Multiple Choice Questions
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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
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
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.
87. Compression fractures of the spine secondary to metastatic disease usually first affect which component of the nervous system :
B) Bowel and bladder function
C) Light touch sensation
D) Pain perception
E) Motor function
86. Which of the following is the gold standard imaging modality for evaluation of a patient with degenerative lumbar
A) Plain radiography
B) Computed tomography
C) Magnetic resonance imaging
D) Postmyelogram computed tomography
E) Varies depending on surgeon preference
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
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
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
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
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
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
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
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
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
76. The deltoid muscle may become paralyzed as a result of injury to which of the following cervical spine nerve roots:
75. Which of the following cervical spine nerve roots may cause paralysis of the diaphragm if injured during an anterior
74. What percentage of spinal infections have concurrent positive blood cultures:
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
E) T12 burst fracture
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
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
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:
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?
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
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
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:
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
D) Becs de perroquet
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
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
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
61. What percentage of women with osteoporotic fractures develop kyphosis:
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
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
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
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
56. Pain is the most common complaint in patients presenting with a primary spine tumor and is present in which percentage of patients:
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%
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
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
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.
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
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
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
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
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.
46. A posterolateral L4-L5 herniated nucleus pulposus can lead to radiculopathy at which level of the affected side:
E) All of the above
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
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.
43. The most effective treatment for malignant intramedullary tumors of the spinal cord is:
A) Surgical excision
B) Radiation therapy
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
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
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
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 :
39. In this slide of a lumbar burst fracture, which column is disrupted to distinguish it from a compression fracture:
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
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
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
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:
B) Neck collar and physical therapy
C) Reduction and collar immobilization
D) Reduction and halo vest immobilization
E) Reduction and fusion
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:
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:
32. Which of the following is not a risk factor for degenerative spondylolisthesis:
A) Female gender
D) Lumbarization of the S1 vertebrae
E) Age older than 60 years
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
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
29. The most common site of a thoracic disk herniation requiring surgery is from levels:
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
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
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:
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
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.
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
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
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
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
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