Multiple Choice Questions

Spine

Please use the comments section at the bottom of the page if you have any query or feedback about any of the questions.

 

69. What percentage of women with osteoporotic fractures develop kyphosis:

A) 10%
B) 15%
C) 25%
D) 30%
E) 60%

Correct Answer: B

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.

Author: Rajesh Bahadur Lakhey

 

68. In kyphosis , Magnetic resonance imaging (MRI) is appropriate in which of the following circumstances:

A) Malignancy is suspected as a cause of kyphosis
B) Neurologic deficit is suspected as a result of kyphosis
C) Patient with congenital kyphosis
D) Patient with back pain and a history of osteoporosis
E) All of the above

Correct Answer: E

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.

Author: Rajesh Bahadur Lakhey

 

67. 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 (CT) imaging. The patient sustained significant gastrointestinal trauma as a result of the bullet traversing his body. 

Management should consist of:

A) Administration of a broad-spectrum antibiotic for 14 days
B) Removal of the bullet fragment at L4
C) Continued serial neurologic examinations
D) Intravenous administration of dexamethasone for 24 hours
E) A, B, and C

Correct Answer: E

Because the bullet entered the patient’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

Author: Rajesh Bahadur Lakhey

 

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

A) Twenty-five percent of patients with complete lesions recover one motor level after 1 year.
B) Thirty-three percent of patients with incomplete lesions usually have a partial or complete recovery after 1 year.
C) Complete lesions occur in more than 50% of all gunshot wounds to the spine.
D) 75% of patients in whom the bullet has passed through the spinal canal will experience a complete lesion.
E) All of the above

Correct Answer: E

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

Author: Rajesh Bahadur Lakhey

 

65. Which of the following statements regarding diskitis is correct:

A) Signs and symptoms of diskitis generally progress rapidly.
B) Intravenous drug use and immunocompromise are not generally considered risk factors for diskitis.
C) Diskitis commonly occurs in the thoracic region of the spine.
D) Blood cultures are generally positive in up to 70% of patients with diskitis.
E) All of the above

Correct Answer: D

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.

Author: Rajesh Bahadur Lakhey

 

64. Which of the following statements is true regarding minimally invasive posterior lumbar interbody fusion:

A) Minimally invasive fusion may only be safely performed with the assistance of endoscopy.
B) Minimally invasive fusion has increased risk of nerve root injury.
C) Internal fixation with pedicle screws is not possible via the minimally invasive approach.
D) Intraoperative fluoroscopy if of great value in minimally invasive fusion.

Correct Answer: D

Intraoperative fluoroscopy or radiography is vital for the proper identification of lumbar level and vertebral structures in minimally invasive posterior lumbar interbody fusions. While endoscopic assistance has been well described as a
method of minimally invasive fusion, it is not vital to this technique. 

There is no evidence of increased risk of nerve root injury with minimally invasive techniques, and it is possible to internally fixate the lumbar segment with pedicle screws through minimally invasive techniques.

Author: Rajesh Bahadur Lakhey

 

63. Pain is the most common complaint in patients presenting with a primary spine tumor and is present in which percentage of patients:

A) 55%
B) 65%
C) 75%
D) 85%
E) 95%

Correct Answer: D

Pain is the most common complaint in patients presenting with a primary spine tumor
A. Present in up to 85% of patients
B. Typically localized to the site of lesion but can be radicular
C. Characterized as:
     1. Progressive
     2. Gradual in onset
     3. Worse at night
     4. Non-mechanical
D. Loosely associated with trauma
Weakness can be seen in up to 42% of patients
Mass is evident in up to 16% of patients
Three percent of patients are asymptomatic
Other symptoms can include:
E. Sensory loss
F. Loss of sphincter control

Author: Rajesh Bahadur Lakhey

 

62. What percentage of osteoblastomas occur in the spine:

A) 20% to 30%
B) 30% to 40%
C) 40% to 50%
D) 50% to 60%
E) 60% to 70%

Correct Answer: C

Osteoblastomas are:
* Osteoblastic bone-forming lesions measuring more than 2 cm in size characterized by marked growth
potential
* Similar in histology and presentation to osteoid osteoma with the main difference being the size of the tumor
* Most common in the 2nd and 3rd decades of life
* Twice as common in men than in women
* Common in the spine:
* Spinal osteoblastomas account for 40% to 45% of all osteoblastomas
o Over half of spinal osteoblastomas occur in the lumbar spine

Author: Rajesh Bahadur Lakhey

 

61. To avoid damages to the vertebral arteries when exposing the posterior aspect of the first cervical vertebra, dissection should be limited to ______ mm from the midline on the superior aspect of C1 and _____ mm from the midline on the posterior aspect of C1.

A) 8 mm; 12 mm
B) 10 mm; 14 mm
C) 12 mm; 16 mm
D) 14 mm; 20 mm
E) 16 mm; 22 mm

Correct Answer: A

One must be careful not to damage the vertebral artery when exposing the posterior and superior aspect of the
C1 vertebra. It is especially important when using a Cobb elevator or an electrocautery not to dissect too far
from the midline.
The vertebral artery lies close to the midline. On the superior aspect, the groove for the vertebral artery lies
8 mm to12 mm from the midline. On the posterior aspect of the vertebral body, the vertebral artery lies
12 mm to 23 mm from the midline.

Author: Rajesh Bahadur Lakhey

 

60. Which of the following is the most common presentation of vertebral osteomyelitis:

A) Fever of unknown origin
B) Lower extremity pain and weakness
C) Unrelenting back pain not relieved by rest
D) Urinary incontinence
E) None of the above. It is usually an incidental finding during an unrelated work-up.

