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Orthopedic Spine Review | Dr Hutaif Spine Surgery Revie -...

Updated: Feb 2026 67 Views
Orthopedic Spine MCQs: Don't just pmid view abstract, master the topic!

Key Medical Takeaway

Looking for accurate information on ORTHOPEDIC MCQS ONLINE 015Spine? Spinal epidural abscesses require careful management. Risk factors for nonsurgical treatment failure include IV drug abuse, diabetes, age over 65, CRP levels exceeding 115, WBC levels above 12.5, and Staphylococcus aureus infection. Surgical intervention becomes necessary if a patient’s neurologic status worsens. For further research, refer to pmid view abstract links provided in studies.

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ORTHOPEDIC MCQS ONLINE 015Spine

QUESTION 1
of 100
What is the most likely diagnosis?
1
Degenerative disk disease
2
Disk herniation with spinal stenosis
3
Epidural and paraspinal abscess
4
Muscle strain
QUESTION 2
of 100
Patients initially treated with intravenous (IV) antibiotics are at higher risk for failure of nonsurgical treatment in the setting of
1
obesity.
2
diabetes.
3
abscess extending over 3 vertebrae.
4
blood culture findings positive for coagulase-negative Staphylococci.
QUESTION 3
of 100
Which clinical finding most strongly suggests that nonsurgical care should be discontinued and surgical intervention is necessary?
1
Progressive weakness
2
C-reactive protein (CRP) level of 75
3
Increased low-back pain
4
White blood cell (WBC) count of 11
QUESTION 4
of 100
Which factor is most important when attempting to prevent interbody graft subsidence?
1
End plate burring
2
Surface contact area
3
Bone quality
4
Use of rigid fixation
QUESTION 5
of 100
Figure 5 is a T2-weighted MR image of a 26-year-old man who has had left leg pain for 3 months that has failed nonsurgical treatment. Surgical decompression is planned. Which approach would provide the most direct ability to perform surgical decompression?

1
Posterior midline approach
2
Retroperitoneal approach
3
Far lateral approach
4
Transpsoas approach
QUESTION 6
of 100
Which intervention most effectively prevents surgical-site infections following spine surgery?
1
Bathing the day of surgery
2
Intravenous (IV) vancomycin
3
Preincision IV antibiotics
4
Vancomycin powder in wound
QUESTION 7
of 100
Figures 7a through 7d are the images of a 31-year-old obese woman who has a long history of low-back pain and intermittent bilateral lower extremity pain. Five days ago her symptoms increased markedly and she was given pain medications upon presentation to her primary care physician. Three days ago she noticed that her bed was wet upon awakening; she also had numbness and tingling in her peroneal area and lower extremities and weakness in her lower extremities. She is brought to your office in a wheelchair. Her examination reveals diminished sensation to light touch in the L4 to S4 dermatomes and 0-1/5 strength in all muscle groups in her bilateral lower
extremities with the exception of her hip flexors, hip adductors, and quadriceps, which are 5/5 in strength. She has decreased sphincter tone on rectal examination. You recommend immediate decompressive laminectomy. What is the likelihood she will regain bladder function after surgery?
A
B
C
D




1
0% to 20%
2
21% to 40%
3
41% to 60%
4
61% to 80%
QUESTION 8
of 100
Among patients with adolescent idiopathic scoliosis, a thoracolumbosacral orthosis is most effective for which type of curve?
1
Apex of the curve is at T3
2
Apex of the curve is at T8
3
Apex of the curve is at L1
4
Apex of the curve is at L2
QUESTION 9
of 100
Figures 9a through 9c are the preoperative radiographs and a T2-weighted MR image of a patient treated with surgery for spondylolisthesis and neuroforaminal stenosis. Figure 9d is the postsurgical radiograph. Interbody fusion offers which advantage over posterolateral fusion (PLF)?
A
B
C D




