SPINE

356 Q
1/7 ( 50Q )

COLLECTED BY
DR. A. AWAJI
 1- Acute pain that presents in the lateral arm and shoulder is suggestive of:

(A) Cervical myelopathy

(B) Thoracic outlet syndrome

(C) Radial tunnel syndrome

(D) Cervical disk herniation

(E) Diabetic neuropathy

Explanation:

Acute radiculopathies of the upper extremity are suggestive of soft cervical disk herniations.
Three types of soft disk herniations have been described:

 Intraforaminal is the most common and is often evidenced by radicular symptoms

in a dermatomal distribution.
 Posterolateral herniation results in predominantly motor symptoms.
 Midline disk herniations may result in myelopathy.

2- The major risk factor for nonunion in a type 2 odontoid fracture is:

(A) Age >35 years old

(B) Posterior displacement >5 mm

(C) Anterior displacement >5 mm

(D) Smoking history

(E) Flexion 30�

Explanation:

A posterior displacement >5 mm has the greatest risk of nonunion. However, age >65 years
old is a next risk factor. Type 2 odontoid fractures have the highest rate of nonunion of the 3
types and there has been reported to be >60% nonunion when not treated with a halo
immobilization. Halo traction is a viable alternative for a patient who has minimal
displacement and/or is not a candidate for surgery.
 3- 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

Explanation:

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.

4- The natural history of which of the following spinal deformities in children carries
with it the highest risk of paraplegia?

(A) Congenital lordosis

(B) Congenital kyphosis

(C) Neuromuscular scoliosis

(D) Idiopathic scoliosis

(E) Postlaminectomy kyphosis

Explanation:

Congenital kyphosis, if left alone, is the most likely cause of paraplegia of all noninfectious
spinal deformities. Defects of formation are more progressive than defects of segmentation,
and paraplegia is common with defects that have an apex at T4-T9, the watershed area of
spinal cord blood flow.

Treatment is usually surgical. There is no evidence of successful nonoperative treatment for

congenital kyphosis. An early, limited posterior fusion, coupled with anterior growth, may
result in a slow correction of the kyphosis. For kyphosis >55� in children older than 5 years
of age, anterior and posterior spinal fusions are necessary. The tethering structures
anteriorly must be released (anterior longitudinal ligament, annulus fibrosus) and distraction
anteriorly is maintained by autogenous strut grafts. Posteriorly, compression instrumentation
is required with fusion. If neurological compromise exists preoperatively, magnetic resonance
imaging is necessary to delineate the area of compression so that an anterior cord
decompression may be performed successfully
 5- Certain physical examination maneuvers attempt to elicit tension signs. When used
in the supine position, these maneuvers are designed to apply stretch or tension
on the sciatic nerve and any inflamed nerve root against a herniated lumbar disk.
Which of the following physical examination tests is not a tension sign maneuver:

(A) Lasegue sign

(B) McMurray sign

(C) Bowstring sign

(D) The sitting room test

(E) Contralateral straight-leg raising test

Explanation:

McMurray sign is used to detect a torn meniscus in the knee and will have minimal effect on
the sciatic nerve.

 Lasegue sign is the classic straight-leg raising test.

 The bowstring sign is a variation of the straight-leg raising test performed with the
knee in a flexed position. Digital pressure is then applied over the popliteal space
in an attempt to reproduce the tension sign.
 The sitting room test is performed with the patient in a sitting position. The hip
remains flexed at 90� while the examiner extends the ipsilateral knee.
 The contralateral straight-leg raising test is performed in the same manner as the
straight-leg raising test except the contralateral, or nonpainful, leg is raised.

6- On physical examination, the umbilicus is a superficial landmark for the bifurcation

of the aorta into the common iliac arteries and overlies this disk space:

(A) L1/L2

(B) L2/L3

(C) L3/L4

(D) L4/L5

(E) L5/S1

Explanation:

The umbilicus is a superficial landmark that often lies over the anterior L3/L4 disk space,
which is the location of the aortic bifurcation into the common iliac arteries. Below this
arterial division, in lean individuals, one can palpate the anterior bodies of L4, L5, and S1.
 7- When performing a physical examination, if running the pointed edge of a reflex
hammer along the crest of a patient's tibia causes extension of the great toe while
the remaining toes splay or plantarflex, this finding would indicate:

(A) A Babinski reflex is present

(B) A Babinski reflex is absent

(C) A Positive Oppenheim test

(D) A Negative Oppenheim test

(E) None of the above

Explanation:

An Oppenheim test is considered positive when running a pointed object along a patient's
tibial crest elicits splaying or plantarflexion of the smaller toes with great toe extension. An
Oppenheim test is considered negative when this reaction is not present.

 A Babinski reflex is present when running a pointed object across the plantar
surface of a patient's foot elicits splaying or plantarflexion of the toes with
extension of the great toe. A Babinski reflex is considered absent when the toes
either do not move or all five toes flex and/or bunch up in response to the
stimulus.

8- Beevor sign is a physical examination maneuver that tests the integrity of the
rectus abdominus muscles that are segmentally innervated by the anterior primary
divisions of the T5-T12/L1 nerve roots. When performing this test, the patient is
asked to perform a partial sit-up. A positive Beevor sign is indicated by:

(A) Pain in the abdominal musculature

(B) Simultaneous raising both lower extremities

(C) The absence of any deviation of the umbilicus

(D) The presence of umbilical deviation

(E) Pain radiating down both lower extremities

Explanation:

When performing a sit-up, umbilical deviation due to abnormal contraction of the rectus
musculature indicates either a partial or complete loss of segmental innervation to a portion
of the rectus abdominus and/or paraspinal musculature. It is frequently seen in patients with
certain neurological disorders such as meningomyelocele and poliomyelitis.
 9- 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

Explanation:

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.

10- The most common presenting symptom of a patient with a thoracic disk herniation
is:

(A) Anterior band-like chest pain

(B) Intrascapular pain

(C) Epigastric pain

(D) Lower extremity pain

(E) Lower extremity weakness

Explanation:

Brown et al reported on a series of 55 patients initially treated with conservative

management. Anterior band-like chest pain occurred in 67% of his patients. Lower extremity
complaints accounted for 20% and ranged from weakness (16%) to parasthesias (4%).

11- A 12-year-old girl presents with back pain of 3 months� duration. She is a Risser
stage 2. She displays a left thoracic curve of 27� on radiographs. The next study
obtained in the work-up should be:

(A) Lateral bending films

(B) Computerized tomography scan of the spine

(C) Head computerized tomography

(D) Magnetic resonance image of the thoracic spine

(E) Ultrasound of the kidneys

Explanation:
Left thoracic curves are unusual in idiopathic scoliosis. A magnetic resonance image of the
thoracic spine is mandatory in the work-up to rule out diastematomyelia, tethered spinal
cord, spinal tumor, or other type of congenital anomaly.
 12- Which test is most specific for diagnosing spinal column infection:

(A) White blood count

(B) Erythrocyte sedimentation rate

(C) Carbon-reactive protein

(D) Blood culture

(E) Biopsy

Explanation:

Vertebral biopsy, either via open or computed tomography-guided means, is most specific
even though false-negative rates for closed and open biopsies are 30% and 14%,
respectively.

 A patient�s white blood count may be normal even in acute spinal infection.
 Although often elevated, erythrocyte sedimentation rate and carbon-reactive
protein are nonspecific tests.
 Blood cultures are negative in more than 75% of patients.

13- The treatment of choice for spinal epidural abscess is:

(A) Four weeks of antibiotics

(B) Parenteral antibiotics until the erythrocyte sedimentation rate falls to half of its pretreatment value

(C) Surgical drainage plus a prolonged course of antibiotics

(D) Spinal fusion

(E) Bracing and analgesia

Explanation:
It is generally believed that pockets of pus, whether they are epidural, paravertebral, or
psoas abscesses, must be drained in addition to antimicrobial therapy.

14- Which of the following antibiotics would not be useful in staphylococcal vertebral
osteomyelitis:

(A) Cefuroxime

(B) Nafcillin

(C) Cefazolin

(D) Ciprofloxicin

(E) Tobramycin

Explanation:
Aminoglycosides, such as tobramycin, are active against gram-negative organisms. First- and
second-generation cephalosporins are alternatives to semisynthetic penicillins that may be
useful if the organism is not resistant. Ciprofloxicin has also been considered a possible
alternative to penicillins against gram-positive vertebral osteomyelitis.
Slide 1

15- Which type of biomechanical force(s) acts on the anterior portion of the
thoracolumbar junction (T12-L2) at rest in a standing position:

(A) Compression

(B) Compression and shear

(C) Compression and tension

(D) Tension

(E) Shear and torsion

Explanation:

The thoracolumbar junction is normally a straight portion of the spine (no lordosis or
kyphosis) and the vertebral bodies are subject to compressive forces at rest when the
patient is in a standing position. The posterior osteoligamentous structures are subject to
tension along with the paraspinous muscles that help to maintain an upright posture.
 16- What is the most common source of neurologic compression in a patient with
lumbar spinal stenosis due to degenerative changes in the lumbar spine:

(A) Disk

(B) Inferior articular process

(C) Superior articular process

(D) Pars intrarticularis

(E) Lamina

Explanation:

Degenerative spinal stenosis is the most common variety of spinal stenosis and usually
manifests compression of the thecal sac in the lateral recess of the canal (defined as the
area of the spinal canal between the facet joints and the intervertebral disk). The primary
cause of stenosis is hypertrophy of the facet joint with compression from the superior
articular process. This must be relieved for a patient to achieve an adequate decompression.

17- The biceps reflex is diminished by compression of which of the following cervical
spine nerve roots:

(A) C4

(B) C5

(C) C6

(D) C7

(E) C8

Explanation:

Although there is a small contribution from the C6 cervical spine nerve root, the biceps reflex
is primarily derived from the C5 cervical spine nerve root.
 18- If the C7 cervical spine nerve root is injured during a posterior decompression of
the cervical spine, then sensation is lost in which of the following areas:

(A) The lateral aspect of the arm from the shoulder to the elbow

(B) The medial aspect of the arm from the shoulder to the elbow

(C) The lateral border of the forearm including the thumb

(D) The middle finger

(E) The medial border of the forearm including the little finger

Explanation:

The C7 cervical spine nerve root supplies sensation to the skin over the volar aspect of the
middle finger.

 C5 � Lateral aspect of the arm from the shoulder to the elbow

 C6 � Lateral border of the forearm including the thumb
 C7 � Middle finger
 C8 � Medial border of the forearm including the little finger
 T1 � Medial aspect of the arm from the shoulder to the elbow

19- If the C8 cervical spine nerve root is injured during a posterior spinal
decompression, then sensation is lost over which of the following areas:

(A) The lateral aspect of the arm from the shoulder to the elbow

(B) The medial aspect of the arm from the shoulder to the elbow

(C) The lateral border of the forearm including the thumb

(D) The middle finger

(E) The medial border of the forearm including the little finger

Explanation:

The C8 cervical spine nerve root supplies sensation to the medial border of the forearm
including the little finger.

 C5 � Lateral aspect of the arm from the shoulder to the elbow

 C6 � Lateral border of the forearm including the thumb
 C7 � Middle finger
 C8 � Medial border of the forearm including the little finger
 T1 � Medial aspect of the arm from the shoulder to the elbow
 20- 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

Explanation:

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

21- The left medial and lateral gastrocnemius muscles are weak in a patient after a
lumbar spine decompression. Which of the following nerve roots is injured:

(A) L3

(B) L4

(C) L5

(D) S1

(E) S2

Explanation:

The medial and lateral gastrocnemius muscles are principally innervated by the S1 nerve root through
the tibial nerve. Although the nerve is principally innervated by the S1 nerve root, the tibial 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
Slide 1

22- A 45-year-old man has neck pain following a motor vehicle accident. His neurologic examination
is normal. His plain radiographs are shown (Slide). The most likely diagnosis is:

(A) Cervical strain (whiplash-type injury)

(B) Compression fracture of C5

(C) Unilateral facet dislocation

(D) Bilateral facet dislocation

(E) Spinous process fracture

Explanation:

The lateral radiograph shows translation and kyphosis at the level of injury. The facets of C4
do not superimpose on each to create a "double sail" sign. This patient has a unilateral facet
dislocation. With unilateral facet dislocations, there is usually 3 mm to 4 mm of forward
translation and 5� to 7� of angulation.
Slide 1

23- 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
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 immobilization

(E) Reduction and fusion

Explanation:

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. This is a ligamentous injury so
reduction and immobilization will not result in satisfactory healing.

24- In which of the following nerve roots is compression neuropathy common in

cervical spondylosis:

(A) C3 and C4

(B) C4 and C5

(C) C5 and C6

(D) C6 and C7

(E) C7 and C8

Explanation:The nerve roots that are most commonly affected in cervical spondylosis are
C6 and C7, secondary to degenerative changes in the C5-C6 and C6-C7 nerve roots. Patients
may have specific dermatomal pain or pain that is diffuse and poorly localized.
 25- The sagittal plumb line should fall:

(A) Anterior to the C4 vertebral body

(B) Through the L3-L4 intervertebral disk

(C) Posterior to the anterosuperior corner of S1

(D) Through the T11 intervertebral disk

(E) Anterior to the S1 body

Explanation:

Radiographic assessment of the sagittal balance is usually made with a patient standing, with
his or her arms flexed forward 90� and supported on a bar. Radiographic assessment is
recorded on a 36-inch cassette. Several reference points regarding this technique have
appeared in the literature. These points include a plumb line through the center of the C7
vertebral body, passing 35 mm to 56 mm posterior to the anterosuperior border of S1.

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

(A) Immediate surgical exploration and repair

(B) Delayed surgical repair 2 weeks after injury

(C) Immediate surgical exploration followed by delayed repair weeks to months later

(D) Observation only

(E) Observation followed by delayed surgical exploration if no functional recovery is found

Explanation:

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

27- The term Schmorl�s nodule refers to:

(A) A giant synovial cyst

(B) An enlarged paravertebral lymph node

(C) A pathologic dorsal root ganglion

(D) Superior or inferior displacement of an intervertebral disk

(E) Anterior displacement of an intervertebral disk

Explanation:

Superior and inferior displacements into the vertebral body are known as Schmorl�s nodules
 28- 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

Explanation:

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

29- Untreated low back pain most commonly:

(A) Improves spontaneously

(B) Undergoes progressive worsening prompting further medical care

(C) Leads to neurological decompensation

(D) No studies have been done to evaluate the natural history of untreated low back pain.

(E) Progresses to chronic failed back syndrome

Explanation:

Generally, patients diagnosed with low back pain should undergo 4 weeks of conservative
treatment with an accepted prognosis of predominantly spontaneous improvement over a 4-
week period, regardless of treatment.

30- Which of the following is the most common location of adult degenerative
spondylolisthesis:

(A) L1-L2 interspace

(B) L2-L3 interspace

(C) L3-L4 interspace

(D) L4-L5 interspace

(E) L5-S1 interspace

Explanation:

The L4-L5 interspace is the most common location of adult degenerative spondylolisthesis.
 31- Which of the following statements is true regarding the initial diagnostic
radiographic evaluation of patients with spondylolisthesis:

(A) Initial diagnostic radiographic evaluation includes plain radiographic imaging of lumbar spine with flexion
and extension.
(B) Computed tomography of the lumbar spine region is the first order diagnostic imaging study.

(C) Spondylolisthesis is a clinical diagnosis; no imaging studies are indicated.

(D) Initial diagnostic radiographic evaluation includes magnetic resonance imaging of the lumbar spine to
evaluate spinal stenosis and nerve root compression.
(E) If spondylolisthesis is suspected, myelogram is necessary for diagnosis.

Explanation:

Plain radiographs should be performed in a standing position as some cases of

spondylolisthesis can be missed if x-rays are taken in a supine position. Forward
displacement of L4 on L5 and more rarely L5 on S1 or L3 on L4, without a pars
interarticularis defect is often demonstrated. Other radiologic findings of osteophyte
formation, such as disk-space narrowing, endplate sclerosis, vacuum disk sign, facet sclerosis
and hypertrophy, are consistent with long-standing degenerative disease. Hemisacralization
of L5 may be revealed. Flexion, extension, and lateral bending films often reveal
hypermobility.

32- Limitation of hyperextension in the lumbosacral spine is controlled by the:

(A) Posterior longitudinal ligament

(B) Anterior longitudinal ligament

(C) Ligamentum flavum

(D) Interspinous ligament

(E) Intertransverse ligament

Explanation:

More flexion-extension motion occurs in the caudal segments of the lumbar spine than in the
upper and middle levels. The well-developed anterior longitudinal ligament and the anterior
portion of the annulus fibrosus are important inhibitors of hyperextension.

33- 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.

Explanation:

The clinical syndrome of lumbar stenosis correlates with a measured anteroposterior

diameter of the dural sac of less than 10 mm.
 34- Which of the following is the most common source of infection in vertebral
osteomyelitis:

(A) Trauma

(B) Iatrogenic

(C) Hematogenous spread

(D) Spontaneous

(E) Unknown mechanism

Explanation:

Hematogenous seeding from another primary source is the most common causative agent.
Hematogenous spread of infections is believed to affect the spine via septic emboli in the
endarteriolar circulation of segmental spinal arteries at the vertebral endplates. The majority
of cases of pyogenic spondylitis begin in the subchondral, metaphyseal region of the anterior
subligamentous portion of the vertebral body � the portion with the greatest arterial supply
and the most anastomoses.

35- The endplates and pedicles of which of the following vertebra are normally parallel
to the ground in a standing individual:

(A) L1

(B) L3

(C) S1

(D) T1

(E) T12

Explanation:

The alignment of the spine is important in normal upright posture. There is a normal degree
of lordosis in the cervical and lumbar spines and a moderate degree of kyphosis in the
thoracic spine. The head, spine, and pelvis are connected and balanced. If the spine is out of
balance, then a deformity can develop causing fatigue of the paraspinal muscles.

The normal sagittal alignment in the upright patient is as follows:

 Plumb line

The sagittal plumb line falls from the odontoid process through the C7-T1
intervertebral disk and then anterior to the thoracic spine. The plumb line then
crosses the spine at the T12-L1 intervertebral disk, and then travels posterior to
the spine. The plumb line crosses at the posterior corner of the S1 vertebra.

The endplates and pedicles of the L3 vertebra are normally parallel to the ground
 36- Patients with anterior cord syndrome usually presents with:

(A) Preservation of motor function, preservation of pain and temperature sensation, and loss of vibration and
touch sensation
(B) Preservation of motor function, with loss of pain, temperature, vibration, and touch sensation

(C) Motor paralysis, loss of pain, temperature, vibration, and touch sensation

(D) Motor paralysis, loss of pain and temperature sensation, and preservation of vibration and touch sensation

(E) Motor paralysis, loss of vibration and touch sensation, and preservation of pain and temperature sensation

Explanation:

Anterior cord syndrome is due to injury of the anterior elements of the spinal cord, which is
usually due to a space-occupying lesion anterior to the cord such as vertebral body fracture
fragments, a herniated disk, or a hematoma. The clinical presentation consists of:

 Complete motor paralysis (loss of anterior corticospinal tract)

 Loss of pain/temperature sensation (loss of lateral and anterior spinothalamic
tracts)
 Preservation of vibration sensation/proprioception and light touch sensation
(preservation of dorsal columns)

In less severe cases, some motor function is preserved through the lateral corticospinal
pathways. Prognosis is generally poor and in patients with absence of sacral sensation (pin
prick/temperature) after 24 hours following injury, recovery is seen in 10% of patients

37- 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%

Explanation:

I. 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
II. Weakness can be seen in up to 42% of patients
III. Mass is evident in up to 16% of patients
IV. Three percent of patients are asymptomatic
V. Other symptoms can include:
A. Sensory loss
B. Loss of sphincter control
 38- Which of the following is considered to be a malignant primary spine tumor:

(A) Osteoblastoma

(B) Eosinophilic granuloma

(C) Giant cell tumor

(D) Chordoma

(E) Aneurysmal bone cyst

Explanation:

I. Primary benign tumors of the spine are:

A. Slow-growing
B. Well-circumscribed
C. Usually occur in patients younger than 21 years of age
D. Involve the vertebral body and posterior elements of the spine
1. Overall slight predilection for the posterior elements
2. Location of tumor is an important factor in determining the
type of tumor
E. Examples include:
1. Osteochondroma
2. Osteoid osteoma
3. Osteoblastoma
4. Aneurysmal bone cyst
5. Giant cell tumor
6. Eosinophilic granuloma
II. Primary malignant tumors of the spine are:
A. Fast-growing
B. Permeative
C. Usually occur in patients older than 21 years of age
D. Examples include:
1. Multiple myeloma/solitary plasmacytoma
2. Osteosarcoma
3. Chondrosarcoma
4. Ewing's sarcoma/primitive neuroectodermal tumor
5. Chordoma
6. Lymphoma

39- All of the following are elements of the lateral mass of cervical spinal segments
except:

(A) Inferior articulating process

(B) Superior articulating process

(C) Spinous process

(D) Transverse process

(E) Transverse foramen

Explanation:

The lateral mass of the cervical spinal segments includes the inferior and superior articulating
processes, the transverse foramen, and the transverse process. The spinous process is not
an element of the lateral mass.
 40- A 21-year-old man presented to the emergency department after sustaining a low-
velocity gunshot wound to his midback resulting in grade 0 (out of 5) weakness in
his quadriceps and tibialis anterior muscles. His extensor hallucis longus and
gastrocnemius/soleus muscles were grade 3 (out of 5) bilaterally. His sensation
remained intact. An intradural bullet fragment was seen at T12. No fracture was
seen on computed tomography (CT) scan. Management should consist of:

(A) Administration of methylprednisolone 30 mg/kg bolus followed by an infusion of 5.4 mg/kg for 24 hours.