Correct Answer: C

The most common presenting sign of vertebral osteomyelitis is back pain and malaise, often of 3 months’ duration or
greater. It is often well localized to the affected level and the nature is not unlike most degenerative spinal conditions.
A high index of suspicion is essential to make a timely diagnosis. Back pain that awakens a patient at night is a
hallmark of infection or tumor. Pain associated with infection tends to be relentless and not related to activity level.
Most patients have percussion tenderness over the involved segments. Fevers are noted in fewer than half of patients.

Author: Rajesh Bahadur Lakhey

 

59. Which of the following methods is the standard in diagnosing vertebral metastatic disease:

A) Plain radiography demonstrating lytic lesion
B) Computed tomography with bony destruction respecting adjacent vertebral levels
C) Magnetic resonance imaging with typical destructive lesion characteristics
D) Tissue biopsy
E) There is no standard of care in diagnosing vertebral metastasis.

Correct Answer: D

The only definitive method of determining the presence and nature of metastatic tumor is vertebral biopsy. Computed
tomography-guided biopsy of the spine provides an accurate access to the lesion. Open biopsy is indicated when
image guided biopsy is not feasible or non-diagnostic. 

Differential diagnosis mainly involves spinal infections, osteoporosis, disk disease, and multiple myeloma.

Author: Rajesh Bahadur Lakhey

 

58. Which of the following statements is true regarding lumbar degenerative scoliosis:

A) Lumbar degenerative scoliosis is most commonly distributed to the left.
B) Lumbar degenerative scoliosis is most commonly distributed to the right.
C) Lumbar degenerative scoliosis is most commonly evenly distributed between left and right.
D) The distribution of lumbar degenerative scoliosis depends on age of patient at the time of onset.
E) No data are available.

Correct Answer: C

Degenerative lumbar scoliosis occurs in approximately the same number of women as men. Lumbar curves are
generally smaller than those in idiopathic scoliosis and are more evenly distributed between left and right, also in contrast to idiopathic curves that occur predominantly to the left.

Author: Rajesh Bahadur Lakhey

 

57. Initial nonoperative management of adult degenerative spondylolisthesis includes all of the following except:

A) Physical therapy
B) Anti-inflammatory medication
C) Modified activity
D) Strict bed rest
E) Support brace

Correct Answer: D

Conservative treatment for degenerative spondylolisthesis is consistent with the conservative care of most
degenerative spinal disorders. It includes modified activity, physical therapy (conditioning exercises emphasizing
lumbar flexion and progression to aerobic conditioning), anti-inflammatory medication, and sometimes spinal support
with a corset or light-weight brace.

Author: Rajesh Bahadur Lakhey

 

56. Which of the following is the most common presentation of degenerative spondylolisthesis in an adult patient:

A) Acute onset paraparesis
B) Bowel and bladder dysfunction
C) Severe shooting lower extremity pain
D) Low back pain usually of chronic duration
E) These patients are usually asymptomatic

Correct Answer: D

Adult patients with degenerative spondylolisthesis most commonly complaint of mechanical pain due to repetitive
motion at degenerated intervertebral and facet joints. Patients present with a history of low back pain that may or may not radiate to the buttocks. Symptoms are usually alleviated by sitting.

Author: Rajesh Bahadur Lakhey

 

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

A) A complete history, physical examination, and follow-up imaging studies only if indicated
B) A complete history, physical examination, and plain radiographs
C) A magnetic resonance imaging study of the lumbar spine
D) A computed tomography of the lumbar spine
E) No evaluation is needed on initial visit as most low back pain resolves spontaneously

Correct Answer: A

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 Care Policy and Research Clinical 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

Author: Rajesh Bahadur Lakhey

 

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

A) The natural history of a herniated lumbar disk is usually consistent with approximately 90% spontaneous resolution without intervention by 3 months’ follow-up.
B) Surgical intervention is often required for definitive and long-term treatment.
C) Despite aggressive surgical correction, permanent neurological deficits are common.
D) Surgical diskectomy is a contraindication in patients with neurologic deficit.
E) The natural history of lumbar disk herniations has not been studied.

Correct Answer: A

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.

Author: Rajesh Bahadur Lakhey

 

53. A posterolateral L4-L5 herniated nucleus pulposus can lead to radiculopathy at which level of the affected side:

A) L3
B) L4
C) L5
D) S1
E) All of the above

Correct Answer: C

A posterolateral herniated nucleus pulposus can lead to compression of the traversing nerve, which is heading for the
foramen of the subadjacent vertebral body.

Author: Rajesh Bahadur Lakhey

 

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

A) Traumatic injury treated with steroids
B) Ischemic injury treated by medical management
C) Chronic metabolic treated by correcting the underlying cause
D) Compressive lesion treated by surgical decompression
E) Idiopathic, no treatment is needed

Correct Answer: D

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.

Author: Rajesh Bahadur Lakhey

 

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

A) A sharp laceration injury
B) A blunt laceration injury
C) Contusion and stretch injuries
D) A proximal root avulsion
E) Traumatic peripheral nerve injuries occur with approximately the same frequency.

Correct Answer: C

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 injuriesn usually result from extreme movements of the limbs, most commonly the shoulder joint with involvement of the brachial plexus.

Author: Rajesh Bahadur Lakhey

 

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

A) Surgical excision
B) Radiation therapy
C) Chemotherapy
D) Surgical excision followed by a combination of chemotherapy and radiation therapy.
E) Neither a single treatment modality nor a combination of treatment modalities has proven effective in significantly improving mortality

Correct Answer: E

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

Author: Rajesh Bahadur Lakhey

 

49. A 70-year-old man complains of severe, burning pain in both calves after he ambulates approximately one block. He denies significant back pain. He has long-standing, insulin-dependent diabetes mellitus and a history of coronary artery disease. The patient has smoked two packs of cigarettes each day for more than 30 years. The patient is diagnosed with neurogenic claudication. 