1
Decreased blood loss
2
Less neural retraction
3
Improved neuroforaminal height
4
Lower fusion rates
QUESTION 10
of 100
A 55-year-old man who has had multiple lumbar fusions during the last 10 years and a lumbar lordosis of 25 degrees notes difficulty standing upright without flexing his knees.
1
Postoperative deep surgical site infection
2
Proximal junctional kyphosis
3
Pedicle screw cut-out
4
Pseudarthrosis
5
Sagittal imbalance
QUESTION 11
of 100
An 80-year-old woman with osteoporosis and thoracic kyphosis has a spinal fusion from T12-S1.
1
Postoperative deep surgical site infection
2
Proximal junctional kyphosis
3
Pedicle screw cut-out
4
Pseudarthrosis
5
Sagittal imbalance
QUESTION 12
of 100
A 65-year-old woman with diabetes has fever and erythema 2 weeks after undergoing instrumented spinal fusion.
1
Postoperative deep surgical site infection
2
Proximal junctional kyphosis
3
Pedicle screw cut-out
4
Pseudarthrosis
5
Sagittal imbalance
QUESTION 13
of 100
A 60-year-old man with a pelvic incidence of 75 degrees undergoes an instrumented fusion for degenerative scoliosis from T11-S1, achieving a lumbar lordosis of 50 degrees.
1
Postoperative deep surgical site infection
2
Proximal junctional kyphosis
3
Pedicle screw cut-out
4
Pseudarthrosis
5
Sagittal imbalance
QUESTION 14
of 100
A 50-year-old woman undergoes an L4-S1 laminectomy and noninstrumented fusion for degenerative spondylolisthesis.
1
Postoperative deep surgical site infection
2
Proximal junctional kyphosis
3
Pedicle screw cut-out
4
Pseudarthrosis
5
Sagittal imbalance
QUESTION 15
of 100
A 25-year-old athletic woman has a 16-week history of left lower-extremity radiating pain in an S1 distribution. MR images obtained by her family physician reveal a large L5-S1 paracentral disk herniation impinging on the left S1 nerve root. You suggest a left-sided L5-S1 microdiskectomy and tell her that when comparing tubular diskectomy and open procedures
1
there are no differences in functional outcome.
2
open diskectomy is associated with superior functional outcomes.
3
tubular diskectomy is associated with superior short- and long-term results.
4
tubular diskectomy is associated with inferior short-term results but superior long-term outcomes.
QUESTION 16
of 100
A 58-year-old man has had increasing midback pain for 8 weeks. Radiographs reveal mild osteopenia and mild disk degeneration but no fractures or lesions. An MRI of the spine reveals diskitis with a small-intensity signal within the spinal canal that is consistent with an epidural abscess at T11-12. The patient is neurologically intact but in significant pain. CT-guided biopsy of the disk space is positive for methicillin-sensitive Staphylococcus aureus. What is the most appropriate treatment?
1
Intravenous (IV) antibiotics for 6 weeks and clinical observation
2
Observation and bracing alone
3
Laminectomy and posterior spinal fusion with IV antibiotics
4
Anterior spinal debridement and fusion with IV antibiotics
QUESTION 17
of 100
While performing long fusion with osteotomies for a patient with adult scoliosis and sagittal plane deformity, the neurophysiologist reports a change in motor-evoked potentials in the lower extremities. What is the most appropriate next step?
1
Perform an immediate wake-up test
2
Continue with the surgery and reassess in 5 minutes
3
Administer intravenous methylprednisolone
4
Ensure that mean arterial blood pressure is 80 or higher
QUESTION 18
of 100
A
B
Figures 18a and 18b are the lumbar spine radiographs of a 72-year-old man with no significant medical history who has had severe back pain for 3 weeks. He denies radiating symptoms, weakness, or numbness when he is seen in the emergency department. He is sent home with a soft corset. At his followup visit he continues to describe significant back pain with activity that is not relieved with oral narcotic mediations. A follow-up CT scan shows a nondisplaced fracture through all 3 columns of the spine. What is the most appropriate treatment?



1
Nonsteroidal anti-inflammatory drugs (NSAIDS), physical therapy, and activity modification
2
Continued soft corset use
3
Thoracolumbosacral orthosis (TLSO) bracing
4
Posterior stabilization
QUESTION 19
of 100
A
B
Figures 19a and 19b are the CT scans of an 18-year-old man who was a restrained driver in a rollover motor vehicle collision. What was the primary mechanism of injury?

1
Axial load
2
Rotation
3
Extension
4
Distraction
QUESTION 20
of 100
A number of potential complications are associated with the direct lateral approach to the lumbar spine; which complication is most common?



1
Infection
2
Iliopsoas weakness
3
Injury to the aorta
4
Foot drop
QUESTION 21
of 100
A lateral transpsoas interbody fusion with percutaneous pedicle screws was performed. When compared with those undergoing open laminectomy and fusion, this patient can expect
1
a longer hospital stay.
2
a higher complication rate.
3
higher risk for postoperative thigh pain.
4
no relief of lower extremity symptoms.
QUESTION 22
of 100
The above surgery was performed with recombinant human bone morphogenetic protein-2 (rhBMP-2). She reports immediate relief of her leg pain and is discharged home on postoperative day 2. The patient reports new-onset radicular pain and weakness in her leg 1 year later. Figures 22a and 22b are her postoperative CT myelogram images. What is the most likely cause of her pain?
22A B


1
Excessive retraction of the traversing nerve root
2
Bony overgrowth from the use of BMP protein in the disk space
3
Osteomyelitis with compression of the nerve roots
4
Inadequate decompression after surgery
QUESTION 23
of 100
Standard guidelines necessitate the use of intraoperative neurophysiological monitoring for patients undergoing surgery for which condition?
1
Primary lumbar disk herniation
2
Adolescent idiopathic scoliosis
3
Cervical spondylotic myelopathy
4
No conditions; there are no official guidelines
QUESTION 24
of 100
A 56-year-old man has upper thoracic pain after undergoing stereotactic radiosurgery for a blastic metastatic lesion in the vertebral body of T5. He has normal alignment without collapse, but the tumor involves the entire vertebral body. Which factor increases this patient's risk for a pathologic fracture?
1
Location of the lesion at T5
2
History of stereotactic radiation
3
Blastic nature of the tumor
4
Tumor involving all of the vertebral body
QUESTION 25
of 100
A
B
C
What is the appropriate first step when confirming the diagnosis of a neurologically intact, 73-year-old man who has the images shown in Figures 25a through 25c?