(B) Application of a thoracolumbosacral orthosis (TLSO).

(C) Administration of broad-spectrum antibiotics for 14 days.

(D) Removal of the bullet fragment.

(E) Removal of the bullet fragment and instrumented fusion from T10 to L2.

Explanation:

In complete and incomplete lesions from T12 to L4, removal of the bullet fragment from the
canal has been associated with significant motor recovery. This improvement is not seen in
other regions of the spine.

High-dose steroids have not been shown to offer improvement in patients with spinal cord
injury after a gunshot wound, and the complications of high-dose steroids have been
documented in this population. The majority of gunshot wounds to the spine are stable
injuries. This patient�s CT scan does not demonstrate any instability. Therefore, neither
nonoperative (eg, TLSO bracing) nor operative (instrumented fusion) stabilization is
indicated. While infection after transalimentary bullet wounds to the spine is a well-
documented complication, this patient�s injury was sustained from the back, thereby
avoiding the alimentary canal and obviating the need for intravenous antibiotics

41- Which of the following instruments are of value to a surgeon when performing
minimally invasive lumbar fusions:

(A) Surgical loupes and headlight

(B) Operating microscope

(C) Intraoperative fluoroscopy

(D) Surgical loupes and headlight and operating microscope

(E) Surgical loupes and headlight, operating microscope, and intraoperative fluoroscopy

Explanation:

All of the above instruments are of value to a surgeon when performing minimally invasive
lumbar fusion.
Slide 1

42- What type of fracture is presented in the radiograph (Slide):

(A) Teardrop fracture

(B) Burst fracture

(C) Compression fracture

(D) Hangman�s fracture

(E) Clay-shoveler�s fracture

Explanation:

Clearly seen in this radiograph is a fracture along the anterior/inferior vertebral body, which
is a characteristic of a teardrop fracture.

43- Which of the following is a distinguishing feature of a C7 radiculopathy rarely

found in C6 radiculopathies:

(A) Paresthesia of the middle finger

(B) Anterior chest pain

(C) Little to no pain in associated muscles

(D) �Epaulet� pain in the associated shoulder and lateral arm

(E) None of the above

Explanation:

C7 radiculopathies classically entail pain and/or sensory changes involving the middle finger.
C6 radicular symptoms generally involve the thumb and first finger. C8 radiculopathies
involve the pinkie and ring fingers.
 44- Which of the following statements concerning burners and stingers is incorrect:

(A) Burners and stingers typically result from depression of the ipsilateral shoulder and deviation of the neck to
the contralateral side.
(B) Burners and stingers are commonly seen in elderly patients.

(C) In treating burners and stingers, it is important to restore pain-free mobility in the upper extremities by
strengthening and stretching.
(D) Follow-up and patient education are important in all cases of burners and stingers, regardless of the
duration of symptoms.
(E) None of the above

Explanation:

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

45- A 26-year-old man with HIV presents to your office with symptoms of lower back
pain, difficulty with ambulation, loss of appetite, mild fever, and malaise for 2
weeks. The patient states that he has had difficulty with compliance to his medical
management. You suspect that he has a low CD4 count, which is confirmed by
laboratory tests. Physical examination reveals tenderness at the L4-L5 level. The
patient has abnormal gait. Ankle dorsiflexion and plantarflexion are 1 out of 5
bilaterally. The Achilles tendon reflex is absent bilaterally; all other reflexes are
normal. A T2-weighted magnetic resonance imaging (MRI) study shows slightly
increased intensity of the disk at the L4-L5 level and an obvious epidural abscess.
Conventional radiographs of the lumbar region are normal. Management of this
patient should consist of:

(A) Admission to the intensive care unit (ICU) and intravenous administration of broad-spectrum antibiotics

(B) Consideration of urgent surgical intervention and evacuation of the epidural abscess

(C) Counseling the patient on the importance of compliance with medical management

(D) Surveillance for signs of further neurologic deterioration

(E) All of the above

Explanation:

All of the above answer choices are correct. The patient described above has HIV and is
severely immunocompromised. Because of the severity of the patient�s condition,
immediate admission to the ICU and intravenous administration of a broad-spectrum
antibiotic regimen is indicated. Biopsy and drainage of the infected regions should be
performed. It is important in this case to monitor the patient for any signs of neurologic
deterioration. Finally, to prevent recurrent cases of diskitis, or other infections, it is important
to counsel the patient on compliance with medical management.
 46- 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

Explanation:

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.

47- Which of the following is a contraindication to kyphoplasty:

(A) Local osteomyelitis

(B) Osteoblastic lesions

(C) Sepsis

(D) Bleeding diathesis

(E) All of the above

Explanation:

It is important to properly evaluate a patient prior to any surgical procedure. If a patient

presents with osteomyelitis, osteoblastic lesions, sepsis, or bleeding diathesis, then surgery
should be postponed until the underlying condition is corrected
 48- Approximately how many vertebral compression fractures occur in the United
States annually:

(A) 70,000

(B) 500,000

(C) 700,000

(D) 1 million

(E) 1.5 million

Explanation:

There are approximately 700,000 reported vertebral compression fractures annually in the
United States.

49- What is the prevalence of Schmorl�s nodes in the general population:

(A) 3%

(B) 7%

(C) 10%

(D) 15%

(E) 19%

Explanation:

Approximately 10% of the population has Schmorl�s nodes, which are often completely
benign.
 50- A 34-year-old man presents to the emergency department after sustaining a low-
velocity gunshot wound to the upper back. Radiologic studies reveal bullet
fragments scattered throughout the T6 to T8 levels. No evidence of instability is
present on conventional radiographs and computed tomography. The patient was
stabilized and a full neurologic examination was performed, revealing no major
neurologic deficits. Management of this patient should consist of:

(A) Removal of the bullet fragments from the T6 to T8 vertebral bodies

(B) Removal of the bullet fragments from the T6 to T8 vertebral bodies and instrumented fusion from T4 to
T10
(C) High-dose intravenous methylprednisolone administration for 24 hours

(D) Broad-spectrum antibiotic administration for 7 days

(E) Nonoperative treatment (eg, thoracolumbosacral bracing) and regular observation for progression of any
neurologic deficits

Explanation:

Removal of the bullet fragments from the T6 to T8 levels is not indicated because the patient
does not have neurologic deficits and therefore does not require spinal cord decompression
via bullet removal. Decompression via bullet removal for neural deficits in the thoracic spine
has been shown to result in higher rates of complications compared with nonoperative
management. High-dose steroid administration is not indicated in patients with gunshot
wounds to the spine because the benefits of steroids are outweighed by the risks. The
administration of broad-spectrum antibiotics is not indicated in this patient because the bullet
did not pass through the gastrointestinal tract. Nonoperative management and regular
observation for progression of neurologic deficits is important in this patient because of the
localization of the bullet fragments to the thoracic spine, the lack of neurologic deficits, and
the lack of instability
 SPINE
356 Q
2/7 ( 50Q )

COLLECTED BY
DR. A. AWAJI
 1- A cervical disk herniation that causes weakness in the wrist extensors will likely
produce sensory changes in the:

(A) Lateral arm

(B) Ulnar forearm

(C) Radial forearm

(D) Long finger

(E) Hypothenar eminance

Explanation:

The wrist extensors are innervated by C6. Weakness would likely be the result of a C5-C6
cervical disk herniation, thus causing a C6 radiculopathy. The dermatome of C6 includes the
radial side of the forearm and radial digits

2- In order to diagnose a disk herniation, the preferred test is:

(A) Electromyogram

(B) Flexion-extension roentgenograms

(C) Computerized tomography scan

(D) Magnetic resonance imaging (MRI) with gadolinium

(E) MRI without gadolinium

Explanation:

Magnetic resonance imaging (MRI) has become the modality of choice for diagnosis of disk
herniation. It is readily available, noninvasive, and has proven as accurate as post-
myelogram computerized tomography scans in the evaluation of cervical radiculopathy. An
MRI study should include a T1- and T2-weighted image sequence with both sagittal and axial
images.
 3- The structure most at risk during lateral mass screw placement is the:

(A) Vertebral artery

(B) Nerve root

(C) Spinal cord

(D) Recurrent laryngeal nerve

(E) Thoracic duct

Explanation:Lateral mass screws placed in the cervical spine for plate fixation are directed
30� lateral and 15� cephalad from a point 1 mm medial to the mid-portion of the particular
pillar. The nerve root exits at the anterolateral portion of the facet joint and is at risk of
injury. The vertebral artery may be injured in screws placed too medially. The spinal cord is
essentially free of danger with accepted techniques.

4- A 48-year-old man presents with a closed head injury requiring intubation and
isolated bilateral facet dislocation. The next appropriate step is:

(A) Closed reduction with axial traction with Gardner-Wells tongs

(B) Posterior open reduction and posterior cervical platting

(C) Emergent magnetic resonage imaging

(D) Neurostabilization until the patient�s neurologic status improves

(E) Administration of Decadron (Merck & Co., West Point, Pa.) 10 mg/hr intravenously

Explanation:The patient has a severe closed head injury and is unable to tolerate a close
reduction maneuvers with Gardner-Wells tongs. Emergent magnetic resonance imaging
should be obtained to evaluate the potential presence of a disk herniation at the dislocation.
Should a disk herniation be present, anterior approach and diskectomy should be performed
prior to reduction maneuvers.

5- A major indication for surgical decompression of an L1 burst fracture is:

(A) Loss of anterior body height of 60%

(B) Retropulsion of canal fragments to 50% of canal size

(C) Kyphosis of 15�

(D) Post-void residual of 450 mL

(E) Presence of a posterior lamina fracture

Explanation:Generalized treatment algorithms for burst fractures involving upper lumbar

spine have relative indications for surgery that include 50% loss of height, 25% of kyphosis,
and 50% canal compromise. Absolute indications for decompression include neurological
deficits including a potential conus injury. Post-void residual of > 450 mL is suggestive of
sacral root injury at the level of conus. Bradford suggests that anterior decompression of this
injury has favorable outcome with frequent resolution or improvement of symptoms.
 6- An injury associated with a type 1 fracture of the odontoid is:

(A) Concomitant fracture of the body at C2

(B) Burst fracture of the lumbar spine

(C) Atlanto-occipital dislocation

(D) Rupture of the transverse ligament

(E) Associated Jefferson fracture of the ring of C1

Explanation:

Type 1 fractures are a rare entity. They are frequently treated with immobilization with a
hard collar if isolated. There have been numerous reports in the literature of a type 1
fracture of the odontoid being associated with an atlanto-occipital dislocation, and this injury
must be suspected. The potential for missing atlanto-occipital dislocation may lead to a fatal
outcome.

7- Six months ago, an 11-year-old premenarchal girl with adolescent idiopathic

scoliosis had a right thoracic curve from T5 to T12 measuring 20�. Her physical
examination was normal. She returned to the office and a standing posteroanterior
radiograph demonstrates a 28� right thoracic curve from T5 to T12; she is Risser
stage 0. A lateral radiograph shows a thoracic kyphosis of 10�. At this time, you
recommend:

(A) Repeat radiograph in 6 months

(B) Thoracic flexibility exercises

(C) Full-time use of a thoracolumbosacral orthosis

(D) Electrical stimulation

(E) Posterior spinal fusion with instrumentation

Explanation:

In skeletally immature patients with adolescent idiopathic scoliosis and curves approaching
30� with documented progression, bracing may be effective at preventing further
progression of the curve. Risk of progression in adolescent idiopathic scoliosis is related to
curve magnitude and remaining growth potential. The risk of further progression in this
patient is 68%, and bracing is indicated. Electrical stimulation and physical therapy have not
been shown to affect the natural history of scoliosis. Surgery may be indicated in patients
with more severe curves. In the sagittal plane, hypokyphosis is usually present in adolescent
idiopathic scoliosis.
 8- The most appropriate indication, after scoliosis curve progression, for a posterior
spinal fusion with segmental instrumentation to the pelvis in a severely involved
spastic quadriplegic child with cerebral palsy is:

(A) Pelvic obliquity

(B) Deterioration in function

(C) Poor nutritional status

(D) Normal pulmonary function

(E) Non-ambulatory status

Explanation:

Patients with a spastic quadriplegic pattern of cerebral palsy have higher than 25% incidence
of scoliosis. This neuromuscular scoliosis differs from that of idiopathic scoliosis in that it is
usually a long C-shaped thoracolumbar curve that may involve the pelvis. Frequently,
posterior spinal fusion from T1 to the sacrum is required with rigid segmental
instrumentation with stabilization to the pelvis (a unit rod).

Indications for fusion in these patients include curve progression and loss of function. This
can include loss of sitting ability, poor pulmonary function due to poor pulmonary toiletting,
and recurrent infection such as decubitus ulcers. These children are most often non-
ambulators and are dependent on wheelchair sitting supports for postural control.

9- A 10-year-old boy with Down syndrome presents with his parents who have
noticed that his endurance for walking seems to have decreased, and he seems
clumsier. Your physical examination reveals generalized ligamentous laxity, but no
other musculoskeletal abnormalities. His neurological examination is normal. His
flexion/extension cervical spine radiographs are abnormal. The most likely
pathophysiology is:

(A) Os odontoideum

(B) Arnold-Chiari malformation

(C) Klippel-Feil syndrome

(D) Hypothyroidism

(E) Transverse atlantal ligament insufficiency

Explanation:

Children with Down syndrome (trisomy 21) have a higher incidence of hypothroidism,
congenital heart disease, leukemia, and slipped capital femoral epiphysis. About 20% of
children with Down syndrome develop atlantoaxial instability due to incompetence of the
transverse atlantal ligament, and fortunately, most are asymptomatic.

Patients with Down syndrome should be screened for atlantoaxial instability with routine
flexion/extension lateral cervical radiographs, especially prior to athletic participation. An
atlanto-dens interval (ADI) of >5 mm should be treated with activity restriction in the
absence of myelopathy. With symptoms of cervical myelopathy or an ADI >7 mm, an
atlantoaxial arthrodesis is indicated.
 10- 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

Explanation:

This patient has a slipped vertebral apophysis as a result of trauma. This is analagous to a
Salter-Harris 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.
Figure 1

Figure 2

11- A 42-year-old male has a history of 6 months of pain in the lower thoracic region.
Recently, the patient developed weakness in the right lower extremity, bladder
and bowel movement. Plain x-rays were normal, but an magnetic resonance
imaging (MRI) showed a posterolateral thoracic disk herniation at the level of T10-
T11 (Slides 1 and 2). Which of the following is the best suggested treatment?

(A) Bed rest

(B) Thoraco-lumbar orthosis

(C) Laminectomy and decompression

(D) Diskectomy through thoracotomy or costotransverectomy

(E) Thoracotomy, vertebractomy, strut graft and internal fixation

Explanation:

Conservative treatment should be considered for patients without major neurologic deficits.
Posterior laminectomy and decompression provides inadequate exposure of the herniated
Disk. Vertebractomy, strut bone graft and instrumentation are not necessary. Thoracotomy
and costotransversectomy are commonly used for disk herniations at the levels of T4-T12.
 12- The superior aspect of the iliac crest often bisects this midline spinal structure:

(A) L2/L3 disk space

(B) L3 vertebral body

(C) L3/L4 disk space

(D) L4/L5 disk space

(E) L5/S1 disk space

Explanation:

The L4/L5 intervertebral disk space is located by placing your fingers at the top of a patient's
iliac crests, while allowing your thumbs to meet at the midline of the spine between the
palpable L4 and L5 spinous processes.

13- A 28-year-old woman complains of pain and numbness in her lower legs bilaterally
for approximately 2 months following strenuous moving of furniture. She now
states that she has not voided in the past 48 hours and that her abdomen area is
markedly distended. Which is the most likely causative lesion of the patient's
symptoms:

(A) Cauda equina syndrome

(B) Far-lateral disk herniation

(C) Posterolateral disk herniation

(D) Spinal stenosis

(E) Muscle spasms of the lower back

Explanation:

This patient's symptoms are most consistent with cauda equina syndrome. This surgical
emergency can present with bowel or bladder dysfunction, and bilateral lower extremity
symptoms are also often present.
 14- What is the most common sequence of steps performed during a midline open
disectomy in the treatment and excision of a herniated posterolateral lumbar disk:

(A) The paraspinal musculature is stripped from the lamina of the vertebra, the ligamentum flavum is excised,
portions of the superior and inferior lamina are removed, the nerve root and dural sac is retracted, and the
disk herniation is excised.
(B) The ligamentum flavum is excised, the paraspinal musculature is stripped from the lamina of the vertebra,
portions of the superior and inferior lamina are removed, the nerve root and dural sac is retracted, and the
disk herniation is excised.
(C) The ligamentum flavum is excised, the paraspinal musculature is stripped from the lamina of the vertebra,
the nerve root and dural sac is retracted, portions of the superior and inferior lamina are removed, and the
disk herniation is excised.
(D) The paraspinal musculature is stripped from the lamina of the vertebra, the disk herniation is excised, the
ligamentum flavum is excised, the nerve root and dural sac is retracted, and portions of the superior and
inferior lamina are removed.
(E) Ligamentum flavum is excised, the disk herniation is excised the paraspinal musculature is stripped from
the lamina of the vertebra, the nerve root and dural sac is retracted, and portions of the superior and
inferior lamina are removed.

Explanation:

The traditional surgery for the excision of a herniated posterolateral lumbar disk is by means
of a midline incision. This procedure is then performed in a stepwise fashion: The paraspinal
musculature is stripped from the lamina of the vertebra; the ligamentum flavum is then
excised; portions of the superior and inferior lamina are removed; and the nerve root and
dural sac are identified and carefully retracted. This is followed by excision of the herniated
disk material and wound closure.

15- One traditional surgery performed for the treatment of a symptomatic

posterolateral lumbar disk herniation is a partial laminectomy and lumbar disk
excision by means of a midline incision. What is the long-term (>2 years) success
rate for relief of both leg and low back pain, respectively:

(A) 80% and 93%

(B) 93% and 80%

(C) 93% for both

(D) 80% for both

(E) 55% and 65%

Explanation:

The success rate following a partial laminectomy and lumbar disk excision for a
posterolateral herniated disk for relief of both leg and low back pain is predictable at 93%
and 80%, respectively.
 16- When performing a neurological examination, if a surgeon has a patient resist
thigh adduction against resistance, the surgeon is testing which nerve(s):

(A) Segmental nerves from T1-L1

(B) Femoral nerve

(C) Obturator nerve

(D) Sciatic nerve

(E) Segmental nerves from L5-S1

Explanation:

The obturator nerve innervates most of the hip adductor group, which consists of neurologic
levels L2, L3, and L4.

17- When trying to distinguish hamstring tightness/discomfort from sciatic

pain/radiculopathy, surgeons can perform a straight-leg raise test on the affected
side until the point at which the patient develops discomfort. This is followed by
slightly lowering the affected extremity. While holding the patient's leg in this
position, what maneuver could be performed in order to help reproduce true
sciatic pain:

(A) Rotate the patient's foot medially 10�

(B) Rotate the patient's foot laterally 10�

(C) Plantarflex the patient's foot

(D) Dorsiflex the patient's foot

(E) Perform a Babinski test

Explanation:

Dorsiflexion of the foot, known as Braggard test, adds additional tension or stretch to the
sciatic nerve and may help reproduce the sciatic pain/radiculopathy
 18- A 52-year-old man sustained an L1 burst fracture after falling from a ladder 3
weeks ago. He was found neurologically intact after initial examination. He has
been treated with conservative management since the accident, but he now
complains of an inability to void along with numbness and tingling in both of his
legs. Computed tomography scan shows worsening conus compression. On
physical examination, you discover that he has weak anal sphincter tone. Your
next step in the treatment of this patient should be:

(A) Anterior decompression and fusion with grafting with or without instrumentation

(B) High-dose steroids

(C) Laminectomy

(D) Posterior fusion with instrumentation

(E) Continue conservative management with follow-up in 1 month

Explanation:

This patient has deteriorating neurological findings involving the cauda equina; therefore,
surgical decompression is indicated. An anterior approach will directly decompress the neural
structures.

 Performing a laminectomy alone is actually contraindicated as it may increase

potential spinal instability.
 A posterior approach to achieve a fusion with instrumentation may not fully
decompress the neural structures, although this is somewhat controversial

Slide 1

19- This radiograph shows a grade I spondylolisthesis of L5 on S1. This is due to a

defect in what anatomical area:
 (A) Superior articular process

(B) Inferior articular process

(C) Pars interarticularis

(D) Pedicle

(E) Lamina

Explanation:

The anatomical region involved in a spondylolisthesis is the pars interarticularis that is

located between the superior and inferior articular processes and is a high stress area of
relatively thinner bone.