What is the most likely source of his symptoms:

A) Herniated lumbar disk
B) Isthmic spondylolisthesis
C) Degenerative spinal stenosis at L3-L4
D) Degenerative spinal stenosis at L4-L5
E) Metastatic tumor

Correct Answer: D

The most common cause of neurogenic claudication in this patient is degenerative stenosis. L4-L5 is the most
commonly affected level. Herniated lumbar disk is less likely. Although a metastatic tumor is possible, especially
in light of the patient’s smoking history, the absence of back pain makes this unlikely.

Author: Rajesh Bahadur Lakhey

 

48. Canal compromise in burst fractures (Slide) is caused by:

A) Lamina fracture and anterior migration
B) Migration of the posteroinferior vertebral body
C) Retropulsion of the posterosuperior vertebral body
D) Narrowing of the interpedicular distance
E) Herniated disk material

Correct Answer: C

An essential component of burst fractures, as described first by Denis, is the involvement of the middle column.
Typically, the posterosuperior vertebral body is separated from the remainder of the body and encroaches into the spinal canal, causing damage to the neural elements. No other part of the middle column is a standard component of
the injury.

Author: Rajesh Bahadur Lakhey

 

47. When evaluating thoracolumbar burst fractures, it is important to remember that the spinal cord ends in the conus
medullaris, which typically is present at what level :

A) T12
B) L1
C) L2
D) L3
E) L4

Correct Answer: B

While the conus medullaris can end anywhere from T12 to L3, in the majority of patients it is present at the L1 level.
Injury at this level is much different from injury to the spinal cord or the cauda equina

Author: Rajesh Bahadur Lakhey

 

46. In this slide of a lumbar burst fracture, which column is disrupted to distinguish it from a compression fracture:

A) Anterior
B) Lateral
C) Posterior
D) Middle
E) Medial

Correct Answer: D

Denis was the first surgeon to include the middle column in his description of thoracolumbar fractures and to
accentuate its importance in fracture stability. The defining characteristic of a burst fracture is disruption of the middle column, which distinguishes these fractures from compression fractures. Involvement of the middle column indicates an unstable fracture pattern.

Author: Rajesh Bahadur Lakhey

 

45. The axial computed tomography scan depicts a patient with spinal stenosis (Slide). The primary source of neural compression is impingement on the traversing nerve root by the:

A) Superior facet of the level below
B) Inferior facet of the level above
C) Redundant ligamentum flavum
D) Overgrown medial pedicle
E) Herniated nucleus pulposus

Correct Answer: A

Spinal stenosis involves narrowing of the spinal canal by a combination of factors. Degeneration of the disk with
dehydration allows loss of disk height and bulging posteriorly into the canal. The ligamentum flavum becomes
redundant at the segment due to loss of the disk height and buckling of the ligament. Chief among the sources of
compression, however, is the overgrowth of the facet joint, which acts to autostabilize the motion segment. The facets
are oriented in an oblique plane, depending on the level involved. 

The superior facet of the subjacent vertebral body lies anterior and lateral to its counterpart from the level above, forming a shingle configuration. The superior articular process, therefore, lies adjacent to the shoulder of the traversing nerve root and is a significant source of lateral recess stenosis.

Author: Rajesh Bahadur Lakhey

 

44. A 45-year-old woman has pain in her right upper extremity and neck. The sagittal T2-weighted magnetic resonance
image is presented (Slide 1) as well as an axial image (Slide 2). Her pain has not responded to nonsteroidal antiinflammatory drugs or physical therapy.

 Which of the following is the most appropriate treatment:

A) Needle aspiration of the C4-C5 intervertebral space
B) 6-week course of antibiotics and bracing
C) Needle biopsy of C4 or C5
D) Mammography and technetium bone scan
E) Anterior cervical diskectomy

Correct Answer: E

The axial magnetic resonance scan shows a disk herniation, and the sagittal view shows prominent osteophytes.
There is no evidence of an infection or a neoplasm. This patient is a candidate for anterior disckectomy and fusion.

Author: Rajesh Bahadur Lakhey

 

43. A 40-year-old woman has severe neck pain following a motor vehicle accident. Her plain lateral radiograph of the spine is shown (Slide). A sagittal magnetic resonance scan is shown (Slide). 

The most likely diagnosis is:

A) Pseudosubluxation of C5 on C6
B) Compression fracture of C5
C) Unilateral facet dislocation
D) Bilateral facet dislocation
E) Degenerative sponylolisthesis C5 on C6

Correct Answer: D

There is significant subluxation of C5 on C6 on the plain radiograph. The facets of C5 and C6 have lost their normal
relationship. This patient has a bilateral facet dislocation. There is compression and significant changes within the
spinal cord. This patient should be treated with reduction and fusion.

Author: Rajesh Bahadur Lakhey

 

42. A 35-year-old man has neck pain following a motor vehicle accident. His axial computed tomography scan is shown
(Slide). 

The most appropriate treatment would be:

A) Observation
B) Neck collar and physical therapy
C) Reduction and collar immobilization
D) Reduction and halo vest immobilization
E) Reduction and fusion

Correct Answer: E

The axial computed tomography scan of C4-C5 shows a unilateral facet dislocation. The superior facet of C5 lies
posterior to the inferior facet of C4. This relationship should be the exact opposite. Also, notice that C4 is rotated on
the body of C5 and translated forward.
Unilateral facet dislocation must be reduced and treated with fusion. This is a ligamentous injury that does not heal
properly following reduction and immobilization.

