Multiple Choice Questions

Spine

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

 

90. Which of the following is the most important factor responsible for a decreasing proportion of patients with complete
paraplegia after sustaining a spinal cord injury today compared with four decades ago:

A) Improvements in rehabilitative measures
B) Advances in operative techniques and instrumentation
C) New and novel medication therapy
D) Higher patient motivation and participation in therapy and rehabilitation
E) Better initial triage, resuscitation, and clinical management of patients

Correct Answer: E

Improvements in the initial triage, resuscitation, and clinical management of spinal cord– injured patients are likely
responsible for a decreasing proportion of patients with complete paraplegia. 

Currently, approximately 45% of spinal cord–injured patients have a complete injury, as opposed to 70% four decades ago.

Author: Rajesh Bahadur Lakhey

 

89. Based on the three-column model of spinal stability, an unstable spinal injury is defined as:

A) An injury that disrupts no less than all three columns
B) Disruption of any of the three columns is considered unstable
C) Disruption of more than one column
D) Disruption of all three columns plus neurological injury
E) The three-column model of injury is not a reliable marker of instability

Correct Answer: C

The three-column spine consists of the anterior, middle, and posterior columns. 

In this widely used classification system, the middle column is the key to instability. If the middle column is disrupted, in addition to either the anterior or posterior columns, then instability results.

Author: Rajesh Bahadur Lakhey

 

88. Clinical symptoms of lumbar spinal stenosis usually correlate with a canal anteroposterior diameter of less than:

A) 20 mm
B) 15 mm
C) 10 mm
D) 5 mm
E) There is no correlation.

Correct Answer: C

The clinical syndrome of lumbar stenosis correlates with a measured anteroposterior diameter of the dural sac of less
than 10 mm.

Author: Rajesh Bahadur Lakhey

 

87. Compression fractures of the spine secondary to metastatic disease usually first affect which component of the nervous system :

A) Balance
B) Bowel and bladder function
C) Light touch sensation
D) Pain perception
E) Motor function

Correct Answer: E

When metastatic tumor grows, the posterior longitudinal ligament may be destroyed first and followed by involvement of the spinal cord. 

Spinal cord compromise can result from direct compression of an enlarging metastatic mass or intradural spreading of the metastatic tumor cells. 

Retropulsion of osseous fragments or metastatic mass into the spinal canal also may be caused by pathological fracture and vertebral collapse. 

The motor function of the anterior part of the spinal cord (anterior corticospinal tract) is usually affected first, followed by sensory loss (dorsal columns)

Author: Rajesh Bahadur Lakhey 

 

86. Which of the following is the gold standard imaging modality for evaluation of a patient with degenerative lumbar
scoliosis:

A) Plain radiography
B) Computed tomography
C) Magnetic resonance imaging
D) Postmyelogram computed tomography
E) Varies depending on surgeon preference

Correct Answer: D

Myelography, especially with postmyelogram computed tomography, is considered the imaging modality of choice in
evaluation of bony elements and spinal stenosis with neural compression in patients with degenerative lumbar
scoliosis

Author: Rajesh Bahadur Lakhey

 

85. Which of the following is NOT a routinely used imaging modality for evaluation of spinal pathology:

A) Plain radiography
B) Computed tomography
C) Magnetic resonance imaging
D) Diskography
E) Myelogram

Correct Answer: D

Diskography is a diagnostic technique that has been used since the 1950’s. The study involves injection of dye into an
intervertebral disk space. A positive study is one in which the injected dye is not contained within the disk space or in
which the injection reproduces the characteristic distribution of the patient’s pain. The current role of diskography
remains undefined and, at this time, diskography is not a first-line diagnostic study in the evaluation of patients with
low back pain

Author: Rajesh Bahadur Lakhey

 

84. Which of the following is the most common location of vertebral osteomyelitis along the spinal axis:

A) Craniocervical junction
B) Thoracic spine
C) Lumbar spine
D) Sacral spine
E) Cervical spine

Correct Answer: C

Lumbar spine is the most common region of the spine affected by hematogenous spread of organisms leading to
osteomyelitis followed by the thoracic spine.