1
Order a prostate-specific antigen (PSA) level
2
Perform a 2-level corpectomy and reconstruction with tissue sent for pathologic analysis
3
Fine-needle aspiration
4
Bone scan
QUESTION 26
of 100
Based on this patient's history and examination, what is the best next step?
1
Order a confirmatory erythrocyte sedimentation rate (ESR)
2
Obtain blood cultures
3
Initiate empiric broad-spectrum antibiotics
4
Perform surgical decompression
QUESTION 27
of 100
Blood cultures reveal methicillin-sensitive Staphylococcus aureus (MSSA). The patient's examination remains unchanged. In addition to outpatient serial laboratory studies and weekly observation for neurologic deterioration, which of the following is the most appropriate for nonoperative treatment?
1
Interventional radiology placement of an epidural drain
2
An 8-week course of intravenous (IV) vancomycin
3
An 8-week course of IV nafcillin
4
An 8-week course of oral amoxicillin
QUESTION 28
of 100
Clinical characteristics of patients who are ideal for a nonsurgical treatment trial (instead of surgery) include
1
absence of neurologic deficits and MSSA infection.
2
normal blood pressure and normal heart rate.
3
negative blood cultures, cocaine abuse
4
normal blood pressure and normal heart rate
QUESTION 29
of 100
What would be the advantage of surgery for the patient described in this scenario?
1
Shorter length of antibiotic therapy
2
Reduced mortality risk
3
Reduced risk for neurologic deterioration
4
Reduced risk for chronic pain
QUESTION 30
of 100
A
B
C
Figures 30a through 30c are the radiograph and MR images of a 54-year-old woman who has severe leg pain with walking. Her treatment has included 12 weeks of
physical therapy, anti-inflammatory medications, and narcotic pain relievers, and she is interested in surgery. Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) is recommended. When compared with open TLIF, MIS TLIF is associated with



1
shorter hospital stay.
2
lower rates of fusion.
3
higher complication rates.
4
worse long-term outcomes.
QUESTION 31
of 100
An orthopaedic surgeon is counseling a patient regarding risk for complications following lumbar fusion via a direct lateral approach. Surgery at which level is most likely to injure the lumbosacral plexus?
1
L1-2
2
L2-3
3
L3-4
4
L4-5
QUESTION 32
of 100
Figure 32 shows the T2-weighted MR image through the L4-5 level of a 60-year-old man who has new-onset acute right lower-extremity pain and numbness and weakness in his right quadriceps muscle. The arrow in Figure 32 is pointing to which structure?

1
Lumbar synovial cyst
2
Dorsal root ganglion
3
Herniated nucleus pulposus
4
Ligamentum flavum
QUESTION 33
of 100
One year after undergoing anterior cervical decompression and fusion, what percentage of patients still have dysphagia?
1
10% to 15%
2
30% to 35%
3
50% to 55%
4
70% to 75%
QUESTION 34
of 100
What is the most appropriate initial diagnostic imaging study for a patient with presumed diskogenic low-back pain?
1
MRI
2
Discography
3
CT discography
4
Radiography
QUESTION 35
of 100
Figure 35 is the sagittal MR image of a 56-year-old woman who has a 3-year history of severe back pain. Her pain is worse with flexion at the lumbosacral junction and is relieved with extension. She denies any pain in her lower extremities and has no symptoms of neurogenic claudication. Which mediators play roles in the pathogenesis of this condition?

1
Transforming growth factor-beta (TGF-ß), bone morphogenetic protein-2 (BMP-2), latent membrane protein 1
2
Tissue inhibitor of matrix metallo-proteinase-1 (MMP-1), growth and development factor-5, noggin
3
Gremlin, MMP, biglycan
4
Tumor necrosis factor-alpha (TNF-a), Interleukin-1 (IL-1), MMP
QUESTION 36
of 100
A 45-year-old woman with a history of rheumatoid arthritis has C1-C2 instability with neurologic deterioration. Her posterior atlanto-dens interval is 10 mm. Which fixation technique will be the most biomechanically sound to facilitate fusion across the atlanto-axial junction?

1
Gallie fusion
2
Use of C1-C2 transarticular screws
3
Brooks fusion
4
Onlay grafting with a halo vest
QUESTION 37
of 100
What is the most likely diagnosis considering this patient's history and examination?
1
Metastatic disease of the spine
2
Neurogenic claudication
3
Degenerative joint disease of the hips
4
Degenerative scoliosis
QUESTION 38
of 100
In addition to MR imaging, what is the most appropriate additional radiographic study at this time?
1
Mechanical axis of the lower extremities
2
Long-standing radiograph of the entire spine
3
Nuclear medicine: triple-phase bone scan
4
Hyperextension radiograph of the lumbar spine
QUESTION 39
of 100
In addition to her planned primary procedure, how can the surgeon best improve this patient's lumbar lordosis?
1
Placement of bilateral iliac screws
2
Use of an interbody strut at L5-S1
3
Extension of instrumentation to T11
4
Extension lumbosacral orthosis
QUESTION 40
of 100
The patient is treated by another physician and undergoes the procedure shown in Figures 40a and 40b. She currently cannot stand upright. Spinopelvic measurements reveal her pelvic incidence to be 85 degrees and pelvic tilt to be 40 degrees. Her lordosis from T12-S1 is 35 degrees. Which additional surgical procedure should be considered?
40A
B