Author: Rajesh Bahadur Lakhey

 

41. If the peroneus longus and peroneus brevis muscles are weak in a patient who has radicular back pain, then which of the following nerve roots is compressed:

A) L3
B) L4
C) L5
D) S1
E) S2

Correct Answer: D

The peroneus brevis and peroneus longus muscles are principally innervated by the S1 nerve root through the
superficial peroneal nerve. Although the nerve is principally innervated by the S1 nerve root, the superficial peroneal
nerve is derived from the L5, S1, and S2 nerve roots.
The muscles principally innervated by the S1 nerve root are the:
* Peroneus longus and peroneus brevis
* Gastrocnemius-soleus complex
* Gluteus maximus

Author: Rajesh Bahadur Lakhey

 

40. If the extensor digitorum longus and extensor digitorum brevis muscles are weak in a patient who has radicular back pain, then which of the following lumbosacral nerve roots is compressed:

A) L1
B) L2
C) L3
D) L4
E) L5

Correct Answer: E

The extensor hallucis longus muscle is primarily innervated by the L5 lumbosacral nerve root.
The L5 lumbosacral nerve root innervates the following muscles:
* Extensor hallucis longus
* Extensor digitorum longus and extensor digitorum brevis
* Gluteus medius

Author: Rajesh Bahadur Lakhey

 

39. A patient with a herniated disk has a diminished patellar tendon reflex. Which of the following lumbosacral nerve roots is affected:

A) L1
B) L2
C) L3
D) L4
E) L5

Correct Answer: D

The patellar tendon reflex is primarily transmitted through the L4 lumbosacral nerve root. Although the L4 lumbosacral nerve root is the primary transmitter, the L2 and L3 lumbosacral nerve roots also contribute to the fibers. A weak reflex is present if the L4 lumbosacral nerve root is completely cut and fibers of the L2 and L3 lumbosacral nerve roots are still present. The patellar tendon reflex is seldom completely absent unless a patient has primary muscle or anterior
horn lesions.

Author: Rajesh Bahadur Lakhey

 

38. Which of the following is not a risk factor for degenerative spondylolisthesis:

A) Female gender
B) Diabetes
C) Oophorectomy
D) Lumbarization of the S1 vertebrae
E) Age older than 60 years

Correct Answer: D

Degenerative spondylolisthesis is present in approximately 10% of women older than 60 years of age. This condition is present more frequently in women, patients with an L4-5 or L3-4 level, patients with diabetes, and patients who have undergone oophorectomy.

Author: Rajesh Bahadur Lakhey

 

37. In the face of vertebral infection and progressive deformity, surgical reconstruction should:

A) Never use instrumentation
B) Never use allograft bone
C) Always be approached posteriorly
D) Always involve an aggressive debridement
E) Always follow extensive antibiotic treatment until the infection is eradicated

Correct Answer: D

Surgical reconstruction in the face of spinal infection may be indicated should progressive neurological deficit or
deformity occur. Such reconstruction may be successful if an aggressive debridement of all infectious foci is done,
even if instrumentation or allograft is used. The optimal approach is dictated by the location of the infection and the
type and degree of deformity (and is often anterior or anterior-posterior).

Author: Rajesh Bahadur Lakhey

 

36. Which of the following is more characteristic of tuberculoid rather than pyogenic spinal infection:

A) Bony destruction on plain radiography
B) Elevated erythrocyte sedimentation rate
C) Prolonged onset of mild back pain despite extensive destruction seen on radiograph
D) High fevers, weight loss, and night pain
E) Predilection for the cervical spine

Correct Answer: C

Spinal tuberculosis typically follows an indolent course early on despite radioqraphic findings out of proportion to the
exam. Pyogenic and tuberculoid spinal infections involve the thoracic spine more commonly than the cervical spine.
Both spinal infections may result in bony destruction, elevated erythrocyte sedimentation rates, and may or may not
present with constitutional symptoms.

Author: Rajesh Bahadur Lakhey

 

35. Which of the following is not a surgical indication in the treatment of spinal column infection:

A) Persistent back pain and elevated carbonreactive protein despite 8 weeks of intravenous antibiotics and bracing
B) Progressive neurological deficit and magnetic resonance image evidence of epidural abscess
C) Progressive kyphotic collapse
D) Development of sepsis
E) Extension of infection into the disk space

Correct Answer: E

Uncomplicated spinal osteomyelitis and diskitis are treated nonoperatively. Operative debridement, decompression,
and stabilization may be useful in cases of abscess, sepsis, neurological deficit, and progressive deformity.

Author: Rajesh Bahadur Lakhey

 

34. The most common site of a thoracic disk herniation requiring surgery is from levels:

A) T1-T4
B) T4-T7
C) T8-T11
D) T11-T12
E) T12-L1

Correct Answer: C

T8-T11 is the most common site of disk herniation that requires surgery. A review of 71 patients with 82 thoracic disk
herniations undergoing surgery found that 66% of disks were between T8-T11. The most common disk level was T9-
T10, which represented 26% of the herniations.

Author: Rajesh Bahadur Lakhey

 

33. A 48-year-old man presents with acute onset of unilateral, anterior band-like chest pain after lifting heavy machinery
at work. The history and physical examination and the magnetic resonance image confirm a T9-T10 thoracic disk herniation. The best initial treatment for this patient is:

A) Bed rest and traction for 6 weeks
B) Costotransversectomy to remove the T9-T10 disk herniation
C) Activity modification and physical therapy
D) Transthoracic decompression of the disk
E) Laminectomy and decompression of the disk

Correct Answer: C

Brown et al retrospectively reviewed the natural history of symptomatic thoracic disk herniations and found 77% of
patients did well with nonsurgical management. The patients returned to their previous level of activity following activity modification and physical therapy.