Author: Rajesh Bahadur Lakhey

 

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

A) Conservative management yields better long-term outcome
B) Surgical intervention has better long-term results
C) No statistically significant difference in outcome is noted despite the type of treatment used
D) No long-term data are available
E) None of the above

Correct Answer: C

The prognosis of herniated lumbar disks is generally good regardless of treatment. 

Patients operated on for proven disk herniations improved more rapidly than patients treated nonoperatively. However, within 4 to 5 years, the outcomes begin to approximate each other.

Author: Rajesh Bahadur Lakhey

 

82. Common presentations of cauda equina syndrome include:

A) Severe low back pain with nausea and vomiting
B) Acute onset unilateral foot drop
C) Progressive chronic low back pain radiating to the gluteal region
D) Saddle anesthesia and bowel and/or bladder dysfunction
E) Fever, photophobia, and nuchal rigidity

Correct Answer: D

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

Author: Rajesh Bahadur Lakhey

 

81. A sequestered disk herniation refers to:

A) Bulging of the nucleus through a weakened annulus
B) Rupture of the nucleus through the annulus
C) Rupture of the nucleus through the annulus and the posterior longitudinal ligament
D) Rupture of the nucleus through the posterior longitudinal ligament
E) Separation of a herniated fragment from the disk

Correct Answer: E

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

Author: Rajesh Bahadur Lakhey

 

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

A) 2 hours
B) 4 hours
C) 8 hours
D) 12 hours
E) 24 hours

Correct Answer: C

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

Author: Rajesh Bahadur Lakhey

 

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

A) An imaging study, preferably magnetic resonance imaging (MRI), of the injured region
B) Electromyography and nerve conduction velocity studies
C) A doppler ultrasound to study blood flow to the injured area
D) An MRI of the entire spine to evaluate possible spinal cord injury
E) A detailed neurologic evaluation noting distal motor function

Correct Answer: E

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

Author: Rajesh Bahadur Lakhey

 

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

A) History and physical examination is often sufficient to make the diagnosis.
B) Imaging characteristics of malignant astrocytomas on magnetic resonance imaging (MRI) are specific enough to make the diagnosis.
C) Malignant astrocytoma of the spinal cord is a clinical diagnosis and is only confirmed after post-mortem tissue evaluation.
D) An open biopsy with tissue evaluation is the only way to make the diagnosis.
E) Computed tomography with a myelogram

Correct Answer: D

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

Author: Rajesh Bahadur Lakhey

 

77. What is the advantage of performing a magnetic resonance image (MRI) to evaluate spinal cord lesions:

A) The post-contrast enhancement pattern is sensitive and specific in diagnosing malignant tumors                                                
B) The diagnosis is often made based on imaging location of a tumor, thus avoiding the need for invasive tissue diagnosis.
C) Magnetic resonance imaging is more sensitive than computed tomography (CT) myelography
D) Magnetic resonance imaging has no advantage as a diagnostic tool in evaluating spinal cord lesions
E) Magnetic resonance imaging is a helpful, adjunct diagnostic tool that can elucidate characteristics of spinal cord lesions and help narrow the differential diagnosis

Correct Answer: B

Although diagnosis and localization of spinal column tumors depends on a patient’s history and physical
examination, differentiation of intramedullary versus extramedullary location of a tumor relies primarily on image
findings. 

The most common imaging modality is MRI. Lesion signal abnormalities, cerebral spinal fluid (CSF) capping, and cord or cauda equina displacement signify extramedullary masses, even without contrast.
Gadolinium enhancement increases the sensitivity of the MRI, as almost all spinal cord tumors demonstrate
some contrast enhancement. 

Although more sensitive than MRI, myelography and postmyelography CT are rarely used initially due to their invasive nature.

Author: Rajesh Bahadur Lakhey

 

76. The deltoid muscle may become paralyzed as a result of injury to which of the following cervical spine nerve roots:

A) C4
B) C5
C) C6
D) C7
E) C8

Correct Answer: B

The deltoid muscle is almost entirely innervated by the C5 cervical spine nerve root.

