Question 1

Unilateral facet dislocation may be distinguished radiographically from bilateral facet dislocation by which of the following features:

Explanation

Unilateral jumped facets typically involve anterolisthesis of the upper vertebral body, which is less than 25%. Misalignment of the spinous processes and spinal canal compromise may be seen with either unilateral or bilateral facet dislocation. Subluxation greater than 50% and marked angular deformity are characteristics of bilateral facet dislocations.

Question 2

The annual incidence of cervical radiculopathy in men is 107.3 per 100,000 and 63.5 per 100,000 in women. The incidence for both groups occurs within which of the following peak age ranges:

Explanation

Although the incidence rate of cervical radiculopathy in men is nearly double the rate found in women, the peak age range is the same (50-54 years).

Question 3

Which of the following structures are found within an intervertebral foramen:

Explanation

In addition to the dorsal root ganglion, connective tissue, radicular artery and vein, and recurrent meningeal nerves, spinal nerve roots and adipose also comprise an intervertebral foramen.

Question 4

Most cervical radiculopathy occurs as a result of inflammatory mediators released after mechanical injury, without direct compression of the nerve root(s).

Explanation

Question 5

C1 reflexes include which of the following:

Explanation

The C 1 reflex, while rarely tested, involves the jaw jerk.

Question 6

Typical C 3 reflexes include which of the following:

Explanation

No reflexes are associated with the C3 spinal nerve.

Question 7

Which of the following is a distinguishing feature of a C 7 radiculopathy rarely found in C 6 radiculopathies:

Explanation

C 7 radiculopathies classically entail pain and/or sensory changes involving the middle finger. C 6 radicular symptoms generally involve the thumb and first finger. C 8 radiculopathies involve the pinkie and ring fingers.

Question 8

Studies suggest that cervical radiculopathy (or related pathology) of which nerve root may partially explain the phenomenon of cervicogenic headaches:

Explanation

Headaches observed with upper cervical pathology may be due, in part, to the convergence of C 1-, C 2-, and C 3-level pain fibers with second-order neurons of the descending sensory tract of cranial nerve V.

Question 9

Which of the following diagnostic tests is preferred for suspected cervical radiculopathy:

Explanation

Although myelogram and nerve conduction studies are useful tests, they are invasive. Magnetic resonance imaging studies are the most appropriate choice for diagnosis. Most important in the diagnosis of cervical radiculopathy is a thorough history and physical examination.

Question 10

What is the preferred treatment method for patients with cervical radiculopathy:

Explanation

Most patients with cervical radiculopathy are best treated medically after the age of 50. In other age groups, based on the history, physical examination, and number of involved nerve roots, a combination of the above methods may be appropriate. Surgical therapy may be necessary in patients refractory to medical management.

Question 11

A 17-year-old high school football player presents to the emergency department after being removed from play following a harsh tackle. The patient reports a sharp burning and stinging pain through his left arm that has not resolved since the tackle. A careful history revealed that this is the fourth episode of burning and stinging pain. In each episode of pain, the symptoms have lasted longer than the previous episode. The patient also reports that he has suffered from two prior episodes of transient weakness and numbness in all extremities following harsh tackles. Which of the following statements concerning this patient is correct:

Explanation

It is important to understand the current return to play criteria for cervical spine injuries in athletes. There is an absolute contraindication to return to play in patients who have: a) more than two previous episodes of transient quadriparesis/quadriplegia, b) clinical history, physical examination findings, or imaging confirmation of cervical myelopathy/myelomalacia, and c) continued cervical neck discomfort, decreased range of motion, or any evidence of a neurologic deficit from baseline after any cervical spine injury. Patient education and follow-up are always indicated in patients with burners and stingers. This patient should not participate in football games, exercise, or practice until full mobility and strength has returned, and all neurologic symptoms have resolved.

Question 12

Which of the following statements regarding radiographic evaluation of patients with burners and stingers is correct:

Explanation

The Torg ratio is calculated using an extension lateral cervical radiograph. To calculate the Torg ratio, divide the distance between the midpoint of the posterior aspect of the vertebral body to the nearest point on the corresponding spinolaminar line by the anteroposterior width of the vertebral body. A Torg ratio , 0.8 is associated with cervical spinal stenosis and sustained burners and stingers in athletes with cervical spine-extension- compression type injuries.C orrect Answer: A Torg ratio , 0.8 indicates that cervical spinal stenosis may be present, and an extension lateral cervical conventional radiograph is used to determine the Torg ratio.