Author: Rajesh Bahadur Lakhey

 

32. Surgical treatment of thoracic disk herniation by a laminectomy is contraindicated because this procedure is associated with which of the following:

A) Incomplete relief of symptoms
B) High incidence of neurologic damage
C) Destabilization of the spine
D) High incidence of recurrence
E) High incidence of post-laminectomy kyphosis

Correct Answer: B

There is a high incidence of spinal cord injury associated with thoracic disks removed by laminectomy. The advent of
alternative procedures, such as costotransversectomy and transthoracic decompression, has led to a decrease in
spinal cord injury admissions. Also, patients who do not improve after laminectomy are less likely to be helped by later
anterior decompression.

Author: Rajesh Bahadur Lakhey

 

31. When considering surgical intervention in the management of low back pain, it is crucial to try and identify the possible offending agent or pain generator. Based on awake anatomical stimulation studies, what percentage of patients should report significant discomfort when a nerve root is either compressed or stretched in an attempt to elicit pain:

A) 99%
B) 60%
C) 40%
D) 20%
E) 1%

Correct Answer: A

Studies have reported on diskectomies in awake patients performed under local anesthesia. Anatomic spinal structures were stimulated prior to additional local anesthesia placed into these deeper areas and patients were asked to report any pain. Compression or stretching of nerve roots caused significant pain 100% of the time. Stimulation of the posterior dura caused significant pain only 1% of the time

Author: Rajesh Bahadur Lakhey

 

30. A 35-year-old woman has been complaining of severe unrelenting mid to low back pain for the past 5 months. Conservative management, consisting of bed rest and nonsteroidal anti-inflammatory drugs (NSAIDs), has not decreased the intensity of her symptoms. She immigrated to the United States from Vietnam 6 months ago. Based on the sagittal magnetic resonance image below .

The next step in her management is:

A) Antibiotics with gram-positive coverage
B) Surgical decompression and reconstruction
C) Biopsy of the lesion to obtain a specimen for pathology
D) Continued conservative management and observation
E) Physical therapy for low back strengthening

Correct Answer: C

It is prudent to determine the underlying etiology of this lesion. Tuberculous spondylitis is increasing in frequency and
must be suspected in people who emigrate from countries where tuberculosis is endemic. A biopsy of the region must
be obtained in order to make the diagnosis of tuberculosis accurately or any other infectious and noninfectious
causative agent in order to determine proper management.

Author: Rajesh Bahadur Lakhey

 

29. An 11-year-old boy sustains a fall while jumping on a trampoline. He has moderate back pain, an L-5 radiculopathy, and weakness of the right extensor hallucis longus. Radiographs and a computerized tomography scan of the lumbar spine demonstrate a slipped vertebral apophysis. 

The recommended treatment is:

A) Laminectomy and excision of annulus and vertebral bony margin
B) Bed rest
C) Thoracolumbosacral orthosis
D) Physical therapy
E) Spinal traction

Correct Answer: A

This patient has a slipped vertebral apophysis as a result of trauma. This is analagous to a SalterHarris type II fracture. A portion of the apophysis and annulus slip posteriorly and may impinge on the exiting nerve root. These usually do not resolve spontaneously or improve with conservative therapy, and excision is indicated. The disk fragments and retropulsed bone must be removed from the canal with a laminectomy for exposure.

Author: Rajesh Bahadur Lakhey

 

28. A 12-year-old girl presents to the clinic with scoliosis detected by school screening. Her past medical history includes ophthalmologic observation for Lisch nodules of the iris. She has just started her menstrual periods. On physical exam, she has axillary freckles and normal neurological function. Standing radiographs of the spine illustrate a 32° right thoracic curve from T4 to T10 and rib pencilling. In the sagittal plane, she has a thoracic kyphosis of 30°. 

The most likely diagnosis is:

A) Adolescent idiopathic scoliosis
B) Congenital kyphoscoliosis
C) Neurofibromatosis-1 (NF-1)
D) Neurofibromatosis-2 (NF-2)
E) Stickler disease

Correct Answer: C

Neurofibromatosis (von Recklinghausen disease) is an autosomal dominant disorder that affects connective
tissue. The most common type is NF-1, and is associated with primary skeletal disorders such as scoliosis,
cortical thinning and pseudarthrosis of the tibia. It is the result of an abnormality on chromosome 17, and is also
associated with:
* Café au lait spots
* Neurofibromas
* Axillary or inguinal freckling
* Iris hamartomata (Lisch nodules)
Scoliosis in NF-1 can occur in 2 patterns. The first is similar to idiopathic scoliosis. The second, or dystrophic
type is marked by short, sharper deformities, scalloping of the vertebral bodies, rib pencilling, enlarged foramina
and severe apical vertebral body rotation. Some authors have demonstrated that curves characterized as
idiopathic in childhood can take on dystrophic characteristics later in life and progress rapidly. Treatment is
usually surgical.

Author: Rajesh Bahadur Lakhey

 

27. During posterior cervical plating, several techniques can be employed. 

The recommended lateral mass screw position is:

A) 10° laterally, 90° perpendicular to the lateral mass
B) 50° cephalad and 30° laterally
C) 30° laterally and 15° cephalad
D) 15° laterally and 30° cephalad
E) 60° laterally and 30° medially

Correct Answer: C

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.

