Question 1

A 54-year-old man presents with low back pain and lower extremity weakness. Imaging shows a solitary lesion located in the conus medullaris with enhancement after administration of gadolinium. The most likely diagnosis is:

Explanation

Ependymomas are the most common intramedullary tumor in adults and are found with equal prevalence in middle-aged men and women. They are most prevalent in the caudal regions of the spinal cord around the conus medullaris and filum terminale. Epidermoid cysts and dural-based meningiomas are extramedullary tumors. Astrocytomas are most commonly found in the lower cervical region, and a patient presents with neck pain and upper extremity deficits.

Question 2

Which of the following diagnostic modalities is used most often to evaluate suspected malignant astrocytomas of the spinal cord:

Explanation

Clinically, early symptoms of intramedullary tumors are nonspecific. Almost all intramedullary tumors show contrast uptake. Even though there are specific MRI characteristics to each tumor, enough variability and overlap exists in their radiologic appearance that histological examination is still required for definitive diagnosis.

Question 3

The most effective treatment for malignant intramedullary tumors of the spinal cord is:

Explanation

Despite treatment, a poor prognosis is given to patients with malignant intramedullary tumors. The median survival time for patients with cervical tumors is 3 to 6 months. Surgical excision, radiation, and chemotherapy are not found to significantly improve survival. Treatment is generally supportive.

Question 4

Initially, the most appropriate method to evaluate a patient with suspected peripheral nerve injury involves:

Explanation

After a traumatic injury to peripheral nerves, early clinical examination is imperative. The key is to test for motor function in the most distal aspect of the nerve and be able to localize the site of injury. Imaging studies are far less sensitive than clinical examinations. Electromyography and nerve conduction velocity studies are usually performed during the follow-up examination to assess for residual, or recovery of, function.

Question 5

The type of peripheral nerve injury that requires acute repair is:

Explanation

The type of traumatic peripheral nerve injury dictates the timing of repair. If a nerve has been sharply transected, then repair should be performed within 72 hours. This can be accomplished during the repair of associated skin, vessels, muscles, and tendons. For a sharply transected but partially cut nerve, early repair is also recommended. Bluntly transected nerves require delayed repair. Contusion and stretch injuries may require delayed surgery.

Question 6

The proper treatment plan for contusion and stretch peripheral nerve injuries involves:

Explanation

For contusion and stretch peripheral nerve injuries, delayed surgery is recommended. Patients are followed for several weeks to months and monitored for functional nerve recovery. If there is no evidence of regeneration, then surgical exploration is performed.

Question 7

The most common type(s) of peripheral nerve injury is:

Explanation

The most common types of traumatic nerve injuries are contusion and stretch injuries. A severe blow to soft tissues or even a fracture can cause a contusion. Gunshot wounds, for example, may produce contusion injuries. Stretch injuries usually result from extreme movements of the limbs, most commonly the shoulder joint with involvement of the brachial plexus.

Question 8

Which of the following is the anatomic origin of the Brown-Sequardâ s syndrome:

Explanation

Brown-Sequardâ s syndrome often results from penetrating wounds that cause anatomical hemisection of the cord. Shear injury to the central cord usually results in the central cord syndrome. Contusions to the spinal cord lead to level-specific and long-tract findings depending on the location of contusion. Complete transsection leads to complete neurologic loss.

Question 9

Which of the following is the most common cause of and the treatment for conus medullaris syndrome:

Explanation

Conus medullaris syndrome is caused by upper and lower motor neuron injury because of a combined spinal cord and nerve root injury caused by thoracolumbar injuries (levels between T-11 and L-1). Causative agents are compressive in nature such as a compression fracture or herniated disk. Treatment is emergent surgical decompression. The prognosis is better for incomplete injuries.

Question 10

Which of the following is the most important prognostic sensory modality during examination of a patient with a spinal cord injury:

Explanation

The most important prognostic sensory modalities are those carried in the lateral spinothalamic tract rather than dorsal columns.

Question 11

Which of the following is the time window from the time of injury during which treatment of nonpenetrating spinal cord injury with methylprednisolone is indicated:

Explanation

Administration of methylprednisolone within 8 hours of injury provides benefit to patients with spinal cord injury. Treatment of patients arriving after 8 hours of treatment has been shown to worsen morbidity. Therefore, patients arriving at trauma centers within this time receive methylprednisolone treatment as part of the standard of care. The exception is the group of patients with penetrating spinal cord injuries where the risk of treatment outweighs the potential benefits.

Question 12

Pain from a herniated lumbar disk is caused by:

Explanation

The annulus is composed of alternating laminae that are primarily composed of type I and type II collagen. The annulus is thinnest posterolaterally and thickest anteriorly. As the disk is loaded, the nucleus transfers axial loads to the annulus in the form of hoop stresses. With degenerative or traumatic processes, fissures or tears may develop in the annulus and the nucleus can become herniated. A herniated nucleus pulposus is a foreign material to the surrounding structures. The combination of mechanical pressure on a nerve root and local inflammation can lead to neurologic signs and symptoms.