Question 13

Which of the following statements concerning burners and stingers is incorrect:

Explanation

Burners and stingers are usually seen in children, adolescents, and athletes. Choice A is correct, and explains why burners and stingers are typically seen in tackle injuries sustained by football players and in motorcycle accidents. Choices C and D are correct because management of patients with burners and stingers should always include strengthening, stretching, patient education, and follow-up.

Question 14

A 26-year-old man with HIV presents to your office with symptoms of lower back pain, difficulty with ambulation, loss of appetite, mild fever, and malaise for 2 weeks. The patient states that he has had difficulty with compliance to his medical management. You suspect that he has a low C D4 count, which is confirmed by laboratory tests. Physical examination reveals tenderness at the L4-L5 level. The patient has abnormal gait. Ankle dorsiflexion and plantarflexion are 1 out of 5 bilaterally. The Achilles tendon reflex is absent bilaterally; all other reflexes are normal. A T2-weighted magnetic resonance imaging (MRI) study shows slightly increased intensity of the disk at the L4-L5 level and an obvious epidural abscess. C onventional radiographs of the lumbar region are normal. Management of this patient should consist of:

Explanation

All of the above answer choices are correct. The patient described above has HIV and is severely immunocompromised. Because of the severity of the patientâ s condition, immediate admission to the ICU and intravenous administration of a broad-spectrum antibiotic regimen is indicated. Biopsy and drainage of the infected regions should be performed. It is important in this case to monitor the patient for any signs of neurologic deterioration. Finally, to prevent recurrent cases of diskitis, or other infections, it is important to counsel the patient on compliance with medical management.

Question 15

Which of the following statements regarding diskitis is correct:

Explanation

Diskitis is usually indolent, and patients live with symptoms for several months before seeking treatment. Intravenous drug use and immunocompromise are two important risk factors for diskitis, along with surgical procedures involving the spine. Diskitis rarely occurs in the thoracic spine; instead, diskitis usually occurs in the lumbar spine. Blood cultures should be taken in any patient with suspected diskitis.

Question 16

Which of the following statements regarding lesions of the spinal cord caused by bullet wounds is true:

Explanation

All of the statements are true. Knowledge of these facts is important in decision-making and management of patients who are victims of gunshot wounds to the spine.

Question 17

An 18-year-old man presents to the emergency department after sustaining a high-velocity gunshot wound to the umbilical region of the abdomen. An exit wound is found at the L3-L5 region of the lower back. Neurological examination shows grade 0/5 strength in his tibialis anterior muscles, gastrocnemius/soleus muscles, and extensor hallucis longus muscles bilaterally. His quadriceps and hamstrings strength is grade 2/5 bilaterally. A bullet fragment was seen at L4 within the spinal canal on computed tomography (C T) imaging. The patient sustained significant gastrointestinal trauma as a result of the bullet traversing his body. Management should consist of:

Explanation

Because the bullet entered the patientâ s umbilical region of the abdomen, significant gastrointestinal damage is suspected. When this occurs, administration of a broad-spectrum antibiotic for 7 to 14 days is indicated to prevent infection and sepsis from gastrointestinal flora. The bullet fragment at L4 should be removed because studies have shown that removal of a bullet from a patient with complete or incomplete neural deficits at T12 to L4 is associated with statistically significant increases in motor recovery as compared to nonoperative management. Intravenous administration of dexamethasone is not indicated for gunshot wounds to the spine because the benefits of steroids do not outweigh the risks.

Question 18

Magnetic resonance imaging (MRI) is appropriate in which of the following circumstances:

Explanation

It is appropriate to obtain an MRI in all of the above circumstances. Magnetic resonance imaging allows a physician to evaluate the cerebrospinal fluid and spinal cord to localize the cause of a neurologic deficit. The presence of back pain in a patient with kyphosis and osteoporosis suggests the possibility of a vertebral compression fracture; these fractures may not always be seen with conventional radiographs. The use of MRI is recommended for the evaluation of a patient with congenital kyphosis to evaluate the morphology of the malformed segment and to rule out associated pathology.

Question 19

What percentage of women with osteoporotic fractures develop kyphosis:

Explanation

Approximately 15% of women with osteoporotic fractures develop kyphosis. This is often due to the presence of multiple vertebral compression fractures with segmental kyphosis at each level.