Author: Rajesh Bahadur Lakhey

 

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

A) Soft collar immobilization
B) Hard Philadelphia cervical orthosis
C) Halo vest immobilization
D) Open reduction and operative posterior stabilization
E) Gardner-Wells tongs application and awake reduction, then posterior stabilization

Correct Answer: D

The Levine classification of traumatic spondylolisthesis or Hangman fractures involving C2 in the type 3 injury has a combined bilateral facet dislocation at C2-C3 as well as the traumatic spondylolisthesis of the axis. Closed reduction could not be performed secondary to the traumatic spondylolisthesis at the C2 isthmus.

Author: Rajesh Bahadur Lakhey

 

25. With a right-sided anterior cervical spine approach, the structure at increased risk is the:

A) Recurrent laryngeal nerve
B) Superior laryngeal nerve
C) Hypoglossal nerve
D) Thoracic duct
E) Esophagus

Correct Answer: A

The left recurrent laryngeal nerve enters the thorax within the carotid sheath before looping around the aortic arch and ascending into the neck between the trachea and the esophagus. On the right side, the nerve exits the carotid sheath at a higher level, making the nerve susceptible to injury during the surgical dissection.

Author: Rajesh Bahadur Lakhey

 

24. A useful test to differentiate cervical radiculopathy from diabetic peripheral neuropathy is:

A) Hemoglobin A1C
B) Magnetic resonance imaging
C) Computerized tomography-myelogram
D) Electrodiagnostic testing
E) Cervical flexion/extension roentgenograms

Correct Answer: D

An electromyogram detects motor changes as a result of nerve compression. It can be used to
differentiate cervical radiculopathy from peripheral neuropathy.

Author: Rajesh Bahadur Lakhey

 

23. The most accurate way to monitor the motor tracts during spinal surgery is to stimulate which of the following regions:

A) Tibial nerve
B) Peroneal nerve
C) Motor cortex
D) Gastrocnemius
E) Proximal spinal cord

Correct Answer: C

The most accurate way to monitor the motor tracts of the spinal cord is to stimulate the motor cortex. Stimulation at the level of the spinal cord conducts mainly antidromically through sensory pathways. Stimulation of the tibial and peroneal nerve is performed for monitoring sensory pathways only; these are an important indicator of spinal cord integrity but do not monitor the motor pathways per se. Stimulation of the gastrocnemius does not have any value for monitoring.

Author: Fouad Chaudery


22. Which part of the body is removed last in a posterior vertebral column resected via a posterior approach:

A) The lamina 
B) The pedicles
C) The anterior wall of the vertebral body
D) The posterior vertebral cortex 
E) The transverse process

Correct Answer: D

To protect and stabilize the neural elements, the posterior vertebral cortex is left intact to be resected last.

Author: Fouad Chaudery

 

21. Which of the following conditions does not have a risk of cervical deformity greater than the general population

A) Neurofibromatosis
B) Larsen syndrome
C) Diastrophic dysplasia
D) Achondroplas
E) Down syndrome

Correct Answer: D

Achondroplasia is associated with frequent stenosis of the foramen magnum in infancy, as well as lower cervical stenosis. However, it is not associated with an actual deformity of the cervical spine. By contrast, neurofibromatosis, Larsen syndrome, and diastrophic dysplasia are associated with infantile cervical kyphosis. Down syndrome is associated with the risk of upper cervical instability.

Author: Fouad Chaudery

 

20. According to National Institutes of Health (NIH) criteria, what is the minimum number of 15-mm café-au-lait macules required as a diagnostic criterion for neurofibromatosis in postpubertal patients:

An Update on Neurofibromatosis Type 1: Not Just Café-au-Lait Spots,  Freckling, and Neurofibromas. An Update. Part I. Dermatological Clinical  Criteria Diagnostic of the Disease | Actas Dermo-Sifiliográficas

A) One
B) Two 
C) Three
D) Four
E) Six

Correct Answer: E

The NIH criteria require at least six 15-mm café-au-lait macules in postpubertal patients. Café-au-lait macules must be larger than 5 mm in prepubertal patients

Author: Fouad Chaudery

 

19. Which of the following is found less often in children with lumbosacral agenesis as compared to controls:

A) Cervical spine anomalies
B) Maternal diabetes 
C) Hip dislocation 
D) Spina bifida
E) Genu recurvatum

Correct Answer: E

Patients with lumbosacral agenesis often have knee flexion contractures as compared with controls. All of the other features listed are common in patients with lumbosacral agenesis.

Author: Fouad Chaudery

18. Nine days after surgery, a 16-year-old boy with idiopathic scoliosis has a temperature of 39.5° C. Wound aspiration reveals gram-positive cocci in clusters. Your next step in management is:

A) Begin intravenous cephalosporin and monitor the response
B) Begin intravenous vancomycin and monitor the response 
C) Begin hyperbaric oxygen and intravenous antibiotics
D) Open and debride the wound, leaving the instrumentation in place 
E) Open and debride the wound, and remove the instrumentation

Correct Answer: D

Open debridement is the treatment of choice if an early deep wound infection is confirmed after spinal fusion. The instrumentation is left in place to stabilize the wound and promote fusion. The wound is closed as long as it can be cleaned up adequately during surgery, and muscle has a healthy appearance. If this cannot be achieved or if several debridements fail, the wound may be left open

Author: Fouad Chaudery

17. A patient with hemophilia A has a hematoma of the iliopsoas. He has a partial femoral nerve palsy. Treatment involves continuous factor replacement and:

A) Open drainage 
B) Decompression of the fascia over the femoral nerve
C) Percutaneous insertion of a drainage tube
D) Embolization of feeder vessels by interventional radiologist
E) Observation 

Correct Answer: E

The standard treatment of a psoas abscess is continuous factor replacement. Surgery is usually unnecessary, but it may be considered in cases of acute palsy with severe pain unresponsive to medical therapy. A percutaneous drainage tube is not recommended because the hematoma may be difficult to locate or drain.