Question 13

The term Schmorlâ s nodule refers to:

Explanation

Superior and inferior displacements into the vertebral body are known as Schmorlâ s nodules.

Question 14

A far lateral herniated nucleus pulposus at the L4-L5 level would lead to signs and symptoms of which nerve root on the affected side:

Explanation

A far lateral herniated nucleus pulposus, which is less common, can lead to compression of the nerve root that has already exited the supra-adjacent foramen. Therefore, a far lateral L4-L5 herniated nucleus pulposus leads to L4 nerve root compression.

Question 15

A sequestered disk herniation refers to:

Explanation

A sequestered herniation is a separation of a herniated fragment from the disk from which it came.

Question 16

Common presentations of cauda equina syndrome include:

Explanation

In patients with suspected central herniated nucleus pulposus, cauda equina syndrome must not be missed as it could cause irreversible neurological damage. C auda equina syndrome presents with saddle anesthesia and bowel or bladder changes.

Question 17

Which of the following statements is true regarding the natural history of a herniated lumbar disk:

Explanation

A period of rest is prescribed for 1 to 2 days with supports under the knees and neck to minimize root tension. Also, nonsteroidal anti-inflammatory drugs are used. Prolonged bed rest is no longer advocated because it can lead to deconditioning of compensatory musculature. Ambulation is begun as tolerated after the first few days of an acute event. More than one-half of patients who initially present with low back pain recover within 1 week and more than 90% of patients recover in 1 to 3 months. Physical therapy is started as tolerated.

Question 18

Long-term follow-up studies of surgical versus conservative treatment of herniated lumbar disks indicate:

Explanation

The prognosis of herniated lumbar disks is generally good regardless of treatment. Patients operated on for proven disk herniations improved more rapidly than patients treated nonoperatively. However, within 4 to 5 years, the outcomes begin to approximate each other.

Question 19

The predominant cause of low back pain in the general population, aside from the general sprain and strains of the paraspinal structures, is attributed to:

Explanation

The consequences of normal aging of the spine include progressive disk dehydration, chemical alterations and subsequent mechanical incompetenceâ of the intervertebral disk, which may be manifested in low back pain, although an exact correlation between disk degeneration and low back pain has not been established. Nevertheless, many believe that the predominant cause of persistent low back pain is degeneration of the disk.

Question 20

Initial work-up of an otherwise healthy individual with acute onset low back pain should include:

Explanation

All patients presenting with back pain should have a thorough history taken and a complete physical exam including a detailed neurologic exam. In the recently published Agency for Health C are Policy and Research C linical Practice Guideline on Acute Low Back Pain Problems in Adults, it was concluded that a focused physical exam was sufficient to assess a patient with acute or recurrent low back pain of fewer than 4 weeks duration, unless findings suggested an underlying tumor, or an infectious, a traumatic or a major neurologic syndrome.

Question 21

A 45-year-old woman presents with progressive bilateral lower extremity weakness and sensory loss. MRI of the thoracic spine reveals a well-circumscribed, centrally located intramedullary lesion with a prominent cleavage plane and polar cysts. It demonstrates intense enhancement with gadolinium. What is the most likely diagnosis?

Explanation

Ependymomas are the most common intramedullary spinal cord tumors in adults. They are typically centrally located, well-circumscribed with a distinct cleavage plane allowing for gross total resection, and often feature polar cysts.

Question 22

A 50-year-old man presents with radicular pain. MRI shows an intradural, extramedullary 'dumbbell-shaped' mass causing widening of the C5-C6 neural foramen. The tumor is eccentric to the spinal cord. Which of the following is the most likely origin of this lesion?

Explanation

Schwannomas are the most common benign nerve sheath tumors in the spine and classically arise from the dorsal (sensory) roots. They frequently grow through the neural foramen, creating a dumbbell shape.

Question 23

A 60-year-old female presents with thoracic myelopathy. MRI reveals an intradural, extramedullary mass with a broad base attached to the dura. The mass enhances homogeneously with contrast and displays a 'dural tail' sign. Punctate calcifications are noted on CT. What is the most likely diagnosis?

Explanation

Spinal meningiomas occur predominantly in middle-aged or elderly women, most often in the thoracic spine. Key imaging features include a broad dural attachment, a dural tail on contrast MRI, and psammomatous calcifications.

Question 24

A 35-year-old patient with a known history of von Hippel-Lindau disease presents with myelopathy. MRI of the cervical spine reveals an intramedullary mass with an associated cyst and prominent signal flow voids. What is the most appropriate surgical strategy for this lesion?

Explanation

Hemangioblastomas are highly vascular intramedullary tumors associated with VHL disease. Surgical treatment consists of resecting the highly vascular mural nodule; the cyst wall is non-neoplastic and does not require resection.

Question 25

A 65-year-old man presents with dull, aching lower back pain and bowel dysfunction. Imaging of the sacrum reveals a midline destructive lytic lesion with a large pre-sacral soft tissue mass. Histology demonstrates lobules of large cells with prominent intracytoplasmic vacuoles. Which of the following is the most appropriate treatment?