Question 20

A 7-year-old boy presents to the emergency department (ED) with fever, headache, neck pain, nausea, vomiting, and mental status changes. The patient was involved in a motor vehicle accident in his parentâ s car and experienced whiplash 4 weeks prior to his presentation at the ED. Laboratory studies show an elevated white blood cell (WBC ) count and erythrocyte sedimentation rate (ESR). Which of the following statements concerning this patient is correct:

Explanation

The patient presented with the classic signs and symptoms of pediatric bacterial meningitis. Meningitis should be suspected in patients with neck pain, fever, and altered mental status. A lumbar puncture may show C SF with a high neutrophil count, high protein level, and decreased glucose; a C SF culture may reveal bacteria such as H influenzae. In children with a history of trauma, it is important to note that no radiographic findings may be present in 19% to 34% of patients. Because of the severity of the patients symptoms and diagnosis of bacterial meningitis, it is important to admit him to the PIC U and begin intravenous antibiotics.

Question 21

Which of the following factors is most strongly predictive of nonunion in a patient managed non-operatively for a Type II odontoid fracture?

Explanation

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

Question 22

In a patient presenting with an acute L4-L5 far-lateral (extraforaminal) disc herniation, which nerve root is most likely compressed?

Explanation

A far-lateral or extraforaminal disc herniation at L4-L5 compresses the exiting L4 nerve root. This contrasts with a paracentral herniation at the same level, which would compress the traversing L5 root.

Question 23

A 30-year-old male sustains a flexion-distraction (Chance) fracture of L1 during a motor vehicle collision. Which of the following associated injuries must be urgently ruled out?

Explanation

Chance fractures are commonly caused by lap-belt injuries, which create a flexion-distraction mechanism. They are highly associated with intra-abdominal hollow viscus injuries, occurring in up to 50% of cases.

Question 24

An 80-year-old female with long-standing ankylosing spondylitis presents with neck pain after a ground-level fall. Initial plain radiographs are read as normal. What is the most appropriate next step in management?

Explanation

Patients with ankylosing spondylitis are at high risk for highly unstable spine fractures even after low-energy trauma. CT scan of the entire cervical spine is mandatory because fractures are frequently missed on plain radiographs.

Question 25

During anterior cervical discectomy and fusion (ACDF), the sympathetic trunk is at risk of injury if dissection strays too far laterally. The sympathetic trunk lies anterior to which of the following structures?

Explanation

The sympathetic trunk rests on the lateral border of the longus colli muscle. Injury to it during an anterior approach to the cervical spine can result in Horner's syndrome.

Question 26

Which of the following physical examination findings is most specific for cervical myelopathy?

Explanation

The inverted brachioradialis reflex is highly specific for cervical myelopathy, indicating a lower motor neuron lesion at C5-C6 and an upper motor neuron lesion below. Spurling's test is specific for cervical radiculopathy.

Question 27

Which of the following is considered the most significant risk factor for nonunion in a Type II odontoid fracture treated nonoperatively with a halo vest?

Explanation

Risk factors for nonunion in Type II odontoid fractures include initial displacement > 5 mm, age > 65 years, posterior displacement, and comminution. Displacement > 5 mm drastically reduces fusion rates when treated with halo immobilization alone.

Question 28

According to the Levine and Edwards classification of traumatic spondylolisthesis of the axis (Hangman's fracture), a Type IIA fracture is best managed by which of the following?

Explanation

Type IIA fractures result from flexion-distraction and feature severe angulation with minimal translation. Axial traction is strictly contraindicated as it will exacerbate the injury; they must be reduced with gentle compression and extension.

Question 29

A 65-year-old male with severe cervical spondylosis develops disproportionately greater motor impairment in his upper extremities compared to his lower extremities following a hyperextension injury. Which spinal cord tracts are primarily involved in this classic syndrome?

Explanation

This presentation is classic for Central Cord Syndrome. It preferentially damages the medial portion of the lateral corticospinal tracts, which topographically carry motor fibers supplying the upper extremities.

Question 30

In a patient with long-standing rheumatoid arthritis, which of the following radiographic measurements is the most reliable predictor of impending or irreversible neurologic deficit due to atlantoaxial subluxation?

Explanation

The Posterior atlantodental interval (PADI), also known as the space available for the cord (SAC), is the most critical prognostic indicator. A PADI less than 14 mm is associated with a high risk of permanent neurologic deficit.

