from a true traumatic subluxation. How is this line correctly drawn?

Explanation

The Swischuk line (posterior cervical line) is drawn from the anterior aspect of the C1 spinous process to the anterior aspect of the C3 spinous process. If the anterior cortex of the C2 spinous process misses this line by more than 2 mm, a true subluxation is suspected.

Question 77

According to the Sorensen criteria, what is the strict radiographic requirement for the diagnosis of classic Scheuermann's kyphosis?

Explanation

Sorensen classically defined Scheuermann's disease as a thoracic kyphosis featuring greater than 5 degrees of anterior wedging in at least three consecutive vertebrae. Endplate irregularities and Schmorl's nodes are supportive but not sufficient alone for the classic definition.

Question 78

A 65-year-old male presents with difficulty buttoning his shirts and a broad-based gait. Physical examination reveals an inverted supinator reflex. This specific clinical sign strongly suggests pathology at which spinal level?

Explanation

The inverted supinator reflex consists of finger flexion when the brachioradialis reflex is tested. It indicates an upper motor neuron lesion below C5 and a lower motor neuron lesion at C5-C6, heavily pointing to cervical spondylotic myelopathy at the C5-C6 level.

Question 79

Klippel-Feil syndrome is characterized by the congenital fusion of two or more cervical vertebrae. Which of the following organ system anomalies is most frequently associated with this syndrome?

Explanation

Genitourinary tract anomalies, particularly renal issues such as unilateral renal agenesis, are the most commonly associated systemic abnormalities in Klippel-Feil syndrome, occurring in about 30% of patients. Renal ultrasound is mandatory upon diagnosis.

Question 80

In a patient with a suspected Jefferson burst fracture of C1, an open-mouth odontoid radiograph is obtained. According to the Rule of Spence, what radiographic finding indicates a high likelihood of a ruptured transverse ligament?

Explanation

The Rule of Spence dictates that if the combined overhang of the lateral masses of C1 on C2 exceeds 6.9 mm on an AP open-mouth radiograph, it implies an incompetent transverse ligament. This indicates a highly unstable Jefferson fracture requiring rigid stabilization.

Question 81

An infant is diagnosed with Congenital Muscular Torticollis (CMT) presenting with a tight right sternocleidomastoid muscle. The parents should be advised that the child requires careful screening for which commonly associated condition?

Explanation

Congenital Muscular Torticollis (CMT) has a well-known association with Developmental Dysplasia of the Hip (DDH), occurring in up to 20% of cases. All infants with CMT should undergo clinical or ultrasound screening for DDH.

Question 82

An infant presents with intermittent torticollis, dystonic posturing of the neck, and back arching that tends to occur after feeding. Neurological exam is otherwise normal. What is the most appropriate next step in management?

Explanation

The clinical picture is characteristic of Sandifer syndrome, which consists of spasmodic torsional dystonia with arching of the back and rigid opisthotonic posturing associated with gastroesophageal reflux. The best next step is evaluating and treating the reflux.

Question 83

A patient with advanced rheumatoid arthritis is undergoing evaluation of the cervical spine prior to total knee arthroplasty. Which of the following radiographic measurements represents the most critical indication for prophylactic cervical spine stabilization?

Explanation

In rheumatoid cervical spine involvement, the posterior atlanto-dental interval (PADI) is the most reliable indicator of the available space for the spinal cord. A PADI of less than 14 mm is considered a critical threshold and an absolute indication for surgical stabilization to prevent paralysis.

Question 84

A 55-year-old male with pre-existing cervical spondylosis suffers a hyperextension injury in a motor vehicle collision. He presents with profound bilateral upper extremity weakness but relatively preserved lower extremity strength. What is the most likely diagnosis?

Explanation

Central cord syndrome typically occurs following a hyperextension injury in patients with pre-existing cervical canal stenosis. It is characterized by disproportionately greater motor impairment in the upper extremities compared to the lower extremities.

Question 85

Which of the following explains the high rate of non-union seen in Anderson and D'Alonzo Type II odontoid fractures?