Explanation

Chordomas are locally aggressive malignant tumors arising from notochord remnants, classically presenting with physaliferous cells. En bloc wide resection is the treatment of choice to minimize local recurrence.

Question 26

A 16-year-old boy presents with severe, progressive back pain that is worse at night and dramatically relieved by ibuprofen. Examination reveals a rigid scoliosis. Radiographs and CT show a 1.2 cm radiolucent nidus with surrounding sclerosis in the left pedicle of T10. The scoliosis convexity is most likely located:

Explanation

Osteoid osteomas of the spine classically occur in the posterior elements and cause a painful, rigid scoliosis. The tumor is characteristically located on the concave side of the curve (convexity away from the lesion) due to asymmetric muscle spasm.

Question 27

A 14-year-old girl presents with back pain and a palpable midline mass. Imaging shows a highly expansile, multicystic, radiolucent lesion involving the spinous process and lamina of L2. MRI demonstrates fluid-fluid levels within the cysts. What is the most likely diagnosis?

Explanation

Aneurysmal bone cysts (ABCs) in the spine typically involve the posterior elements and appear as expansile, lytic lesions. MRI classically demonstrates fluid-fluid levels due to blood settling within the cystic spaces.

Question 28

A 55-year-old man presents with progressive back pain and lower extremity weakness. Imaging reveals a highly destructive, vascular lesion in the L1 vertebral body causing epidural compression. Biopsy confirms metastatic clear cell renal cell carcinoma. What is the most critical pre-operative step before surgical decompression?

Explanation

Renal cell carcinoma and thyroid carcinoma metastases are notoriously hypervascular. Preoperative angiographic embolization is essential to reduce intraoperative blood loss during surgical decompression and stabilization.

Question 29

A 5-year-old boy presents with localized back pain and a torticollis. Radiographs reveal a complete collapse of the C4 vertebral body (vertebra plana) with relative preservation of the adjacent disc spaces. Laboratory results are normal. Which of the following is the most appropriate initial management?

Explanation

Eosinophilic granuloma often presents as vertebra plana in children. It is typically a self-limiting condition, and initial management consists of observation, immobilization (bracing/collar), and symptomatic pain control.

Question 30

A 60-year-old patient with known metastatic renal cell carcinoma presents with a Bilsky grade 3 epidural spinal cord compression at T8. The patient has mechanical back pain and progressive paraparesis. What is the best treatment paradigm?

Explanation

Renal cell carcinoma is radioresistant. For high-grade epidural cord compression (Bilsky grade 3), 'separation surgery' is indicated to decompress the spinal cord and create space, followed by targeted SBRT.

Question 31

A 28-year-old woman presents with severe sacral pain. Imaging shows a large, eccentric, purely lytic 'soap-bubble' lesion destroying the S1 and S2 vertebral bodies. Biopsy reveals multinucleated giant cells interspersed with mononuclear stromal cells. Which systemic medication targets the primary pathophysiology of this tumor?

Explanation

Giant cell tumors of the bone express RANKL by the neoplastic stromal cells, which recruits osteoclast-like giant cells. Denosumab, a monoclonal antibody against RANKL, is an effective targeted therapy to shrink these tumors.

Question 32

The Weinstein-Boriani-Biagini (WBB) surgical staging system for spinal tumors is primarily designed to:

Explanation

The WBB staging system divides the vertebra into 12 radiating clock-face zones and multiple tissue layers. It is used specifically to plan complex en bloc resections for primary malignant or aggressive benign spinal tumors.

Question 33

A 62-year-old man presents with diffuse bone pain and fatigue. Radiographs show multiple punched-out lytic lesions in the skull and spine. A technetium-99m bone scan is performed. What is the expected finding on the bone scan?

Explanation

Multiple myeloma characteristically lacks osteoblastic activity. Therefore, despite extensive lytic bone destruction, a standard technetium-99m bone scan often appears normal or shows 'cold' (photopenic) defects rather than increased uptake.

Question 34

A 45-year-old man is diagnosed with a solitary plasmacytoma of the L3 vertebra without systemic involvement (normal bone marrow biopsy and no M-spike on SPEP). He has minimal localized pain and no neurological deficits. What is the definitive treatment?

Explanation

Solitary bone plasmacytomas are highly radiosensitive. Definitive local radiation therapy is the standard of care and provides excellent local control, though many patients eventually progress to multiple myeloma.

Question 35

A 50-year-old man presents with severe mid-back pain. CT shows a large lytic mass in the T10 vertebral body with areas of 'rings and arcs' calcifications extending into the epidural space. Biopsy confirms primary conventional chondrosarcoma. What is the most appropriate management?

Explanation

Conventional chondrosarcoma is both radioresistant and chemoresistant. The only curative treatment option is complete en bloc wide excision with negative margins.

Question 36

Osteoblastoma and osteoid osteoma of the spine share similar histologic appearances. Which of the following clinical or radiographic features most reliably distinguishes an osteoblastoma from an osteoid osteoma?