Question 31

During an anterior cervical discectomy and fusion (ACDF) at the C6-C7 level, a right-sided surgical approach is chosen. Which of the following structures is at a higher risk of injury compared to a left-sided approach?

Explanation

The right recurrent laryngeal nerve is at higher risk during right-sided lower cervical approaches because it leaves the vagus nerve more proximally and courses at a more oblique, unprotected angle compared to the left nerve.

Question 32

A 25-year-old is involved in a severe motor vehicle collision and sustains a Jefferson burst fracture. On the AP open-mouth radiograph, what combined lateral mass overhang measurement indicates disruption of the transverse alar ligament (Rule of Spence)?

Explanation

The Rule of Spence dictates that a combined overhang of the C1 lateral masses on C2 > 6.9 mm on an open-mouth view implies transverse ligament rupture, rendering the C1 ring highly unstable.

Question 33

Which of the following physical examination findings is most specific for diagnosing a severe upper motor neuron lesion such as cervical myelopathy?

Explanation

An inverted brachioradialis reflex (finger flexion or triceps extension when the brachioradialis tendon is tapped) strongly indicates cervical myelopathy, representing simultaneous lower motor neuron damage at C5/C6 and upper motor neuron damage below that level.

Question 34

In the evaluation of traumatic atlanto-occipital dissociation, the Powers ratio is utilized. Which of the following values definitively indicates anterior atlanto-occipital dislocation?

Explanation

The Powers ratio is the distance from basion to posterior arch of C1 divided by the distance from opisthion to anterior arch of C1. A normal ratio is < 0.9, while a ratio > 1.0 defines anterior translation/dissociation.

Question 35

A 45-year-old patient presents with neck pain radiating to the thumb and index finger. Examination reveals weakness in wrist extension and a diminished brachioradialis reflex. Which cervical nerve root is most likely compressed?

Explanation

C6 radiculopathy typically manifests with numbness in the thumb and index finger, weakness in wrist extension, and a diminished brachioradialis reflex.

Question 36

What is a major indication for utilizing a posterior approach (laminoplasty or laminectomy with fusion) rather than an anterior approach for ossification of the posterior longitudinal ligament (OPLL)?

Explanation

A posterior approach relies on preserved cervical lordosis to allow the spinal cord to drift posteriorly away from the anterior compressive OPLL mass. Multi-level disease (>3 levels) is better treated posteriorly if lordosis is intact.

Question 37

A 60-year-old patient with ankylosing spondylitis sustains a minor fall resulting in an extension-type cervical fracture. Even without immediate neurologic deficit, which of the following life-threatening complications is most frequently associated with this specific injury pattern?

Explanation

Patients with ankylosing spondylitis have rigid, vascularized bone and altered epidural venous plexus dynamics. Fractures often tear these vessels, predisposing them to rapidly expanding, compressive epidural hematomas.

Question 38

During the initial assessment of a complete cervical spinal cord injury, the return of the bulbocavernosus reflex clinically signifies:

Explanation

The bulbocavernosus reflex is typically the first reflex to return after a spinal cord injury. Its return signifies the end of spinal shock, meaning any persistent neurologic deficits are likely permanent.

Question 39

Unilateral cervical facet dislocation typically occurs via which distinct mechanism of injury?

Explanation

Unilateral facet dislocations result from a coupling of flexion, distraction, and axial rotation. This causes one inferior articular process to ride up and over the superior articular process of the vertebra below.

Question 40

In a patient presenting with Klippel-Feil syndrome, what is the most common associated non-skeletal congenital anomaly?

Explanation

Genitourinary anomalies (such as unilateral renal agenesis or horseshoe kidney) are the most common non-skeletal associations in Klippel-Feil syndrome, affecting up to 30-40% of patients. Renal ultrasound is routinely recommended.

Question 41

Which of the following defines the 'K-line' in the evaluation of cervical ossification of the posterior longitudinal ligament (OPLL)?

Explanation

The K-line connects the midpoints of the anteroposterior diameter of the spinal canal at C2 and C7. If the OPLL exceeds this line anteriorly (K-line negative), posterior decompression alone is insufficient.

Question 42

When evaluating the boundaries of the cervical intervertebral foramen, which anatomical structure forms its anterior border?