Author: Fouad Chaudery

16. A patient with L4 level myelomeningocele has developed a full-thickness pressure sore on the heel that has a central necrosis and is draining. While undergoing debridement in the local emergency department, the patient develops labored respiration and a nondetectable blood pressure. The most likely cause is:

A) Latex allergy
B) Aortic dissection 
C) Septic shock
D) Spontaneous tension pneumothorax 
E) Shunt failure

Correct Answer: A

Latex sensitivity is common in patients with spina bifida because of frequent exposure through catherizations and procedures. Latex avoidance is becoming the standard in institutions that commonly treat patients with spina bifida, but community hospitals that rarely see such patients may not always be aware of this problem.

• Dissection is not likely unless the patient has a connective tissue disorder.
• Septic shock is not likely to develop from a freely draining peripheral ulcer.
• Tension pneumothorax is not any more likely in patients with spina bifida than in the general population.
• Although it is important to be aware of shunt failure, it is not likely in this procedure which is done without anesthetic.

Author: Fouad Chaudery

15. A 12-year-old boy with achondroplasia has a gradual 40° thoracolumbar kyphosis. He is unable to walk more than two blocks. Magnetic resonance imaging reveals spinal stenosis, and the patient is scheduled to undergo posterior decompression from T12-S1. In addition to this procedure, you recommend:

A) Observation with serial radiographs every 4 months 
B) Postoperative brace for 6 months
C) In situ fusion with bone graft 
D) Posterior fusion across the kyphosis with instrumentation
E) Anterior corpectomy and fusion of T12

Correct Answer: D

Extensive posterior decompression poses a high risk of postoperative increase in kyphosis because of both the patient’s age and pre-existing kyphosis.

• Observation would not be a good idea because the risk is already known to be high.
• Neither a brace nor an uninstrumented fusion would prevent the deformity from developing.
• Corpectomy is not indicated because the kyphosis is not focal.
• Posterior instrumented fusion at the time of decompression is indicated.

Author: Fouad Chaudery

14. A 12-year-old girl is referred because of a positive school scoliosis screen. She has a curve of 16° from T5 to T12, convex to the right. She also complains of mild back pain over the region of the curve several times per week. Neurologic examination is normal. Recommended treatment includes:

A) Magnetic resonance imaging
B) Technetium bone scintigraphy with SPECT
C) Treatment with a thoracolumbosacral orthosis
D) Computed tomography of the thoracic spine 
E) Home exercises and re-examination in follow-up

Correct Answer: E

Home exercises and re-examination in follow-up is the most appropriate treatment in view of lack of any worrisome features. If this child had severe pain or significant night pain, then further imaging studies would be warranted.

• The magnetic resonance imaging is not indicated in this situation.
• The bone scan has a low likelihood of being positive.
• Bracing is not indicated for the curve or the pain.
• Computer tomography is unlikely to demonstrate any pathology.

Author: Fouad Chaudery

13. A “stinger” (transient weakness of the upper extremity commonly seen after a blow to the head and shoulder in football) most commonly affects the:

A) Spinal cord 
B) C-5/C-6 nerve roots 
C) C-7/C-8 nerve roots 
D) Axillary nerve 
E) Musculocutaneous nerve 

Correct Answer: B

"Stingers" are common in football. They generally result from a transient stretch to the C-5/C-6 nerve roots resulting in temporary loss of strength of the biceps, deltoid, and spinatus muscles. It is generally safe to allow the athlete to return to participation, provided the cervical spine examination is normal and any neurological deficits have completely resolved. 

Author: Fouad Chaudhry

 

 

12. The skin over the umbilicus is innervated by which of the following levels:

A) T2
B) T4
C) T7
D) T10
E) T12

Correct Answer: D

T4

Nipple line

T7

Xiphoid process

T10

Umbilicus

T12

Groin

Author: Fouad Chaudhry

 
 

 

11. The extensor hallucis longus muscle is innervated by which of the following nerve roots:

A) L1
B) L2
C) L3
D) L4
E) L5

Correct Answer: E

Remember that the L5 nerve root innervates the following muscles:
• Extensor hallucis longus
• Extensor digitorum longus and brevis
• Gluteus medius

Author: Fouad Chaudhry

 
 

 

10. The skin of the proximal one-third of the anterior thigh just distal to the inguinal ligament is innervated by which of the following sensory segmental levels: 

A) T12
B) L1
C) L2
D) L3
E) L4

Correct Answer: B

L1

Thigh, proximal third, and anterior

L2

Thigh, middle, and anterior

L3

Thigh, distal third, and anterior

Author: Fouad Chaudhry

 

 

9. The most common location of a chordoma is: 

A) Cervical vertebra
B) Thoracic vertebra
C) Lumbar vertebra
D) Sacrococcygeal region
E) Spheno-occipital region 

Correct Answer: D

Over 50% of the time, chordomas commonly occur in the sacrococcygeal region. Cervical, thoracic, and lumbar vertebral chordomas account for approximately 10% of chordomas. The remaining chordomas occur in the spheno-occipital region.

Author: Fouad Chaudhry

 

8. When harvesting an iliac crest bone graft from the post. approach, what anatomic structure is at greatest risk for injury if a Cobb elevator is directed too caudal?

A) Sciatic nerve
B) Cluneal nerves
C) Inferior gluteal artery
D) Superior gluteal artery
E) Sacroiliac joint

Best answer:  D

If a Cobb elevator is directed caudally while stripping the periosteum over the iliac wing, it will encounter the sciatic notch. Although this puts the sciatic nerve at risk, the fi rst structure encountered is the superior gluteal artery. Because it is tethered at the superior edge of the notch, it is very vulnerable to injury and can then retract inside the pelvis, making it diffi cult to obtain hemostasis. 