Explanation

Osteoblastoma is histologically identical to osteoid osteoma but is distinguished by a nidus larger than 1.5 to 2.0 cm. It is also less likely to be completely relieved by NSAIDs and has a higher tendency for local aggression.

Question 37

A 30-year-old patient with neurofibromatosis type 1 (NF-1) is evaluated for a new spinal nerve root tumor. Biopsy reveals a spindle cell neoplasm. Which of the following histologic or anatomical characteristics differentiates a neurofibroma from a schwannoma?

Explanation

Neurofibromas intertwine with and incorporate the native nerve fibers, making them difficult to resect without sacrificing the nerve. Schwannomas are eccentrically located and push the nerve fibers aside, allowing for potentially nerve-sparing enucleation.

Question 38

A 12-year-old boy presents with progressive paraparesis, fever, and weight loss. Imaging demonstrates a permeative destructive lesion of the T6 vertebra with a large paraspinal soft tissue mass. Biopsy reveals sheets of uniform, small round blue cells that are strongly positive for CD99. What cytogenetic abnormality is characteristic of this tumor?

Explanation

Ewing sarcoma is characterized by small round blue cells expressing CD99. The hallmark cytogenetic abnormality is the t(11;22)(q24;q12) translocation, resulting in the EWS-FLI1 fusion protein.

Question 39

A 40-year-old male presents with mechanical back pain and is found to have an expansile, osteolytic lesion isolated to the posterior elements of L4. Biopsy shows blood-filled spaces separated by septa containing giant cells and woven bone. During surgical treatment (curettage), massive bleeding is encountered. The most effective non-surgical adjunct to reduce recurrence of this specific lesion is:

Explanation

The diagnosis is an aneurysmal bone cyst (ABC). Due to its highly vascular nature and risk of significant intraoperative blood loss, preoperative selective arterial embolization is a crucial adjunct that also helps decrease local recurrence rates.

Question 40

Regarding the neurological outcome following surgery for spinal intramedullary tumors, which of the following preoperative factors is the most consistent predictor of a patient's long-term functional status?

Explanation

The preoperative neurological status is the strongest and most consistent predictor of functional outcome after the resection of intramedullary spinal cord tumors. Patients with minimal deficits before surgery are most likely to maintain good function postoperatively.

Question 41

A 45-year-old female presents with progressive weakness in her bilateral lower extremities. MRI of the thoracic spine reveals a centrally located intramedullary spinal cord lesion with a "hemosiderin cap" and an associated syrinx. What is the most likely diagnosis?

Explanation

Ependymomas are the most common intramedullary spinal cord tumors in adults. They typically present centrally within the cord, often with an associated syrinx and a characteristic hemosiderin cap on T2-weighted MRI due to microhemorrhages.

Question 42

A 60-year-old woman is found to have an intradural extramedullary mass in the thoracic spine causing mild cord compression. MRI demonstrates a "dural tail" sign and homogeneous enhancement with gadolinium. What is the most appropriate initial surgical management?

Explanation

The clinical and radiographic presentation is classic for a spinal meningioma. The gold standard treatment is gross total resection, which should include excision or extensive coagulation of the dural attachment to minimize recurrence.

Question 43

A 35-year-old man presents with progressive back pain and lower extremity paresthesias. MRI demonstrates an enhancing intramedullary nodule with a large associated cyst. He also has a history of retinal angiomas. Which of the following genetic syndromes is most closely associated with this patient's spinal lesion?

Explanation

The patient's presentation suggests a spinal hemangioblastoma, characterized by an enhancing mural nodule and an associated cyst. Hemangioblastomas are a hallmark of Von Hippel-Lindau (VHL) disease, which also presents with retinal angiomas and renal cell carcinomas.

Question 44

A 12-year-old boy presents with severe thoracic back pain and progressive myelopathy. MRI reveals a solid, poorly circumscribed intramedullary lesion extending over five vertebral levels with patchy enhancement. What is the most appropriate primary surgical treatment?

Explanation

Astrocytomas are the most common intramedullary tumors in children and are typically infiltrative and poorly circumscribed. Gross total resection is rarely possible without significant neurologic morbidity, so biopsy, maximal safe debulking, and adjuvant therapy are the standard of care.

Question 45

A 55-year-old man presents with intractable mechanical lower back pain. Imaging shows a lytic lesion involving the L3 vertebral body, and biopsy confirms metastatic renal cell carcinoma. The Spinal Instability Neoplastic Score (SINS) is 14. Which of the following is the most crucial step prior to surgical decompression and stabilization?

Explanation

Renal cell carcinoma and thyroid carcinoma metastases to the spine are highly vascular. Preoperative selective arterial embolization is critically important to minimize life-threatening intraoperative blood loss during decompression and stabilization.

Question 46

A 40-year-old male presents with bowel and bladder dysfunction. MRI shows a large, destructive midline sacral mass. Histology reveals physaliferous cells in a myxoid background. Which of the following represents the optimal management?

Explanation

The clinical and histologic features (physaliferous cells) confirm a sacral chordoma. Chordomas are locally aggressive and relatively radioresistant, making en bloc wide surgical resection the only chance for potential long-term cure.