Explanation

The anterior border of the cervical intervertebral foramen is formed by the uncinate process (uncovertebral joint) and the adjacent intervertebral disc. Hypertrophy here directly compresses the exiting nerve root.

Question 43

Using the Subaxial Cervical Spine Injury Classification (SLIC) system, what is the total score for a neurologically intact patient presenting with a simple C5 burst fracture and an intact posterior ligamentous complex on MRI?

Explanation

The SLIC score assigns 2 points for a burst morphology. With an intact discoligamentous complex (0 points) and intact neurologic status (0 points), the total score is 2, indicating nonoperative management.

Question 44

Which of the following represents an absolute contraindication to closed reduction with cranial tongs/traction in an awake patient with a cervical facet dislocation?

Explanation

An unstable or severe rostral skull fracture is an absolute contraindication for applying cranial traction tongs (e.g., Gardner-Wells). Intoxication or uncooperativeness is a relative contraindication.

Question 45

To mitigate the incidence of postoperative dysphagia following a multi-level Anterior Cervical Discectomy and Fusion (ACDF), which intraoperative maneuver is most supported by evidence?

Explanation

Deflating and subsequently re-inflating the endotracheal tube cuff after retractor placement reduces the compressive pressure against the pharyngeal wall and recurrent laryngeal nerve, significantly lowering the risk of postoperative dysphagia.

Question 46

Horner's syndrome, a known complication of lower cervical spine surgery or trauma, results from injury to the sympathetic chain. At what precise anatomical location does the sympathetic trunk typically form the stellate ganglion?

Explanation

The stellate ganglion is formed by the fusion of the inferior cervical and the first thoracic sympathetic ganglia. It is located anterior to the C7-T1 junction, making it vulnerable during cervicothoracic junction approaches.

Question 47

An 82-year-old male with severe congestive heart failure and COPD sustains a Type II odontoid fracture after a low-energy fall. He is neurologically intact. Which of the following is the most appropriate management for this patient?

Explanation

In elderly patients with severe comorbidities, rigid cervical collar immobilization is heavily favored. Surgical intervention and halo vest placement both carry unacceptably high morbidity and mortality rates in frail, elderly populations.

Question 48

A 55-year-old male presents with severe radicular leg pain. Magnetic resonance imaging demonstrates a far lateral (extraforaminal) disc herniation at the L4-L5 level. Which nerve root is most likely to be compressed?

Explanation

A far lateral (extraforaminal) disc herniation compresses the exiting nerve root at that specific level. Therefore, an L4-L5 far lateral disc herniation compresses the L4 nerve root.

Question 49

Degenerative spondylolisthesis most commonly occurs at which spinal level, and is associated with which facet joint orientation?

Explanation

Degenerative spondylolisthesis most commonly affects the L4-L5 level. It is strongly associated with sagittally oriented facet joints, which provide less biomechanical resistance to anterior shear forces.

Question 50

A 13-year-old premenarcheal girl is diagnosed with Adolescent Idiopathic Scoliosis. Radiographs demonstrate a Risser 0 stage and a right thoracic curve measuring 34 degrees. What is the most appropriate next step in management?

Explanation

Bracing is indicated for skeletally immature patients (Risser 0-2) presenting with curve magnitudes between 25 and 45 degrees. A TLSO is the standard of care to prevent curve progression in this demographic.

Question 51

A 60-year-old man with a history of renal cell carcinoma presents with progressive lower extremity weakness. Imaging shows a destructive metastatic lesion at T8 causing spinal cord compression. Prior to surgical decompression and stabilization, what is the most important preparatory step?

Explanation

Renal cell carcinoma and thyroid carcinoma bone metastases are notoriously hypervascular. Preoperative selective arterial embolization is highly recommended to significantly reduce massive intraoperative blood loss during decompression.

Question 52

Which of the following clinical presentations is the hallmark of Central Cord Syndrome?

Explanation

Central cord syndrome typically occurs after a hyperextension injury in a stenotic cervical spine. It selectively damages the centrally located cervical tracts, causing disproportionately greater motor impairment in the upper extremities compared to the lower extremities.

Question 53

A 45-year-old man with advanced Ankylosing Spondylitis suffers a hyperextension injury to his neck. Initial CT shows a C6-C7 fracture through the disc space. Two days post-admission, he develops sudden, rapidly progressive quadriplegia. What is the most likely cause of his deterioration?