Author: Rajesh Bahadur Lakhey

 

75. Which of the following cervical spine nerve roots may cause paralysis of the diaphragm if injured during an anterior
approach:

A) C3
B) C4
C) C5
D) C6
E) C7

Correct Answer: B

The C4 cervical spine nerve root provides the primary innervation of the diaphragm.

Author: Rajesh Bahadur Lakhey

 

74. What percentage of spinal infections have concurrent positive blood cultures:

A) 5%
B) 25%
C) 55%
D) 75%
E) 95%

Correct Answer: B

Even though the majority of spinal infections are considered hematogenous in origin, only 25% of infections
occur with positive blood cultures.

Author: Rajesh Bahadur Lakhey

 

73. A 53-year-old man presents with progressive mid to low back pain increasing in severity for 1 month. He is 8 months post a T6-T11 fusion for a T9 burst fracture. 

Radiographs reveal a solid fusion with well-placed instrumentation. There is collapse of his T12 vertebral body with increased radiodensity that was not present at his last postoperative visit. 

His most likely diagnosis is:

A) Old T12 compression fracture
B) Kummell disease
C) Scheuermann disease
D) Tuberculosis
E) T12 burst fracture

Correct Answer: B

Kummell disease is post-traumatic osteonecrosis of the vertebral body. It is characterized by increased
radiodensity of the vertebral body in association with collapse days to years after the initial injury. It is believed
to be secondary to a vascular injury at the time of fracture. Kummell disease usually affects the lower thoracic
spine and upper lumbar spine in middle-aged and older people. These patients are at increased risk for delayed
neurologic injury if further collapse continues.

Author: Rajesh Bahadur Lakhey

 

72. A 38-year-old construction worker falls from a scaffolding and sustains a pure flexion-compression injury to T12. 

In this type of injury, which portion of the vertebral body fails first:

A) End plate
B) Subcortical cancellous bone
C) Posterior elements
D) Middle column
E) Lamina

Correct Answer: A

Failure occurs first at the end plate. The intact intervertebral disk has limited compressibility. Therefore, when
the compressive forces exceed the disk compressibility, the load is transmitted to the contiguous bone. The end
plate will rupture first followed by the subcortical cancellous vertebral bone.

Author: Rajesh Bahadur Lakhey

 

71. A 42-year-old man sustained a twisting injury to his low back 5 months ago. Since the injury, he has persistent low back pain that radiates into his right thigh and down to his posterior calf. 

The patient underwent a magnetic resonance imaging of his lumbar spine revealing a small posterolateral lumbar disk herniation at the L4L5 level. 

Over the past month, the patient states that his leg pain has been getting progressively better and has almost disappeared over the past week with the use of nonsteroidal anti-inflammatory medications and occasional bed rest.

The next step in the management of this patient should be:

A) A lumbar computed tomography scan
B) Repeat magnetic resonance image
C) Surgical excision of the herniated disk
D) Continued conservative management
E) Epidural steroid injection

Correct Answer: D

The patient has shown continued improvement of his symptoms including the leg pain with conservative
treatment. 

Epidural steroids would be indicated if this patient had continued or worsening leg pain and/or low
back pain.

Author: Rajesh Bahadur Lakhey

 

70. A 43-year-old man develops pain radiating down his left leg from a far-lateral disk herniation at the L5/S1 level. 

Which is the most likely nerve root contributing to his discomfort:

A) L2
B) L3
C) L4
D) L5
E) S1

Correct Answer: D

Typically, for a posterolateral disk herniation, the traversing or more distal nerve root is often involved. 

With a far-lateral disk herniation (as in this case), the exiting nerve root is usually involved. In this case, it would
be the L5 nerve root.

 

Author: Rajesh Bahadur Lakhey

 

69. A 57-year-old man with known lung cancer and metastatic disease complains of increasing low back pain. 

How often is the lumbar spine involved when a patient has known spinal metastasis?