Question 47

An 8-year-old boy presents with back pain. Radiographs demonstrate a "vertebra plana" of the T8 vertebral body. The child is neurologically intact. Which of the following is the most appropriate initial management?

Explanation

Vertebra plana in a child is classically caused by Langerhans Cell Histiocytosis (Eosinophilic Granuloma). In the absence of progressive neurologic deficit or severe instability, observation and bracing are recommended, as the vertebral height often reconstitutes over time.

Question 48

A 16-year-old girl presents with a rigid thoracic scoliosis and night pain relieved by ibuprofen. Imaging reveals a sclerotic lesion with a central lucent nidus in the left T9 pedicle. In which direction will the apex of her scoliosis typically point?

Explanation

The lesion is an osteoid osteoma. Muscle spasm secondary to the inflammatory mediators (prostaglandins) released by the nidus causes a convex deformity, so the apex of the scoliosis points away from the side of the lesion.

Question 49

A 25-year-old woman has an expansile, radiolucent lesion involving the L2 posterior elements. MRI shows multiple fluid-fluid levels. A biopsy confirms a benign, blood-filled cystic lesion. Which genetic alteration is commonly associated with this primary pathology?

Explanation

The lesion is an aneurysmal bone cyst (ABC), characterized by fluid-fluid levels on MRI. Primary ABCs are neoplasms frequently driven by a translocation involving the USP6 gene on chromosome 17.

Question 50

A 30-year-old female presents with sacral pain. Imaging shows a lytic, expansile mass in the S1-S2 vertebral bodies. Biopsy demonstrates mononuclear cells and multinucleated giant cells. Which of the following targeted medical therapies is often used preoperatively to facilitate surgical resection by inducing an osteosclerotic shell?

Explanation

Denosumab is a monoclonal antibody against RANKL used in giant cell tumors of bone. It inhibits osteoclast-like giant cells, arresting tumor growth and forming a peripheral sclerotic rim that facilitates intralesional curettage or en bloc resection.

Question 51

A 65-year-old man presents with progressive lower extremity paraparesis. MRI reveals an extradural mass causing severe cord compression at T10. Histology confirms multiple myeloma. According to the Patchell criteria, which of the following is an absolute indication for surgical decompression over primary radiotherapy?

Explanation

While multiple myeloma is highly radiosensitive, indications for surgery over primary radiation include spinal instability, bony compression of the cord, progression despite radiation, or need for open biopsy. Mechanical instability always requires surgical stabilization.

Question 52

A 42-year-old male undergoes surgery for a mass of the filum terminale. Histology confirms a myxopapillary ependymoma. What is the most critical intraoperative technical factor to prevent tumor recurrence?

Explanation

Myxopapillary ependymomas are WHO grade I tumors but have a high propensity for local recurrence and cerebrospinal fluid (CSF) seeding if the tumor capsule is violated. En bloc resection with an intact capsule is paramount for minimizing recurrence.

Question 53

A 55-year-old female with breast cancer presents with a metastatic lesion to the L1 vertebral body compressing the thecal sac without a neurological deficit (Bilsky grade 1c). What is the accepted paradigm for "separation surgery" in this patient prior to stereotactic body radiation therapy (SBRT)?

Explanation

Separation surgery aims to decompress the spinal cord, creating a safe margin (usually 2-3 mm) between the dura and the tumor. This allows for the subsequent delivery of ablative high-dose SBRT without causing radiation necrosis to the spinal cord.

Question 54

Which of the following intradural extramedullary spinal tumors is classically described histologically by alternating regions of high cellularity (Antoni A) and low cellularity (Antoni B) with palisading Verocay bodies?

Explanation

Schwannomas are benign peripheral nerve sheath tumors that commonly present as intradural extramedullary spinal masses. Their classic histologic appearance features dense Antoni A areas containing Verocay bodies, alongside looser, myxoid Antoni B areas.

Question 55

Which of the following is the most common primary intramedullary spinal cord tumor in adults?

Explanation

Ependymomas are the most common primary intramedullary spinal cord tumors in adults, whereas astrocytomas are the most common in children.

Question 56

A 14-year-old boy presents with a painful thoracic scoliosis. He reports the pain is worse at night and dramatically improves with ibuprofen. Radiographs and CT are most likely to show a nidus located in the:

Explanation

Osteoid osteomas in the spine typically present with painful scoliosis. The tumor is almost always located in the posterior elements on the concave side of the scoliotic curve.

Question 57

A 55-year-old woman presents with progressive myelopathy. MRI reveals an intradural, extramedullary mass in the thoracic spine with homogeneous enhancement and a characteristic "dural tail". The most likely diagnosis is:

Explanation

Meningiomas are typically intradural extramedullary tumors that most commonly occur in the thoracic spine of middle-aged women. A "dural tail" on contrast-enhanced MRI is a classic pathognomonic finding.