Explanation

Patients with Ankylosing Spondylitis have highly vascularized epidural spaces and altered biomechanics, placing them at an exceptionally high risk for developing an epidural hematoma following spinal fractures. Prompt MRI and decompression are required.

Question 54

A patient presents with a severe L5 radiculopathy due to an L4-L5 paracentral disc herniation. Which of the following physical examination findings is most specific to the L5 nerve root?

Explanation

The L5 nerve root innervates the extensor hallucis longus and supplies sensation to the dorsum of the foot and the first web space. The patellar reflex is mediated by L4, and ankle plantar flexion is primarily S1.

Question 55

What is the classic clinical triad for a spinal epidural abscess, and what is the gold-standard imaging modality for diagnosis?

Explanation

The classic triad for a spinal epidural abscess is back pain, fever, and progressive neurologic deficit. The gold standard for diagnosis is a gadolinium-enhanced MRI of the entire spine to evaluate for skip lesions.

Question 56

Which of the following describes the widely accepted radiographic diagnostic criteria for Scheuermann's kyphosis?

Explanation

The classic Sorensen criteria for diagnosing Scheuermann's disease require radiographic evidence of anterior vertebral body wedging of greater than 5 degrees in at least three consecutive vertebrae.

Question 57

A Hangman's fracture represents a traumatic spondylolisthesis of the axis (C2). What is the primary mechanism of injury responsible for this fracture pattern?

Explanation

A Hangman's fracture involves bilateral pars interarticularis fractures of C2. It is typically caused by hyperextension combined with axial loading forces, frequently seen in motor vehicle accidents or falls.

Question 58

A 65-year-old male with severe Cervical Spondylotic Myelopathy (CSM) requires surgical decompression. Preoperative radiographs reveal a rigid cervical kyphosis of 15 degrees. Which of the following surgical approaches is most appropriate?

Explanation

Posterior decompression procedures (laminectomy or laminoplasty) rely on the spinal cord drifting backward away from anterior compression, which cannot occur in a kyphotic spine. An anterior or combined approach is necessary when the spine is kyphotic.

Question 59

According to the Denis three-column classification of thoracolumbar fractures, which structures comprise the middle column?

Explanation

The Denis 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 this column distinguishes a burst fracture from a simple compression fracture.

Question 60

A 70-year-old man presents with bilateral leg pain upon walking. Which of the following historical features most strongly differentiates neurogenic claudication from vascular claudication?

Explanation

Flexion of the lumbar spine (e.g., leaning over a shopping cart) increases the cross-sectional area of the spinal canal and neural foramina, temporarily relieving compression on the cauda equina in neurogenic claudication.

Question 61

Grisel's syndrome is best defined as which of the following?

Explanation

Grisel's syndrome is a non-traumatic atlantoaxial rotatory subluxation most often seen in children. It typically follows upper respiratory tract infections or head/neck procedures due to inflammatory laxity of the transverse ligament.

Question 62

In a patient suspected of having Cauda Equina Syndrome, which of the following is considered the most sensitive early clinical sign or symptom?

Explanation

Urinary retention is the most sensitive early clinical finding in cauda equina syndrome. A normal post-void residual volume (typically <100-200 mL) makes the diagnosis of cauda equina syndrome highly unlikely.

Question 63

Which classification of odontoid fractures is associated with the highest rate of nonunion when managed conservatively?

Explanation

Type II odontoid fractures occur at the base of the dens and have the highest rate of nonunion. This is due to the watershed blood supply of the dens and the relative instability of the fracture pattern.

Question 64

Using the Thoracolumbar Injury Classification and Severity (TLICS) score, which of the following clinical scenarios most definitively indicates the need for surgical intervention (score > 4)?

Explanation

In the TLICS system, a translational/rotational injury yields 3 points, a complete neuro deficit yields 2 points, and a ruptured PLC yields 3 points. A total score greater than 4 is a strict indication for surgical stabilization.

Question 65

A patient suffers a penetrating knife wound to the thoracic spine resulting in a spinal cord hemisection (Brown-Sequard Syndrome). Which of the following deficit patterns is expected below the level of injury?

Explanation

Brown-Sequard syndrome results from a hemisection of the spinal cord. The patient will exhibit ipsilateral loss of motor function and proprioception (corticospinal tract and dorsal columns) and contralateral loss of pain and temperature (spinothalamic tract).

Question 66

According to the Quebec Task Force classification of Whiplash-Associated Disorders, what clinical features distinguish a Grade III injury from a Grade II injury?