1
Single-level pedicle subtraction osteotomy
2
Single-level Smith-Petersen osteotomy
3
Instrumentation removal
4
Percutaneous fusion of the sacroiliac joints
QUESTION 41
of 100
The patient's postsurgical radiographs reveal a sagittal vertical axis of +8 cm. In addition to the usual issues encountered during the early postsurgical period, what should the surgeon be most concerned about?
1
Instrumentation-related pain
2
Broken rod
3
Sacroiliac dissociation
4
Proximal junctional failure
QUESTION 42
of 100
Bearing in mind her current condition as shown in Figures 40a and 40b, the surgeon should inform the patient and family that if she is to stand erect, she
1
needs further spinal extensor strengthening.
2
will need to wear a spinal brace indefinitely.
3
will need another spinal surgery.
4
will need a spinal cord stimulator.
QUESTION 43
of 100
If additional posterior spinal surgery is performed to allow the patient to stand erect, the surgeon will need to advise the family about the risks of the procedure. In addition to risk for neurologic injury, what is the most likely complication?
1
Substantial blood loss
2
Cerebral vascular accident
3
Degeneration of sacroiliac joints
4
Cervical spine stenosis
QUESTION 44
of 100
A 78-year-old athletic woman has a history of severe back pain without antecedent trauma. She was in the emergency department 2 days ago with a T12 compression fracture. A dual x-ray absorptiometry (DEXA) scan performed earlier this year revealed a T-score of -2.8. Her condition may be attributable to
1
translocation of chromosomes X and 18.
2
variant of the EXT1 gene.
3
polymorphism of p53.
4
polymorphism of the COL1A1 gene.
QUESTION 45
of 100
A
B
Figures 45a and 45b are the CT and MR spine images of an 82-year-old man who has a history of ankylosing spondylitis falls onto his back. He has no
neurologic deficits upon examination in the emergency department. What is the most appropriate next step?


1
Obtain upright radiographs
2
Thoracolumbar orthosis
3
Posterior stabilization and fusion
4
Laminectomy
QUESTION 46
of 100
A 17-year-old girl is involved in a motor vehicle collision and sustains the injury shown in Figures 46a through 46c. She is neurologically intact in her bilateral lower extremities. Definitive treatment should consist of
A
B
C



1
anterior reduction, stabilization, and fusion at L1-2.
2
anterior reduction, stabilization, and fusion at T12-L3.
3
posterior reduction, stabilization, and fusion at L1-2.
4
posterior reduction, stabilization, and fusion at T12-L4.
QUESTION 47
of 100
What is the advantage of percutaneous pedicle screw fixation over open instrumentation and fusion for a thoracolumbar burst fracture without neurologic deficit?
1
Better clinical outcomes
2
Less blood loss
3
Less pseudarthrosis risk
4
Lower revision surgery rate
QUESTION 48
of 100
A 25-year-old man with a large central disk herniation at L4-5 with normal motor strength, perineal numbness, and difficulty urinating for 36 hours
1
Fracture displacement or subluxation leading to neurologic injury
2
Symptomatic epidural hematoma
3
Sepsis and death
4
Permanent nerve root injury and neurologic deficit
5
Loss of bowel or bladder control
QUESTION 49
of 100
A 65-year-old man with ankylosing spondylitis has a fall from a standing height. He previously had minimal range of motion in his cervical spine, but now notices he is better able to extend his head. He is seen in the emergency department and released with a soft collar for use as needed.
1
Fracture displacement or subluxation leading to neurologic injury
2
Symptomatic epidural hematoma
3
Sepsis and death
4
Permanent nerve root injury and neurologic deficit
5
Loss of bowel or bladder control
QUESTION 50
of 100
A 74-year-old man with ankylosing spondylitis falls off a step stool and now has a minimally displaced T10-T11 extension-type fracture. He is initially treated with percutaneous pedicle screw fixation from T8-L1 and has good pain relief. The next day, however, he experiences increased back pain and loss of strength in his lower extremities.
1
Fracture displacement or subluxation leading to neurologic injury
2
Symptomatic epidural hematoma
3
Sepsis and death
4
Permanent nerve root injury and neurologic deficit
5
Loss of bowel or bladder control
QUESTION 51
of 100
What is the chief mechanism of action of parathyroid hormone (PTH) in the treatment of patients with osteoporosis?
1
Reduces resorptive activity of osteoclasts
2
Inhibits receptor activator of nuclear factor kappa-B ligand
3
Stimulates osteoblastic bone formation
4
Acts as a selective estrogen modulator
QUESTION 52
of 100
A
B
Figures 52a and 52b are the radiographs of a patient who was involved in a motor vehicle collision. He was wearing his seat belt and is now complaining of midthoracic back pain. Radiographs in the emergency department do not reveal a fracture. What is the most appropriate next step?