Question 58

A 6-year-old boy complains of localized back pain. Lateral radiographs show complete collapse of the T8 vertebral body (vertebra plana) with preservation of the adjacent disc spaces. The most likely diagnosis is:

Explanation

Eosinophilic granuloma (Langerhans cell histiocytosis) is a classic cause of vertebra plana in children. The disc spaces are characteristically preserved, unlike in infectious discitis.

Question 59

A 58-year-old man presents with bowel and bladder dysfunction and sacral pain. Imaging shows a large, destructive midline sacral mass. Biopsy reveals physaliferous cells in a myxoid background. Which of the following is the most appropriate surgical treatment?

Explanation

The patient has a sacral chordoma, characterized histologically by physaliferous cells. The gold standard treatment is wide en bloc excision to minimize the high risk of local recurrence.

Question 60

A 45-year-old woman undergoes a spine CT for an unrelated abdominal issue. An incidental lesion is found in the L2 vertebral body demonstrating a "polka-dot" pattern on axial views and vertical striations on sagittal views. What is the most appropriate management?

Explanation

The imaging findings are classic for a spinal hemangioma showing vertical trabeculations or "jailhouse" striations. Asymptomatic lesions require no further intervention and can be safely observed.

Question 61

Which of the following scoring systems is specifically designed to assess neoplastic spine instability and guide the need for surgical stabilization in patients with spinal metastases?

Explanation

The Spinal Instability Neoplastic Score (SINS) evaluates 6 components to determine structural stability and the need for surgical consultation in neoplastic disease.

Question 62

A 40-year-old man presents with radicular pain. MRI reveals an intradural, extramedullary mass extending through the neural foramen into the extraspinal space, creating a "dumbbell" shape. Histology shows Antoni A and Antoni B tissue patterns. The correct diagnosis is:

Explanation

Schwannomas frequently present as dumbbell-shaped tumors extending through the neural foramen. Histologically, they feature hypercellular Antoni A areas with Verocay bodies and hypocellular Antoni B areas.

Question 63

A 22-year-old woman presents with severe back pain. MRI shows an expansile, multiloculated lytic lesion in the posterior elements of L3 with multiple fluid-fluid levels on T2-weighted sequences. The most likely diagnosis is:

Explanation

Aneurysmal bone cysts (ABCs) typically arise in the posterior elements of the spine in young patients. The presence of fluid-fluid levels on MRI is a hallmark characteristic.

Question 64

A 60-year-old man with a history of renal cell carcinoma presents with acute paraparesis from a T10 metastatic lesion causing spinal cord compression. If surgical decompression is planned, which of the following should ideally precede surgery?

Explanation

Renal cell carcinoma and thyroid cancer metastases to the spine are highly vascular. Preoperative selective arterial embolization is strongly recommended to reduce intraoperative blood loss.

Question 65

Which of the following represents the most common primary malignant bone tumor of the spine in the adult population?

Explanation

Multiple myeloma is the most common primary malignant bone tumor overall and in the spine for adults. It often presents with lytic, "punched-out" lesions and osteopenia.

Question 66

A 28-year-old man presents with progressive lower extremity weakness. MRI identifies a myxopapillary ependymoma located in the conus medullaris and filum terminale. What is the most important factor in preventing local recurrence?

Explanation

Myxopapillary ependymomas are WHO Grade I tumors. Achieving a gross total unruptured en bloc resection provides the highest cure rate and minimizes the risk of local recurrence and CSF dissemination.

Question 67

A 35-year-old man presents with back pain and a large expansile lytic lesion in the L4 vertebral body extending into the pedicle. Biopsy reveals multinucleated giant cells in a stroma of mononuclear cells. If the tumor is deemed unresectable due to neurovascular involvement, the best pharmacologic treatment is:

Explanation

This patient has a giant cell tumor (GCT) of the spine. Denosumab, a RANKL inhibitor, is highly effective for unresectable GCTs by inhibiting osteoclast-like giant cells and causing tumor ossification.

Question 68

Which of the following tumor types is most characteristically associated with von Hippel-Lindau (VHL) syndrome when presenting in the spinal cord?

Explanation

Hemangioblastomas of the central nervous system, including the spinal cord, are strongly associated with von Hippel-Lindau (VHL) disease. They are highly vascular, benign tumors.

Question 69

A routine AP radiograph of the lumbar spine in a 65-year-old man with a history of prostate cancer reveals the "winking owl" sign. This radiographic finding indicates destruction of which anatomical structure?

Explanation

The "winking owl" sign is seen on an AP radiograph when one of the pedicles is destroyed by a lytic process, most commonly a spinal metastasis.

Question 70

A 9-year-old child presents with progressive scoliosis and central nervous system signs. MRI reveals an extensive intramedullary cystic mass expanding the spinal cord from C3 to T2. What is the most likely diagnosis?

Explanation

Astrocytomas are the most common intramedullary spinal cord tumors in children. They are typically eccentric, ill-defined, and frequently associated with tumoral cysts or syringomyelia.

Question 71

In comparing osteoblastoma to osteoid osteoma of the spine, which of the following features is more characteristic of osteoblastoma?

