Question 1

A 48-year-old man presents with a closed head injury requiring intubation and isolated bilateral facet dislocation. The next appropriate step is:

Explanation

The patient has a severe closed head injury and is unable to tolerate a close reduction maneuvers with Gardner-Wells tongs. Emergent magnetic resonance imaging should be obtained to evaluate the potential presence of a disk herniation at the dislocation. Should a disk herniation be present, anterior approach and diskectomy should be performed prior to reduction maneuvers.

Question 2

A major indication for surgical decompression of an L1 burst fracture is:

Explanation

Generalized treatment algorithms for burst fractures involving upper lumbar spine have relative indications for surgery that include 50% loss of height, 25% of kyphosis, and 50% canal compromise. Absolute indications for decompression include neurological deficits including a potential conus injury. Post-void residual of > 450 mL is suggestive of sacral root injury at the level of conus. Bradford suggests that anterior decompression of this injury has favorable outcome with frequent resolution or improvement of symptoms.

Question 3

An injury associated with a type 1 fracture of the odontoid is:

Explanation

Type 1 fractures are a rare entity. They are frequently treated with immobilization with a hard collar if isolated. There have been numerous reports in the literature of a type 1 fracture of the odontoid being associated with an atlanto-occipital dislocation, and this injury must be suspected. The potential for missing atlanto-occipital dislocation may lead to a fatal outcome.

Question 4

A type 3 traumatic spondylolisthesis of the axis, as classified by Levine and Edwards, is best treated with which of the following:

Explanation

The Levine classification of traumatic spondylolisthesis or Hangman fractures involving C 2 in the type 3 injury has a combined bilateral facet dislocation at C 2-C 3 as well as the traumatic spondylolisthesis of the axis. Closed reduction could not be performed secondary to the traumatic spondylolisthesis at the C 2 isthmus.

Question 5

A type 3 Anderson and Montensano fracture of the occipitocondyle is best described as:

Explanation

) An occipital condyle-axial dislocation A type 3 fracture of the occipital condyle is an avulsion fracture from traction of the alar ligament. This usually results from a rotation, lateral bending moment, or combined injury. If the injury is severe, both alar ligaments may be involved and occipitocervical instability may occur. Treatment for a type 3 injury would include a rigid or collar orthosis for 8 to 12 weeks, possible halo mobilization, and, if ligamentous instability has occurred, posterior cervical fusion.

Question 6

An 8-year-old boy has had torticollis for approximately 5 weeks. He has undergone immobilization with a cervical collar without success. The patient has not undergone traction and now has atlantoaxial rotatory subluxation. The best treatment for this patient should be:

Explanation

The treatment protocol for atlantoaxial rotatory subluxation is based on the onset and length of time of deformity. Soft collar treatment for this deformity is best if treated within 1 week of onset. For deformities lasting up to 1 month, in-house hospitalization with traction is warranted. However, the success of this treatment declines markedly after 1 month, at which time posterior C 1-C 2 fusion is warranted.

Question 7

During posterior cervical plating, several techniques can be employed. The recommended lateral mass screw position is:

Explanation

Surgical technique for cervical lateral mass fixation as described by An and colleagues is 30° of Lateral angulation and 15° of angulation cephalad to the facet joint.. This has been described as the safest recommended technique for lateral mass screw placement.

Question 8

A 35-year-old man presents 3 years after a motor vehicular trauma. It is now 3 years following operative stabilization of the spine at C 7. He complained of mild weakness in his right upper extremity at the biceps level and has corresponding parasthesias in the right thumb. The next step in the evaluation of this patient is:

Explanation

The patient is a 35-year old man has been stable since his injury. The most important evaluation for this individual would be magnetic resonance imaging to rule out potential cervical cord syrinx that has occurred given new onset weakness and sensory changes proximal to his injury.

Question 9

A 55-year-old man with ankylosing spondylitis has a minor fall and is suffering with neck pain. Anteroposterior and lateral radiographs are negative with no evidence of fracture. He has no neurologic loss and has normal strength with the exception of severe restricted motion. Twelve hours following injury, he is found to have bilateral bicep and tricep weakness. The appropriate management and the work up of this individual is:

Explanation

The patient is within 12 hours of having normal cervical spine films. Approximately one third of patients with ankylosing spondylitis incur occult injuries to the cervical spine that are not identified by plain films prior to kyphotic progression. A bone scan would delineate a fracture after 72 hours. However, the presence of progressive weakness should raise suspicion of a potential epidural hematoma. For this reason, magnetic resonance imaging would better delineate epidural hematoma.

Question 10

A 2-year-old boy with a congenital heart anomaly has a 40° thoracolumbar curvature. Standing posteroanterior and lateral radiographs reveal vertebral anomalies indicative of congenital scoliosis. Which of the following patterns of congenital scoliosis has the worst prognosis for progression?

Explanation

Congenital spinal deformity is caused by structural abnormalities in the vertebrae that can result in asymmetric growth, such as scoliosis or kyphosis. It has been classified in 2 types. Type I involves defects of formation and type II involves defects of segmentation. However, in many instances, deformities can be a mixture of both. Defects of formation include segmented or unsegmented hemivertebrae and wedge vertebrae. Defects of segmentation include block vertebrae, unilateral bars, or unilateral bars with hemivertebrae. The potential for progression is dependent on the growth potential of the anomalies. The presence of healthy-appearing disks between the hemivertebra and its normal counterparts indicates good growth potential and risk for progression. A unilateral bar on the opposite side of a segmented hemivertebra acts as a tether on the concave side of the curve and has the most likelihood for progression. Children with congenital scoliosis also have a significant incidence of associated anomalies, both intraspinal and other organ systems. About 30% have a spinal dysraphism such as diastematomyelia, meningocele or lipoma. Other associated anomalies include Klippel-Feil syndrome (25%), genitourinary tract abnormalities (30%), cardiac defects (12%), and Sprengelâ s deformity (10%).