20- The natural history of an asymptomatic thoracic disk herniation is:

(A) Rapid progression to a symptomatic thoracic disk herniation

(B) A slow progression to a symptomatic thoracic disk herniation

(C) To remain asymptomatic

(D) To completely resorb and remain asymptomatic

(E) To completely resorb and progress to a degenerative disk

Explanation:

The natural history of an asymptomatic thoracic disk herniation is to remain asymptomatic

and exhibit little change in size. In a series of 48 asymptomatic thoracic disk herniations,
Wood found that all disks remained asymptomatic at follow-up with little fluctuation in size of
the disk.

21- 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

Explanation:

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.
 22- An absolute indication for surgical management of thoracolumbar burst fractures
is:

(A) Canal compromise greater than 10%

(B) Canal compromise greater than 30%

(C) Kyphotic deformity greater than 10%

(D) Kyphotic deformity greater than 30%

(E) Progressive neurologic deficit

Explanation:

Patients with a neurologic deficit or a progressive neurologic deficit should undergo operative
decompression. Controversy exists as to the amount of kyphosis and canal compression that
is considered acceptable. Support can be found in the literature for both operative and
nonoperative management of neurologically intact burst fractures. Each patient must be
evaluated on a case by case basis and followed closely after injury.

23- How common are spinal infections following penetrating injury to the spine:

(A) 2%

(B) 20%

(C) 60%

(D) 80%

(E) 95%

Explanation:

One study found that 5 of 239 patients with gunshot or stab wounds developed meningitis,
paravertebral abscess, vertebral osteomyelitis, or epidural abscess.

24- Which of the following patients is not at increased risk for isthmic
spondylolisthesis:

(A) Football lineman

(B) Gymnast

(C) Eskimo

(D) Nonambulatory patient

(E) Weight lifter

Explanation:

Isthmic spondylolisthesis is most common in white men and least common in black women.
It is thought to arise from repetitive hyperextension of the lumbar spine causing a stress
fracture of the pars intra-articularis. Sports such as weight lifting, gymnastics, football, and
javelin throwing have a particularly high incidence of this condition. Isthmic spondylolisthesis
is never present at birth and is rare in nonambulatory patients.
 25- A patient with radicular pain is experiencing skin numbness on the medial aspect
of his leg and great toe. Which of the following nerve roots is effected:

(A) L2

(B) L3

(C) L4

(D) L5

(E) S1

Explanation:

When examining patients, it is important to remember the sensory dermatomes. The medial
aspect of the leg, foot, and great toe are supplied by the L4 lumbosacral nerve root. The
tibial crest separates the L4 and L5 dermatomes on the leg.

 L4 Medial aspect of leg, foot, and great toe

 L5 Lateral aspect of the leg and toes 2 through 4
 S1 Lateral aspect of the fifth toe

26- Which of the following sensory areas is affected by compression of the C6 nerve
root:

(A) Lateral forearm into the radial side of the hand

(B) Base of neck, medial shoulder

(C) Posterior neck, occiput

(D) Ulnar side of the forearm and hand

(E) Posterolateral forearm into the middle finger of the hand

Explanation:

It is important to remember the sensory dermatome when examining patients who have
neck and upper extremity pain:
C3 Posterior neck, occiput
C4 Base of neck, medial shoulder
C5 Base of neck to shoulder and upper arm
C6 Lateral forearm into the radial side of the hand
C7 Posterolateral forearm into the middle finger of the hand
C8 Ulnar side of the forearm and hand
 27- Computerized tomography scans are efficacious for detecting which of the
following conditions:

(A) Marrow changes

(B) Lytic lesion suspected on Plain L spine film

(C) Intrathecal abnormalities

(D) Instability patterns

(E) Intervertebral disk hydration

Explanation:

Computerized tomography scans are excellent for assessing bone structure, especially in
patients with metastatic bone disease and primary bone tumors of the spine. Computerized
tomography is useful for distinguishing between bone and soft tissue compression in neural
compressive disorders.

28- A 35-year-old construction worker has left leg pain and difficulty walking. His
examination is normal except for decreased sensation to the lateral border of the
left foot, the inability to walk on the toes of the left foot, and a positive stretch test
producing left heel and lateral foot pain. A magnetic resonance image shows a
large posterolateral herniated nucleus pulposus on the left side at L5-S1. The gait
abnormality is most likely due to:

(A) Cauda equina syndrome

(B) L5 radiculopathy and gastrocsoleus muscle complex denervation

(C) L5 radiculopathy and extensor hallucis longus weakness

(D) S1 radiculopathy and gastrocsoleus muscle complex denervation

(E) S2 denervation and extensor hallucis longus weakness

Explanation:

In the lumbar spine, direct posterior and posterolateral disk herniations typically compress
the traversing nerve root. In this patient, the herniated disk at the L5-S1 level compresses
the shoulder of the S1 nerve root as it comes off the dural sac. The S1 nerve root supplies
sensation to the posterior calf and lateral border of the foot, and motor chiefly to the
gastrocsoleus muscle complex.
 29- Following an osteoporotic compression fracture, the risk of sustaining another
compression fracture at a different level is increased by:

(A) 2 times

(B) 5 times

(C) 8 times

(D) 10 times

(E) 15 times

Explanation:

Osteoporosis is a systemic disease affecting more than 24 million Americans. Osteoporosis

results in progressive bone mineral loss and concurrent changes in bony architecture, which
leave the spinal column vulnerable to compression fractures, often after minimal or no
trauma. There are an estimated 700,000 osteoporotic vertebral compression fractures (VCFs)
in the United States each year, of which more than one third become chronically painful.
Approximately 85% of VCFs are due to primary osteoporosis and the remainder due to
secondary osteoporosis or malignancies. These VCFs lead to progressive sagittal spine
deformity and changes in spinal biomechanics and are believed to contribute to a fivefold
increased risk of further fracture by virtue of force transmission to weak vertebrae above or
below. Whether the fracture is painful or not, the spinal deformity caused by two or more
fractures dramatically impacts health, daily living, and medical costs through loss of lung
capacity, loss of appetite, reduced mobility, chronic pain, and/or clinical depression.

30- Normal sagittal thoracic alignment is:

(A) 5� to 10� of kyphosis due to the adjacent lordotic cervical and lumbar segments

(B) Straight because of the rib cage

(C) Lordotic to support the body weight anteriorly

(D) 20� to 50� of kyphosis between T1 and T10

(E) 60� to 80� of kyphosis between T1 and T10

Explanation:

Thoracic kyphosis has contributions from the trapezoidal shapes of the thoracic vertebrae,
from the intevertebral disk positions, and from the stiffness of the ribs and sternum. The
reported normal values range from 20� to 50�.
Slide 1

31- 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. A
magnetic resonance image (MRI) of the patient is obtained (Slide). What does the
MRI show:

(A) Critically severe stenosis at L3-L4 and L4-L5

(B) Moderate lumbar spinal stenosis at L3-L4 and L4-L5

(C) Herniated lumbar disk

(D) Moderate lumbar stenosis at L3-L4, L4-L5, and L5-S1

(E) Lumbar metastatic disease

Explanation:The MRI shows moderately severe lumbar stenosis at L3-L4 and L4-L5. While
the degree or severity of stenosis remains subjective, terming this stenosis critical is an
exaggeration. The section of the axial images at L5-S1 is not in plane with the disk, hence
there appears to be lateral recess stenosis at this level also. The sagittal images, however,
do not confirm this diagnosis. There is no evident lumbar disk herniation, and there are no
findings indicative of lumbar metastatic disease.

32- 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.

Explanation:Despite treatment, a poor prognosis is given to patients with malignant

intramedullary tumors. The median survival time for patients with cervical tumors is 3 to 6
months. Surgical excision, radiation, and chemotherapy are not found to significantly
improve survival. Treatment is generally supportive.
 33- 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.

Explanation:

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

34- 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

Explanation:

Administration of methylprednisolone within 8 hours of injury provides benefit to patients

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

35- 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

Explanation:The prognosis of herniated lumbar disks is generally good regardless of

treatment. Patients operated on for proven disk herniations improved more rapidly than
patients treated nonoperatively. However, within 4 to 5 years, the outcomes begin to
approximate each other.
 36- The predominant cause of low back pain in the general population, aside from the
general sprain and strains of the paraspinal structures, is attributed to:

(A) Spondylolisthesis

(B) Herniated nucleus pulposus

(C) Spinal stenosis

(D) Degenerative disk disease

(E) Vascular insufficiency

Explanation:

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

37- An otherwise healthy 56-year-old patient with suspected spinal stenosis after
history and physical examination undergoes plain radiography that is unremarkable
for spondylolisthesis. The next feasible imaging modality that is indicated in aiding
the diagnosis is:

(A) No more imaging studies are needed

(B) A computed tomography myelogram

(C) Magnetic resonance imaging

(D) Ultrasound

(E) Spinal angiogram

Explanation:

Although a computed tomography myelogram is slightly more specific and sensitive than
magnetic resonance imaging (MRI) in evaluating lumbar stenosis, MRI is almost as sensitive
and it is noninvasive. Therefore, in an otherwise healthy patient without contraindications, an
MRI should be considered as the next imaging modality.
 38- Superior articulating facets in the lumbosacral spine differ from those in the
thoracic spine because facets in the lumbosacral spine:

(A) Face posteriorly

(B) Face dorsomedially

(C) Have a thicker facet joint capsule

(D) Face superolaterally

(E) Are fused and are not true joints

Explanation:

The paired superior articular facets are directed dorsomedially with their corresponding
inferior articular processes directed ventrolaterally. These diarthrodial articulations possess
thin, lax joint capsules capable of a limited gliding articulation between adjoining vertebrae.
They permit flexion, lateral bending and extension, but resist rotation due to both size and
facet orientation. The facets alone can bear up to 18% of the compressive load.

39- A 26-year-old man who was involved in a motor vehicle accident is found to have
a T12 compression fracture on plain radiography without evidence of posterior
extrusion. The likelihood of finding another fracture in the spinal axis with further
evaluation is:

(A) Highly remote, these fractures are usually isolated

(B) 10% to 15%

(C) 50% to 75%

(D) A low thoracic fracture is almost always associated with another fracture in the spine.

(E) The incidence of noncontiguous-associated fractures in the spine is not known.

Explanation:

A thorough workup in these patients is essential; approximately 10% to 15% of patients will
have noncontiguous injuries located elsewhere in the spine.

40- The watershed zone of the spinal cord most closely correlates with which region of
the spinal cord:

(A) C5-C7

(B) T4-T6

(C) T7-T9

(D) T11-L1

(E) L3-L5

Explanation:

A watershed zone refers to an area that is supplied purely by end arteries. Therefore, during
periods of hypoperfusion, it is the most likely region to sustain an ischemic injury. In the
spinal cord, this region lies in the T7-T9 region as it is a watershed zone between the rostral
anterior spinal artery distribution and the caudal dominant lumbar segmental artery.
 41- Which of the following is the imaging modality of choice with the highest relative
sensitivity and specificity in patients with suspected vertebral osteomyelitis:

(A) Plain radiography

(B) Computed tomography with contrast administration

(C) Magnetic resonance imaging with contrast administration

(D) Post myelogram computed tomography

(E) Vertebral osteomyelitis is primarily a clinical diagnosis

Explanation:Magnetic resonance imaging (MRI) is the modality of choice for spinal

infections. An MRI study provides excellent visualization of the neural elements and can
determine whether the inflammatory process extends beyond the margins of disk and bone.
MRI also provides excellent regional anatomic information. Scans performed with and
without intravenous gadolinium are diagnostic in 90% to 95% of cases.

42- Which of the following levels most significantly contributes to the blood supply of
the cervical spinal cord:

(A) C2 (accompanying the left C2 spinal nerve)

(B) C4 (accompanying the right C4 spinal nerve)

(C) C6 (accompanying the left C6 spinal nerve)

(D) C7 (accompanying the right C7 spinal nerve)

(E) T1 (accompanying the right T1 spinal nerve)

Explanation:The major blood supply to the cervical spinal cord comes from the anterior
spinal artery, which arises from the deep cervical artery. This vessel most commonly
accompanies the left C6 spinal nerve.

43- Patients with Brown-S�quard syndrome usually presents with:

(A) Ipsilateral paralysis, loss of contralateral vibration and touch sensation, and loss of ipsilateral pain and
temperature sensation
(B) Ipsilateral paralysis and loss of contralateral vibration, and touch, pain, and temperature sensation

(C) Ipsilateral paralysis, loss of ipsilateral vibration and touch sensation, and loss of contralateral pain and
temperature sensation
(D) Contralateral paralysis, loss of ipsilateral vibration and touch sensation, and loss of contralateral pain and
temperature sensation
(E) Contralateral paralysis, loss of contralateral vibration and touch sensation, and loss of ipsilateral pain and
temperature sensation

Explanation:Brown-S�quard Syndrome usually results from hemisection of the spinal cord,

which is often a result of trauma (eg, penetrating stab wounds). Clinical presentation usually
consists of:

 Ipsilateral paralysis
 Loss of ipsilateral vibration and touch sensation
 Loss of contralateral pain and temperature sensation
 44- When an osteoid osteoma occurs in the spine, it can involve all of the following
except:

(A) Facets

(B) Transverse processes

(C) Pedicles

(D) Rib heads adjacent to thoracic vertebrae

(E) Vertebral body

Explanation:

When an osteoid osteoma occurs in the spine, involvement of the posterior elements of the
vertebra is typical and includes:

 Lamina
 Pedicles
 Transverse processes
 Facets
 Rib heads adjacent to thoracic vertebrae

45- Typical symptoms of a spinal osteoblastoma include all of the following except:

(A) Torticollis

(B) Painful scoliosis

(C) Stiffness

(D) Diskogenic pain

(E) Radicular symptoms

Explanation:

The most common symptoms of spinal osteoblastomas include:

 Pain
o Usually the first and most common presenting symptom
o Night pain is not as common as it is with osteoid osteomas
 Night pain is not as common as it is with osteoid osteomas
 Painful scoliosis
 Torticollis
 Stiffness
 Radicular symptoms usually due to mass effect
 46- Which of the following statements is false regarding minimally invasive
transperitoneal anterior lumbar interbody fusion:

(A) This technique may be safely performed at all lumbar levels.

(B) This technique allows direct access to pathology in the vertebral body.

(C) Laparoscopy is of great value in the transperitoneal approach to the anterior lumbar spine.

(D) There is a potential risk of injuring the aorta and its bifurcation with this technique.

(E) None of the above

Explanation:

Due to the potential risk of injury to the aorta and its bifurcation, which occurs at the L4
level, this procedure is difficult and may be impossible to perform above the L4 level.
Retroperitoneal approaches allow access to more superior lumbar levels due to the more
lateral trajectory taken to avoid the aorta and its bifurcation.

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

(A) There is no contraindication to return to play in this patient.

(B) There is a relative contraindication to return to play in this patient.

(C) There is an absolute contraindication to return to play in this patient.

(D) Because this patient has suffered repeated episodes of transient pain after tackles, he is obviously
experienced enough to not need education and counseling to help prevent recurrence.
(E) The patient should not participate in football games, but should feel free to continue lifting weights and
practicing.

Explanation:

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

(A) Spina bifida

(B) Scheuermann�s kyphosis

(C) Degenerative disk disease

(D) Trauma

(E) Osteoporosis

Explanation:

Schmorl�s nodes are seen in association with several disorders including Scheuermann�s
kyphosis, degenerative disk disease, trauma, and osteoporosis. Schmorl�s nodes are not
commonly seen in patients with spina bifida

49- Which approach(es) will provide access to the middle and anterior columns of the
thoracic spine:

(A) Posterior

(B) Anterior (thoracotomy)

(C) Anterior and posterolateral (costotransversectomy)

(D) Interlaminar

(E) None of the above

Explanation:

The anterior and posterolateral approaches provide access to the vertebral body (the
anterior and middle columns of the spine) for performance of a corpectomy procedure, for
example.

50- What percentage of patients with cervical myelopathy living in North America
exhibit ossification of the posterior longitudinal ligament:

(A) 1%

(B) 5%

(C) 10%

(D) 25%

(E) 50%

Explanation:Although ossification of the posterior longitudinal ligament is considered most

common in the Japanese population, 25% of North Americans with cervical myelopathy
exhibit signs of this condition.
 SPINE
356 Q
3/7 ( 50Q )

COLLECTED BY
DR. A. AWAJI
 1- A 35-year-old man presents 3 years after a motor vehicular trauma. It is now 3
years following operative stabilization of the spine at C7. He complained of mild
weakness in his right upper extremity at the biceps level and has corresponding
parasthesias in the right thumb. The next step in the evaluation of this patient is:

(A) Anteroposterior lateral flexion extension radiographs of the cervical spine

(B) Computerized tomography scan of the cervical spine

(C) Magnetic resonance imaging of the cervical spine

(D) Physical therapy with range of motion and strengthening exercises of both upper extremities

(E) Anti-inflammatory medication for presumed tendonitis

Explanation:

The patient is a 35-year old man has been stable since his injury. The most important
evaluation for this individual would be magnetic resonance imaging to rule out potential
cervical cord syrinx that has occurred given new onset weakness and sensory changes
proximal to his injury.

2- 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 bicep and tricep 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

Explanation:

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.
 3- A 15-year-old boy with adolescent idiopathic scoliosis has a right thoracic curve
from T5 to T11 measuring 45� and a left thoracolumbar curve from L1 to L4
measuring 32�. He is Risser stage 2 and has a hypokyphotic thoracic spine.
Bending films demonstrate moderate flexibility in the lumbar curve. He was
prescribed a thoracolumbosacral orthosis since age 14, but his scoliosis has
progressed. His physical exam reveals a prominent right rib hump and mild right
shoulder elevation. His head is centered above his pelvis. His neurological
examination is normal. You recommend:

(A) Continued full-time use of the orthosis until skeletal maturity

(B) Discontinuation of the orthosis due to failure

(C) Repeat evaluation in 6 months

(D) Posterior spinal fusion T5-L4 with instrumentation

(E) Posterior spinal fusion of the thoracic curve only with instrumentation

Explanation:This patient has a right thoracic curve with a compensatory left lumbar curve
pattern of adolescent idiopathic scoliosis. There has been documented progression into the
surgical range despite bracing, and he still has some growth remaining. Surgical intervention
is indicated. This curve pattern (King II, Lenke D) can be approached posteriorly with
thoracic fusion alone to the neutral and stable vertebra and instrumentation to obtain and
maintain correction. The unfused lumbar curve will spontaneously correct to balance the
fused thoracic curve. Care must be taken to avoid fusion into the lower lumbar spine and
preserve motion segments.

4- 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

Explanation: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:

 Caf� 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.
 5- 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

Explanation:

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.

6- A 28-year-old woman complains of pain and numbness in her lower legs bilaterally
for approximately 2 months following strenuous moving of furniture. She now
states that she has not voided in the past 48 hours and that her abdomen area is
markedly distended. What diagnostic test must be performed in order to support
the suspected diagnosis:

(A) Voiding cystourethrogram

(B) Magnetic resonance imaging of the lumbosacral spine

(C) Posteroanterior and lateral plain radiographs of the lumbar spine

(D) Spinal puncture to rule out infection

(E) Electromyography of the lower extremities

Explanation:

Based on history and physical examination, the suspected diagnosis is cauda equina
syndrome. This potential surgical emergency requires immediate spinal imaging. A magnetic
resonance imaging of the lumbosacral spine is the most appropriate test.
 7- 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

Explanation:

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.

8- The following nonoperative treatments have not been proven effective in the early
acute stage (2 weeks to 3 months) of low back pain:

(A) Nonsteroidal anti-inflammatory drugs

(B) Bed rest

(C) Anesthetic/corticosteriod injections into the epidural space

(D) Intrathecal anesthetic/corticosteriod injections

(E) Intraspinal anesthetic/corticosteriod injections

Explanation:

 Nonsteroidal anti-inflammatory drugs have been shown effective and are

frequently used during the acute phase of low back pain. Their main effect is to
alleviate soft tissue inflammation that is often present in the early phase.
 Patient questionnaires have identified bed rest as among the most frequently
prescribed treatments for lower back pain. It has been shown that bed rest results
in reduced intradiskal pressure that occurs in the supine position.
 Anesthetic/corticosteriod injections are widely advocated for the treatment of low
back pain and can be administered along nerve roots, into the sacroiliac joints,
intervertebral disks, paraspinal soft tissues, and the epidural space or intrathecally
for many conditions. However, there is no evidence that intraspinal steroids have
an effective role in the acute management of low back pain.
 9- 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

Explanation:

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.

10- Which disorder does not represent a rheumatologic/inflammatory condition

associated with causing low back pain:

(A) Rheumatoid arthritis

(B) Reiter syndrome

(C) Psoriatic arthritis

(D) Ankylosing spondylitis

(E) Osteoarthritis

Explanation:

Although osteoarthritis is the most common arthritic disorder associated with low back pain,
it is not a rheumatologic condition. Rheumatoid arthritis, Reiter syndrome, psoriatic arthritis,
and ankylosing spondylitis are all rheumatologic or inflammatory conditions associated with
the development of low back pain.

11- 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%

Explanation:

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 (if they are involved).
 12- A 35-year-old woman presents with severe back pain. Radiographic evaluation
reveals a thoracic curve of 70� and a loss of thoracic kyphosis. Surgery is
recommended to correct the deformity. Which of the following tests must be
ordered as part of the preoperative evaluation:

(A) Electrocardiogram (ECG)

(B) Pulmonary function tests

(C) Electromyelogram (EMG)

(D) Chest radiograph

(E) Somatosensory evoked potentials (SSEP)

Explanation:

Thoracic curves greater than 65� may affect pulmonary function, especially when they are
combined with thoracic lordosis. This patient displays a thoracic curve of 70� and a loss of
the normal thoracic kyphosis; therefore, pulmonary function tests are part of the routine
evaluation.