1
Nonsteroidal medication and follow up as needed
2
Repeat radiographs in 1 week
3
MR imaging of the thoracic spine
4
Flexion-extension radiographs
QUESTION 53
of 100
A 70-year-old otherwise healthy woman is undergoing correction of thoracic kyphosis with spinal cord compression via a posterior approach. She receives an inhaled anesthetic, her mean arterial pressure is 93 mm Hg, and her core temperature is 37.2°C. Her spinal cord is being monitored with somatosensory-evoked potentials and transcranial motor-evoked potentials. She has very low amplitude and increased latency as detected by neurophysiologic monitoring. Which action should be taken?


1
A Stagnara wake-up test should be performed immediately.
2
The patient's mean arterial pressure should be increased immediately.
3
The anesthesia team should use propofol instead of isoflurane.
4
The patient's core temperature should be decreased to 35°C.
QUESTION 54
of 100
A B
Figures 54a and 54b are the radiographs of a 21-year-old man who has a long history of thoracic back pain. His lumbar spine is asymptomatic. He has failed prolonged nonsurgical treatment. Surgical correction should consist of
1
anterior release and fusion at T4-10.
2
posterior instrumentation and fusion at T9-L5.
3
posterior instrumentation and fusion at T2-L2.
4
posterior instrumentation and fusion at T6-pelvis.
QUESTION 55
of 100
The patient asks why the proximal kyphosis occurred. You indicate that she has several risk factors for this condition, including
1
her age, fusion to the sacrum, and upper instrumented vertebra at T3.
2
her age, 360-degree fusion, and obesity.
3
diabetes, history of neuropathy, and pelvic instrumentation.
4
upper instrumented vertebra at T3, obesity, and diabetes.
QUESTION 56
of 100
Considering her current symptoms, history, and examination findings, you believe that the most efficacious means with which to address this patient's junctional kyphosis is
1
cervico-thoracic-lumbosacral orthosis to immobilize the kyphosed segment.
2
removal of the posterior instrumentation because she has had a successful fusion.
3
anteroposterior instrumented fusion at T2-3 to address the collapsed interspace.
4
revision posterior instrumentation with extension of the fusion to T1 to span the area of junctional kyphosis.
QUESTION 57
of 100
What are this patient's risk factors for postsurgical infection?
1
Presence of posterior spinal instrumentation
2
Anterior approach performed during the index procedure
3
Diabetes and obesity
4
Surgery performed in the thoracic spine
QUESTION 58
of 100
Which complication is most frequently encountered after revision surgery to treat junctional kyphosis?
1
Deep surgical-site infection
2
Pseudoarthrosis
3
Neurological injury
4
Adjacent segment degeneration
QUESTION 59
of 100
During the revision surgical procedure, thoracic pedicle screws are placed. Following placement, triggered electromyography (EMG) is performed by stimulating the pedicle screw heads. During testing the right T2 pedicle screw head returns a threshold of 2 mA. What does this reading indicate?
1
The right T2 pedicle screw is well seated within the pedicle.
2
The right T2 pedicle screw has breached the pedicle wall and has violated the costovertebral junction.
3
There is a breach in the right T2 pedicle wall, but the screw is not in contact with a neural structure.
4
There is a breach in the right T2 pedicle and the screw is in contact with a neural structure.
QUESTION 60
of 100
A
B
Figures 60a and 60b are the postmyelography CT images of a 62-year-old man who has had low-back and bilateral lower-extremity pain. His pain began approximately 1 year ago and there was no precipitating event. The location of the pain is in the lower lumbar region in the midline and it radiates into the buttocks and thighs bilaterally. The pain is exacerbated by standing and walking and relieved by forward spine flexion. He reports no pain while sitting or lying supine. Upright radiographs demonstrate 4 mm of anterolisthesis of L4 on L5. What is the most appropriate surgical procedure?


1
Microdiskectomy
2
Posterior decompression
3
Posterior decompression and fusion
4
Anterior lumbar interbody fusion
QUESTION 61
of 100
A 78-year-old man with ankylosing spondylitis sustains a minor fall. Shortly afterward he experiences sudden worsening of his chronic back pain and is brought to the emergency department by his caregiver. Radiographs and a CT scan of the spine do not show a clear fracture. What is the most appropriate next step?
1
Nonsteroidal anti-inflammatory drugs
2
MRI of the spine
3
CT myelography
4
Flexion-extension plain films
QUESTION 62
of 100
A
B
C
Figures 62a through 62c are the MR images and CT scan of a 65-year-old man with a history of diabetes mellitus, hypertension, and smoking. He has a 6-week history of increasing midback pain, lower extremity pain, and weakness. What is the most likely diagnosis, and how should this diagnosis be confirmed?