Question 11

Six months ago, an 11-year-old premenarchal girl with adolescent idiopathic scoliosis had a right thoracic curve from T5 to T12 measuring 20°. Her physical examination was normal. She returned to the office and a standing posteroanterior radiograph demonstrates a 28° right thoracic curve from T5 to T12; she is Risser stage 0. A lateral radiograph shows a thoracic kyphosis of 10°. At this time, you recommend:

Explanation

In skeletally immature patients with adolescent idiopathic scoliosis and curves approaching 30° with documented progression, bracing may be effective at preventing further progression of the curve. Risk of progression in adolescent idiopathic scoliosis is related to curve magnitude and remaining growth potential. The risk of further progression in this patient is 68%, and bracing is indicated. Electrical stimulation and physical therapy have not been shown to affect the natural history of scoliosis. Surgery may be indicated in patients with more severe curves. In the sagittal plane, hypokyphosis is usually present in adolescent idiopathic scoliosis.

Question 12

A 15-year-old boy with adolescent idiopathic scoliosis has a right thoracic curve from T5 to T11 measuring 45° and a left thoracolumbar curve from L1 to L4 measuring 32°. He is Risser stage 2 and has a hypokyphotic thoracic spine. Bending films demonstrate moderate flexibility in the lumbar curve. He was prescribed a thoracolumbosacral orthosis since age 14, but his scoliosis has progressed. His physical exam reveals a prominent right rib hump and mild right shoulder elevation. His head is centered above his pelvis. His neurological examination is normal. You recommend:

Explanation

This patient has a right thoracic curve with a compensatory left lumbar curve pattern of adolescent idiopathic scoliosis. There has been documented progression into the surgical range despite bracing, and he still has some growth remaining. Surgical intervention is indicated. This curve pattern (King II, Lenke D) can be approached posteriorly with thoracic fusion alone to the neutral and stable vertebra and instrumentation to obtain and maintain correction. The unfused lumbar curve will spontaneously correct to balance the fused thoracic curve. Care must be taken to avoid fusion into the lower lumbar spine and preserve motion segments.

Question 13

A 1-year-old male infant is referred by his pediatrician for evaluation of possible scoliosis. Otherwise, he is healthy. His physical exam reveals normal neurologic function, plagiocephaly and a flexible thoracic curve. Radiographs reveal a left thoracic curve with a C obb angle of 36° and no vertebral anomalies. The apical ribs are in Phase I, and the rib-vertebral angle difference is 18°. At this time, management should include:

Explanation

Infantile idiopathic scoliosis is rare in this country and not well understood. It is more common in Europe, occurs more frequently in boys, and left thoracic curves predominate. Plagiocephaly, or a flattening of the posterior skull on the convex side of the spinal curvature, is frequently found in these patients, suggesting a postural cause of both. There are 2 types of infantile idiopathic scoliosis: resolving and progressive. Distinguishing between the 2 types has obvious consequences regarding prognosis and treatment. Prior to Mehtas work, identification of the type of infantile idiopathic scoliosis was difficult, because it was not related to curve magnitude, age at onset, rate of progression, or degree of rotation. Mehta showed that the 2 groups were distinguishable by the relationship of the ribs to the apical vertebral body on the posteroanterior radiograph. Ribs that do not overlap the vertebral body are in Phase I, and ribs that do overlap the vertebral body on the convexity of the curve are in Phase II. The rib- vertebral angle is constructed by the intersection of a line perpendicular to the apical vertebral endplate with a line drawn along the long axis of the corresponding rib. The rib-vertebral angle (RVA) difference is the difference of the RVA of the concave and convex ribs of the apical vertebra. In scoliosis, the convex ribs form a more acute angle than the concave ribs, so this difference is >0. Mehta concluded that curves in which the ribs are in Phase I and the RVA difference is < 20° have a better prognosis (resolving type) and require just observation. Treatment for progressive curves includes serial body casts, orthoses, or surgery for severe curves. Various surgical approaches include posterior spinal fusion, instrumentation without fusion to allow spinal growth, or anterior convex hemiepiphysiodesis with posterior hemiarthrodesis.

Question 14

The most appropriate indication, after scoliosis curve progression, for a posterior spinal fusion with segmental instrumentation to the pelvis in a severely involved spastic quadriplegic child with cerebral palsy is:

Explanation

Patients with a spastic quadriplegic pattern of cerebral palsy have higher than 25% incidence of scoliosis. This neuromuscular scoliosis differs from that of idiopathic scoliosis in that it is usually a long C -shaped thoracolumbar curve that may involve the pelvis. Frequently, posterior spinal fusion from T1 to the sacrum is required with rigid segmental instrumentation with stabilization to the pelvis (a unit rod). Indications for fusion in these patients include curve progression and loss of function. This can include loss of sitting ability, poor pulmonary function due to poor pulmonary toiletting, and recurrent infection such as decubitus ulcers. These children are most often non-ambulators and are dependent on wheelchair sitting supports for postural control.

Question 15

A 12-year-old boy with Duchenne muscular dystrophy has a 25° curve in the thoracolumbar spine with moderate pelvic obliquity. His pulmonary function tests are 70% of predicted function. He uses a wheelchair for ambulation, but is able to stand for transfers. Management should include:

Explanation

Scoliosis in patients with Duchenne muscular dystrophy typically becomes progressive when ambulation ceases. For curves >20°, posterior spinal fusion with instrumentation is indicated. Fixation to the pelvis is necessary to improve sitting if pelvic obliquity is present. Severe, collapsing scoliosis can result without operative intervention and can result in diminishing pulmonary function and loss of sitting ability. Surgery can be safely undertaken if pulmonary function remains >40% of predicted function, but anterior surgery causes morbidity on an already compromised pulmonary system. Nonoperative treatment such as orthoses or trunk supports offer little in the way of controlling progression and are generally not well tolerated by these patients.