13- 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

Explanation:

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.

14- Symptoms of spinal infection may include all of the following except:

(A) Activity-related back pain

(B) Fever

(C) Neurological deficit

(D) Torticollis

(E) Decreased spinal range of motion

Explanation:

Neck or back pain associated with spinal infection is relentless and constant. The pain is not
usually associated with activity. There may be night pain as well. Other symptoms and signs
are variable, requiring a high degree of suspicion. Fever occurs less than 50% of the time
and neurological deficit less than 10% of the time. Paraspinal muscle spasms may result in
decreased range of motion or torticollis.
 15- All of the following organisms may cause granulomatous opportunistic spinal
infection in immunocompromised patients except:

(A) Mycobacteria

(B) Nocardia

(C) Actinomyces

(D) Staphylococcus

(E) Brucella

Explanation:

Staphylococcal infection is typically pyogenic, not granulomatous.

16- Antibiotic treatment for spinal tuberculosis includes all of the following except:

(A) Isoniazid

(B) Ethambutol

(C) Pyrazinamide

(D) Rifampin

(E) Cefotaxime

Explanation:

A four-drug regimen against spinal tuberculosis is recommended because of the high

prevalence of organism resistance. Cefotaxime is a cephalosporin not active against
mycobacterial infection.

17- Which of the following statements is true regarding the bulbocavernosus reflex:

(A) This reflex is a sign of a spinal cord injury.

(B) This reflex is mediated by the S3 and S4 segments of the spinal cord.

(C) This reflex may be elicited by pulling on an indwelling catheter that causes a contraction of the cremaster
muscle.
(D) This reflex often means that a spinal cord injury is complete.

(E) This reflex is mediated by the S3 and S4 segments of the spinal cord, and this reflex often means that a
spinal cord injury is complete.

Explanation:

The bulbocavernosus reflex is mediated by the S3 and S4 regions of the spinal cord. This
reflex is elicited by pulling on an indwelling catheter or squeezing the glans penis or clitoris
and observing contraction of the anal sphincter. The bulbocavernosus reflex may be absent
soon after a spinal cord injury due to spinal shock, but it often returns in 24 to 48 hours and
indicates the end of spinal shock. A better sense of prognosis of a spinal cord injury is
possible after spinal shock has ended.
 18- Which of the following is the best indication for a laminectomy in a patient who
has sustained a thoracolumbar burst fracture with a neurologic deficit:

(A) Spinal cord compression

(B) A lamina fracture is present on a computerized tomography scan

(C) A small epidural hematoma is present on a magnetic resonance image

(D) Greater than 30� of kyphosis on a lateral radiograph

(E) Greater than 50% canal compromise on a computerized tomography scan

Explanation:

A laminectomy is never indicated as the sole method of treatment for a thoracolumbar burst
fracture. Laminectomy creates additional instability at the level of the fracture and does not
effectively decompress the spinal cord, which is compressed anteriorly from the retropulsed
bony fragment. When lamina fractures are present on a computerized tomography scan,
there is a significant incidence of dural tears and entrapped nerve tissue within the lamina
fracture. Surgeons should consider performing a laminectomy in addition to other methods
of achieving anterior decompression and stabilization of a burst fracture with a lamina
fracture.

19- Which recommendations for the pharmacologic treatment of spinal cord injuries
resulted from the NASCIS-II trials:

(A) Treat all patients with a spinal cord injury with methylprednisolone 30 mg/kg over 1 hr followed by a
maintenance rate of 5.4 mg/kg/hr for 23 hours.
(B) Treat only patients who present within the first 8 hours of a spinal cord injury with methylprednisolone 30
mg/kg over 1 hr followed by a maintenance rate of 5.4 mg/kg/hr for 23 hours.
(C) Treat all patients with a spinal cord injury with decadron 10 mg/kg bolus followed by 1 mg/kg/hr for 23
hours.
(D) Treat only patients who present within the first 8 hours of a spinal cord injury with decadron 10 mg/kg
bolus followed by 1 mg/kg/hr for 23 hours.
(E) Treat only patients who present with complete spinal cord injuries within the first 8 hours of a spinal cord
injury with methylprednisolone 30 mg/kg over 1 hr followed by a maintenance rate of 5.4 mg/kg/hr for 23
hours.

Explanation:

The NASCIS-II recommendations are to treat patients who present with an incomplete spinal
cord injury within 8 hours of the injury with methylprednisolone 30 mg/kg over 1 hour
followed by a maintenance rate of 5.4 mg/kg/hr for 23 hours. Because it is difficult to tell
which patients have a complete or incomplete spinal cord injury in this time frame due to
spinal shock, it has generally been accepted to treat all patients with spinal cord injuries with
this treatment protocol as long as they present within the first 8 hours of the injury.
 20- If the flexor carpi radialis is weak after a spinal decompression, then which of the
following nerve roots is injured:

(A) C5

(B) C6

(C) C7

(D) C8

(E) T1

Explanation:

The flexor carpi radialis is the most powerful wrist flexor and is innervated by the C7 cervical
spine nerve root. The flexor carpi ulnaris, which is weaker than the flexor carpi radialis, is
innervated by the C8 cervical spine nerve root.
Slide 1
21- A patient comes into your office with neck and arm pain. The patient�s plain radiograph
is shown (Slide). Which of the following signs is most likely to be found on physical
examination:

(A) Triceps muscle weakness

(B) Deltoid muscle weakness

(C) Finger flexion weakness

(D) Numbness on the lateral forearm into the radial side of the hand

(E) Numbness on the ulnar side of the forearm and hand

Explanation:

The lateral radiograph shows narrowing of the C5-C6 intervertebral disk space with
osteophytes arising anteriorly and posteriorly. This degenerative process results in facet joint
hypertrophy, osteophytes in the uncovertebral joints, and hypertrophy of the ligamentum
flavum. The C6 nerve root is compressed resulting in numbness on the lateral forearm into
the radial side of the hand. Elbow and wrist extension may be affected, and the biceps
tendon reflex may be diminished or absent.

It is important to remember the sensory dermatome when examining patients who have
neck and upper extremity pain:
C3 Posterior neck, occiput
C4 Base of neck, medial shoulder
C5 Base of neck to shoulder and upper arm
C6 Lateral forearm into the radial side of the hand
C7 Posterolateral forearm into the middle finger of the hand
C8 Ulnar side of the forearm and hand
Slide 1
22- 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

Explanation:

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.

23- Which of the following populations is most at risk for compression fractures of the spine:

(A) Middle-aged black women

(B) Elderly caucasian men

(C) Menopausal females of Inuit (Alaskan native) descent

(D) Elderly fair-skinned women of northern European descent

(E) Heavy laborers

Explanation:

Osteoporosis is an age-related decrease in bone mass usually associated with a loss of

estrogen in postmenopausal women. Sedentary, thin white women of northern European
descent are most severely affected. In addition, smoking, heavy drinking, and certain
pharmacological agents, such as phenytoin, increase the severity of the disease. Women
who breastfed their infants or those with low vitamin D or calcium diets are also at increased
risk.
24- The following are all purported benefits of percutaneous intraosseous
methylmethacrylate injection (vertebroplasty) for the treatment of osteoporotic compression
fractures except:

(A) Decreased stiffness of the segment, distributing stress at adjacent levels

(B) Rapid pain relief

(C) Prevention of further compression fractures by restoring sagittal alignment

(D) Faster return to ambulation

(E) Increased mobility leading to prevention of further osteoporosis

Explanation:

Traditional treatment for patients with osteoporotic vertebral compression fractures (VCFs)
includes bed rest, analgesics, and bracing. This type of medical management does not
restore spinal alignment, and the lack of mobility increases the rate of demineralization.
Because of the inherent risks and invasive nature, surgical treatment of osteoporotic VCFs
has been limited to patients with concurrent spinal instability or neurologic compromise.
Reconstruction with structural bone graft and instrumentation may be performed from an
anterior or posterior approach; however, the success of these techniques is limited by a
patient�s poor bone quality and general medical condition.

Augmentation of VCFs with polymethylmethacrylate (PMMA), "vertebroplasty," involves the

forced injection of low viscosity PMMA cement into the closed space of the collapsed
vertebral body. Although vertebroplasty is currently being used successfully for pain relief in
VCFs, this technique does not restore the height of the collapsed vertebral body.

25- 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) T10

(B) L1

(C) L2

(D) L3

(E) L4

Explanation:

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.
Slide 1
26- 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. A magnetic resonance image (MRI) of
the patient is obtained, as well as a myelogram (Slide). Conservative options in this patient
include:

(A) Medication

(B) Epidural steroids

(C) Conditioning exercise

(D) All of the above

(E) None of the above, proceed to surgery

Explanation:

The myelogram confirms the diagnosis of lumbar spinal stenosis at L3-L4 and L4-L5. There is
no myelographic block, although the stenosis is significant. A trial of conservative therapy is
appropriate for this patient.
Slide 1

Slide 2
27- 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. Based upon the patient�s
history, magnetic resonance image (MRI) (Slide 1), and computed tomography (CT)-
myelogram (Slide 2) available for your review, what is the correct diagnosis in this patient:

(A) Lumbar metastatic disease

(B) Lumbar spinal stenosis

(C) Lumbar herniated disk

(D) Degenerative lumbar spondylolisthesis

(E) Ankylosing spondylitis

Explanation:There is no evidence of lumbar metastases in this patient. The CT-myelogram

shows compression arising posterior to the thecal sac, making a disk herniation less likely.
Similarly, there is no evidence of a lumbar disk herniation on MRI. The patient�s sagittal
alignment is well maintained, with no spondylolisthesis evident. Ankylosing spondylitis
generally presents in younger patients, and the classic radiographic finding of spontaneous
arthrodesis is not present.
28- A 75-year-old woman presents with low back pain that is worse with motion and bilateral
lower extremity pain that is worse with ambulation. She notes that the pain extends down
the posterior aspects of her lower extremities, from the buttocks to the calves. The pain
limits her activity � she can only ambulate approximately one block before having to rest.
She reports that lumbar flexion, notably leaning over a walker or a shopping cart,
considerably diminishes her lower extremity pain. She has a significant past medical history
of coronary artery disease, and she has had previous angioplasty of her coronary vessels. On
examination, her lower extremity pulses are easily palpable. What radiographic evaluation
would you obtain to best establish her diagnosis:

(A) Plain L-spine films

(B) Angiogram of lower extremity vessels

(C) MRI of cervical spine

(D) Computed tomography (CT) of lumbar spine

(E) Magnetic resonance image (MRI) of lumbar spine

Explanation:

The most efficacious and least invasive means of evaluation for lumbar spinal stenosis is
MRI. A CT scan, while showing bony anatomy well, may not provide adequate information
about soft tissue structures. Plain films are nonspecific and, although they are often used as
an initial evaluation, may not yield adequate diagnosis. This patient�s symptom complex
does not correlate with vascular claudication.

29- Pain from a herniated lumbar disk is caused by:

(A) Rupture of the thecal sac

(B) Local instability due to a ruptured nucleus pulposus

(C) Ischemia and potential necrosis of the nerve root

(D) Associated spinal stenosis

(E) Herniated nucleus pulposus and the resulting local inflammation

Explanation:

The annulus is composed of alternating laminae that are primarily composed of type I and
type II collagen. The annulus is thinnest posterolaterally and thickest anteriorly. As the disk
is loaded, the nucleus transfers axial loads to the annulus in the form of hoop stresses. With
degenerative or traumatic processes, fissures or tears may develop in the annulus and the
nucleus can become herniated.

A herniated nucleus pulposus is a foreign material to the surrounding structures. The

combination of mechanical pressure on a nerve root and local inflammation can lead to
neurologic signs and symptoms.
30- 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

Explanation:

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.

31- Which of the following is the most common complaint at time of presentation in patients
with metastatic spine disease:

(A) Difficulty with balance

(B) Difficulty with urination

(C) Night sweats

(D) Pain during the night

(E) Numbness in the lower extremities

Explanation:

The most common manifestation of metastatic disease is persistent pain. Pain is most
marked at night and aggravated by movement. History of trauma is usually absent. Pain is
followed by weakness of the lower extremities, sensory loss, and bladder and bowel
changes.

32- Which of the following is the most common organism identified in cases of vertebral
osteomyelitis:

(A) Staphylococcus aureus

(B) Streptococcus pneumoniae

(C) Haemophilus influenzae

(D) Escherichia coli

(E) Anaerobic gram-negative rods

Explanation:

Staphylococcus aureus remains the most common causative organism, but an increasing
proportion of cases are due to gram-negative and anaerobic organisms such as Proteus,
Escherichia coli and Pseudomonas.
33- Which of the following is the hallmark distinguishing feature of vertebral osteomyelitis
when compared to a neoplastic process on imaging:

(A) Uniform enhancement after administration of gadolinium in the neoplasia

(B) Destruction of disk space and encroachment of adjacent vertebral body in vertebral osteomyelitis

(C) Lack of endplate involvement in the neoplastic process

(D) Evidence of a compression fracture in vertebral osteomyelitis

(E) There are no distinguishing radiographic features between vertebral osteomyelitis and a tumor.

Explanation:

The crossing of the infectious process along the disk space to involve adjacent vertebrae is a
hallmark feature of osteomyelitis used to differentiate it from a neoplastic process.

34- The normal range of thoracic kyphosis is:

(A) 0� to 10�

(B) 5� to 20�

(C) 20� to 50�

(D) 35� to 50�

(E) 40� to 60�

Explanation:

The normal range of thoracic kyphosis is 20� to 50�. The mean in normal adults is 35�.
The normal range of lumbar lordosis is 40� to 80�. The mean in normal adults is
approximately 60�.

The spine is usually straight in the sagittal plane between T10 and L2. The majority of
lumbar lordosis occurs between L4 and S1.

35- Which of the following regions of the spine is normally straight:

(A) T1 to T6

(B) T7 to T12

(C) T10 to L2

(D) L1 to L4

(E) T12 to S1

Explanation:

The normal range of thoracic kyphosis is 20� to 50�. The mean in normal adults is 35�.
The normal range of lumbar lordosis is 40� to 80�. The mean in normal adults is
approximately 60�.

The spine is usually straight in the sagittal plane between T10 and L2. The majority of
lumbar lordosis occurs between L4 and S1
36- Which of the following is true regarding the alignment of the spine with aging:

(A) Thoracic kyphosis decreases; lumbar lordosis increases

(B) Thoracic kyphosis decreases; lumbar lordosis decreases

(C) Thoracic kyphosis increases; lumbar lordosis decreases

(D) Thoracic kyphosis increases; lumbar lordosis increases

(E) The alignment of the spine undergoes no significant changes with aging.

Explanation:

The normal range of thoracic kyphosis is 20� to 50�. The mean in normal adults is 35�.
The normal range of lumbar lordosis is 40� to 80�. The mean in normal adults is
approximately 60�.

The spine is usually straight in the sagittal plane between T10 and L2. The majority of
lumbar lordosis occurs between L4 and S1.

With aging, due to changes in the intervertebral disks, thoracic kyphosis increases and
lumbar lordosis increases. There is loss of height of the intervertebral disks.

37- Osteochondromatosis is a hereditary genetic disorder that is caused by:

(A) Mutation in the fibrillin-1 gene

(B) Translocation between chromosomes 9 and 22

(C) Mutation in the g-fos gene

(D) Translocation between chromosomes 11 and 22

(E) Mutation in the EXT1, EXT2, and/or EXT3 genes

Explanation:

Osteochondromatosis (also known as hereditary multiple exostoses) is a genetic disorder

that is autosomal dominant with incomplete penetrance in women. The genetic defect occurs
on the EXT1, EXT2, and EXT 3 genes located on chromosome 8q24. Mutation in the fibrillin-1
gene is seen in patients with Marfan syndrome. Translocation between chromosomes 9 and
22 is seen in myxoid chondrosarcoma. Mutation in the g-fos gene is seen in patients with
Ollier�s disease. Translocation between chromosomes 11 and 22 is present in patient�s
with Ewing�s tumor.
38- Typical histologic features of an osteoid osteoma include all of the following except:

(A) Chondrocytes in an arrangement similar to that of a physis

(B) Nidus composed of haphazardly arranged network of osteoid trabeculae

(C) Varying degrees of mineralization with greatest mineralization in the center of the lesion

(D) Osteoblasts rimming the trabeculae

(E) Vascularized spindle cell stroma

Explanation:

The histologic features of an osteoid osteoma include the following:

 Nidus composed of haphazardly arranged network of osteoid trabeculae

 Varying degrees of mineralization with greatest mineralization in the center of the
lesion
 Loose fibrovascular connective tissue between trabeculae
o Osteoblasts rimming the trabeculae
o Vascularized spindle cell stroma

39- When an osteoblastoma occurs in the spine, it can involve all of the following except:

(A) Facets

(B) Transverse processes

(C) Pedicles

(D) Lamina

(E) Vertebral body

Explanation:

When an osteoblastoma occurs in the spine, involvement of the posterior elements of the
vertebra is typical and includes:

 Lamina
 Pedicles
 Transverse processes
 Facets
 Rib heads adjacent to thoracic vertebrae
40- Patients presenting with a primary spine tumor most often characterize their pain as:

(A) Constant, sudden in onset, worse at night, mechanical, and loosely associated with trauma

(B) Constant, gradual in onset, worse at night, non-mechanical, and loosely associated with trauma

(C) Progressive, gradual in onset, worse at night, non-mechanical, and loosely associated with trauma

(D) Progressive, sudden in onset, worse at night, mechanical, and loosely associated with trauma

(E) Progressive, gradual in onset, worse at night, mechanical, and loosely associated with trauma

Explanation:

I. 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
a. Loosely associated with trauma
D. Weakness can be seen in up to 42% of patients
E. Mass is evident in up to 16% of patients
F. Three percent of patients are asymptomatic
G. Other symptoms can include:
1. Sensory loss
2. Loss of sphincter control

41- Primary malignant tumors of the spine have which of the following characteristics:

(A) Slow-growing, well-circumscribed, and usually occur in patients older than 21 years of age

(B) Slow-growing, well-circumscribed, and usually occur in patients younger than 21 years of age

(C) Fast-growing, permeative, and usually occur in patients older than 21 years of age

(D) Fast-growing, permeative, and usually occur in patients younger than 21 years of age

(E) Fast-growing, permeative, and usually occur in patients older than 40 years of age

Explanation:

I. Primary benign tumors of the spine are:

A. Slow-growing
B. Well-circumscribed
C. Usually occur in patients younger than 21 years of age
D. Involve the vertebral body and posterior elements of the spine
1. Overall slight predilection for the posterior elements
2. Location of tumor is an important factor in determining the type of tumor
E. Examples include:
1. Osteochondroma
2. Osteoid osteoma
3. Osteoblastoma
4. Aneurysmal bone cyst
5. Giant cell tumor
6. Eosinophilic granuloma
II. Primary malignant tumors of the spine are:
A. Fast-growing
B. Permeative
C. Usually occur in patients older than 21 years of age
D. Examples include:
1. Multiple myeloma/solitary plasmacytoma
2. Osteosarcoma
3. Chondrosarcoma
4. Ewing's sarcoma/primitive neuroectodermal tumor
5. Chordoma
6. Lymphoma
42- Which of the following serves as the best landmark for proper screw entry into the
lumbar pedicle:

(A) The junction of the transverse process and inferior facet

(B) The junction of the transverse process and superior facet

(C) The articulating interface of the superior and inferior facets

(D) The medial border of the superior facet

(E) There is no relationship between the nerve root and the superior facet.

Explanation:

The junction of the transverse process and the inferior facet represents the most appropriate
entry point of the pedicle screw. This junction directly overlies the pedicle and ensures safe
placement through the pedicle and into the vertebral body.

43- To avoid vertebral artery injury during cervical lateral mass screw placement, it is best
to:

(A) Start at the midpoint and aim the screw laterally

(B) Start at the midpoint and aim the screw medially

(C) Start medially and aim the screw perpendicular

(D) Start medially and aim the screw medially

(E) Start laterally and aim the screw medially.

Explanation:

To avoid injury to the vertebral artery when placing lateral mass screws, it is best to avoid
placing the screw in the medial portion of the lateral mass, where the vertebral body is most
likely to be found.

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

(A) Misalignment of the spinous processes

(B) Subluxation >50%

(C) Subluxation <25%

(D) Marked angular deformity

(E) Spinal canal compromise

Explanation:

Unilateral jumped facets typically involve anterolisthesis of the upper vertebral body, which is
less than 25%. Misalignment of the spinous processes and spinal canal compromise may be
seen with either unilateral or bilateral facet dislocation. Subluxation greater than 50% and
marked angular deformity are characteristics of bilateral facet dislocations.
45- The annual incidence of cervical radiculopathy in men is 107.3 per 100,000 and 63.5 per
100,000 in women. The incidence for both groups occurs within which of the following peak
age ranges:

(A) 45-49 years

(B) 50-54 years

(C) 55-59 years

(D) 60-64 years

(E) 65-69 years

Explanation:

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

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

(A) Dorsal root ganglion

(B) Connective tissue

(C) Radicular artery and vein

(D) Recurrent meningeal nerves

(E) All of the above

Explanation:

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

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

(A) A Torg ratio > 0.8 indicates that cervical spinal stenosis may be present.