Explanation

Type II odontoid fractures occur at the junction of the dens and the body of C2. This region represents a vascular watershed zone, predisposing these fractures to a high rate of non-union, especially when displaced or in older patients.

Question 86

Ossification of the posterior longitudinal ligament (OPLL) is characterized by heterotopic ossification of the spinal ligaments. Which demographic and spinal region is most classically associated with this condition?

Explanation

OPLL is most prevalent in Asian males, particularly of Japanese descent. It predominantly affects the cervical spine and can present with progressive cervical myelopathy due to canal stenosis.

Question 87

A 24-year-old male is involved in a high-speed motor vehicle accident. Radiographs reveal bilateral pars interarticularis fractures of C2 (Hangman's fracture). What is the primary mechanism of injury for this specific fracture pattern?

Explanation

A Hangman's fracture (traumatic spondylolisthesis of the axis) is typically caused by a forceful hyperextension of the neck combined with axial loading, often seen in motor vehicle accidents or diving injuries.

Question 88

A 35-year-old manual laborer presents with severe lower neck pain after forcefully shoveling heavy snow. Radiographs show an isolated avulsion fracture of the C7 spinous process. What is this fracture commonly termed?

Explanation

A Clay Shoveler's fracture is an avulsion fracture of the lower cervical or upper thoracic spinous processes (classically C6, C7, or T1). It results from sudden, forceful contraction of the trapezius and rhomboid muscles or hyperflexion.

Question 89

A patient presents with radiating right arm pain. Examination reveals a diminished brachioradialis reflex, decreased sensation over the lateral forearm and thumb, and weakness in wrist extension. Which cervical nerve root is most likely compressed?

Explanation

A C6 radiculopathy classically presents with a diminished brachioradialis reflex, sensory deficits over the radial forearm and thumb, and motor weakness in wrist extension (extensor carpi radialis longus/brevis) and elbow flexion.

Question 90

A 3-year-old girl refuses to walk and has severe back pain. She is afebrile with normal white blood cell counts, but her ESR and CRP are markedly elevated. Early radiographs are normal. What is the most likely diagnosis?

Explanation

Pediatric discitis typically affects children under 5 years old presenting with back pain or refusal to walk. It is characterized by elevated inflammatory markers (ESR, CRP) despite often normal early plain radiographs, though narrowing of the disc space may appear later.

Question 91

A 7-year-old boy presents with localized severe back pain. Radiographs reveal a completely flattened vertebral body (vertebra plana) in the thoracic spine with preserved adjacent disc spaces. What is the most likely underlying etiology?

Explanation

Eosinophilic granuloma (Langerhans cell histiocytosis) in the spine classically causes symmetrical collapse of the vertebral body, resulting in 'vertebra plana' (Calvé's disease). The adjacent intervertebral disc spaces are characteristically preserved.

Question 92

Arnold-Chiari Malformation Type II is a complex congenital anomaly of the hindbrain. It is almost universally associated with which of the following spinal abnormalities?

Explanation

Chiari II malformation involves the downward displacement of the cerebellar vermis and tonsils, the fourth ventricle, and the medulla through the foramen magnum. It is almost universally associated with myelomeningocele (spina bifida).

Question 93

According to the Fielding and Hawkins classification of atlantoaxial rotatory subluxation, what defines a Type I injury?

Explanation

Fielding and Hawkins Type I atlantoaxial rotatory subluxation is characterized by unilateral facet subluxation/fixation with an intact transverse ligament, meaning there is no anterior displacement of the atlas (ADI < 3 mm).

Question 94

A 45-year-old male with long-standing Ankylosing Spondylitis presents after a minor ground-level fall with severe neck pain. Radiographs reveal a cervical fracture. What is a hallmark characteristic of fractures in the ankylosed spine?

Explanation

Fractures in an ankylosed spine act like long bone fractures. They typically propagate completely across the anterior, middle, and posterior columns (often transdiscal) and are highly unstable, carrying a high risk of neurologic injury and epidural hematoma.

Orthopedic Prometric MCQs - Chapter 3 Part 1

Orthopedic Prometric MCQs - Chapter 3 Part 37

Orthopedic Prometric MCQs - Chapter 3 Part 37

Chapter Index