Question 16

A 6-year-old girl with a lumbar level paraplegia secondary to myelomenigocele presents with a rapidly progressive thoracolumbar scoliosis. The most accurate test to determine the etiology of the spinal deformity is:

Explanation

Children with myelodysplasia are at risk for scoliosis, but a rapidly progressive curve should alert the physician to aggressively investigate the etiology. Causes include: Tethered cord Syringomyelia Shunt failure Progressive hydromyelia Arnold-C hiari malformation All of these conditions can be readily diagnosed by a magnetic resonance imaging scan of the brain and spinal cord. Radiologic imaging such as radiographs, computerized tomography scans, or bone scans for bony lesions is rarely helpful. Cerebrospinal fluid analysis is unlikely to reveal an answer regarding scoliosis. In the presence of a working ventriculoperitoneal shunt, the most likely etiology in this child is a tethered cord. Increased lumbar lordosis, back pain, or an increase in lower root level spasticity should alert the clinician to the possible presence of a tethered cord.

Question 17

An 11-year-old girl presents with low back pain for 2 monthsâ duration. She is an elite gymnast and has missed 2 meets because of the pain. Physical exam reveals pain with hyperextension of the lumbar spine. Her neurological exam is normal. Radiographs of the lumbar spine, including oblique views, are normal. The recommendation is:

Explanation

Athletes involved in sports requiring repetitive hyperextension or rotation of the lumbar spine are susceptible to stress fractures of the pars interarticularis or spondylolysis. Two months of insidious back pain warrants a diagnostic work up, and radiographs may be nondiagnostic in the early period. A bone scan with single photon emission computed tomography will confirm the diagnosis in a patient with a history and physical findings of spondylolysis. Magnetic resonance imaging is rarely helpful in the diagnosis of this bony lesion, but it may be the next diagnostic modality if the bone scan was negative and the pain continued. Rest with immobilization is usually the first line of treatment for spondylolysis. In cases of refractory pain, controversy exists in the surgical management of this condition. Some authors favor repair of the lytic defect and others prefer a posterolateral fusion.

Question 18

An 8-year-old girl presents with back pain and an abnormal gait. She walks with externally rotated feet and limited hip flexion. She has a palpable step-off at the lumbosacral junction and hamstring tightness. Radiographs of the lumbosacral spine demonstrate a dysplastic spondylolisthesis with a slip angle of 55° and slippage of 60% of L5 on S1. The recommended course of treatment is:

Explanation

Spondylolisthesis is the forward slipping of 1 vertebra on the next caudal vertebra. Spondylolisthesis in children can be classified into 2 types: isthmic and dysplastic. Isthmic spondylolisthesis is an entity in which there is a lesion in the pars interarticularis that permits forward slippage; the articular facets are normal. Dysplastic or congenital spondylolisthesis implies that there is a congenital deficiency in the L5-S1 facet that allows forward slipping. There is no defect or elongation in the pars. Growing children, particularly females, with dysplastic spondylolisthesis are at risk for further progression. This patients abnormal gait is due to hamstring tightness, probably due to the lumbosacral instability and nerve root irritation. With a grade III slip, back pain, and an abnormal gait, this patient is a candidate for an in situ posterolateral spinal fusion. Use of instrumentation is controversial, especially because the long-term results of in situ noninstrumented fusions are superior.

Question 19

The following can be found in the examination and radiographs of a child with Scheuermann disease:

Explanation

Scheuermann disease is increased thoracic kyphosis, usually rigid, occurring in adolescent males. The etiology is unknown, but has included theories dealing with avascular necrosis of the ring apophysis, growth plate abnormalities, biologic and mechanical causes. The classic definition is increased thoracic kyphosis (>45°) with 5° or more of anterior wedging at 3 sequential vertebrae. Other radiographic abnormalities include: Endplate irregularities Spondylolysis C ompensatory lumbar hyperlordosis Schmorlâ s nodes Hamstring tightness and rigid thoracic kyphosis is noted on physical examination, and neurological function is normal. Treatment consists of bracing in skeletally immature patients with a thoracolumbosacral orthosis, but many adolescent male patients are noncompliant with bracing. In the skeletally mature patient with pain and severe deformity (>65° of kyphosis), posterior spinal fusion with instrumentation is indicated. Occasionally, anterior diskectomy and interbody fusion with posterior fusion and instrumentation are required for severe deformity correction. Postural kyphosis is also common in adolescent males, but the vertebral changes are not present, and the deformities are usually more supple. Treatment is hyperextension exercises.

Question 20

The natural history of which of the following spinal deformities in children carries with it the highest risk of paraplegia?

Explanation

Congenital kyphosis, if left alone, is the most likely cause of paraplegia of all noninfectious spinal deformities. Defects of formation are more progressive than defects of segmentation, and paraplegia is common with defects that have an apex at T4-T9, the watershed area of spinal cord blood flow. Treatment is usually surgical. There is no evidence of successful nonoperative treatment for congenital kyphosis. An early, limited posterior fusion, coupled with anterior growth, may result in a slow correction of the kyphosis. For kyphosis >55° in children older than 5 years of age, anterior and posterior spinal fusions are necessary. The tethering structures anteriorly must be released (anterior longitudinal ligament, annulus fibrosus) and distraction anteriorly is maintained by autogenous strut grafts. Posteriorly, compression instrumentation is required with fusion. If neurological compromise exists preoperatively, magnetic resonance imaging is necessary to delineate the area of compression so that an anterior cord decompression may be performed successfully.

Question 21

A 25-year-old male presents with severe neck pain following a motor vehicle collision. Radiographs demonstrate a unilateral facet dislocation at C5-C6. What is the classic mechanism of this specific injury?

Explanation

Unilateral facet dislocations are primarily caused by a flexion-rotation mechanism. In contrast, bilateral facet dislocations are typically caused by pure flexion-distraction forces.

Question 22

A 40-year-old unrestrained driver suffers a Levine-Edwards Type IIA traumatic spondylolisthesis of the axis (Hangman's fracture). What is the most appropriate initial non-operative management?

Explanation

Type IIA Hangman's fractures feature oblique fracture lines and severe angulation with minimal translation. Traction is contraindicated as it exacerbates the distraction; they are treated with mild compression in slight extension.

Question 23

A 19-year-old restrained passenger in a high-speed collision sustains a flexion-distraction injury (Chance fracture) of L2. Which of the following associated injuries must be actively ruled out due to its high incidence?