(B) A Torg ratio , 0.8 indicates that cervical spinal stenosis may be present.

(C) An extension lateral cervical conventional radiograph is used to determine the Torg ratio.

(D) A Torg ratio > 0.8 indicates that cervical spinal stenosis may be present, and an extension lateral cervical
conventional radiograph is used to determine the Torg ratio.
(E) A Torg ratio , 0.8 indicates that cervical spinal stenosis may be present, and an extension lateral cervical
conventional radiograph is used to determine the Torg ratio.

Explanation:

The Torg ratio is calculated using an extension lateral cervical radiograph. To calculate the
Torg ratio, divide the distance between the midpoint of the posterior aspect of the vertebral
body to the nearest point on the corresponding spinolaminar line by the anteroposterior
width of the vertebral body. A Torg ratio , 0.8 is associated with cervical spinal stenosis and
sustained burners and stingers in athletes with cervical spine-extension-compression type
injuries.
48- What percentage of women with osteoporotic fractures develop kyphosis:

(A) 10%

(B) 15%

(C) 25%

(D) 30%

(E) 60%

Explanation:Approximately 15% of women with osteoporotic fractures develop kyphosis.

This is often due to the presence of multiple vertebral compression fractures with segmental
kyphosis at each level.

49- A 30-year-old man underwent an anterior lumbar discectomy and fusion at L4-L5 and L5-
S1 through an anterior retroperitoneal approach 1 month ago. He now reports that he is
unable to obtain and maintain an erection. The most likely cause of this condition is:

(A) Disruption of the sympathetic nerves during anterior lumbar exposure

(B) Traction on the parasympathetic nerve at the L4-L5 level

(C) Not related to the surgical dissection

(D) Injury to the pudendal nerves in the anterior sacral region during dissection at the L5-S1 level

(E) Sexual dysfunction secondary to retrograde ejaculation

Explanation:Sexual dysfunction is a common condition after extensive anterior lumbar

surgical dissection. Erectile dysfunction is often nonorganic but may be related to
parasympathetic injury. The parasympathetic nerves are deep in the pelvis at the level of S2-
S3 and S3-S4 and are not usually involved in the surgical field for anterior L4-L5 and L5-S1
procedures. Retrograde ejaculation is the result of injury to the sympathetic chain on the
anterior surface of the major vessels crossing the L4-L5 level and at the L5-S1 interspace.
Erectile function and orgasm are not affected by sympathetic injury. The pudendal nerve is
primarily a somatic nerve and is not located in the surgical field

50- A 46-year-old patient with cervical myelopathy undergoes a multilevel posterior cervical
laminectomy from C3 to C7. The risk of post laminectomy kyphosis is greatest with removal
of which of the following structures:

(A) More than 80% of the lamina

(B) More than 50% of each facet joint

(C) Interspinous ligament

(D) Facet joint capsules

(E) Ligamentum flavum

Explanation:Post laminectomy kyphosis is often seen in patients who have removal of more
than 50% of each facet joint or 100% of one facet joint. It is not commonly seen with
removal of the ligamentum flavum or interspinous ligament. Less frequently, post
laminectomy kyphosis is seen with removal of more than 80% of the lamina or excision of
the facet joint capsules
 SPINE
356 Q
4/7 ( 50Q )

COLLECTED BY
DR. A. AWAJI
 1- Initial management of cervical radiculopathy includes all of the following except:

(A) Nonsteroidal anti-inflammatory drugs

(B) Cervical immobilization

(C) Physical therapy

(D) Anterior cervical discectomy and fusion

(E) Home traction

Explanation:

Initial management of cervical radiculopathy is nonoperative. This includes:

 Nonsteroidal anti-inflammatory drugs

 Occasional narcotic analgesic medications
 Immobilization in a soft collar for 10 to 14 days
 Physical therapy with emphasis on isometric exercises
 Home traction

Surgical intervention is indicated for patients who fail nonoperative treatment. Motor deficits
intertractable pain may serve as indication for early surgical therapy. In addition, patients
with intertractable pain or motor deficits may be recommended for early surgery.

2- With a left-sided anterior cervical spine approach, the structure at increased risk
for injury is the:

(A) Recurrent laryngeal nerve

(B) Superior laryngeal nerve

(C) Hypoglossal nerve

(D) Thoracic duct

(E) Esophagus

Explanation:

On the left side of the neck, the thoracic duct ascends lateral to the carotid sheath and is at
potential risk for laceration with resulting chylothorax. This potential risk must be avoided by
remaining medial to the carotid sheath during the left-sided anterior cervical spine approach.
 3- A 3-year-old boy is referred by the pediatrician for neck stiffness. He has a mild
hearing loss, but is otherwise healthy. On examination, his neck is rather short,
and he has limitation of lateral rotation and bending, but flexion and extension are
normal. There are no palpable bands in his neck. The anteroposterior and lateral
cervical spine films ordered by the pediatrician show a congenital fusion of cervical
vertebrae. The most likely diagnosis is:

(A) Klippel-Feil syndrome

(B) Fixed atlantoaxial rotatory subluxation

(C) Congenital muscular torticollis

(D) Arnold-Chiari malformation

(E) Axial neck pain

Explanation:

The classic findings of Klippel-Feil syndrome include a short neck, low posterior hairline, and
decreased neck range of motion, but <50% of patients have all 3 elements of the triad. The
neck motion is limited due to congenital fusion of cervical vertebrae, and the severity of
cervical spine involvement usually heralds associated manifestations. Facial asymmetry,
cranial nerve palsy, deafness, cardiac anomalies, and synkinesia may be detected in the
involved child.

It is important to differentiate congenital muscular torticollis from Klippel-Feil syndrome,

because releasing the sternocleidomastoid muscle will not correct a bony deformity. Static
lateral radiographs of the cervical spine may appear normal in young children, as ossification
of abnormal levels has not yet occurred. Flexion/extension lateral radiographs are useful to
define congenital fusions, and magnetic resonance imaging may further delineate the
anatomy. It is also important to test neck motion in all planes, because flexion/extension
may be normal if movement occurs through just a few spared levels.

Children with Klippel-Feil syndrome rarely develop neurological symptoms as a result of the
congenital cervical fusion. Later in life, they may develop neurological impairment as a result
of instability or degenerative disk disease.

4- The patient was diagnosed with spinal stenosis of the lumbosacral spine. In
addition to educating the patient about his condition, the most appropriate initial
treatment is:

(A) Walking program

(B) Nonsteroidal anti-inflammatory drugs

(C) Lumbar traction

(D) Spinal decompression and fusion

Explanation:

Initial treatment begins with patient education, a physical therapy regime (gentle
conditioning exercises), judicious activity change, and sometimes spinal support with a corset
or light-weight brace. Anti-inflammatory nonsteroidal drugs provide some relief of symptoms
for many patients.
 5- 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

Explanation:

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.
Slide 1

6- A 22-year-old woman sustained an injury to her low back 1 year ago while playing
rugby. She now complains of excruciating low back pain with numbness and
tingling into her left buttock. This pain is affecting her daily living activities. The
patient underwent 6 months of conservative management consisting of restriction
of activities, physical therapy, and anti-inflammatory medication with little relief.
Based on the image below, the next appropriate step in the management of this
patient is:

(A) Continued conservative management

(B) Posterolateral fusion at the L5/S1 level with bone graft

(C) Laminectomy at the L2/L3 level

(D) Laminectomy at the L3/L4 level

(E) Diskectomy at the L3/L4 level

Explanation:

The patient has an L5/S1 spondylysis with a grade 1 spondylolisthesis. This patient has
undergone a sufficient attempt at conservative management with continued unrelenting low
back pain. The next most appropriate step in the management of this condition is a
posterolateral fusion at the L5/S1 level with autologous bone graft
 7- In describing idiopathic scoliosis, there are several terms given to curve patterns
on radiographs to describe the specific type of spinal deformity present. Which
term best describes an area of the spine with a lateral curve that lacks normal
flexibility noted radiographically by its failure to demonstrate segmental mobility or
correction on supine side-bending radiographs:

(A) Primary curve

(B) Compensatory curve

(C) Major curve

(D) Minor curve

(E) Structural curve

Explanation:

The above question is describing a structural (nonflexible) curve.

 A primary curve is the earliest of several curves that may eventually develop.
 The term major curve is used to designate the largest structural curve.
 The minor curve refers to the smallest structural curve and is usually more flexible
than the major curve.
 The compensatory curve is located above or below a major curve to attempt to
maintain normal body alignment.

8- A 32-year-old woman is diagnosed on magnetic resonance imaging with a far-

lateral disk herniation at the L3/L4 level causing radiating right lower extremity
discomfort across the anterior aspect of her knee with no motor or reflex
abnormalities. Which of the following nerve roots is most likely affected:

(A) L1

(B) L2

(C) L3

(D) L4

(E) L5

Explanation:

A far-lateral or foraminal disk herniation often affects the exiting or more proximal nerve
root. The traversing or more distal nerve root is typically affected from a posterolateral disk
herniation. In this case, the patient has a far-lateral disk herniation at the L3/L4 level
resulting in L3 nerve root symptomatology.
 9- A 27-year-old man comes in for examination. He complains of worsening pain in
his lower back. He states that the pain started 4 days ago after lifting a heavy box.
The patient's neurological exam is completely nonfocal. The initial management of
this patient should include:

(A) Computed tomography scan of the lumbar spine with contrast

(B) Epidural steroid injection

(C) Magnetic resonance image of the lumber spine

(D) Bed rest of short duration along with nonsteroidal anti-inflammatory medications

(E) Computed tomography scan of the lumbar spine without contrast

Explanation:This patient's neurological exam is normal and his injury was recent; this is
most likely a soft tissue injury to his low back. Due to the patient's age and the fact that this
is most likely not a serious injury, an initial conservative approach would be most
appropriate. Epidural steroids or a selective nerve root block would be indicated if this
patient developed worsening low back complaints or radicular pain in association with his low
back pain.

10- 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

Explanation: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.

11- The most common location for a thoracic disk herniation is:

(A) Central

(B) Lateral

(C) Centrolateral

(D) Medial

(E) Mediolateral

Explanation:

The most common locations for a thoracic disk herniation are centrolateral (94%) and lateral
(6%). Disks classified as centrolateral have the bulk of the disk herniation medial to the
lateral margin of the thecal sac.
 12- Which of the following describes the magnetic resonance image (MRI) appearance
of vertebral osteomyelitis:

(A) Increased signal onT1 images, decreased on T2 images

(B) Decreased signal onT1 images, decreased on T2 images

(C) Decreased signal onT1 images, increased on T2 images

(D) Increased signal onT1 images, increased on T2 images

(E) MRI is usually unable to detect vertebral osteomyelitis

Explanation:Magnetic resonance image (MRI) carries a 95% accuracy rate. Infected disk
and vertebral bone appear on MRI with decreased signal onT1 images and increased signal
on T2 images. Gadoliniun enhancement is useful in differentiating spinal infection or abscess
from epidural scar in the postoperative setting.

13- If the triceps muscle is weak after a spinal decompression, then which of the
following nerve roots is injured:

(A) C5

(B) C6

(C) C7

(D) C8

(E) T1

Explanation:
The triceps muscle extends the elbow and is innervated by the C7 cervical spine nerve root.

Motor innervations include:

 Shoulder abduction (deltoid) - - C5

 Elbow flexion - - C5
 Wrist extension - - C6, C7
 Wrist flexion - - C7
 Finger extension - - C7
 Finger flexion - - C8
 Finger abduction/adduction - - T1
 14- If the extensor hallucis longus muscle is weak in a patient who has radicular pain,
then which of the following lumbosacral nerve roots is compressed:

(A) L1

(B) L2

(C) L3

(D) L4

(E) L5

Explanation:

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

15- The Achilles tendon reflex (ankle reflex) is absent in a patient who has radicular
back pain. Which of the following nerve roots is compressed:

(A) L4

(B) L5

(C) S1

(D) S2

(E) S3

Explanation:

The Achilles tendon reflex is based on the triceps muscle group (medial and lateral
gastrocnemius muscles and soleus muscle) and is transmitted through the S1 nerve root.

Reflexes and associated nerve roots include:

 Patellar tendon reflex L4

 Posterior tibial reflex L5
 Achilles tendon reflex S1
 16- Which of the following is the only accepted pharmacological agent for the acute
treatment of a spinal cord injury:

(A) GM-1 ganglioside

(B) Tirilazad (lipid peroxidation inhibitor)

(C) Nimodipine (calcium channel blocker)

(D) Naloxone (opoid antagonist)

(E) Methylprednisolone

Explanation:

Methylprednisolone is currently the only accepted pharmacologic agent for the treatment of
spinal cord injury. The North American Spinal Cord Injury Studies (NASCIS) found significant
motor and sensory improvement in patients who were treated within 8 hours of injury with a
methylprednisolone bolus of 30 mg/kg, followed by an infusion of 5.4 mg per hour for 24
hours.

Other agents have been studied in animal experiments but have not been promising in
clinical trials.

17- A 16-year-old boy sustains a burst fracture of L2. Radiographs indicate loss of
approximately 20% of vertebral height anteriorly and 10� of kyphosis. He is
neurologically intact. Management should include:

(A) Anterior decompression and strut graft reconstruction

(B) Posterior indirect decompression with transpedicular instrumentation and fusion

(C) Laminectomy, open reduction of the bony intrusion, and fusion

(D) An initial period of bed rest, monitoring the patient for ileus, and early mobilization in an extension orthosis
or body cast
(E) Delayed reconstruction of the spine when the initial injury has been determined

Explanation:

Burst fractures represent 17% of major spine fractures. Instability and failure occur in the
anterior and middle columns. Fifty percent of patients have a neurologic deficit. These
fractures are considered unstable if there is more than 50% to 60% anterior compression,
20� to 25� of kyphosis, more than 50% of canal compromise, and posterior injury.
Incomplete or progressive neurologic deficits require early decompression and stabilization.
Treatment of the stable fracture without neurologic deficit is hyperextension bracing for 3 to
4 months.
 18- 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

Explanation:

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.

19- The distinguishing phenotypic feature that differentiates a schwannoma from a

neurofibroma is:

(A) The consistently hard and irregular surface of a schwannoma tumor

(B) The lack of a capsule around a neurofibroma tumor

(C) The presence of a dissection plane between the tissue and a schwannoma tumor

(D) Distinctly differing locations of occurrence along the spinal axis

(E) There is no phenotypic distinguishing characteristic that differentiates a schwannoma from a neurofibroma.

Explanation:

Nerve sheath tumors account for 25% of intradural spinal cord tumors in adults and can be
further broken down into either schwannomas or neurofibromas. Schwannomas are more
common than neurofibromas, most commonly occurring in patients 30 to 50 years of age,
equally between the sexes. Most schwannomas arise in the dorsal nerve root.
Neurofibromas, however, have a predilection to the ventral root. Both tumors primarily are
intradural but as many as 10% to 15% can escape through the dura to form a dumbbell
shape and exist as both an intradural and extradural tumor. Histologically, fibrous tissue and
nerve fibers make up a neurofibroma. Grossly, neurofibromas appear as a fusiform
enlargement of the nerve, making a clear distinction between tumor and nerve impossible.
Macroscopically, schwannomas look like smooth globoid masses sitting on the nerve fiber
and a clear resection plane is apparent.
 20- 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

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

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

(A) Pain and temperature sensation carried by the spinothalamic tracts

(B) Light touch and joint position carried by the dorsal column tracts

(C) Joint position carried by the spinocerebellar tract

(D) All modalities carry the same prognostic value

(E) Sensory examination has no prognostic value in evaluation of spinal cord injury patients

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

22- 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

Explanation:

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.
 23- Which of the following is the most common cause of lumbar stenosis:

(A) Congenital

(B) Posttraumatic

(C) Degenerative

(D) Iatrogenic

(E) Idiopathic

Explanation:

Degenerative lumbar stenosis is the most common cause of lumbar stenosis. With normal
aging of the disk, the water-binding capacity of the nucleus pulposus is dissipated,
diminishing its ability to withstand normal compressive and rotational forces. With
progressive degeneration of the disk, collapse occurs. This collapse results in overriding of
the facet joints and relative lengthening of adjacent capsular and ligamentous structures.

Continued instability, which may be multidirectional, results in hypertrophic changes about

the periphery of the vertebral body at its annular attachments. Radiographically, these are
seen as traction osteophytes. Similarly, osteophytes form about the facet joints, which lead
to compromise of the neural canal. With disease progression, hypertrophic changes
predominate, leading to ankylosis and auto stabilization. In patients with less than optimal
canal configurations or dimensions or those with excessive hypertrophic degenerative
changes, narrowing of the spinal canal, lateral recesses, and neural foramina may result in
neurogenic signs and symptoms.

24- Which of the following is the most common presentation of a patient with lumbar
stenosis:

(A) Foot drop

(B) Acute onset of pain in bilateral lower extremities

(C) Chronic low back pain with neurogenic claudication

(D) Saddle anesthesia

(E) Intermittent urinary incontinence

Explanation:

The most common complaint in patients with spinal stenosis is chronic low back pain with
worsening and lower extremity weakness after ambulation (claudication). Symptoms are
often resolved by rest and/or leaning forward.
 25- Which of the following is the most commonly fractured location along the
thoracolumbar axis:

(A) The cervicothoracic junction

(B) The mid-thoracic region

(C) The thoracolumbar region

(D) The lumbar region

(E) The lumbosacral junction

Explanation:
Up to 60% of spinal injuries occur between the T11 and L1 segments. The rigid thoracic rib
cage and coronal orientation of the facets permit lateral bending and rotation but little
flexion and extension. The facet joints then transition caudally to a more sagittal orientation
in the lumbar spine, allowing increased flexion/extension but limiting lateral motion. These
factors create a stress concentration at the thoracolumbar junction, which is demonstrated
by the high incidence of injury at the T11 to L1 segments.

26- Compression fractures of the spine, although typically considered a one-column

injury, can be unstable. Findings at time of presentation suggestive of an unstable
fracture include:

(A) Pain out of proportion to the physical examination

(B) Radiographic findings of more than one compression fracture

(C) Initial kyphosis greater than 20� to 30�

(D) Loss of less than 50% of anterior vertebral body height

Explanation:
Compression fractures are inherently stable and may be treated with extension bracing or
casting. If, however, the flexion injury is severe enough, damage to the posterior ligaments
can result and the injury becomes unstable. Criteria for this instability were developed by
McAfee and include more than 20� to 30� of initial kyphosis or more than 50% loss of
anterior vertebral height, applicable to both compression and burst fractures.

27- 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

Explanation:
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 two-thirds four decades ago
 28- Based on the current consensus on treatment of acute spinal cord injury,
intravenous steroid treatment is considered to have potential benefit if begun
within how many hours of original injury:

(A) 3

(B) 5

(C) 8

(D) 12

(E) 24

Explanation:

The results of the National Acute Spinal Cord Injury Study II (NASCIS II) demonstrated
significant motor and sensory improvement in patients who were treated within 8 hours of
injury with a methylprednisolone bolus of 30 mg/kg, followed by an infusion of 5.4 mg/kg
per hour for 24 hours.

29- The normal range of lumbar lordosis is:

(A) 0� to 10�

(B) 10� to 20�

(C) 20� to 50�

(D) 40� to 80�

(E) 60� to 90�

Explanation:

The normal range of thoracic kyphosis is 20� to 50�. The mean in normal adults is 35�.
The normal range of lumbar lordosis is 40� to 80�. The mean in normal adults is
approximately 60�.

The spine is usually straight in the sagittal plane between T10 and L2. The majority of
lumbar lordosis occurs between L4 and S1
 30- Central cord syndrome is typically due to:

(A) An axial compression injury with resultant injury to the central gray matter

(B) A hyperextension injury with compression of the cord by herniated disk material anteriorly

(C) A hyperextension injury with compression of the cord by osteophytes anteriorly and infolded ligamentum
flavum posteriorly
(D) A hyperflexion injury with compression of the cord by herniated disk material anteriorly

(E) A hyperflexion injury compression of the cord by the anterior longitudinal ligament anteriorly and
osteophytes posteriorly

Explanation:

Central cord syndrome is the most common incomplete spinal cord lesion and is usually seen
in patients with preexisting cervical spondylosis who then sustain a hyperextension injury to
the cervical spine. This mechanism causes compression of the cord by osteophytes anteriorly
and the infolded ligamentum flavum posteriorly with resulting injury to the central gray
matter. The clinical presentation is variable but usually consists of:

 Greater loss of motor neurons to the upper extremities than the lower extremities
often resulting in profound weakness in the arms and hands, and some weakness
in the legs and feet
 Variable sensory loss

Patients with central cord syndrome have variable return of function but are usually left with
some degree of residual deficit and spasticity.