Explanation

Osteoblastomas are larger (> 2 cm), locally aggressive, less responsive to NSAIDs, and have a higher propensity for causing neurologic deficits and recurring after curettage.

Question 72

A patient with neurofibromatosis type 1 (NF1) presents with a rapidly progressive, sharp, short-segment thoracic kyphoscoliosis. Which of the following MRI findings is strongly associated with this dystrophic curve pattern?

Explanation

Dystrophic kyphoscoliosis in NF1 is characterized by a sharp, short-segment curve. Classic associated findings include dural ectasia, penciling of the ribs, enlarged neural foramina, and vertebral scalloping.

Question 73

A 50-year-old woman with a history of breast cancer presents with thoracic back pain. MRI shows a single vertebral metastasis at T7 with epidural extension causing mild cord compression. Based on the Tokuhashi scoring system, a score of 12 (high score) suggests:

Explanation

In the Tokuhashi scoring system, a high score (12-15) predicts a survival of more than 1 year. In these patients, aggressive excisional surgery (e.g., corpectomy and stabilization) is indicated for isolated metastatic lesions.

Question 74

A 16-year-old male presents with fever and severe low back pain. Imaging shows a permeative, destructive lesion in the L4 vertebral body with a large associated soft-tissue mass. Biopsy reveals small round blue cells that are CD99 positive. The most likely diagnosis is:

Explanation

Ewing sarcoma typically presents in adolescents with a permeative bony lesion, soft tissue mass, and systemic symptoms. Histologically, it is composed of small round blue cells that stain positive for CD99.

Question 75

A 45-year-old female presents with progressive spastic paraparesis and sensory loss. MRI reveals a well-circumscribed, centrally located, strongly enhancing intramedullary spinal cord lesion at T8 with an associated syrinx. What is the most likely diagnosis?

Explanation

Ependymoma is the most common intramedullary spinal cord tumor in adults and typically presents as a centrally located, well-circumscribed, enhancing mass often associated with a syrinx. Gross total resection is often possible due to a distinct cleavage plane.

Question 76

A 6-year-old child presents with torticollis and upper extremity weakness. MRI demonstrates an eccentrically located, ill-defined intramedullary lesion in the cervical spinal cord that expands the cord. What is the most likely diagnosis?

Explanation

Astrocytomas are the most common intramedullary spinal cord tumors in children. They are typically eccentrically located and ill-defined, making gross total resection difficult compared to ependymomas.

Question 77

A 60-year-old woman presents with thoracic radicular pain. MRI reveals an intradural, extramedullary, homogeneously enhancing mass with a broad base on the dura and a "dural tail". What is the best initial surgical management strategy?

Explanation

The clinical and radiographic presentation is classic for a spinal meningioma. The standard of care is gross total surgical resection, which often includes excision or coagulation of the dural attachment to minimize recurrence.

Question 78

Which of the following histologic findings is most characteristic of a spinal schwannoma?

Explanation

Schwannomas are characterized histologically by alternating regions of high cellularity (Antoni A) containing Verocay bodies, and low cellularity (Antoni B). Psammoma bodies are seen in meningiomas, and perivascular pseudorosettes in ependymomas.

Question 79

A 35-year-old male undergoes an MRI of the lumbar spine for chronic back pain. The scan incidentally reveals a T1-hyperintense, T2-hyperintense vertebral body lesion at L2 with a "polka-dot" appearance on axial CT. No cortical breakthrough is noted. What is the most appropriate management?

Explanation

The findings describe a classic asymptomatic vertebral hemangioma, characterized by increased signal on T1 and T2 MRI and a "polka-dot" or "corduroy" appearance on CT. Asymptomatic lesions require no further intervention and are observed.

Question 80

A 55-year-old man presents with bowel and bladder dysfunction and severe sacral pain. Radiographs reveal a large destructive, midline lytic lesion of the sacrum. Biopsy shows cords of large vacuolated cells (physaliferous cells) in a myxoid background. What is the optimal definitive treatment?

Explanation

Chordomas are locally aggressive, chemoresistant, and radioresistant tumors derived from notochordal remnants. The standard of care for achievable cure is en bloc wide surgical excision with negative margins.

Question 81

A 7-year-old boy complains of localized back pain. Radiographs of the thoracic spine show uniform collapse of the T7 vertebral body (vertebra plana) with preservation of the adjacent disc spaces. What is the most likely diagnosis?

Explanation

Langerhans cell histiocytosis (eosinophilic granuloma) is the most common cause of vertebra plana in a child. Adjacent disc spaces are classically preserved, differentiating it from discitis/osteomyelitis.

Question 82

A 16-year-old boy presents with severe thoracic back pain that is worse at night and completely relieved by ibuprofen. CT scan shows a 1 cm radiolucent nidus with surrounding sclerosis in the pedicle of T9. Which of the following is the most appropriate next step if conservative management fails?

Explanation

The clinical picture is classic for an osteoid osteoma. If conservative management with NSAIDs fails, minimally invasive procedures such as CT-guided radiofrequency ablation (RFA) are the treatment of choice.