Explanation

Chance fractures (flexion-distraction injuries) are frequently associated with lap-belt usage. Up to 50% of these patients have an associated hollow viscus or bowel injury that requires urgent general surgery evaluation.

Question 24

An 80-year-old male with pre-existing cervical spondylosis falls forward, striking his chin. He presents with profound upper extremity weakness but is able to move his lower extremities against gravity. What is the most likely diagnosis?

Explanation

Central cord syndrome often occurs after hyperextension injuries in elderly patients with stenotic cervical canals. It presents with upper extremity motor deficits that are characteristically more severe than lower extremity deficits.

Question 25

Which spinal cord injury syndrome is characterized by loss of motor function and pain/temperature sensation distal to the lesion, while preserving proprioception, and carries the poorest prognosis for functional recovery?

Explanation

Anterior cord syndrome results from injury to the anterior two-thirds of the spinal cord (often vascular), preserving the dorsal columns (proprioception). It carries the worst prognosis for motor recovery.

Question 26

A 30-year-old male falls 15 feet, sustaining an L1 burst fracture. He is neurologically intact. MRI confirms severe disruption of the posterior ligamentous complex (PLC). According to the Thoracolumbar Injury Classification and Severity (TLICS) system, what is his total score and management recommendation?

Explanation

The TLICS score is calculated as follows: Burst fracture morphology (2) + Intact neurology (0) + PLC disrupted (3) = Total score of 5. A score of 5 or greater is an indication for operative management.

Question 27

A 28-year-old male sustains a knife stab wound to the back, resulting in a spinal cord hemisection at T8. Which of the following clinical findings is expected below the level of the lesion?

Explanation

Brown-Sequard syndrome (cord hemisection) causes ipsilateral loss of motor function and proprioception (corticospinal and dorsal columns cross high), and contralateral loss of pain and temperature (spinothalamic tract crosses early).

Question 28

A patient presents after a high-speed collision with severe upper cervical pain. Lateral radiographs show a Basion-Dental Interval (BDI) of 14 mm. What is the most appropriate definitive management?

Explanation

A BDI greater than 10 mm indicates Atlanto-Occipital Dissociation (AOD), a highly unstable ligamentous injury. Definitive management requires surgical stabilization via occipitocervical fusion.

Question 29

In a patient with a suspected C1 (Jefferson) fracture, an open-mouth odontoid radiograph demonstrates a combined lateral mass overhang of 8 mm on C2. What specific structure is presumed incompetent based on this finding?

Explanation

According to the Rule of Spence, a combined lateral mass overhang of C1 on C2 greater than 6.9 mm on an open-mouth radiograph strongly suggests rupture of the transverse atlantal ligament.

Question 30

A 6-year-old child presents after an MVC with transient numbness and weakness in all extremities. Cervical radiographs and CT are normal. MRI shows spinal cord edema at C3-C4 without ligamentous injury. What is the appropriate management?

Explanation

This is Spinal Cord Injury Without Radiographic Abnormality (SCIWORA), common in pediatric populations due to spinal elasticity. Management is generally conservative with rigid collar immobilization for up to 12 weeks.

Question 31

A 55-year-old male sustains an isolated gunshot wound to the abdomen that transverses the bowel and lodges in the L3 vertebral body. He is neurologically intact. What is the recommended management of the spinal injury?

Explanation

For trans-abdominal gunshot wounds to the spine without neurologic deficit or structural instability, routine bullet extraction is contraindicated. Treatment focuses on broad-spectrum IV antibiotics to prevent infection from bowel flora.

Question 32

A 60-year-old male with long-standing ankylosing spondylitis presents with neck pain after a ground-level fall. Initial plain radiographs of the cervical spine are reported as negative. What is the most appropriate next step?

Explanation

Patients with ankylosing spondylitis have a rigid, brittle spine and are at extremely high risk for occult, highly unstable fractures even from minor trauma. A CT scan or MRI is mandatory regardless of negative plain films.

Question 33

A 35-year-old female sustains a pelvic ring injury including a sacral fracture. According to the Denis classification of sacral fractures, which zone is most frequently associated with cauda equina syndrome and bowel/bladder dysfunction?

Explanation

Denis Zone 3 fractures involve the central sacral canal. Because they directly compromise the central canal, they carry the highest risk (over 50%) of serious neurologic deficits including bowel, bladder, and sexual dysfunction.

Question 34

A trauma patient presents with hypotension, bradycardia, and warm extremities following a C5 burst fracture with complete paralysis. What is the most likely etiology of his hemodynamic instability?

Explanation

Neurogenic shock is a hemodynamic phenomenon caused by loss of sympathetic vascular tone after high spinal cord injury, leading to hypotension and bradycardia. Spinal shock, by contrast, refers purely to temporary loss of neurologic reflexes.

Question 35

According to the Eastern Association for the Surgery of Trauma (EAST) guidelines, what is the most appropriate modality to clinically clear the cervical spine in an obtunded, intubated adult trauma patient?

Explanation

Modern EAST guidelines state that a high-quality, negative CT scan of the cervical spine is sufficient to clear the cervical spine and safely remove the collar in obtunded adult trauma patients.

Question 36

A 25-year-old male presents with bilateral jumped facets at C6-C7 following a diving accident. He is awake, alert, and cooperative, with an incomplete spinal cord injury. What is the recommended initial management step?

Explanation

In awake, alert, and cooperative patients with facet dislocations, closed reduction via cranial tong traction is safe and indicated before obtaining an MRI. An obtunded patient requires an MRI before any reduction attempt.

Question 37

A 14-year-old gymnast complains of chronic lower back pain exacerbated by extension. Oblique lumbar radiographs demonstrate a "Scotty dog with a collar" sign. What is the underlying pathology?

Explanation

The "Scotty dog with a collar" sign on oblique lumbar radiographs represents a defect or stress fracture in the pars interarticularis, known as spondylolysis.

Question 38

A 45-year-old male sustains a severe flexion-distraction injury of the thoracolumbar spine with profound disruption of the posterior ligamentous complex. The anterior vertebral body is largely intact. Which classification historically best describes this bony/ligamentous injury pattern?