A) 5%
B) 15%
C) 50%
D) 85%
E) 99%

Correct Answer: D

In 85 % of patients with metastatic disease to the spine, the lumbar region vertebral body is involved. If operable, the vertebral body lesion can be managed via an anterior approach with a corpectomy, as opposed to a posterior approach with laminectomy and removal of all involved posterior elements.

Author: Rajesh Bahadur Lakhey

 

68. Some of the more common risk factors that could predispose a person to developing low back pain are listed below.
Which risk factor has not been implicated:

A) Occupations requiring the use of jackhammers
B) Being above normal bodyweight
C) Cigarette or other tobacco consumption
D) Female gender
E) Occupations requiring the frequent operation of motor vehicles

Correct Answer: D

Being female has not been implicated as a risk factor in the development of low back pain. Occupations that
require heavy lifting, the use of jackhammers, and operating motor vehicles, as well as the usage of tobacco
products and being overweight have all been associated with a higher incidence of developing low back pain.

Author: Rajesh Bahadur Lakhey

 

67. What physical examination maneuvers listed below check the status of the L4 neurologic level:

A) Sensation on the lateral side of the ankle, the patellar tendon reflex, and plantar eversion
B) Sensation on the lateral side of the ankle, the patellar tendon reflex, and plantar inversion
C) Sensation on the lateral side of the ankle, the Achilles tendon reflex, and plantar inversion
D) Sensation on the medial side of the ankle, the Achilles tendon reflex, and plantar inversion
E) Sensation on the medial side of the ankle, the patellar tendon reflex, and plantar inversion

Correct Answer: E

Sensation on the medial side of the ankle, the patellar tendon reflex, and plantar inversion are associated with
the L4 neurologic level. 

Sensation on the lateral side of the ankle and the Achilles tendon reflex are associated with the S1 neurologic level.

Author: Rajesh Bahadur Lakhey

 

66. On physical examination, a patient with a weak extensor hallucis longus muscle might be expected to have a farlateral disk herniation at what level in the spine:

A) L2/L3
B) L3/L4
C) L4/L5
D) L5/S1
E) S1/S2

Correct Answer: D

A far-lateral disk herniation in the lumbar spine often compromises the more proximal, or exiting,
nerve root and not the more distal, or traversing, nerve root most typically affected in a posterolateral disk herniation. Therefore, a far-lateral disk herniation at the L5 - S1 level could

Author: Rajesh Bahadur Lakhey

 

65. When palpating the sacral triangle in the posterior aspect of a patient’s lower back, if gaps are present between the spinous processes or no lumbar or sacral bony prominences are detected, this is suggestive of:

A) Spina bifida
B) Gibbus deformity
C) Scoliosis
D) Becs de perroquet

Correct Answer: A

When palpating the lumbosacral area (sacral triangle), if palpable gaps are present between the spinous processes or there is an absence of lumbar and/or sacral bony prominences, this is suggestive of spina bifida.
* A Gibbus deformity is characterized by a sharp kyphosis and is often found in the thoracic spine.
* Scoliosis is identified by a lateral curvature of the spine
* A palpable "step-off" of one spinous process relative to the next would be suggestive of a spondylolisthesis.
* Becs de perroquet is a radiographic feature associated with tuberculosis of the lumbar spine in which bony bridges form across the sides of two adjacent vertebrae.

Author: Rajesh Bahadur Lakhey

 

64. Appropriate treatment of a nondisplaced Jefferson fracture is:

A) Hard cervical orthosis
B) Halo vest
C) Soft collar
D) Posterior surgical stabilization
E) Nerve treatment necessary

Correct Answer: A

Fractures involving the C1 or atlas are generally caused by axial compression with either a flexion or extension
force. Generally, fractures involving the C1 consist of multiple fragments. 

The classical Jefferson fracture is a 4- part fracture of the atlas and can be unstable. However, in this situation, a nondisplaced fracture represents a relatively stable injury. An open-mouth odontoid anteroposterior radiograph is frequently useful to evaluate unstable patterns. 