1
Thoracic tumor; CT-guided biopsy
2
Thoracic tumor; 3-phase bone scan
3
Thoracic discitis and osteomyelitis; CT-guided biopsy
4
Thoracic discitis and osteomyelitis; tagged white blood cell scan
QUESTION 63
of 100
Misplaced pedicle screws are the most common complication associated with pedicle screw instrumentation. Many physicians use continuous electromyography (EMG) monitoring and direct stimulation of the screw to produce a peripheral EMG response. Which EMG stimulation minimum threshold indicates an accurately placed pedicle screw?
1
Higher than 20 mA
2
Higher than 15 mA
3
Higher than 10 mA
4
5 to 10 mA
QUESTION 64
of 100
What is the most significant benefit of percutaneous transforaminal lumbar interbody fusion (TLIF) vs open posterior lumbar interbody fusion (PLIF)?
1
Preservation of the paraspinal muscle sleeve
2
Higher fusion rate
3
More measurable intraoperative blood loss
4
Improved ability to evacuate the disk space
QUESTION 65
of 100
Figure 65 is the lumbar spine MR image of a 63-year-old woman who has a 3-year history of increasingly bothersome back pain and bilateral buttock and leg pain. She has performed 6 weeks of physical therapy, received epidural injections, and experienced some good short-term results, but her leg pain continues to worsen. What is the most appropriate course of treatment?

1
Anterior lumbar interbody fusion L4-5
2
L4-5 hemilaminotomy and diskectomy
3
Lumbar laminectomy L4-L5 posterior fusion
4
Lumbar laminectomy at L4-5
QUESTION 66
of 100
A 63-year-old woman who was treated with decompression and instrumented L4-L5 interbody fusion for degenerative spondylolisthesis demonstrates solid fusion on radiographs.
1
Deep surgical-site infection
2
Adjacent segment degeneration
3
Pressure ulcers
4
Iatrogenic neurologic injury
5
Incidental durotomy
QUESTION 67
of 100
A 28-year-old obtunded man with a T12 burst fracture is treated in a thoracolumbosacral orthosis.
1
Deep surgical-site infection
2
Adjacent segment degeneration
3
Pressure ulcers
4
Iatrogenic neurologic injury
5
Incidental durotomy
QUESTION 68
of 100
A 42-year-old man with an L1 burst fracture, no neurologic deficit, and evidence of disruption of the posterior ligamentous complex as observed on MRI is treated with percutaneous stabilization without fusion.
1
Deep surgical-site infection
2
Adjacent segment degeneration
3
Pressure ulcers
4
Iatrogenic neurologic injury
5
Incidental durotomy
QUESTION 69
of 100
A 46-year-old man with a sacral chordoma is treated with sacrectomy.
1
Deep surgical-site infection
2
Adjacent segment degeneration
3
Pressure ulcers
4
Iatrogenic neurologic injury
5
Incidental durotomy
QUESTION 70
of 100
An awake and alert patient with neck pain arrives at the emergency department after an automobile crash. Upon examination he is weak in the left deltoid and biceps muscles (3/5 strength). CT scans performed 2 hours after admission are shown in Figures 70a and 70b. His weakness deteriorates
to 1/5 strength in the upper and lower extremities. What is the most appropriate treatment?
A
B


1
Immediate closed reduction in the intensive care unit while the patient is awake
2
Posterior spinal laminectomy and fusion with instrumentation
3
Anterior cervical diskectomy, corpectomy, and plating
4
High-dose methylprednisolone
QUESTION 71
of 100
Pain emanating from the sacroiliac (SI) joint is best identified by which of the following maneuvers?



1
Reproduction of pain with the Gaenslen test
2
Reproduction of pain with the SI joint compression test
3
Presence of bone marrow edema on short tau inversion recovery sequence of MR images.
4
More than 75% pain reduction following fluoroscopically guided SI joint injection.
QUESTION 72
of 100
What is the best next step in managing her pain?
1
Additional conventional radiation
2
En bloc spondylectomy
3
Palliative spinal cord decompression and stabilization
4
Epidural steroid injection
QUESTION 73
of 100
What is the most appropriate systemic therapy for this patient in the short term?
1
Bisphosphonate therapy
2
Monoclonal antibody against receptor activator of nuclear factor kappa beta ligand
3
Doxorubicin
4
Dexamethasone
QUESTION 74
of 100
If surgery is chosen, what is the optimum procedure?
1
Transthoracic corpectomy followed by posterior instrumentation
2
Percutaneous pedicle screw stabilization
3
Costotransversectomy with posterior instrumentation
4
Posterior total en bloc spondylectomy
QUESTION 75
of 100
What is the goal of surgical treatment in this scenario?
1
To cure cancer
2
To prolong life
3
To relieve pain
4
To reverse neurologic symptoms
QUESTION 76
of 100
An obtunded 80-year-old man was found alone in his apartment after an apparent fall. A CT scan performed in the emergency department shows that he has an extensile injury of an ankylosed cervical spine. The fracture extends across the ossified C5-C6 disk space and into the lamina of C5. There is 1.5 cm of widening between the C5 and C6 vertebrae anteriorly. The patient's family asks you about the long-term impact of the fracture on his functional capacity and survival. You advise them that patients with fractures of the cervical spine with ankylosing conditions have
1
An unknown prognosis until they can participate in an examination.
2
Higher rates of neurologic deficit and mortality than other same-age people.
3
Higher rates of neurologic deficit than other same-age people, but comparable mortality rates.
4
Similar rates of neurologic deficit and mortality as other same-age people.
QUESTION 77
of 100
Which clinical signs are consistent with the diagnosis of cauda equina syndrome?