31- A patient with cauda equina syndrome and the full spectrum of symptons presents
with:

(A) Severe low back pain, sciatica, saddle anesthesia, and preservation of bladder vesicular control

(B) Severe low back pain, sciatica, urinary retention, and preservation of perianal sensation

(C) Severe low back pain, saddle anesthesia, loss of motor and sensation in the lower extremities, and
preservation of bulbocavernosus reflex.
(D) Severe low back pain, loss of motor and sensation in the lower extremities, and preservation of bladder
vesicular control
(E) Severe low back pain, sciatica, saddle anesthesia, urinary retention, and loss of bulbocavernosus reflex

Explanation:

Cauda equina syndrome is a severe neurologic disorder that results from an injury to the
neural elements within the thecal sac between the conus medullaris and the lumbosacral
nerve roots (ie, cauda equina or "horse's tail"). Cauda equina syndrome usually occurs as a
result of lumbar disk herniation with compression of the cauda equina and requires urgent
surgical decompression. Clinical presentation includes:

 Severe low back pain

 Bilateral or unilateral sciatica
 Saddle anesthesia
 Motor or sensory deficit
 Bladder and bowel vesicular involvement (classically leading to urinary retention)
 With a complete lesion, a loss of bulbocavernosus reflex, anal wink, and reflexes in
the lower extremities
 32- Which of the following statements is true regarding the sacroiliac joint:

(A) The anterior supporting structures are stronger than the posterior supporting structures.

(B) Sectioning of the sacrotuberous and sacrospinous ligaments results in increased motion.

(C) The sacroiliac joint withstands medially directed forces better than the lumbosacral spine.

(D) Counter-nutation (forward rotation of the ilium on the sacrum) is the most common motion.

(E) The posterior interosseous ligaments are weak.

Explanation:

The sacroiliac joint is the largest axial joint in the body. The anterior capsule is thin and
weaker than the posterior capsule. The posterior supporting structures are strong and are
comprised of a tough interosseous ligament, a long posterior sacroiliac ligament, and strong
sacrotuberous, sacrospinous ligaments. Joint innervation usually occurs anteriorly in the S2
ventral rami. Compared with the lumbosacral spine, the sacroiliac joint can better withstand
medial forces, but is weaker in axial compression and in axial torsion. Nutation (backward
rotation of less than 4� and 1.6 mm rotation of the ilium on the sacrum) is the most
common motion in the sacroiliac joint. Increased motion of the sacroiliac joint occurs only
with sectioning of the interosseous ligaments.

33- Treatment of a vertebral osteoid osteoma includes all of the following except:

(A) Surgical excision/curettage of the nidus

(B) En-bloc resection

(C) Observation if symptoms are mild

(D) Aspirin/salicylates/nonsteroidal anti-inflammatory drugs (NSAIDs)

(E) Radiofrequency ablation

Explanation:

Treatment of osteoid osteomas in the spine include the following:

 Aspirin/salicylates/NSAIDs
o Administered for up to 2 years
o Successful in up to 50% cases
 Radiofrequency ablation (RFA)
o Usually computed tomography-guided
o Clinical success rates as high as 97% have been reported with 1 to 2
treatments
 Surgical excision of the nidus/curettage
o Necessary when aspirin/salicylates/NSAIDs cannot be tolerated for long
periods of time and RFA is not possible or unsuccessful
o Can usually be accomplished through a posterior approach
 En-bloc resection or a more radical procedure play no role in management
 34- 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%

Explanation:

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:
o Spinal osteoblastomas account for 40% to 45% of all osteoblastomas
o Over half of spinal osteoblastomas occur in the lumbar spine

35- Primary spinal tumors account for:

(A) 0.4% of all tumors and 1% of all bone tumors

(B) 0.4 % of all tumors and 10% of all bone tumors

(C) 0.4 % of all tumors and 25% of all bone tumors

(D) 0.04% of all tumors and 10% of all bone tumors

(E) 0.04 % of all tumors and 25% of all bone tumors

Explanation:

Neoplasms of the spine can be broadly categorized into metastatic tumors and primary
tumors. Primary spinal tumors are rare and account for 0.04% of all tumors and 10% of all
bone tumors.
 36- What percentage of trabecular bone must be destroyed before changes can be
seen on plain radiographs:

(A) 20% to 40%

(B) 30% to 50%

(C) 40% to 60%

(D) 60% to 80%

(E) 70% to 90%

Explanation:

I. Imaging studies used most frequently in the diagnosis of primary spine tumors
include:
A. Plain radiographs
1. Initial imaging study
2. Recommended for any patient with prolonged back pain (>6
weeks)
3. Identify 30% to 70% of spine tumors at presentation
4. Early lesions difficult to detect because 30% to 50% of
trabecular bone must be destroyed before changes can be
seen
5. Absence of the pedicle is usually the earliest radiographic sign
of vertebral
6. Cortical bone loss easier to detect than destruction of
trabecular bone
7. "Winking owl" sign
8. Disk space generally preserved
9. Geographic lesions with well-circumscribed borders suggest a
benign tumor
10. Permeative lesions suggest a malignant tumor
B. Bone scan
1. Technetium (Tc)-99m
2. Can identify lesions 3 to 18 months before plain radiographs
3. Sensitivity 74%, specificity 81%
4. False negative in up to 60% of patients with multiple myeloma
5. Single photon emission computerized tomography scan can
improve both sensitivity (87%) and specificity (91%)
6. When used in combination with gallium scanning, Tc-99 bone
scan can help to differentiate between tumors and infections
C. Computed tomography/myelography
1. Best test to determine extent of bony destruction
2. Important in surgical planning
3. Myelography usually used only when magnetic resonance
imaging (MRI) not possible (danger of complete myelographic
block)
D. MRI
1. Modality of choice in evaluating tumors of the spine
2. Noninvasive
3. Allows direct visualization of entire spinal cord
4. Visualization of soft tissues
5. Sensitivity 92%, specificity 90%
6. Additional lesions in 20% to 24%, and 10% will have multiple
levels of cord compression
 37- Advantages of minimally invasive lumbar interbody fusion over traditional open
interbody fusion include:

(A) Minimal muscle dissection and trauma

(B) Wider surgical exposure

(C) Better fusion rates

(D) Lowered risk of nerve root injury

Explanation:

Minimally invasive lumbar interbody fusion involves less muscle dissection and trauma than
traditional open approaches. The surgical exposure is more limited, though, and there is no
evidence to date of minimally invasive techniques providing better fusion rates or lowered
risk of nerve root injury.

38- Regarding the anatomy of the lumbar pedicle, which of the following statements is
true:

(A) The pedicle is located at the origin of the transverse process.

(B) The exiting nerve root is found immediately superior to the lumbar pedicle.

(C) The pedicle is located at the base of the superior facet, at the origin of the transverse process.

(D) The pedicle joins the vertebral body at its inferior border.

(E) There is no relationship between the pedicle and the superior facet.

Explanation:

The lumbar pedicle is the bony bridge that connects the posterior vertebral elements to the
anterior body. The pedicle is located at the base of the superior facet, at the origin of the
transverse process. The exiting nerve root traverses immediately inferior to the superior
segment pedicle, and the pedicle joins the vertebral body at its superior half.

39- Common indications for lumbar pedicle screw fixation include:

(A) Rigid stabilization for patients undergoing arthrodesis or interbody fusion

(B) Correction of lumbar spinal deformity

(C) Stabilization after trauma to the lumbar spine

(D) Rigid stabilization for patients undergoing arthrodesis or interbody fusion, and correction of lumbar spinal
deformity
(E) Rigid stabilization for patients undergoing arthrodesis or interbody fusion, correction of lumbar spinal
deformity and stabilization after trauma to the lumbar spine

Explanation:

Common indications for pedicle screw fixation include rigid stabilization for patients
undergoing arthrodesis or interbody fusion, correction of deformity, and stabilization after
trauma.
 40- Advantages of minimally invasive lumbar interbody fusion over traditional open
interbody fusion include:

(A) Minimal muscle dissection and trauma

(B) Wider surgical exposure

(C) Better fusion rates

(D) Lowered risk of nerve root injury

(E) Better decompression

Explanation:

Minimally invasive lumbar interbody fusion involves less muscle dissection and trauma than
traditional open approaches. The surgical exposure is more limited, though, and there is no
evidence to date of minimally invasive techniques providing better fusion rates or lowered
risk of nerve root injury.

41- Which of the following is/are potential complications associated with posterior
cervical decompression and placement of lateral mass screws:

(A) Injury to the vertebral artery

(B) Compression injury to the spinal cord

(C) Traction injury to the cervical nerve roots

(D) Injury to the vertebral artery and traction injury to the cervical nerve roots only

(E) Injury to the vertebral artery, traction injury to the cervical nerve, and traction injury to the cervical nerve
roots

Explanation:

All of the above are potential complications associated with posterior cervical decompression
and placement of lateral mass screws.

42- The technique for C1-C2 lateral mass fixation may involve:

(A) Removal of the posterior arch of C1

(B) Placing the C2 screws through the pedicle

(C) Following a medial trajectory with the C1 screws

(D) Removal of the posterior arch of C1, and placing the C2 screws through the pedicle only

(E) Removal of the posterior arch of C1, placing the C2 screws through the pedicle, and following a medial
trajectory with the C1 screws

Explanation:

The C1 and C2 levels have unique anatomies that require variation in lateral mass screw
fixation technique. Removing the C1 arch assists in proper placement of the C1 screws via a
lateral trajectory. The C2 pedicle is large, and pedicle screws are commonly placed at this
level to avoid vertebral artery injury in the small lateral masses. C1 lateral mass screws
follow the long axis of the C1 lateral mass as visualized on pre-operative CT scanning.
 43- Which of the following conditions is not associated with cervical fractures:

(A) Rheumatoid arthritis

(B) Ossiculum terminale

(C) Ankylosing spondylitis

(D) Os odontoideum

(E) None of the above

Explanation:

Rheumatoid arthritis, ankylosing spondylitis, and os odontoideum have been associated with
fractures as part of their presentation or etiology. Os odontoideum is most likely an old
nonunion fracture or injury to vascular supply of the developing odontoid process. However,
one has to differentiate true os odontoideum from the more common ossiculum terminale,
which describes the nonunion of the apex at the secondary ossification center and is not a
fracture.

44- Which imaging modality is usually the least sensitive in diagnosing discitis:

(A) Plain radiograph

(B) Computed tomography (CT) scan

(C) Magnetic resonance image (MRI)

(D) Technetium bone scan

(E) Tomograms

Explanation:

The least helpful modality in diagnosing early discitis is the plain radiograph. Fluoroscopy
does not give insight into the state of the intervertebral disk. It can suggest loss of disk
height or involvement of the vertebral bone but will not reveal infection limited to the disk.
The CT scan is useful because of its excellent resolution of bony structures and associated
changes secondary to disk infection. MRI is the best modality to characterize the soft tissues
in the cervical spine.

45- Pott�s disease is most commonly treated by:

(A) Decompression

(B) Antibiotic therapy and immobilization

(C) Antibiotic therapy only

(D) Spinal orthosis

(E) Decompression and fusion

Explanation:

The treatment of tuberculous involvement of the spine is rarely surgical. Most commonly, the
spine remains stable and fusion is not necessary. However, orthosis in combination with
long-term antibiotic therapy is the key for successful treatment. A collar is sufficient to
provide enough stability and comfort for the lesion to heal.
Slide 1

46- What type of fracture is presented in the radiograph (Slide):

(A) Teardrop fracture

(B) Burst fracture

(C) Compression fracture

(D) Hangman�s fracture

(E) Clay-shoveler�s fracture

Explanation:

Clearly seen in this radiograph is a fracture along the anterior/inferior vertebral body, which
is a characteristic of a teardrop fracture.

47- Which of the following may be used as treatment options for bilateral facet
dislocations:

(A) Traction reduction of dislocations

(B) Halo fixation

(C) Open reduction

(D) Open fixation

(E) All of the above

Explanation:

All of the choices are used in the treatment of bilateral jumped facets, often in combination
or sequence.
 48- C1 reflexes include which of the following:

(A) Sternocleidomastoid reflex

(B) Clavicle reflex

(C) Deltoid reflex

(D) Jaw jerk

(E) Biceps reflex

Explanation:

The C1 reflex, while rarely tested, involves the jaw jerk.

49- Which of the following statements concerning neck pain is incorrect:

(A) Patients with traumatic neck injury and pain must be stabilized and assessed with a full neurologic
examination while immobilized.
(B) Elderly patients may have symptoms of traumatic neck injury without a history of trauma.

(C) Rest, physical therapy, and prolonged immobilization of the neck with a collar are effective in managing
patients with neck pain.
(D) Surgery for neck pain may be indicated for patients with a cervical spine fracture with evidence of
instability, neoplastic disorders, spinal stenosis, and nerve root compression.
(E) Rest and physical therapy

Explanation:

Choices A, B, D, and E are correct and are important considerations with managing a patient
with neck pain. Rest and physical therapy are important and effective in treating neck pain.
Prolonged immobilization of the neck with a collar, however, can result in deconditioning of
the cervical paraspinal musculature, which can increase the patient�s risk for further neck
injury.

50- The most common traumatic indications for occipitocervical fusion include type III
occipital condyle fractures and:

(A) Basilar invagination

(B) Atlanto-axial subluxation

(C) Odontoid fracture

(D) Atlanto-axial dissociation

(E) C1-C2 instability

Explanation:

Basilar invagination and atlanto-axial subluxation are more commonly present in

degenerative disorders and less in trauma. Odontoid fractures are usually treated via C1-C2
fusion or odontoid screw fixation, although less commonly occipitocervical fusion is required.
C1-C2 instability, similarly, is usually treated via C1-C2 stabilization. A more common
traumatic indication for occipitocervical fusion is atlanto-axial dissociation
 SPINE
356 Q
5/7 ( 50Q )

COLLECTED BY
DR. A. AWAJI
 1) 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

Explanation:

An electromyogram detects motor changes as a result of nerve compression. It can be used

to differentiate cervical radiculopathy from peripheral neuropathy.

2) After undergoing an anterior cervical discectomy and fusion through a left-sided

neck incision, the patient is noted to have a drooping eyelid and a right pinpoint
pupil. This is likely due to:

(A) Spinal cord injury

(B) Nerve root injury

(C) Retractor placement

(D) Carotid sheath compression

(E) Vertebral artery injury

Explanation:

This patient has postoperative Horner syndrome. The sympathetic chain lies lateral to the
longus colli muscles. Retractors must be placed deep into these muscles. Retractors placed
ventrally to the longus colli muscles can cause injury to the sympathetic chain, esophagus
medially, and carotid sheath contents laterally.

3) One advantage of posterior laminoforaminotomy in the treatment of cervical

radiculopathy is:

(A) Obviates the need for fusion

(B) Improves nerve root decompression

(C) Easier access to midline disk herniations

(D) Improves wound healing

(E) Improves postoperative alignment

Explanation:

The posterior cervical foraminotomy has a surgical success rate similar to an anterior cervical
discectomy and fusion. Proponents argue that the posterior procedure obviates the need for
fusion, therefore, postoperative immobilization is unnecessary. The posterior approach
cannot address segmental kyphosis or recreate disk space height.
 4) The most frequently involved spinal segment in rheumatoid arthritis is:

(A) C1-C2

(B) C7-T1

(C) C5-C6

(D) T12-L1

(E) L5-S1

Explanation:

C1-C2 is the most frequently involved spinal segment in rheumatoid arthritis (RA), and it is
also the most clinically significant. These articulations are exclusively synovial and the
primary target of RA.

5) A relative contraindication to cervical laminectomy for the treatment of cervical

spondylosis is:

(A) Positive Babinski sign

(B) Cervical lordosis

(C) Positive Hoffman sign

(D) Wrist extensor weakness

(E) Cervical kyphosis

Explanation:

Cervical laminectomy for spondylosis is performed to allow the spinal cord to migrate
posteriorly in order to decompress the spine. This can be accomplished only if the spine is
lordotic. If kyphosis exists, then the cord may remain draped over anterior osteophytes and
continued compression may exist. In cases of cervical kyphosis, anterior decompression is
preferred.

6) 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

Explanation:

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.
 7) A 2-year-old boy with a congenital heart anomaly has a 40� thoracolumbar
curvature. Standing posteroanterior and lateral radiographs reveal vertebral
anomalies indicative of congenital scoliosis. Which of the following patterns of
congenital scoliosis has the worst prognosis for progression?

(A) Block vertebrae

(B) Unilateral unsegmented bar

(C) Fully segmented hemivertebra

(D) Unilateral unsegmented bar with a contralateral fully segmented hemivertebra

(E) Nonsegmented hemivertebra

Explanation:

Congenital spinal deformity is caused by structural abnormalities in the vertebrae that can
result in asymmetric growth, such as scoliosis or kyphosis. It has been classified in 2 types.
Type I involves defects of formation and type II involves defects of segmentation. However,
in many instances, deformities can be a mixture of both. Defects of formation include
segmented or unsegmented hemivertebrae and wedge vertebrae. Defects of segmentation
include block vertebrae, unilateral bars, or unilateral bars with hemivertebrae.

The potential for progression is dependent on the growth potential of the anomalies. The
presence of healthy-appearing disks between the hemivertebra and its normal counterparts
indicates good growth potential and risk for progression. A unilateral bar on the opposite
side of a segmented hemivertebra acts as a tether on the concave side of the curve and has
the most likelihood for progression.

Children with congenital scoliosis also have a significant incidence of associated anomalies,
both intraspinal and other organ systems. About 30% have a spinal dysraphism such as
diastematomyelia, meningocele or lipoma. Other associated anomalies include Klippel-Feil
syndrome (25%), genitourinary tract abnormalities (30%), cardiac defects (12%), and
Sprengel�s deformity (10%).
 8) A 1-year-old male infant is referred by his pediatrician for evaluation of possible
scoliosis. Otherwise, he is healthy. His physical exam reveals normal neurologic
function, plagiocephaly and a flexible thoracic curve. Radiographs reveal a left
thoracic curve with a Cobb angle of 36� and no vertebral anomalies. The apical
ribs are in Phase I, and the rib-vertebral angle difference is 18�. At this time,
management should include:

(A) Observation

(B) Serial body casting to obtain correction

(C) Full-time use of a thoracolumbosacral orthosis

(D) Posterior spinal fusion

(E) Spinal instrumentation without fusion

Explanation:

Infantile idiopathic scoliosis is rare in this country and not well understood. It is more
common in Europe, occurs more frequently in boys, and left thoracic curves predominate.
Plagiocephaly, or a flattening of the posterior skull on the convex side of the spinal
curvature, is frequently found in these patients, suggesting a postural cause of both.

There are 2 types of infantile idiopathic scoliosis: resolving and progressive. Distinguishing
between the 2 types has obvious consequences regarding prognosis and treatment. Prior to
Mehta�s work, identification of the type of infantile idiopathic scoliosis was difficult, because
it was not related to curve magnitude, age at onset, rate of progression, or degree of
rotation.

Mehta showed that the 2 groups were distinguishable by the relationship of the ribs to the
apical vertebral body on the posteroanterior radiograph. Ribs that do not overlap the
vertebral body are in Phase I, and ribs that do overlap the vertebral body on the convexity of
the curve are in Phase II. The rib-vertebral angle is constructed by the intersection of a line
perpendicular to the apical vertebral endplate with a line drawn along the long axis of the
corresponding rib. The rib-vertebral angle (RVA) difference is the difference of the RVA of
the concave and convex ribs of the apical vertebra. In scoliosis, the convex ribs form a more
acute angle than the concave ribs, so this difference is >0. Mehta concluded that curves in
which the ribs are in Phase I and the RVA difference is < 20� have a better prognosis
(resolving type) and require just observation. Treatment for progressive curves includes
serial body casts, orthoses, or surgery for severe curves. Various surgical approaches include
posterior spinal fusion, instrumentation without fusion to allow spinal growth, or anterior
convex hemiepiphysiodesis with posterior hemiarthrodesis.
 9) An 8-year-old girl presents with back pain and an abnormal gait. She walks with
externally rotated feet and limited hip flexion. She has a palpable step-off at the
lumbosacral junction and hamstring tightness. Radiographs of the lumbosacral
spine demonstrate a dysplastic spondylolisthesis with a slip angle of 55� and
slippage of 60% of L5 on S1. The recommended course of treatment is:

(A) Posterolateral spinal fusion

(B) Epidural steroid injection

(C) Physical therapy

(D) Lumbosacral orthosis

(E) Observation with repeat radiographs in 6 months

Explanation:

Spondylolisthesis is the forward slipping of 1 vertebra on the next caudal vertebra.

Spondylolisthesis in children can be classified into 2 types: isthmic and dysplastic. Isthmic
spondylolisthesis is an entity in which there is a lesion in the pars interarticularis that permits
forward slippage; the articular facets are normal. Dysplastic or congenital spondylolisthesis
implies that there is a congenital deficiency in the L5-S1 facet that allows forward slipping.
There is no defect or elongation in the pars.

Growing children, particularly females, with dysplastic spondylolisthesis are at risk for further
progression. This patient�s abnormal gait is due to hamstring tightness, probably due to the
lumbosacral instability and nerve root irritation. With a grade III slip, back pain, and an
abnormal gait, this patient is a candidate for an in situ posterolateral spinal fusion. Use of
instrumentation is controversial, especially because the long-term results of in situ
noninstrumented fusions are superior.