An unstable fracture typically has displacement of the lateral masses greater than 8 mm. If displacement of this amount occurs, generally, the transverse ligament has been disrupted and should be treated by halo vest immobilization. In this nondisplaced situation, a hard Philadelphia collar is the most appropriate form of treatment.

Author: Rajesh Bahadur Lakhey

 

63. An 11-year-old girl presents with low back pain for 2 months’ duration. She is an elite gymnast and has missed 2 meets because of the pain. 

Physical exam reveals pain with hyperextension of the lumbar spine. Her neurological exam is normal. 

Radiographs of the lumbar spine, including oblique views, are normal. 

The recommendation is:

A) Rest, with slow return to training in 4 weeks
B) Custom lumbosacral orthosis
C) Magnetic resonance imaging of the spinal cord
D) Physical therapy exercises
E) Bone scan with single photon emission computed tomography imaging

Correct Answer: E

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

Author: Rajesh Bahadur Lakhey

 

62. A 55-year-old man with ankylosing spondylitis has a minor fall and is suffering with neck pain. 

Anteroposterior and lateral radiographs are negative with no evidence of fracture. 

He has no neurologic loss and has normal strength with the exception of severe restricted motion. 

Twelve hours following injury, he is found to have bilateral bicepes and tricepes weakness. 

The appropriate management and the work up of this individual is:

A) Computerized tomography (CT) anteroposterior lateral radiographs of the cervical spine
B) CT scan of the cervical spine
C) Magnetic resonance imaging (MRI) of the cervical spine
D) Bone scan of the MRI
E) Electromyogram to better delineate all the nerve neuropathy

Correct Answer: C

The patient is within 12 hours of having normal cervical spine films. 

Approximately one third of patients with ankylosing spondylitis incur occult injuries to the cervical spine that are not identified by plain films prior to kyphotic progression. 

A bone scan would delineate a fracture after 72 hours. However, the presence of progressive weakness should raise suspicion of a potential epidural hematoma. For this reason, magnetic resonance imaging would better delineate epidural hematoma.

Author: Rajesh Bahadur Lakhey

 

61. 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

 

60. 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

 

59. 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


 

58. 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

 

57. 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

 

56. 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

 

55. 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
* 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

 

54. 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 and 12 mm
B) 10 mm and 14 mm
C) 12 mm and 16 mm
D) 14 mm and 20 mm
E) 16 mm and 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

 

53. 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

 

52. 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

 

51. 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

 

50. 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

 

49. 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

 

48. 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

 

47. 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

 

46. 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

 

45. 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

 

44. The most common type 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 injuries usually result from extreme movements of the limbs, most commonly the shoulder joint with involvement of the brachial plexus.

Author: Rajesh Bahadur Lakhey

 

43. 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 tumours. The median survival
time for patients with cervical tumours 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

 

42. 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 tumour

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

 

41. Canal compromise in burst fractures 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

 

40. 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

 

39. 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

 

38. The axial computed tomography scan depicts a patient with spinal stenosis 

. 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

 

37. A 45-year-old woman has pain in her right upper extremity and neck. 

The sagittal Xray  image is presented as well as an axial image 

. 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

 

36. A 40-year-old woman has severe neck pain following a motor vehicle accident. 

Her plain lateral radiograph of the spine is shown . A sagittal magnetic resonance scan is also shown. 

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

 

35. A 35-year-old man has neck pain following a motor vehicle accident. 

His axial computed tomography scan is shown. 

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

34. 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

 

33. 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

 

32. 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

 

31. 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. 

Author: Rajesh Bahadur Lakhey

 

30. 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

 

29. 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

 

 

28. 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

 

27. 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

 

26. 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

 

25. 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. 

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

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 non-infectious causative agent in order to determine proper management.

Author: Rajesh Bahadur Lakhey

 

24. 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. 

Posterior ring apophyseal fracture | Radiology Reference Article | Radiopaedia.org

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

 

23. 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

 

22. 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

 

21. 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

 

20. 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.