Question 83

An intradural, extramedullary spinal tumor is resected from the cervical spine of a 40-year-old patient. Pathology demonstrates an encapsulated mass containing spindle-shaped cells arranged in whorls and the presence of calcified concentric structures. What is the most likely diagnosis?

Explanation

The histologic description of whorled spindle cells and psammoma bodies (calcified concentric structures) is pathognomonic for a meningioma. These typically arise in the intradural, extramedullary space.

Question 84

A 65-year-old man with prostate cancer presents with sudden onset lower extremity weakness and hyperreflexia. MRI shows a metastatic lesion at T10 causing severe ventral spinal cord compression. He has a life expectancy of 2 years and is an excellent surgical candidate. What is the best management?

Explanation

According to the Patchell criteria, patients with metastatic spinal cord compression who have a good functional status, an estimated survival >3 months, and an operable tumor benefit more from direct decompressive surgery plus radiation than from radiation alone.

Question 85

A 15-year-old girl presents with progressive back pain. Imaging shows an expansile, multiloculated, osteolytic lesion in the posterior elements of L3. MRI demonstrates distinct fluid-fluid levels within the lesion. What is the most likely diagnosis?

Explanation

Aneurysmal bone cysts (ABCs) in the spine classically involve the posterior elements in adolescents. The hallmark MRI finding is fluid-fluid levels representing blood products of different ages.

Question 86

Which of the following primary spine tumors typically arises from remnants of the primitive notochord?

Explanation

Chordomas arise from embryonic notochordal remnants. They occur most frequently at the ends of the axial skeleton, specifically the sacrococcygeal region and the spheno-occipital skull base.

Question 87

A 30-year-old female presents with slowly progressive lower back pain and saddle anesthesia. MRI reveals a large, well-circumscribed, homogeneously enhancing mass primarily involving the filum terminale. Histology shows ependymal cells arranged around blood vessels. Which variant is most likely?

Explanation

Myxopapillary ependymomas are a distinct subtype that almost exclusively arise in the conus medullaris and filum terminale region. They are slow-growing and demonstrate perivascular pseudorosettes histologically.

Question 88

A 50-year-old patient with known multiple myeloma presents with severe, localized thoracic back pain. Plain films show a compression fracture of T8 without retropulsion, and MRI shows no neural compression. The patient has failed 6 weeks of conservative management. What is the most appropriate intervention for pain relief?

Explanation

In cases of painful pathologic vertebral compression fractures without neural element compression that fail conservative care, vertebral augmentation (kyphoplasty or vertebroplasty) provides excellent and rapid pain relief.

Question 89

In the evaluation of suspected spinal tumors, which imaging modality is considered the gold standard for characterizing intramedullary lesions and assessing the full extent of spinal cord involvement?

Explanation

Contrast-enhanced MRI is the gold standard for evaluating spinal tumors. It provides unmatched soft-tissue resolution to differentiate intramedullary, extramedullary, and extradural lesions.

Question 90

A 25-year-old female presents with a sacral mass. Biopsy reveals mononuclear stromal cells and uniformly distributed multinucleated giant cells. The stromal cells represent the neoplastic component. What is the most common spinal location for this tumor?

Explanation

The histology describes a Giant Cell Tumor (GCT) of bone. When GCTs occur in the spine, the sacrum is by far the most common location.

Question 91

Which of the following genetic syndromes is most strongly associated with the development of multiple spinal hemangioblastomas?

Explanation

Von Hippel-Lindau (VHL) disease is an autosomal dominant condition characterized by the formation of multiple hemangioblastomas in the central nervous system, including the brain and spinal cord, as well as renal cell carcinomas.

Question 92

A 68-year-old man presents with a pathologic fracture of the L4 vertebra. Laboratory evaluation reveals a monoclonal spike on serum protein electrophoresis and hypercalcemia. Which of the following radiographic features is typically ABSENT in this disease process?

Explanation

Multiple myeloma is characterized by purely lytic lesions without reactive bone sclerosis. Because there is no osteoblastic response, bone scans are typically "cold" or false-negative in myeloma.

Question 93

What is the classic neurological presentation differentiating an intramedullary spinal tumor from an extramedullary spinal tumor early in the disease course?

Explanation

Intramedullary tumors often damage the crossing spinothalamic tracts centrally, leading to a dissociated sensory loss (loss of pain and temperature with preserved light touch and proprioception). Extramedullary tumors typically present first with radicular pain due to nerve root compression.

Question 94

A 45-year-old patient with breast cancer develops multilevel blastic and lytic spinal metastases. She is neurologically intact but complains of severe mechanical back pain upon standing, which is entirely relieved by lying down. Radiographs show instability at L2-L3. What is the most appropriate management?

Explanation

Mechanical back pain in the setting of metastatic disease with overt spinal instability is a structural problem that does not respond to radiation or systemic therapy. Surgical stabilization is required to allow upright mobilization and relieve pain.

Orthopedic Prometric MCQs - Chapter 3 Part 1

Orthopedic Prometric MCQs - Chapter 3 Part 30

Orthopedic Prometric MCQs - Chapter 3 Part 30

Chapter Index