1
Saddle anesthesia, hyperreflexia, quadriceps weakness
2
Decreased motor function in the quadriceps and gastrocnemius, hyperreflexia,? and saddle anesthesia
3
More than 5 beats of clonus, saddle anesthesia, and bowel incontinence
4
Urinary retention, saddle anesthesia, and extensor hallucis longus weakness
QUESTION 78
of 100
Based on this patient's MR images, at which location would you expect to find altered sensation?
1
Medial side of left leg
2
Medial side of left foot
3
Dorsum of left foot
4
Lateral aspect of left foot
QUESTION 79
of 100
A minimally invasive diskectomy technique poses potential for
1
increased dural tear risk.
2
a lower success rate for relief of leg pain.
3
a lower overall complication rate.
4
a higher rate of recurrent disk herniation.
QUESTION 80
of 100
A diskectomy is performed in which the disk space is not aggressively debrided. When compared to techniques that involve aggressive debridement of the disk space, this results in
1
less intraoperative blood loss.
2
an increased rate of recurrent disk herniation.
3
a shorter length of hospital stay.
4
a higher rate of surgical complications.
QUESTION 81
of 100
Figure 81 is a lateral thoracic spine radiograph of a 76-year-old man with a history of ankylosing spondylitis who falls and strikes his back. He has moderate thoracic discomfort. An initial examination does not reveal neurologic deficits. He is discharged home that day, but returns 3 days later with profound weakness in his legs. Which imaging study should have been obtained at his initial presentation?

1
Plain radiographs of the lumbar spine
2
Anteroposterior radiograph of the pelvis
3
CT scan of the thoracic spine
4
MRI of the brain ![img](/media/upload/19b1c599-e4a1-4b95-b908-8a5c89f306a5.jpg)
QUESTION 82
of 100
Which factor should most influence a patient's decision to have surgery for adult scoliosis if he or she is younger than age 50?
1
Increasing coronal plane deformity
2
Increasing pain
3
Increasing sagittal balance
4
Invasiveness of the surgical procedure
QUESTION 83
of 100
Figure 83 is the CT scan of a 36-year-old man who fell from a roof. Eight hours later at the emergency department he describes low-back pain with numbness and weakness in his bilateral lower extremity. A neurologic examination reveals 2/5 strength in his quadriceps and iliopsoas bilaterally, 2/5 strength in his right anterior tibialis and gastrocsoleus, and 1/5 strength in his left anterior tibialis and gastrocsoleus. Two hours later, strength in his lower extremities has diminished markedly. What is the best next step?

1
Intravenous (IV) methylprednisolone with a 30-mg/kg loading dose followed by continuous infusion of 5.4 mg/kg/hour for 24 hours
2
Immediate awake traction reduction
3
Emergent open reduction/decompression
4
Admission to the intensive care unit for fluid resuscitation followed by reduction/decompression when stable
QUESTION 84
of 100
A 65-year-old woman undergoes a lumbar laminectomy for spinal stenosis at the L3-L4 level. The surgery and postsurgical course are uncomplicated. Eight weeks after surgery she has severe left anterior thigh, groin, and knee pain with ambulation and standing. Which condition is the most likely cause of her symptoms?
1
Epidural hematoma
2
Osteoarthritis of the hip
3
Miralgia paraesthetica
4
Facet joint pain
QUESTION 85
of 100
Figures 85a through 85c are the sagittal and axial CT scans and sagittal T2 MR image of a 21-year-old man who was thrown from his motocross bike earlier in the day. He now has significant low-back pain; however, he is neurologically intact and has no trouble voiding urine. A standing plain radiograph obtained the next day is shown in Figure 85d. Treatment should involve
A
B
C D




1
resumption of full activity as soon as tolerated.
2
a brace.
3
anterior stabilization and fusion.
4
posterior stabilization and fusion.
QUESTION 86
of 100
A 68-year-old undergoes surgery for adult scoliosis with sagittal imbalance that necessitates a large kyphotic correction.
1
Proximal junctional kyphosis (PJK)
2
Adjacent segment degeneration
3
Intraoperative neurological injury
4
Postsurgical wound infection
QUESTION 87
of 100
A 47-year-old man undergoes a 3-column osteotomy as part of scoliosis surgery. During closure, somatosensory-evoked potentials decrease.
1
Proximal junctional kyphosis (PJK)
2
Adjacent segment degeneration
3
Intraoperative neurological injury
4
Postsurgical wound infection
QUESTION 88
of 100
A 35-year-old undergoes an L4/L5 posterior fusion for spondylolisthesis. Postsurgical radiographs reveal segmental kyphosis and overall sagittal imbalance.
1
Proximal junctional kyphosis (PJK)
2
Adjacent segment degeneration
3
Intraoperative neurological injury
4
Postsurgical wound infection
QUESTION 89
of 100
A 62-year-old woman undergoes a posterior laminectomy and fusion from L3 to S1. Postsurgical images show a pelvic incidence (PI) that is significantly larger than the lumbar lordosis (LL).
1
Proximal junctional kyphosis (PJK)
2
Adjacent segment degeneration
3
Intraoperative neurological injury
4
Postsurgical wound infection
QUESTION 90
of 100
A
B
Figures 90a and 90b are MR images of a 34-year-old man who is referred to your office by his primary care physician after failing 4 months of nonsurgical treatment that included epidural steroids for severe right arm pain occurring in a C6 distribution. He also has associated paresthesias in this region. The patient is weak in elbow flexion and wrist extension. What are his likely outcomes if he is treated with a posterior foraminotomy instead of anterior cervical diskectomy and fusion (ACDF)?