10) The American Spinal Injury Association has developed a classification of spinal
cord injuries. Using this classification system, an Asia C injury is best described as:

(A) Complete motor loss with incomplete sensation

(B) Complete motor loss with complete sensation loss

(C) Incomplete motor loss with some preservation of motor function with groups with less then grade 3
strength
(D) Incomplete motor loss with normal bladder function

(E) Incomplete motor loss with 4+ strength and patchy sensation

Explanation:

Asia C is an incomplete spinal cord injury with reservation of motor function with < grade 3
motor strength.
 11) A 6-year-old boy has neck pain and stiffness following an upper respiratory tract
infection. He presented with his head tilted to the right and turned to the left 3
weeks ago, but a soft cervical collar has not been beneficial. There is no known
history of trauma. A computerized tomography scan shows rotatory subluxation of
C1 on C2. The next step in the treatment of this child is:

(A) Observation

(B) Open reduction and C1-C2 fusion through an anterior approach

(C) In situ C1-C2 fusion posteriorly

(D) Cervical traction

(E) Hard cervical collar

Explanation:This child has torticollis as sequelae of an upper respiratory infection (Grisel

syndrome) and rotatory subluxation (fixation) of C1 on C2. Other causes of torticollis include
congenital muscular torticollis, neurogenic causes, Sandifer syndrome, Klippel-Feil syndrome,
juvenile rheumatoid arthritis, and trauma. The common thread is that all of the etiologies
appear to weaken, through inflammation or force, the supporting soft tissue structures of the
atlantoaxial articulation. The diagnosis is made by dynamic CT scan.

Fielding classified atlantoaxial rotatory subluxation into 4 types:

 Type I is a simple rotatory displacement without an anterior shift, and is the most
common type in children.
 Type II is rotatory fixation with anterior displacement >3 to 5 mm, and is
associated with a deficiency of the transverse ligament and unilateral displacement
of one lateral mass of the atlas.
 Type III rotatory fixation there is anterior displacement >5 mm with bilateral
displacement of the lateral mass with one side displaced more than the other. This
is caused by a deficiency of both the transverse ligament and secondary ligament.
 Type IV is rotatory fixation with posterior displacement where the dens allows
posterior shift of one or both of the lateral masses, and one shifting more than the
other.

Types III and IV are rare but have potential for catastrophe and should be recognized to promptly initiate
treatment.

Children with rotatory fixation of <1 week can be treated with a soft cervical collar and rest for 1 week.
Most cases resolve, but close follow-up is necessary. If spontaneous reduction does not occur after 1-2
weeks, aggressive treatment is necessary. Inpatient halter traction with judicious use of muscle relaxants
and analgesics is recommended. Halo traction is necessary for reduction of longer standing (2-4 weeks)
subluxation. Surgery is indicated in cases of neurological compromise, failure to achieve closed reduction,
long-standing deformity (3 months or more), or recurrence following closed treatment. A Gallie-type
fusion posteriorly is favored.

12) The biggest contribution to lumbar lordosis:

(A) Occurs mostly within the disk spaces

(B) Occurs mostly within the vertebral bodies

(C) Is normally 70�

(D) Decreases with increasing age

(E) Can be visualized best on an anteroposterior plain radiograph

Explanation:

Most of the lumbar lordosis occurs within the disk spaces and not within the vertebral bodies.
Normal lumbar lordosis is between 30�to 50�, increases with age, and is best visualized on
a lateral plain radiograph.
 13) A 38-year-old man injured his neck and spinal cord 6 months ago as a result of a
motorcycle accident. He is now a C6 quadriplegic. He wants to know how his
sexual function will be affected by his condition. The patient should be informed
that:

(A) He should be able to obtain normal erections and ejaculation function.

(B) No erections or ejaculation function will exist.

(C) With external stimulation, a reflex erection is possible but normal ejaculation is not.

(D) Normal erections and ejaculations with low sperm counts are possible.

(E) He has a low probability of being sterile because precise control of thermal regulation of the testes is
usually retained.

Explanation:With this type of spinal cord injury, it is possible to have an erection with
external stimulation; however, ejaculation would have to be facilitated by electrical
stimulation or vibratory means.

14) A 72-year-old man comes to the office complaining of low back and thigh pain that
has been progressively getting worse over the years. The pain now bothers him
during weather changes. The patient tells you that his pain is worse with standing
and walking for long periods. However, leaning forward and sitting alleviates his
discomfort. The patient denies any bladder or bowel complaints. This patient most
likely has:

(A) A herniated lumbar disk

(B) Cauda equina syndrome

(C) Lumbar spinal stenosis

(D) Spinal cord tumor

(E) Vascular insufficiency

Explanation:This patient is presenting with the hallmark symptoms of lumbar spinal

stenosis, which consists of increased back and thigh pain with walking or standing with relief
of the symptoms by leaning forward or sitting down. This patient denies any bladder or
bowel dysfunction that makes cauda equina syndrome unlikely. Although urinary dysfunction
is uncommon in spinal stenosis, it can occur in approximately 3% to 4% of cases.

15) Which anatomic structure(s) may be the cause of referred pain to the lumbar spine
region:

(A) The hip

(B) The rectum

(C) The pelvis

(D) Both the hip and the pelvis

(E) The hip, the pelvis, and the rectum

Explanation:

The hip, rectum, and pelvis may refer pain to the lumbar spine region. In order to perform a
complete physical examination, a rectal exam is recommended on all patients with pain in
the lumbar spine region.
 16) An 18-year-old man comes to the office with a grade IV isthmic spondylolisthesis
and severe left lower extremity discomfort. Which imaging study would best help
identify the site of potential nerve root compression:

(A) Computed tomography scan

(B) Magnetic resonance imaging (MRI) scan

(C) Plain myelography

(D) Bone scan

(E) Positron emission tomography (PET)

Explanation:

An MRI scan would be the imaging study of choice to best identify the site of nerve root
compression because it provides parasagittal views that can help determine the degree of
narrowing of the neural foramina.

 Plain myelography may not accurately identify lateral recess compression.

 A CT scan would produce images perpendicular to the plane of nerve root
compression.
 Bone scan and PET scan would be of little or no help in identifying nerve root
compression.

17) When trying to distinguish sciatic radicular pain from pain following a hamstring
strain, it is important to know that pain from a hamstring strain usually only
involves the posterior aspect of thigh. Sciatic nerve pain may also be associated
with:

(A) Pain radiating down the leg and into the foot

(B) Low back pain

(C) Pain in the opposite leg

(D) Pain radiating down the leg and into the foot, and pain in the opposite leg

(E) Pain radiating down the leg and into the foot, pain in the opposite leg, and low back pain

Explanation:

Sciatic pain can involve all of the above complaints including radicular pain extending down
the leg, low back pain, and pain into the opposite leg.
Slide 1
18) A 45-year-old construction worker with long standing low back pain now notices
bilateral thigh and lower extremity discomfort for the past 6 months. He has undergone
conservative treatment with little success including injection therapy. He cannot perform his
work duties. Based on the lateral radiograph shown below, the next step in the management
of the patient should consist of:

(A) Laminectomy

(B) Continued conservative treatment

(C) Posterolateral fusion in situ without instrumentation

(D) Diskectomy

(E) Decompression and posterolateral fusion in situ with instrumentation.

Explanation:

This patient has an isthmic L4L5 spondylolisthesis with accompanied neuroforaminal

stenosis. He already failed conservative management and would benefit from operative
intervention. This should consist of a decompressive procedure to alleviate his lower
extremity symptomatology along with a fusion procedure of the L4-L5 level due to the
listhesis. If he undergoes a laminectomy alone, he may develop increased low back pain in
the future.
 19) A calcified thoracic disk in the spinal canal is pathognomonic for:

(A) Scheuermann disease

(B) Ankylosing spondylitis

(C) Thoracic disk herniation

(D) Vertebral wedging

(E) Infection

Explanation:

Plain radiographs of the spine are helpful in the diagnosis of disk herniation only if they
demonstrate disk calcification. However, the calcified disk is not always the disk that is
herniated, but it suggests the diagnosis. Detection of a calcified disk on radiograph in the
canal is pathognomonic of herniation.

20) 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

Explanation:

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.

21) Appropriate treatment for spinal infection may include all the following
except:

(A) Antibiotics

(B) Surgical decompression

(C) Brace immobilization

(D) Removal of spinal hardware in the acute postoperative setting

(E) Removal of spinal hardware in the chronic infection

Explanation:

Spinal stability appears to improve healing of spinal infection. Chronic, persistent infections
may require removal of hardware. Antibiotics and immobilization are the mainstays of
treatment. Neurological deficit from epidural abscess or kyphotic collapse may require
operative decompression.
 22) 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

Explanation:

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).

23) According to the Frankel grading scale for a neurologic injury, what is
meant by Frankel C:

(A) There is an antigravity motor function in some distal muscles below the level of the spinal cord injury.

(B) There is an antigravity muscle function in the muscles 1 or 2 root levels below the spinal cord injury.

(C) There is muscle function, but not with adequate power to overcome gravity in some muscles below the
level of the spinal cord injury.
(D) There is muscle function, but not with adequate power to overcome gravity in the muscles 1 or 2 root
levels below the spinal cord injury.
(E) The patient has a chance for further neurologic recovery.

Explanation:

The Frankel grading scale is used to communicate the extent of neurologic injury in the
setting of a spinal cord injury.

 The A category indicates that there is no motor or sensory function below the level
of the injury.
 The B category indicates that there is only sensory function below the level of the
injury.
 The C category indicates that there is muscle function, but not with adequate
power to overcome gravity in some muscles below the level of the spinal cord
injury.
 The D category indicates that there is motor function with at least antigravity
power below the level of the injury.
 The E category indicates that the muscle function below the level of the injury is
normal in power. One can see some motor function for 1-2 root levels below the
level of a spinal cord injury that is due to �root escape� and should not be
confused with distal motor sparing.
 24) Which type of treatment would be most appropriate for a young, healthy
patient with an incomplete spinal cord injury (ASIA C) 5 days following a
T12 burst fracture with 30% canal compromise:

(A) Bed rest, followed by hyperextension casting

(B) Posterior distractive instrumentation and fusion

(C) Posterior fusion in situ

(D) Anterior T12 corpectomy and strut grafting

(E) Anterior T12 corpectomy, strut grafting, and instrumentation

Explanation: Surgery is indicated in patients with an incomplete spinal cord injury with
spinal cord compression. Although some indirect decompression may be achieved early
following the injury using posterior distractive instrumentation, the level of decompression is
often better using an anterior approach (especially several days following the fracture).
Following anterior decompression, either anterior instrumentation or posterior
instrumentation is indicated to stabilize the construct and allow early mobilization.

25) Which of the following nerve roots supplies motor innervation to the
flexor digitorum superficialis (FDS):

(A) C5

(B) C6

(C) C7

(D) C8

(E) T1

Explanation:The FDS flexes the proximal interphalangeal joint and is innervated by the C8
cervical spine nerve root. The FDS is innervated peripherally by the median nerve.

The flexor digitorum profundus flexes the distal interphalangeal joint and is also innervated
by the C8 cervical spine nerve root. The middle and index fingers are supplied by the median
nerve, and the ring and little fingers are supplied by the ulnar nerve.

26) A patient with cauda equina syndrome has decreased perianal sensation.
Which of the following groups of nerve roots is involved:

(A) L2, L3, and L4

(B) L3, L4, and L5

(C) L5, S1, and S2

(D) S1, S2, and S3

(E) S2, S3, S4, and S5

Explanation: Perianal sensation is derived from the S2, S3, S4, and S5 nerve roots.

The sensory distribution is as follows:

 S4-S5 - - Innermost perianal ring

 S3 - - Middle perianal ring
 S2 - - Outermost perianal ring
Slide 1

Slide 2
27) A 45-year-old woman has pain in her right upper extremity and neck. The plain film is is presented
(Slide 1) as well as an axial post myelogram CT images (Slide 2, A & B). Her pain has not responded to
nonsteroidal anti-inflammatory 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

Explanation:

The axial post myelogram CT image 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.
Slide 1
28) The type of disk herniation shown (Slide) at the L5-S1 level is most likely to cause:

(A) Quadriceps weakness and numbness of the medial thigh

(B) Diminished sensation to the anteromedial calf

(C) Weakness of the tibialis anterior

(D) Weakness of the gastrocsoleus complex

(E) Extensor hallucis longus weakness

Explanation:

This slide shows a posterolateral disk herniation on the right. Posterolateral disk herniations
cause compression of the traversing S1 nerve root at this level. Sensation affected is the
posterior calf and lateral border of the foot, while motor innervation is to the gastroc soleus
complex. With far lateral disk herniations, the exiting nerve root is compressed and
symptoms may be seen referred to the level above.

29) A 75-year-old woman presents with low back pain that is worse with motion and bilateral
lower extremity pain that is worse with ambulation. She notes that the pain extends down
the posterior aspects of her lower extremities, from the buttocks to the calves. The pain
limits her activity � she can only ambulate approximately one block before having to rest.
She reports that lumbar flexion, notably leaning over a walker or a shopping cart,
considerably diminishes her lower extremity pain. She has a significant past medical history
of coronary artery disease, and she has had previous angioplasty of her coronary vessels. On
examination, her lower extremity pulses are easily palpable. What would you expect to find
on this patient�s neurological examination:

(A) No abnormal findings on the neurological examination

(B) Mild proximal lower extremity weakness

(C) Severe proximal lower extremity weakness

(D) Mild distal lower extremity weakness

(E) Severe distal lower extremity weakness

Explanation:

Lumbar spinal stenosis is a dynamic process. Patients classically have no deficit until they are
physically active. Therefore, this patient may not have a deficit during her clinic examination.
It would be unusual for her to present with a fixed lower extremity deficit.
30) 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

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

31) 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.

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

32) 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

Explanation:

All patients presenting with back pain should have a thorough history taken and a complete
physical exam including a detailed neurologic exam. In the recently published Agency for
Health 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.
33) A 72-year-old man with acute onset low back pain with increased severity during the
night should be evaluated by:

(A) History and physical examination only

(B) Magnetic resonance imaging of the lumbar spine

(C) History, examination, and urine protein electrophoresis

(D) Computed tomography of the lumbar spine

(E) Plain radiographs of the lumbar spine

Explanation:

An elderly patient with unsolicited low back pain is suggestive of a primary malignancy or
metastatic disease of the lumbar spine. A thorough history and physical examination are
indicated, as well as imaging to evaluate the lumbar spinal axis and the neural elements.

34) Bony contribution to the lumbar lordotic curvature is provided by:

(A) Spinous processes

(B) Articulating facets

(C) Lamina

(D) Pars interarticularis

(E) Vertebral body

Explanation:

The anterior portion of each body has a slightly increased height that contributes to the
sagittal lumbar lordosis. The posterior vertebral arch consists of the paired pedicles, laminae,
and a midline dorsal spinal process.

35) Which of the following is NOT an indication for surgical intervention in metastatic
vertebral disease:

(A) Progressive neurologic deficit

(B) Poor prognosis

(C) Instability of the spine

(D) Uncontrollable pain

(E) Failure of radiation therapy

Explanation:

In patients with metastatic vertebral disease, indications for surgery include progressive
neurologic deficit, instability of the spine, uncontrollable pain, and failure of radiation
therapy. Surgical intervention can add significant morbidity while providing marginal
improvement in longevity of a patient with an already poor prognosis.
36) Burst fractures of the vertebral body require prompt evaluation because:

(A) Although burst fractures of the vertebral body are stable injuries, neurologic deterioration is likely.

(B) Burst fractures of the vertebral body involve two-column injury and are unstable.

(C) Burst fractures of the vertebral body are extremely painful to the patient.

(D) Burst fractures of the vertebral body are commonly associated with other noncontiguous fractures.

(E) Burst fractures of the vertebral body often result in spinal shock.

Explanation:

When the middle column is involved in a compression injury, it is classified as a burst

fracture. This involves axial load on the spine, with or without a flexion component, and
retropulsion of the posterosuperior vertebral body into the spinal canal, thus requiring
prompt medical attention. Neurologic deficit is variable and is related to the severity of the
initial injury and location of the fracture, and only loosely related to the percent of canal
compromise.

37) In reference to the normal sagittal vertical axis (sagittal plumb line), the axis normally
falls from the odontoid process through the C7-T1 intervertebral disk and anterior to the
thoracic vertebra. This normal axis crosses the spinal column at which of the following levels
before crossing the spinal column at the posterior superior border of the S1 vertebral body:

(A) T3-T4 intervertebral disk

(B) T6-T7 intervertebral disk

(C) T8-T10 intervertebral disk

(D) T12-L1 intervertebral disk

(E) L3-L4 intervertebral disk

Explanation:

The alignment of the spine is important in normal upright posture. There is a normal degree
of lordosis in the cervical and lumbar spines and a moderate degree of kyphosis in the
thoracic spine. The head, spine, and pelvis are connected and balanced. If the spine is out of
balance, then a deformity can develop causing fatigue of the paraspinal muscles.

The normal sagittal alignment in an upright patient is as follows:

 Plumb line

The sagittal plumb line falls from the odontoid process through the C7-T1
intervertebral disk and then anterior to the thoracic spine. The plumb line then
crosses the spine at the T12-L1 intervertebral disk, and then travels posterior to
the spine. The plumb line crosses at the posterior corner of the S1 vertebra

The endplates and pedicles of the L3 vertebra are normally parallel to the ground.
38) The vertebral artery on the right side of the body arises from the subclavian artery and
enters the lateral mass foramen of which of the following cervical vertebra (the first one it
enters) before ascending to the brain:

(A) C3

(B) C4

(C) C5

(D) C6

(E) C7

Explanation:

The vertebral artery arises from the subclavian artery on the right side of the body and the
aortic arch on the left side. The vertebral artery enters the lateral mass foramen of the sixth
cervical vertebra before ascending to the brain.

39) 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.

Explanation:

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

40) A potential major complication of lumbar pedicle screws is:

(A) Lateral screw breakout injuring the vertebral artery

(B) Lateral screw breakout injuring the exiting nerve root

(C) Medial screw breakout injuring the vertebral artery

(D) Medial screw breakout injuring the exiting nerve root

(E) Medial screw breakout causing vertebral fracture

Explanation:

The exiting nerve root traverses immediately medial then caudal to the lumbar pedicle.
Therefore, a screw that breaks out medially or inferiorly from the pedicle is a potential risk to
the nerve root.
41) All of the following are elements of the lateral mass of cervical spinal segments except:

(A) Inferior articulating process

(B) Superior articulating process

(C) Spinous process

(D) Transverse process

(E) Transverse foramen

Explanation:

The lateral mass of the cervical spinal segments includes the inferior and superior articulating
processes, the transverse foramen, and the transverse process. The spinous process is not
an element of the lateral mass.

42) A burst fracture results in failure of the:

(A) Anterior column

(B) Middle column

(C) Posterior column

(D) Anterior and middle columns

(E) Middle and posterior columns

Explanation:

A burst fracture by definition is failure of the anterior and middle columns due to axial
loading, which often leads to instability and neurologic impairment.

43) Which of the following fracture types is the most stable fracture:

(A) Teardrop fracture

(B) Burst fracture

(C) Unilateral facet dislocation

(D) Hangman�s fracture

(E) Clay-shoveler�s fracture

Explanation:

The avulsion of part or all of the spinous process that occurs after a violent flexion motion is
a one-column injury. The injury is a stable fracture treated by external orthosis, which rarely
results in neurologic impairment. The other answer choices may be considered stable in
some instances, but none of them are stable all of the time.
44) Which of the following diagnostic tests is preferred for suspected cervical radiculopathy:

(A) Chest radiograph

(B) Magnetic resonance imaging

(C) C-reactive protein assay

(D) Myelogram

(E) All of the above

Explanation:

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

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

(A) Physical therapy

(B) Surgical repair

(C) Medical management (eg, nonsteroidal anti-inflammatory drugs, opioids, and corticosteroids)

(D) Bed rest

(E) None of the above

Explanation:

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

46) 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

Explanation:

Diskitis is usually indolent, and patients live with symptoms for several months before
seeking treatment. Intravenous drug use and immunocompromise are two important risk
factors for diskitis, along with surgical procedures involving the spine. Diskitis rarely occurs in
the thoracic spine; instead, diskitis usually occurs in the lumbar spine. Blood cultures should
be taken in any patient with suspected diskitis.
47) 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) Seventy-five percent of patients in whom the bullet has passed through the spinal canal will experience a
complete lesion.
(E) All of the above

Explanation:

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

48) All of the following are possible treatments for congenital or acquired torticollis except:

(A) No treatment because spontaneous resolution is possible in cases of congenital torticollis

(B) Active and passive stretching therapies in patients with congenital torticollis until puberty

(C) Holding infants so that chin is rotated toward the affected side

(D) Physical therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) and use of a soft collar

(E) Use botulinum toxin, hard collars, or braces in severe cases

Explanation:

Several treatment options exist for congenital and acquired torticollis. In very mild cases of
congenital torticollis, the deformity may be self-limited and no therapy needs to be
administered. Sometimes active and passive stretching of the neck can work well if
performed before 1 year of life. Parents may hold the baby�s head so that the chin is
rotated toward the affected side. Acquired torticollis can also be managed by physical
therapy using NSAIDs and a soft collar. The use of botulinum toxin or braces can be a form
of therapy in recalcitrant cases.