The inferior gluteal artery exits the sciatic notch below the piriformis and is more protected. The cluneal nerves are at risk only if the incision extends too anteriorly, and the sacroiliac joint can be entered while harvesting the graft.

Author: Salam Al-Abayachi

 

7. Through a retroperitoneal approach to the L4-5 disk, what structure must be ligated to safely mobilize the common iliac vessels toward the midline laterally and gain exposure?

A) Obturator vein
B) Iliolumbar vein
C) External iliac vein
D) Middle sacral artery
E) Hypogastric artery

Best answer:  B

To mobilize the common iliac vessels across the midline, the iliolumbar vein must be ligated. It has a short trunk and can be torn if mobilization is attempted without ligation. It is the only branch off the common iliac vessels (there are no arterial branches) prior to the terminal branches, and the internal (hypogastric) and external iliac vessels. 

The middle sacral vessels run distally from the axilla of the bifurcation and are a factor when accessing the L5-S1 disk.

Author: Salam Al-Abayachi

 

6. If a surgeon accidentally burrs through the midlateral wall of C5 during a anterior corpectomy, what structure is at greatest risk for injury?

A) C5 root
B) C6 root
C) Internal carotid artery
D) Vertebral artery
E) Vagus nerve

Best answer:  D

The vertebral artery is contained within the vertebral foramen and thus tethered along-side the vertebral body, making it vulnerable to injury if a drill penetrates the lateral wall. 

The C5 root passes over the C5 pedicle and is not in the vicinity. 

The C6 root passes under the C5 pedicle but is posterior to the vertebral artery and is only vulnerable at the very posterior-inferior corner. The carotid artery and the vagus nerve are both within the carotid sheath and well anterior.

Author: Salam Al-Abayachi

 

5. What structure is located at the tip of the arrow in the figure attached?

A) Left L3 nerve root
B) Right L3 nerve root
C) Right L4 segmental artery
D) Right L4 nerve root
E) Left lateral disk herniation

Best answer:  B

Explanation: The structure shown is the exiting nerve root at the L3-4 disk, which is the right L3 root.

Author: Salam Al-Abayachi

 

4. What structure is most at risk for injury from a retractor against the tracheoesophageal junction during an ant. approach to the cervical spine?

A) Esophagus
B) Trachea
C) Superior laryngeal nerve
D) Recurrent laryngeal nerve
E) Sympathetic chain

Best answer:  D

Although any of these structures can be injured by pressure from the medial blade of a self-retaining retractor, the recurrent laryngeal nerve runs cephalad in the interval between the esopha-gus and trachea and is vulnerable to pressure if caught between the retractor and an infl ated endotra-cheal tube balloon.

Author: Salam Al-Abayachi

 

3.  A 55 year old male presented with urinary retention and saddle paraesthesia. His symptoms began 12 hours ago. He has a cardiac pacemaker inserted. Examination revealed reduced anal tone.

What is the next step in management?

A) MRI scan of the lumbar Spine
B) CT myelogram of the lumbar spine
C) Immediate surgical decompression of the cervical spine
D) Physiotherapy, analgesia, and outpatient follow up
E) High dose corticosteroid

Best answer: B

This patient has classic symptoms of cauda equina syndrome. The most important next step is to identify the source of compression in the lumbar spine. The study of choice is an MRI; however in patients who are unable to undergo an MRI such as those with pacemakers, a CT myelogram should be performed.  

Cauda equina syndrome is a complex of low back pain, bilateral or unilateral sciatica, saddle anaesthesia, motor weakness and bowel/bladder dysfunction.

Cauda equina a surgical emergency. Decompression of the lumbar spine should be performed within 48 hours from the onset of symptoms

Ref :Kostuik JP, Harrington I, Alexander D, Rand W, Evans D: Cauda equina syndrome and lumbar disc hemiation. J Bone Joint Surg Am 1986; 68:386-391

Author : Firas Arnaout

 

2.  A 40 years old man is involved in a road traffic accident and sustains neck injury with C4/C5 dislocation. On examination he has loss of motor function on one side and loss of pain and temperature sensation on the contralateral side. 

Which spinal cord syndrome is associated with these findings?

A) Central cord syndrome
B) Anterior cord syndrome
C) Brown-Sequard syndrome
D) Posterior cord syndrome
E) Neurologic shock

Best answer: C

 

Brown-Sequard syndrome is caused by complete cord hemitransection. On examination; patients have loss of motor power, proprioception and vibration sensation on one side. And contralateral loss of pain and temperature sensation. This syndrome has the best prognosis of all spinal cord injuries.

Ref: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 179-187

Author :Firas Arnaout


1.   A 65 years old man presented with bilateral buttocks and legs pain, worse with standing and walking, and better with leaning forword.On examination, he has normal power in his legs, straight leg raising and pedal pulses normal. 

What is this clinical presentation consistent with?

A) Peripheral vascular disease
B) Disc prolapsed
C) Cauda equine syndrome
D) Spinal stenosis
E) Osteomylitis of the spine

Best answer: D

Spinal stenosis is due to narrowing of the spinal canal by either bony or soft tissue structures. Patients present with neurogenic claudication.MRI is the best investigation. 

Treatment is with analgesia and steroid injection, or surgical with decompression. It is important to differentiate between neurogenic and vascular claudication.

Ref: Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Blood E, Hanscom B, Herkowitz H, Cammisa F, Albert T, Boden SD, Hilibrand A, Goldberg H, Berven S, An H; SPORT Investigators. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med. 2008 Feb 21; 358(8):794-810

Author :Firas Arnaout

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