Explanation

A Chance fracture is a classic flexion-distraction injury that typically fails in tension through the posterior and middle columns, potentially extending into the anterior column either through bone or ligaments.

Question 39

What is the primary anatomical and functional advantage of performing an anterior odontoid screw fixation over a posterior C1-C2 fusion for a suitable Type II odontoid fracture?

Explanation

Anterior odontoid screw fixation is a motion-preserving surgery that maintains the roughly 50 degrees of normal cervical rotation that occurs at the C1-C2 atlantoaxial joint, unlike posterior C1-C2 fusion.

Question 40

A 32-year-old male presents with a T12 burst fracture causing conus medullaris syndrome. He has 60% canal compromise from an anterior retropulsed fragment. Which of the following surgical approaches is generally most favored for direct decompression of the neural elements?

Explanation

An anterior approach (corpectomy) provides direct visual access to remove the anteriorly retropulsed bone fragments compressing the neural canal, followed by strut grafting for anterior column support. Posterior laminectomy alone is generally contraindicated for anterior compression.

Question 41

What is the primary mechanism of injury responsible for a unilateral cervical facet dislocation?

Explanation

Unilateral facet dislocations typically occur via a flexion-rotation mechanism. This results in the disruption of the posterior ligamentous complex on one side, leading to less than 50% anterior translation of the vertebral body.

Question 42

A 30-year-old male sustains a T12 burst fracture. He is neurologically intact, and the posterior ligamentous complex (PLC) is indeterminate on MRI. What is his TLICS score and recommended management?

Explanation

The Thoracolumbar Injury Classification and Severity (TLICS) score assigns 2 points for a burst fracture, 0 points for intact neurology, and 2 points for an indeterminate PLC, totaling 4 points. A score of 4 can be treated operatively or non-operatively based on surgeon preference and patient factors.

Question 43

A 25-year-old restrained passenger in a high-speed MVC presents with a bony Chance fracture of L2. Which of the following is the most commonly associated concomitant injury?

Explanation

Chance fractures are flexion-distraction injuries commonly referred to as seatbelt injuries. They have a high association (up to 40-50%) with intra-abdominal injuries, particularly of hollow viscous organs.

Question 44

An elderly patient with underlying cervical spondylosis sustains a hyperextension injury resulting in upper extremity weakness that is far greater than lower extremity weakness. What is the typical sequence of motor recovery for this condition?

Explanation

Central cord syndrome usually follows a hyperextension injury in a stenotic cervical spine. Recovery typically occurs in a specific pattern: lower extremity, then bowel/bladder, then proximal upper extremity, with fine motor function of the hands recovering last.

Question 45

When placing anterior pins for a halo vest orthosis in an adult, what is the anatomical safe zone to avoid injury to the supraorbital and supratrochlear nerves?

Explanation

Anterior halo pins should be placed in the safe zone located lateral to the lateral two-thirds of the eyebrow, approximately above the equator of the eye. This placement avoids the medially located supraorbital and supratrochlear nerves and the frontal sinus.

Question 46

Which of the following radiographic measurements is most reliable for diagnosing atlanto-occipital dissociation (AOD) on lateral cervical spine imaging in a polytrauma patient?

Explanation

The Basion-Dental Interval (BDI) and Basion-Axial Interval (BAI), known as the Harris measurements, are the most reliable indicators of AOD. A measurement greater than 10 mm on CT or 12 mm on plain films is diagnostic for atlanto-occipital dissociation.

Question 47

A patient presents with a traumatic spondylolisthesis of the axis. CT shows severe angulation and >3mm translation, with C2-C3 facet capsules disrupted. According to Levine and Edwards, what is the classification and recommended non-operative treatment?

Explanation

Type IIA Hangman fractures show severe angulation with minimal translation and are caused by a flexion-distraction mechanism. Traction is contraindicated as it exacerbates the deformity; they must be treated with reduction under compression in a halo vest.

Question 48

A patient with a spinal cord injury has preserved sensory function in the sacral segments S4-S5, but absolutely no motor function is preserved more than three levels below the motor level. What is their ASIA Impairment Scale grade?

Explanation

ASIA B indicates a sensory incomplete spinal cord injury. Sensory function (but not motor function) is preserved below the neurological level and includes the sacral segments S4-S5.

Question 49

A 25-year-old male sustains a stab wound to the right side of his T8 spinal cord. Which of the following classic clinical deficits will he exhibit?

Explanation

Brown-Sequard syndrome involves hemisection of the spinal cord. It causes ipsilateral loss of motor function and proprioception (due to damage to the corticospinal tract and dorsal columns) and contralateral loss of pain and temperature (spinothalamic tract).

Question 50

A 40-year-old man dives into a shallow pool and sustains a C1 burst fracture. An open-mouth odontoid radiograph demonstrates a combined lateral mass overhang of 8 mm. What does this measurement critically indicate?

Explanation

In a Jefferson fracture (C1 burst), the Rule of Spence dictates that a combined lateral mass overhang on C2 of 7 mm or more on an open-mouth view implies rupture of the transverse atlantal ligament. This indicates a highly unstable injury requiring rigid immobilization or surgical fusion.

Question 51

A patient with a flexion teardrop fracture of C5 presents with complete loss of motor function, pain, and temperature sensation below the lesion, but with completely preserved proprioception and vibratory sense. What is the diagnosis?

Explanation

Anterior cord syndrome results from damage to the anterior two-thirds of the spinal cord, often via hyperflexion injuries or anterior spinal artery compromise. It causes loss of motor, pain, and temperature function, but preserves dorsal column function like proprioception and vibration.

Question 52

Which of the following is the most statistically significant risk factor for non-union in a Type II odontoid fracture treated with non-operative halo immobilization?

Explanation

High risk factors for non-union in Type II odontoid fractures include age greater than 50 years, initial displacement greater than 5 mm, posterior displacement, and a fracture gap greater than 1 mm.

Question 53

A patient presents with localized lower cervical pain after repeatedly shoveling heavy snow. Radiographs show a displaced avulsion fracture of the C7 spinous process. What is the most appropriate management?