1
Similar incidence of postsurgical neck pain with higher risk for radiculopathy recurrence at the same level
2
Higher incidence of postsurgical neck pain and radiculopathy recurrence at the same level
3
Higher incidence of postsurgical neck pain and adjacent-level radiculopathy
4
Lower incidence of adjacent segment degeneration and postsurgical neck pain
QUESTION 91
of 100
A
B
C
Figures 91a through 91c are CT images of a 76-year-old man who was involved in a motor vehicle collision. Which of the following scenarios would pose a contraindication to closed reduction of this injury prior to MR imaging?



1
American Spinal Injury Association Impairment Scale Grade B neurologic deficit
2
Nondisplaced frontal bone fracture
3
Obtunded status and a blood alcohol concentration higher than 0.2%
4
Presence of facet fractures
QUESTION 92
of 100
Figures 92a through 92c are the radiographs of a 34-year-old man with low-back pain and an inability to walk upright. What is the appropriate surgical treatment?
A B C



1
Smith-Peterson osteotomies at T12-L1, L1-L2 and L2-3.
2
Vertebral column resection through a posterior approach
3
Anterior-posterior osteotomy
4
Pedicle subtraction osteotomy at L3
QUESTION 93
of 100
During the approach to the lumbar spine for an L4-L5 anterior lumbar interbody fusion, which structure generally is found overlying the anterior surface of the L4 vertebra?
1
Aorta
2
Right common iliac artery
3
Left common iliac vein
4
Right ureter
QUESTION 94
of 100
What are the most likely examination findings of the patient with the images shown in Figures 94a and 94b?
A
B

1
Diminished sensation over the distal anterior thigh and medial leg with quadriceps and anterior tibialis weakness and a diminished patellar tendon reflex on the left
2
Diminished sensation over the posterior leg, lateral leg, and plantar foot with weakness of plantar flexion and a diminished Achilles tendon reflex on the right
3
Diminished sensation over the lateral leg and dorsal foot with anterior tibialis and extensor hallucis longus and anterior tibialis weakness on the left 4- Diminished sensation over the lateral leg and dorsal foot with anterior tibialis and extensor hallucis longus and anterior tibialis weakness on the right
QUESTION 95
of 100
A 69-year-old patient with diabetes has had acute-onset back pain and difficulty with ambulation for several hours. Evaluation reveals a temperature of 38.3°C, a white blood cell (WBC) count of 14000/µL (reference range [rr], 4500-11000/µL), C-reactive protein (CRP) level of 120 mg/L (rr, 0.08-3.1 mg/L), erythrocyte sedimentation rate of 130 mm/h (rr, 0-20 mm/h), normal rectal examination findings, and normal sensation to light touch. Motor function testing of the lower extremities reveals 3/5 ankle dorsiflexion and 4/5 plantar flexion strength bilaterally. An MR image reveals a large epidural abscess from L1-5. What is the most appropriate treatment at this time?


1
Medical management with intravenous (IV) antibiotics and observation
2
CT-guided aspiration of the abscess before initiating antibiotics
3
Surgical decompression and IV antibiotics
4
Blood cultures and re-evaluation in 24 hours
QUESTION 96
of 100
Which factor is most important when making a decision regarding surgery with this patient?
1
Degree of kyphosis
2
Mechanism of injury
3
The patient's other injuries
4
The patient's bone quality
QUESTION 97
of 100
If the patient had an isolated spine injury without neurologic deficit, the most appropriate next step would be
1
anterior corpectomy with percutaneous pedicle screw stabilization.
2
percutaneous pedicle screw stabilization.
3
posterior pedicle screw stabilization with fusion.
4
MRI.
QUESTION 98
of 100
Surgical restoration of sagittal balance of an adult spinal deformity will have which effect on outcome?


1
No effect
2
Improve leg-related symptoms but not back pain
3
Improve quality of life and back pain
4
Improve quality of life and leg-related symptoms
QUESTION 99
of 100
What is the most likely diagnosis?
1
Central cord syndrome
2
Cerebrovascular stroke
3
Spinal epidural abscess
4
Guillain-Barre syndrome from IV drug abuse
QUESTION 100
of 100
What is the most appropriate treatment at this time?




1
IV steroids and antibiotics
2
IV antibiotics
3
Anterior decompression and fusion
4
Posterior laminectomy and instrumented fusion
Table of Contents
Dr. Mohammed Hutaif
Written & Medically Reviewed by
Dr. Mohammed Hutaif
Consultant Orthopedic & Spine Surgeon
Keywords
Prof. Mohammed Hutaif Orthopedic Surgeon Yemen pmid view abstract abstract at pubmed pubmed pmid view spine phila pa
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