Explanation

In the Quebec Task Force classification, Grade II includes neck pain with musculoskeletal signs (decreased ROM, point tenderness). Grade III is defined by neck pain accompanied by objective neurological signs (weakness, sensory deficit, reflex changes).

Question 67

A 65-year-old man with pre-existing cervical spondylosis presents after a hyperextension injury. He has disproportionately greater motor impairment in his upper extremities compared to his lower extremities. Which of the following spinal cord tracts is primarily responsible for the disproportionate upper extremity weakness?

Explanation

The lateral corticospinal tract has a somatotopic organization where the cervical motor fibers are located more medially. This medial location makes them more susceptible to injury in central cord syndrome.

Question 68

Which of the following is considered the most significant risk factor for nonunion in a conservatively managed Type II odontoid fracture?

Explanation

Displacement greater than 5 mm, angulation greater than 10 degrees, age over 50, and delayed diagnosis are significant risk factors for nonunion in Type II odontoid fractures.

Question 69

A 55-year-old male with a long history of ankylosing spondylitis sustains a seemingly minor fall. Radiographs reveal an extension-distraction fracture through the T8-T9 disc space. What is the most appropriate management?

Explanation

Fractures in ankylosing spondylitis are highly unstable due to the altered biomechanics of the fused spine. Long-segment posterior instrumentation (at least three levels above and below) is required to prevent failure.

Question 70

A 30-year-old male falls from a height and sustains an L1 burst fracture. Neurological examination is completely normal. MRI demonstrates an intact posterior ligamentous complex (PLC). What is his Thoracolumbar Injury Classification and Severity (TLICS) score, and what is the recommended treatment?

Explanation

The TLICS score is 2: morphology is burst (2 points), neurological status is intact (0 points), and PLC is intact (0 points). A score of 3 or less indicates non-operative management.

Question 71

A 22-year-old female presents after a high-speed motor vehicle collision where she was wearing a lap belt. She sustains a flexion-distraction injury (Chance fracture) at L2. Which of the following associated injuries must be highly suspected and ruled out?

Explanation

Chance fractures (flexion-distraction injuries) in the setting of lap belt use are highly associated with intra-abdominal injuries. Hollow viscus (bowel) injuries occur in up to 50% of these cases.

Question 72

In evaluating a patient with severe craniocervical trauma, the Powers ratio is calculated to assess for atlanto-occipital dissociation. Which of the following defines a normal Powers ratio?

Explanation

The Powers ratio is the distance from the basion to the posterior arch of C1 divided by the distance from the opisthion to the anterior arch of C1. A normal ratio is less than 1; a ratio greater than 1 indicates anterior atlanto-occipital dissociation.

Question 73

A 14-year-old gymnast presents with persistent low back pain exacerbated by extension. Oblique radiographs of the lumbar spine demonstrate a "Scotty dog" with a collar. Which of the following anatomical structures corresponds to the "neck" of the Scotty dog?

Explanation

On an oblique radiograph of the lumbar spine, the pars interarticularis forms the neck of the "Scotty dog." A break in the neck (collar) indicates a pars defect or spondylolysis.

Question 74

A 45-year-old male presents with severe lower back pain, bilateral sciatica, and saddle anesthesia. Bladder ultrasound reveals a high post-void residual (PVR) volume. What PVR volume is highly sensitive for diagnosing urinary retention associated with cauda equina syndrome?

Explanation

A post-void residual (PVR) volume greater than 500 mL indicates significant urinary retention. It is highly sensitive for cauda equina syndrome in the context of saddle anesthesia and sciatica.

Question 75

A 38-year-old man develops acute right-sided leg pain radiating down the posterior thigh and calf to the lateral border of his foot. He has a diminished Achilles tendon reflex and weakness in ankle plantar flexion. Which nerve root is most likely compressed?

Explanation

Compression of the S1 nerve root classically presents with pain radiating to the lateral foot, weakness in ankle plantar flexion, and a diminished or absent Achilles reflex.

Question 76

A 60-year-old diabetic patient presents with fever, severe back pain, and progressive paraparesis. MRI confirms a spinal epidural abscess. What is the most common causative organism?

Explanation

Staphylococcus aureus is the most common organism responsible for spinal epidural abscesses. It accounts for up to two-thirds of all cases, particularly in diabetic patients and intravenous drug users.