Explanation

A Clay Shoveler's fracture is a stable avulsion fracture of a lower cervical or upper thoracic spinous process. It does not cause structural or neurological instability and is treated purely symptomatically.

Question 54

A 20-year-old male presents with a gunshot wound to the abdomen. The bullet traverses the colon and lodges solidly in the L3 vertebral body. He is neurologically completely intact. What is the most appropriate management of the spinal injury?

Explanation

Gunshot wounds to the spine associated with bowel perforation require broad-spectrum antibiotics, usually for 7-14 days. Surgical removal of the bullet is generally not indicated if the patient is neurologically intact, as surgery significantly increases the risk of complications.

Question 55

According to the Denis three-column theory of the thoracolumbar spine, which anatomic structure defines the posterior limit of the middle column?

Explanation

The middle column consists of the posterior half of the vertebral body, the posterior half of the annulus fibrosus, and the posterior longitudinal ligament (PLL). Disruption of the middle column is the defining characteristic of a burst fracture.

Question 56

A 65-year-old male with long-standing ankylosing spondylitis sustains a low-energy fall. He complains of neck pain but is neurologically intact. Standard lateral plain radiographs are very difficult to interpret due to marked cervicothoracic deformity. What is the next most appropriate step?

Explanation

Patients with ankylosing spondylitis are at extremely high risk for highly unstable, occult fractures even after minor trauma. CT or MRI is mandatory because plain radiographs are notoriously unreliable in these patients due to baseline deformity and severe ossification.

Question 57

A 65-year-old man presents after a hyperextension injury to his neck. Neurological examination demonstrates a greater degree of motor weakness in his upper extremities compared to his lower extremities, along with variable sensory loss. Which of the following is the most likely diagnosis?

Explanation

Central cord syndrome classically occurs after a hyperextension injury in older patients with preexisting cervical spondylosis. It presents with motor deficits that are disproportionately more severe in the upper extremities than the lower.

Question 58

A 25-year-old male is involved in a high-speed motor vehicle collision. Lateral cervical spine radiographs reveal a basion-dens interval of 14 mm. What is the most appropriate definitive management?

Explanation

A basion-dens interval greater than 12 mm indicates atlanto-occipital dissociation (AOD). This represents a highly unstable craniocervical injury requiring definitive surgical stabilization with occipitocervical fusion.

Question 59

A 32-year-old woman is evaluated after a motor vehicle collision. Radiographs show a traumatic spondylolisthesis of the axis with 4 mm of translation and 12 degrees of angulation. Which mechanism of injury is most likely responsible for this fracture pattern?

Explanation

Traumatic spondylolisthesis of the axis (Hangman's fracture) is typically caused by hyperextension and axial loading. The described pattern is a Levine-Edwards Type II fracture, which involves translation and angulation.

Question 60

A patient presents with an L1 burst fracture and paraplegia. Examination reveals loss of motor function, pain, and temperature sensation below the umbilicus, but preserved proprioception and vibratory sense. Which vascular territory is most likely compromised?

Explanation

Anterior cord syndrome involves damage to the anterior two-thirds of the spinal cord, which is supplied by the anterior spinal artery. It results in loss of motor function and pain/temperature sensation while preserving dorsal column function.

Question 61

A 19-year-old male presents after a lap-belt only motor vehicle collision. Radiographs show a horizontal fracture through the spinous process, pedicles, and vertebral body of T12. Which associated injury must be actively ruled out in this patient?

Explanation

Chance fractures are flexion-distraction injuries commonly associated with seatbelt use. They have a high association (up to 40%) with intra-abdominal injuries, particularly hollow viscus perforations.

Question 62

When applying a halo vest for cervical spine immobilization, what is the anatomic safe zone for anterior pin placement to avoid neurovascular injury?

Explanation

Anterior halo pins should be placed 1 cm superior to the lateral third of the eyebrow. This avoids the supraorbital and supratrochlear nerves medially and the temporalis muscle and fossa laterally.

Question 63

An 82-year-old male sustains a Type II odontoid fracture with 3 mm of posterior displacement. He has significant medical comorbidities. What is the most appropriate initial management?

Explanation

In elderly patients with significant comorbidities, a rigid cervical collar is often preferred for Type II odontoid fractures. This is due to the high morbidity and mortality associated with halo vests and surgical intervention in this specific population.

Question 64

A 28-year-old man sustains a C1 burst fracture after diving into a shallow pool. On the open-mouth odontoid radiograph, the combined lateral mass overhang is 8 mm. This finding suggests disruption of which of the following structures?

Explanation

The Rule of Spence dictates that a combined lateral mass overhang of C1 on C2 greater than 6.9 mm on an AP open-mouth radiograph indicates a rupture of the transverse atlantal ligament.

Question 65

A 35-year-old woman is evaluated after a fall. Cervical radiographs reveal a C5-C6 unilateral facet dislocation with approximately 25% anterior translation of C5 on C6. What is the typical mechanism of this injury?

Explanation

Unilateral facet dislocations are typically caused by a flexion-rotation mechanism. They classically present with approximately 25% anterior translation of the superior vertebral body on the lateral radiograph.

Question 66

A trauma patient with a complete C5 spinal cord injury presents with a blood pressure of 80/50 mmHg and a heart rate of 50 bpm. His extremities are warm and well-perfused. Which of the following is the most likely cause of his hemodynamic status?

Explanation

Neurogenic shock is characterized by hypotension and bradycardia due to the loss of sympathetic tone following a high spinal cord injury. Warm, well-perfused extremities distinguish it from hypovolemic shock.

Question 67

A trauma patient is being evaluated for a complete T10 spinal cord injury. The return of the bulbocavernosus reflex signifies which of the following?

Explanation

The return of the bulbocavernosus reflex indicates the end of spinal shock. It confirms that the spinal cord circuitry below the level of injury is intact, allowing for accurate ASIA classification.

Question 68

A 45-year-old man presents to the ER with new-onset bilateral leg weakness, saddle anesthesia, and urinary retention. Post-void residual is 400 mL. What is the most appropriate next step in management?

Explanation

The patient exhibits classic signs of cauda equina syndrome, an orthopedic emergency. An urgent MRI of the lumbar spine is required to confirm the diagnosis and identify the site of compression prior to urgent surgical decompression.

Question 69

A 34-year-old manual laborer complains of lower neck pain after forcefully shoveling heavy snow. Radiographs reveal an isolated oblique fracture through the spinous process of C7. What is the most appropriate management?

Explanation

A Clay Shoveler's fracture is a stable avulsion fracture of a lower cervical or upper thoracic spinous process. Treatment is conservative, focusing on symptomatic relief, analgesics, and early mobilization.

Question 70

A 25-year-old male sustains a gunshot wound to the abdomen. The bullet traverses the colon and lodges in the L3 spinal canal, causing a cauda equina deficit. What is the primary indication for surgical removal of the bullet in this patient?

Explanation

Surgical removal of a bullet in the spinal canal is indicated primarily for progressive neurological deficit or an incomplete deficit with persistent compression (e.g., cauda equina syndrome). Transcolonic passage is considered a relative indication, but neurological status drives the acute intervention.

Question 71

A 40-year-old male is intubated in the ICU following a severe traumatic brain injury. A high-quality, fine-cut CT scan of the cervical spine is interpreted as normal. According to the latest EAST guidelines, what is the most appropriate next step for cervical spine clearance?

Explanation

According to updated Eastern Association for the Surgery of Trauma (EAST) guidelines, the cervical collar can be safely removed in an obtunded trauma patient if a high-quality, fine-cut CT scan is completely negative.

Question 72

A 22-year-old male sustains a sacral fracture resulting from a fall from height. Imaging demonstrates a vertical fracture line extending through the central sacral canal. Based on the Denis classification, what is the expected incidence of neurological injury?

Explanation

A fracture involving the central sacral canal is a Denis Zone III fracture. These fractures carry the highest risk of neurological injury, reported to be greater than 50%, often involving severe bowel and bladder dysfunction.

Question 73

A patient has a T12 burst fracture. MRI shows indeterminate posterior ligamentous complex (PLC) status. The patient is neurologically intact. What is the total TLICS score, and what is the recommended management?

Explanation

The TLICS score is calculated as follows: Burst morphology (2 points), intact neurology (0 points), indeterminate PLC (2 points), yielding a total score of 4. A score of 4 means management can be either operative or non-operative based on surgeon preference.

Question 74

A patient with a C6 spinal cord injury has preserved sensation in the S4-S5 sacral segments. Motor function is preserved below the neurological level, but more than half of the key muscles below the neurological level have a muscle grade of less than 3. What is the appropriate ASIA Impairment Scale grade?

Explanation

ASIA C indicates an incomplete spinal cord injury where motor function is preserved below the neurological level, but more than half of the key muscles below that level have a muscle grade less than 3 (non-antigravity).

Question 75

A 29-year-old male is stabbed in the back. Examination reveals loss of motor function and proprioception on the right lower extremity, and loss of pain and temperature sensation on the left lower extremity. Where is the anatomical lesion located?

Explanation

Brown-Séquard syndrome results from a spinal cord hemisection. It classically presents with ipsilateral loss of motor function and proprioception (corticospinal and dorsal columns) and contralateral loss of pain and temperature sensation (spinothalamic tract).

Question 76

A 65-year-old man sustains a hyperextension injury to his cervical spine during a fall. On examination, he has 2/5 motor strength in his upper extremities and 4/5 motor strength in his lower extremities. Which of the following best describes this neurologic syndrome?

Explanation

Central cord syndrome is characterized by disproportionally greater motor impairment in the upper extremities compared to the lower extremities. It typically occurs in older patients with pre-existing cervical spondylosis who sustain a hyperextension injury.

Question 77

A 24-year-old man is brought to the emergency department after a motorcycle accident with a T6 burst fracture and flaccid paralysis of his lower extremities. Which of the following clinical findings indicates the end of spinal shock?

Explanation

Spinal shock is a temporary physiologic concussion of the spinal cord resulting in flaccid paralysis and areflexia. The return of the bulbocavernosus reflex marks the end of spinal shock, allowing for accurate determination of whether the cord injury is complete or incomplete.

Question 78

A patient sustains a Levine-Edwards Type IIA Hangman's fracture, which is characterized by severe angulation and minimal translation. What is the most appropriate initial management?

Explanation

A Type IIA Hangman's fracture involves severe angulation with distraction, typically due to a flexion-distraction injury. Traction is contraindicated as it exacerbates the deformity; therefore, it is managed with a halo vest applied in slight compression.

Question 79

An open-mouth odontoid radiograph of a patient with a suspected Jefferson fracture shows lateral displacement of the C1 lateral masses relative to C2. According to the Rule of Spence, what total combined overhang indicates a likely rupture of the transverse ligament?

Explanation

The Rule of Spence dictates that a combined overhang of the C1 lateral masses on C2 of 6.9 mm or greater on an AP open-mouth radiograph indicates a highly probable transverse ligament rupture. This renders the C1 ring highly unstable, often necessitating surgical stabilization.

Question 80

A 12-year-old child wearing a lap belt sustains an L2 Chance fracture during a motor vehicle collision. Which of the following associated injuries is most commonly seen with this specific fracture pattern?

Explanation

Chance fractures are flexion-distraction injuries highly associated with seatbelt use. Due to the mechanism of sudden abdominal compression, there is a high incidence (up to 50%) of associated intra-abdominal hollow viscus injuries, such as bowel perforations.

Question 81

A 55-year-old man with advanced ankylosing spondylitis sustains a minor ground-level fall. Initial examination shows no neurologic deficits, but 6 hours later he rapidly develops paraplegia. What is the most likely cause of his deterioration?

Explanation

Patients with ankylosing spondylitis have a rigid, brittle spine prone to highly unstable fractures even with minor trauma. Due to the altered epidural space and bleeding from fractured ossified structures, they are at exceptionally high risk for delayed epidural hematomas requiring urgent decompression.

Question 82

A 60-year-old woman is diagnosed with a Type II odontoid fracture after a fall. Which of the following factors represents the greatest risk for nonunion if managed nonoperatively?