Question 77

A patient sustains an axial load injury resulting in a burst fracture of the C1 ring (Jefferson fracture). Which of the following radiographic measurements on an open-mouth odontoid view suggests rupture of the transverse atlantal ligament?

Explanation

According to the Rule of Spence, if the sum of the overhang of the C1 lateral masses on C2 is greater than 6.9 mm on an open-mouth view, the transverse ligament is likely ruptured.

Question 78

A 5-year-old child presents after a minor fall. Lateral cervical spine radiographs show 3 mm of anterior displacement of C2 on C3. Which of the following radiographic lines is most useful to differentiate physiological pseudosubluxation from true injury?

Explanation

The Swischuk line connects the anterior cortices of the posterior arches of C1 and C3. If the anterior cortex of the C2 posterior arch lies within 1.5 mm of this line, it is considered physiological pseudosubluxation.

Question 79

A patient sustains a traumatic spondylolisthesis of the axis (Hangman's fracture) resulting from combined flexion and compression. Radiographs show severe displacement and angulation with unilateral facet dislocation. According to Levine and Edwards, what type of fracture is this?

Explanation

A Levine-Edwards Type III fracture involves a bipedicle fracture of C2 with unilateral or bilateral facet dislocation of C2 on C3. It is caused by a flexion and compression mechanism.

Question 80

A 50-year-old intravenous drug user presents with chronic back pain and low-grade fevers. MRI shows T1 hypointensity and T2 hyperintensity in the L3 and L4 vertebral bodies with involvement of the intervening disc space. Which of the following is the best initial step for definitive diagnosis?

Explanation

CT-guided needle biopsy is the most appropriate initial step to obtain a definitive microbiological diagnosis. This should be performed before initiating targeted antibiotic therapy in suspected pyogenic spondylodiscitis.

Question 81

A 40-year-old male is placed in a halo vest for a cervical spine fracture. He subsequently reports difficulty opening his eyes and lateral gaze diplopia. Which cranial nerve has been injured, likely due to improper pin placement?

Explanation

The abducens nerve (Cranial nerve VI) is the most commonly injured cranial nerve in halo traction or vest placement. This leads to a lateral rectus palsy and lateral gaze diplopia.

Question 82

A patient complains of anterior thigh pain and weakness in knee extension. Examination reveals a diminished patellar reflex and sensory loss over the medial aspect of the lower leg. Which nerve root is most likely involved?

Explanation

L4 radiculopathy classically involves weakness in knee extension, a diminished patellar reflex, and sensory loss over the medial aspect of the lower leg.

Question 83

During a thoracoabdominal aortic aneurysm repair, the artery of Adamkiewicz is inadvertently ligated. The patient develops paraplegia and loss of pain and temperature sensation, but proprioception and vibratory sense are preserved. What region of the spinal cord is primarily affected?

Explanation

The artery of Adamkiewicz supplies the anterior two-thirds of the spinal cord. Infarction causes anterior cord syndrome, preserving the dorsally located proprioception and vibration pathways.

Question 84

Which of the following patient profiles is most strongly associated with the development of degenerative lumbar spondylolisthesis?

Explanation

Degenerative lumbar spondylolisthesis occurs most frequently at the L4-L5 level. It is classically seen in females over the age of 50, particularly those with more sagittally oriented facet joints.

Question 85

A 28-year-old male sustains a stab wound to the right side of his neck at the C5 level, resulting in a spinal cord hemisection. Which of the following neurological deficits is expected below the level of the lesion?

Explanation

Brown-Sequard syndrome presents with ipsilateral loss of motor function and proprioception, and contralateral loss of pain and temperature. This occurs because the spinothalamic tract crosses near the cord entry level.

Question 86

During an anterior cervical discectomy and fusion, a surgeon considers using recombinant human bone morphogenetic protein-2 (rhBMP-2). Which of the following is a recognized complication specifically associated with the anterior cervical use of rhBMP-2, leading to an FDA warning?

Explanation

The FDA issued a black box warning regarding the use of rhBMP-2 in the anterior cervical spine. It has been associated with life-threatening complications, including massive prevertebral soft tissue swelling, dysphagia, and airway compromise.

Orthopedic Prometric MCQs - Chapter 3 Part 1

Orthopedic Prometric MCQs - Chapter 3 Part 36

Orthopedic Prometric MCQs - Chapter 3 Part 36

Chapter Index