Explanation

Risk factors for nonunion in Type II odontoid fractures include initial displacement greater than 5 mm (or 6 mm depending on the literature), angulation greater than 10 degrees, and age older than 50 years. Operative fixation is generally favored in these high-risk scenarios.

Question 83

A 30-year-old man sustains a gunshot wound to the abdomen, with the bullet lodging in the L3 spinal canal. He presents with a partial, progressive cauda equina syndrome. What is the most appropriate management regarding the spinal injury?

Explanation

While most spinal gunshot wounds are managed nonoperatively, indications for surgical bullet removal include a bullet lodged in the spinal canal causing a progressive neurologic deficit or an incomplete cauda equina syndrome. Steroids are generally contraindicated in penetrating spinal trauma.

Question 84

A trauma patient sustains a highly comminuted Zone III sacral fracture according to the Denis classification. Which of the following neurologic deficits is most likely to be encountered?

Explanation

Denis Zone III sacral fractures involve the central sacral canal. Because the fracture extends through the central canal containing the lower sacral nerve roots, there is a very high incidence (up to 60%) of bowel, bladder, and sexual dysfunction.

Question 85

An awake, alert, and cooperative 35-year-old man presents with a bilateral cervical facet dislocation and an incomplete spinal cord injury following a diving accident. According to standard guidelines, what is the best next step?

Explanation

In an awake, alert, and cooperative patient with a cervical facet dislocation, urgent awake closed reduction using skeletal traction is indicated. An MRI is not mandatory before reduction in this specific patient population, as immediate realignment is prioritized.

Question 86

During the application of a halo vest, the anterior pins are placed too medially, inside the lateral two-thirds of the orbit. Which of the following structures is at greatest risk of injury?

Explanation

The safe zone for anterior halo pins is anterolateral, strictly lateral to the middle third of the orbit. Placement medial to this zone risks injury to the supraorbital and supratrochlear nerves, leading to painful neuromas or loss of forehead sensation.

Question 87

A patient with a flexion teardrop fracture of C5 presents with profound loss of motor function, pain, and temperature sensation below the level of injury, but intact proprioception and vibratory sense. This presentation is characteristic of:

Explanation

Anterior cord syndrome involves damage to the anterior two-thirds of the spinal cord, affecting the corticospinal (motor) and spinothalamic (pain/temperature) tracts. The dorsal columns (proprioception/vibration) are spared, but this syndrome has a poor prognosis for functional recovery.

Question 88

In the Thoracolumbar Injury Classification and Severity (TLICS) score, which of the following neurologic statuses contributes the highest number of points?

Explanation

In the TLICS system, an incomplete spinal cord injury (or cauda equina syndrome) receives 3 points, which is the highest neurologic score. A complete cord injury receives 2 points, reflecting the higher potential for recovery and greater indication for urgent surgery in incomplete lesions.

Question 89

A 28-year-old man is intubated after a high-speed motor vehicle collision. A cross-table lateral radiograph demonstrates a Powers ratio of 1.3. What is the definitive treatment for this condition?

Explanation

A Powers ratio greater than 1 indicates an anterior occipitocervical dissociation, a highly unstable and potentially lethal injury. Due to purely ligamentous disruption, definitive treatment requires rigid surgical stabilization via posterior occipitocervical fusion.

Question 90

A patient sustains a penetrating knife wound to the right side of the T8 spinal cord. Which of the following best describes the expected neurologic deficits below the level of the injury?

Explanation

This describes Brown-Séquard syndrome (spinal cord hemisection). It results in ipsilateral loss of motor function and proprioception (corticospinal and dorsal columns) and contralateral loss of pain and temperature sensation (spinothalamic tract).

Question 91

A 5-year-old child falls from a swing. Cervical radiographs reveal 3 mm of anterior displacement of C2 on C3. The Swischuk line passes 1 mm anterior to the anterior cortex of the posterior arch of C3. What is the most likely diagnosis?

Explanation

Pseudosubluxation of C2 on C3 is a normal physiologic variant in young children due to horizontal facets and ligamentous laxity. A Swischuk line passing within 1.5 mm of the posterior arch of C3 confirms the alignment is physiologic rather than a true fracture or dislocation.

Question 92

A 45-year-old man presents with an L1 burst fracture demonstrating 60% canal compromise and progressive weakness in his lower extremities. What is the most appropriate surgical approach?

Explanation

Anterior corpectomy allows direct decompression of retropulsed bone fragments causing neurologic deficits in burst fractures. Laminectomy alone is contraindicated as it further destabilizes an already compromised anterior and middle column, leading to progressive kyphosis.

Question 93

A trauma patient has complete absence of sensory and motor function below the T10 dermatome following a severe crush injury. The bulbocavernosus reflex is present. What does this signify?

Explanation

The presence of the bulbocavernosus reflex indicates that the period of spinal shock has resolved. If the patient continues to have absent sensory and motor function below the injury level at this stage, the spinal cord injury is classified as complete.

Question 94

A patient with a C5 burst fracture presents with a blood pressure of 80/50 mmHg, a heart rate of 50 beats per minute, and warm, flushed extremities. What is the primary pathophysiology of this presentation?

Explanation

Neurogenic shock occurs with high spinal cord injuries (above T6) due to the loss of descending sympathetic pathways. This leaves parasympathetic tone (vagus nerve) unopposed, resulting in the classic triad of hypotension, bradycardia, and peripheral vasodilation (warm extremities).

Question 95

On a lateral cervical radiograph of a trauma patient, a 'bow tie' or 'bat wing' sign is noted. What percentage of anterior translation of the vertebral body is typically associated with this specific injury?

Explanation

The 'bow tie' sign indicates a unilateral facet dislocation due to the loss of overlapping of the facet joints on the lateral radiograph. This injury is typically associated with roughly 25% anterior translation of the superior vertebral body on the inferior one.

Orthopedic Prometric MCQs - Chapter 3 Part 1

Orthopedic Prometric MCQs - Chapter 3 Part 21

Orthopedic Prometric MCQs - Chapter 3 Part 21

Chapter Index