49) What is the incidence of congenital torticollis in the general population:

(A) 0.1% to 0.3%

(B) 0.5% to 0.8%

(C) 0.3 to 1.0%

(D) 0.3% to 1.9%

(E) 2% to 5%

Explanation:

Epidemiological studies have shown that the incidence of congenital torticollis is

approximately 0.3% to 1.9% in the general population.
50) Occipitocervical fusion is indicated in all of the following situations except:

(A) Diseased C1-C2 facet joints

(B) C1-C2 instability with decompressive laminectomy

(C) C1-C2 instability with intact posterior arch of the atlas

(D) C1-C2 instability with fractured posterior arch of the atlas

(E) Atlanto-occipital instability

Explanation:

An unstable C1-C2 segment, with intact posterior elements, may be treated via a C1-C2
fusion. If decompression is necessary or the posterior elements at C1-C2 are involved, then
extension to the occiput may be necessary.
 SPINE
356 Q
6/7 ( 50Q )

COLLECTED BY
DR. A. AWAJI
 1) 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

Explanation:

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.

2) A 6-year-old girl with a lumbar level paraplegia secondary to myelomenigocele

presents with a rapidly progressive thoracolumbar scoliosis. The most accurate test
to determine the etiology of the spinal deformity is:

(A) Bone scan

(B) Lumbar puncture and cerebrospinal fluid analysis

(C) Magnetic resonance imaging of the brain and spinal cord

(D) Lateral flexion/extension radiographs of the cervical spine

(E) Computerized tomography scan of the spine at the lumbosacral junction

Explanation:

Children with myelodysplasia are at risk for scoliosis, but a rapidly progressive curve should
alert the physician to aggressively investigate the etiology. Causes include:

 Tethered cord
 Syringomyelia
 Shunt failure
 Progressive hydromyelia
 Arnold-Chiari malformation

All of these conditions can be readily diagnosed by a magnetic resonance imaging scan of
the brain and spinal cord. Radiologic imaging such as radiographs, computerized tomography
scans, or bone scans for bony lesions is rarely helpful. Cerebrospinal fluid analysis is unlikely
to reveal an answer regarding scoliosis.

In the presence of a working ventriculoperitoneal shunt, the most likely etiology in this child
is a tethered cord. Increased lumbar lordosis, back pain, or an increase in lower root level
spasticity should alert the clinician to the possible presence of a tethered cord.
 3) 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

Explanation: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.

4) A 4-week-old female infant has congenital muscular torticollis. Which of the

following is not associated with this condition?

(A) Plagiocephaly

(B) Cervical spine anomalies

(C) Developmental dysplasia of the hips

(D) Sternocleidomastoid muscle fibrosis

(E) Difficult delivery

Explanation:Congenital muscular torticollis is the most common cause of torticollis in the

infant and young child. Usually, the children have a history of a breech or difficult delivery or
primiparous birth. The exact etiology is unknown, but theories center around a compartment
syndrome of the sternocleidomastoid muscle as a result of compression of soft tissues
around the neck at the time of delivery. This results in fibrosis of the sternocleidomastoid
muscle, tilting of the head to the ipsilateral side, and rotation of the head to the opposite
side.

Congenital muscular torticollis is associated with developmental dysplasia of the hips in up to

20% of children, so a careful examination of hip stability is mandatory, with dynamic
ultrasound, if necessary. Plagiocephaly or facial and skull deformities occur in progressive
torticollis within the first year of life. The association of metatarsus adductus with congenital
muscular torticollis is variable in the literature. Plain radiographs of the cervical spines of
children with congenital muscular torticollis are always normal, with the exception of the
head tilt and rotation. Treatment initially includes stretching exercises and physical therapy
early in life. Surgery (release of the muscle) is recommended if the torticollis persists after 1
year of age.
 5) Which of the following incomplete spinal cord injury syndromes has the most
potential for recovery:

(A) Anterior cord syndrome

(B) Central cord syndrome

(C) Brown-Sequard syndrome

(D) Posterior cord syndrome

(E) Pyramidal syndrome

Explanation:Brown-Sequard syndrome is described as ipsilateral loss of motor function and

contralateral loss of pain and temperature sensation. This syndrome is caused by penetrating
injuries. Generally < 90% of patient who have this injury will recover ambulation.

6) A 40-year-old victim of a car accident was complaining of anterior chest pain. An x-

ray of the chest showed no widening of the mediastinum and absence of
pneumothorax. Lateral CXR revealed a fractured sternum with the proximal part of
the fracture displaced posteriorly. Which of the following is the next step in the
management of this patient?

(A) Arterial blood gas

(B) Aortogram

(C) Chest bandage for the fractured sternum

(D) Computed Tomography of the chest

(E) Lateral x-ray of the thoracic spine with the patient supine

Explanation:N/A

7) Which of the following is not a routinely used imaging technique for the evaluation of lumbar disk disease:

(A) Myelography

(B) Computer tomography

(C) Magnetic resonance imaging (MRI)

(D) Positron emission tomography (PET)

(E) Bone scan

Explanation:Positron emission tomography (PET) is a technique that measures brain

activity through positron emission from radiolabled glucose.

 Myelography is an invasive procedure with radio-opaque dye placed into

subarachnoid space. It aids in the detection of neural compressive lesions.
 Computer tomography alone offers better visualization of bony lesions, foraminal
spinal stenosis, and lateral disk herniations when compared to plain myelography.
Computer tomography is often combined with myelography.
 Magnetic resonance imaging (MRI) has an advantage over CAT because it detects
soft tissue pathologies, including improved spinal cord imaging in the detection of
intraspinal tumors. MRI also examines the entire spine.
 Bone scanning is a nonspecific but sensitive test. It is useful in detecting
neoplastic, infectious, traumatic, and/or arthritic problems in the spine.
 8) A positive straight-leg raise sign:

(A) Occurs when the obturator nerve is stretched

(B) Is always associated with a history of trauma or injury

(C) Is important in predicting a successful outcome if surgery is performed to excise the herniated fragment

(D) Is a specific test to detect a lumbar disk herniation

(E) Is not sensitive in detecting a lumbar disk herniation

Explanation:

A positive straight-leg raise sign occurs when the sciatic nerve is placed under tension or is
stretched reproducing a radiculopathy. It is also suggestive of inflammation around the nerve
root, hence it is a good predictor of the successful relief of symptoms from surgical
decompression. Additionally, a positive straight-leg raise sign is a relatively sensitive test for
detecting a lumbar disk herniation, but it is not specific. Because the sign is not specific, it
does not necessarily correspond to trauma or injury.

9) 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%

Explanation:

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.
 10) A 32-year-old man develops left lower extremity discomfort following a basketball
game. A magnetic resonance image of the lumbar spine reveals a posterolateral
disk herniation at the level of L4/L5. All of the following conditions could be
associated with this except:

(A) Decreased strength in the hip abductors

(B) Decreased strength in the extensor hallucis longus muscle

(C) Numbness in the lateral aspect of the leg

(D) Decreased strength in plantarflexion of the foot

(E) Pain in the dorsum of the foot

Explanation:

Decreased strength in the hip abductors and in the extensor hallucis longus muscle along
with numbness in the lateral aspect of the leg and pain in the dorsum of the foot can all be
associated with a herniation at the L4/L5 level affecting the L5 nerve root. Decreased
strength in plantarflexion of the foot is present when the S1 nerve root is involved, such as
with a disk herniation at the L5/S1 level.
Slide 1
11) A 16-year-old football lineman develops unrelenting low back pain for the past 3 months.
Based on the magnetic resonance image shown, the next step in the management of this
patient is:

(A) Fusion in situ

(B) Epidural injection therapy

(C) Excision of a herniated disk

(D) Restriction of the exacerbating activity

(E) Observation

Explanation:

This patient has a grade I-II spondylolisthesis of L5 on S1. The initial management should
include restriction of physical activity. Once the symptoms abate, the athlete can return to
the sport. If symptoms return, other interventions are indicated including possible brace
wear.
Slide 1
12) A 50-year-old woman with 3 months of low back pain recently discovers a hard, painless
lump in her breast. Due to the back discomfort, she undergoes plain radiography and
subsequently a computed tomography scan (below). The most likely diagnosis is:

(A) Osteomyelitis

(B) Osteoid osteoma

(C) Fracture

(D) Herniated nucleus pulposis

(E) Metastatic disease

Explanation:

The computed tomography scan reveals a destructive lesion involving the vertebral body
extending into the pedicle in a patient with a suspected breast malignancy. This is a
metastatic lesion until proven otherwise. This patient needs a thorough evaluation of her
breast lesion, as well as her spine lesion, including biopsies. An osteoid osteoma is seen in a
younger population and is seen on a computed tomography scan as a sclerotic round lesion.

13) The most common organism responsible for vertebral column infection is:

(A) Pseudomonas aeruginosa

(B) Staphylococcus epidermidis

(C) Staphylococcus aureus

(D) Escherechia coli

(E) Mycobacterium tuberculosis

Explanation:Staphylococcus aureus accounts for more than 50% of spinal infections and
often results from hematogenous dissemination. Gram-negative organisms are more
common following genitourinary procedures or urinary tract infections. Staphylococcus
epidermidis can complicate spinal surgical wounds, and polymicrobial infection is more
common in these circumstances.
14) 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

Explanation:

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.

15) What percentage of spinal infections have concurrent positive blood cultures:

(A) 5%

(B) 25%

(C) 55%

(D) 75%

(E) 95%

Explanation:Even though the majority of spinal infections are considered hematogenous in

origin, only 25% of infections occur with positive blood cultures.

16) Which of the following comprises the middle column in the Denis three-column model of
the thoracolumbar spine:

(A) Posterior longitudinal ligament, spinal canal, pedicles, and facet joints

(B) Facet joints, intertransverse membrane, and ligamentum flavum

(C) Vertebral body, posterior longitudinal ligament, and disk

(D) Posterior half of the vertebral body, posterior half of the disk, and posterior longitudinal ligament

(E) Interspinous ligament, supraspinous ligament, and ligamentum flavum

Explanation:

The middle column is composed of the posterior half of the vertebral body, posterior half of
the disk, and posterior longitudinal ligament. The middle column, according to Denis, is
important to determine the stability of a thoracolumbar fracture. There is the potential for
instability when the middle column is disrupted.
17) Which of the following statements is true regarding neurogenic shock:

(A) Neurogenic shock is due to severe blood loss associated with a spinal cord injury.

(B) Neurogenic shock can be diagnosed when there is hypotension and tachycardia.

(C) Neurogenic shock is due to increased parasympathetic tone.

(D) Neurogenic shock is best treated with judicious use of fluids and vasopressors.

(E) Neurogenic shock is a sign of an incomplete spinal cord injury.

Explanation:Neurogenic shock is present when there is a spinal cord injury interrupting

sympathetic tone to the heart and blood vessels, and it is heralded by bradycardia and
hypotension. It is important to maintain a reasonable blood pressure to prevent further
damage to the spinal cord due to ischemia. In the absence of significant blood loss from
another source, neurogenic shock must be treated with vasopressor medication and
atropine. Severe neurogenic shock may require cardiac pacing. Fluids must be used carefully
as overzealous use of fluid resuscitation can result in pulmonary edema.

18) 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

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

19) A patient has a fracture dislocation of the cervical spine. Which of the following nerve
roots must be spared to preserve intact finger extension:

(A) C5

(B) C6

(C) C7

(D) C8

(E) T1

Explanation:Finger extensors are innervated by the C7 cervical spine nerve root.

Motor innervations include:

Shoulder abduction (deltoid) - - C5 Elbow flexion - - C5 Wrist extension - - C6, C7 Wrist

flexion - - C7 Finger extension - - C7 Finger flexion - - C8 Finger abduction/adduction - - T1
20) 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

Explanation:

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

21) Testing of the L5 lumbosacral nerve root in a patient who has radicular back pain can be
accomplished through which of the following reflexes or tests:

(A) Patellar tendon reflex

(B) Achilles tendon reflex

(C) Tibialis posterior reflex

(D) Superficial anal reflex

(E) Beevor sign

Explanation:

Although there is not a well-defined reflex arc for the L5 lumbosacral nerve root, the tibialis
posterior reflex can be elicited. The tibialis posterior reflex is mediated through the L5
lumbosacral nerve root.

Reflexes and associated nerve roots include:

 Patellar tendon --- L4

 Achilles tendon --- S1
 Superficial anal reflex --- S2, S3, S4
 Beevor sign refers to asymmetry of the segmental innervation of the rectus
abdominus muscles and when performing a sit-up, there is unilateral segmental
nerve root loss.
22) Which of the following statements regarding the presentation of thoracic disk herniations
is false:

(A) Pain is the principal symptom.

(B) Radicular pain may be present.

(C) Mechanical axial back pain may be present.

(D) Myelopathic pain may be present.

(E) Bowel and bladder symptoms occur in more than 50% of affected patients.

Explanation:

Patients with thoracic disk herniations may present with mechanical axial back pain, radicular
pain, or myelopathy, but pain is the principal symptom. Bowel and bladder symptoms occur
in 10% to 20% of affected patients.

23A) Which of the following statements regarding the treatment of thoracic disk herniations
is true:

(A) The majority of patients can be treated nonoperatively.

(B) Surgical decompression is necessary in most cases.

(C) Laminectomy is the surgical procedure of choice.

(D) The anterior transthoracic approach is used for T1-T4 lesions.

(E) Costotransversectomy is used for large central calcified herniations.

Explanation:

The majority (75%) of patients with thoracic disk herniations may be managed
nonoperatively. Surgical procedures must adequately decompress the involved nerve root.
Posterior approach by laminectomy is usually not adequate, and costotransversectomy is not
effective for large central calcified herniations (an anterior approach is preferred). The
anterior transthoracic approach is effective for T5-T12 lateral and anterior disk herniations.
Slide 1
24) 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

Explanation: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.

25) Which of the following sensory areas is affected by compression of the C7 nerve root:

(A) Base of neck, medial shoulder

(B) Base of neck to shoulder and upper arm

(C) Lateral forearm into the radial side of the hand

(D) Posterolateral forearm into the middle finger of the hand

(E) Ulnar side of the forearm and hand

Explanation:
It is important to remember the sensory dermatome when examining patients who have
neck and upper extremity pain:
C3 Posterior neck, occiput
C4 Base of neck, medial shoulder
C5 Base of neck to shoulder and upper arm
C6 Lateral forearm into the radial side of the hand
C7 Posterolateral forearm into the middle finger of the hand
C8 Ulnar side of the forearm and hand
26) Plain radiographs of the lumbosacral spine are useful for:

(A) Detecting marrow changes

(B) Far lateral herniated intervertebral disks

(C) Distinction between disk material and the dural sac

(D) Lateral recess stenosis

(E) Instability patterns

Explanation:

Plain radiographs are useful for assessing the alignment of the spine, bone destruction by
tumors and infections, and instability patterns. The radiographs also will show degenerative
intervertebral disks.

Plain radiographs are not sensitive for detecting marrow changes, herniated disks, and
neural compression secondary to degenerative changes.

Slide 1
27) 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

Explanation:

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.
28) 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. What questions from his
history can help differentiate vascular from neurogenic claudication:

(A) Distribution of pain

(B) Pattern of sensory loss

(C) Posture changes

(D) Relief of pain with rest

(E) Timing of symptom onset

Explanation:

Pain distribution may be similar in vascular and neurogenic claudication. The pattern of
patient-reported sensory loss is unlikely to be contributory due to the patient�s history of
insulin-dependent diabetes and, presumably, a diabetic peripheral neuropathy. In both
syndromes, pain is relieved with rest. Usually, pain relief is quicker in vascular claudication.
In neurogenic claudication, standing alone may not relieve patient symptoms; sitting is
usually required. Timing of symptom onset is variable in both syndromes. Vascular
claudication usually produces less variability in exercise tolerance. Relief of pain with changes
in posture (bending over a walker or shopping cart) is found only in neurogenic claudication.

29) A 75-year-old woman presents with low back pain that is worse with motion and bilateral
lower extremity pain that is worse with ambulation. She notes that the pain extends down
the posterior aspects of her lower extremities, from the buttocks to the calves. The pain
limits her activity � she can only ambulate approximately one block before having to rest.
She reports that lumbar flexion, notably leaning over a walker or a shopping cart,
considerably diminishes her lower extremity pain. She has a significant past medical history
of coronary artery disease, and she has had previous angioplasty of her coronary vessels. On
examination, her lower extremity pulses are easily palpable. This patient is diagnosed with
degenerative spondylolisthesis with significant lateral recess stenosis. Treatment of this
patient could include:

(A) Epidural steroids

(B) Decompression alone

(C) Decompression with noninstrumented fusion

(D) Decompression with instrumented fusion

(E) All of the above

Explanation:

Treatment options for this patient are legion. Considering her significant coronary artery
disease, a conservative approach using anti-inflammatory drugs, physical therapy, and
epidural steroids might be chosen by some physicians. Surgical options include
decompression alone or decompression with fusion. This patient�s significant mechanical
low back pain encourages some surgeons to include a fusion with the decompression.
30) The type of peripheral nerve injury that requires acute repair is:

(A) A sharp transection

(B) A blunt transection

(C) A contusion injury

(D) A stretch injury

(E) No peripheral nerve injury should be acutely repaired.

Explanation:

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

31) Which of the following is the anatomic origin of the Brown-Sequard�s syndrome:

(A) Ischemic damage to the periphery of the cord

(B) Shear injury to the central cord

(C) Contusion to the dorsal cord

(D) Traumatic hemisection of the cord

(E) Complete transection of the cord

Explanation:

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

32) 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

Explanation:

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.
33) Which of the following is the primitive remnant of the nucleus pulposus:

(A) The smoites

(B) Ectoderm

(C) Midgut

(D) Rhombencephalon

(E) Notocord

Explanation:

The nucleus pulposus is derived from the primitive notochord. It consists predominantly of
hydrated proteoglycans with a minor component of a random network of type I and type II
collagen.

34) Which of the following is the most common region of the spine affected by metastatic
disease:

(A) Craniocervical junction

(B) Cervical region

(C) Thoracic region

(D) Lumbar region

(E) Sacral region

Explanation:

The thoracic spine is the most common site of metastatic disease. This has been attributed
to the watershed zone being located in the low thoracic region.

35) 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.

Explanation:

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.
36) 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.

Explanation:

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.

37) Neurogenic shock is defined as:

(A) Decreased cardiac output due to increased parasympathetic tone

(B) Severe volume depletion leading to hypotension

(C) Widespread gram-negative septicemia with hypoperfusion

(D) Loss of sympathetic tone and widespread vasodilation

(E) Increased cardiac output due to decreased parasympathetic tone

Explanation:

Neurogenic shock is a unique hemodynamic alteration in patients with spinal cord injuries
who have their sympathetic outflow disrupted in addition to the interruption of the motor
and sensory pathways. The loss of sympathetic tone to the heart and peripheral vasculature
leads to bradycardia and hypotension
38) 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

Explanation:

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.

39) Osteochondromatosis is a hereditary genetic disorder that is:

(A) Autosomal recessive with incomplete penetrance

(B) Autosomal recessive with complete penetrance

(C) Autosomal dominant with incomplete penetrance

(D) Sex-linked dominant

(E) Sex-linked recessive

Explanation:

Osteochondromatosis (also known as hereditary multiple exostoses) is a genetic disorder

that is autosomal dominant with incomplete penetrance in women. The genetic defect occurs
on the EXT1, EXT2, and EXT 3 genes located on chromosome 8q24.
40) Typical histologic features of an osteoblastoma include all of the following except:

(A) Vascularized spindle cell stroma

(B) Nidus composed of haphazardly arranged network of osteoid trabeculae

(C) Occasional areas of aneurysmal bone cyst formation

(D) Osteoblasts rimming the trabeculae

(E) Chondrocytes arranged in a zonal pattern

Explanation:Histologically osteoblastoma is similar to an osteoid osteoma; its features

include:

 Irregular osteoid arranged haphazardly with rimming by round osteoblasts

 Loose fibrovascular connective tissue between trabeculae
o Osteoblasts rimming the trabeculae
o Vascularized spindle cell stroma
 Areas of aneurysmal bone cyst formation can be seen

41) Which of the following tumors is considered to be a benign primary spine tumor:

(A) Osteosarcoma

(B) Chordoma

(C) Multiple myeloma

(D) Osteoblastoma

(E) Lymphoma

Explanation:

I. Primary benign tumors of the spine are:

A. Slow-growing
B. Well-circumscribed
C. Usually occur in patients younger than 21 years of age
D. Involve the vertebral body and posterior elements of the spine
1. Overall slight predilection for the posterior elements
2. Location of tumor is an important factor in determining the
type of tumor
E. Examples include:
1. Osteochondroma
2. Osteoid osteoma
3. Osteoblastoma
4. Aneurysmal bone cyst
5. Giant cell tumor
6. Eosinophilic granuloma
II. Primary malignant tumors of the spine are:
A. Fast-growing
B. Permeative
C. Usually occur in patients older than 21 years of age
D. Examples include:
1. Multiple myeloma/solitary plasmacytoma
2. Osteosarcoma
3. Chondrosarcoma
4. Ewing's sarcoma/primitive neuroectodermal tumor
5. Chordoma
6. Lymphoma
42) Which of the following is not a described technique of minimally invasive anterior lumbar
interbody fusion:

(A) Laparoscopic transperitoneal

(B) Endoscopic retroperitoneal

(C) Mini-open retroperitoneal

(D) All of the above are described techniques

(E) None of the above are described techniques

Explanation:

All of the above are well-described techniques of minimally invasive anterior lumbar
interbody fusion.

43) Which of the following statements is true regarding the C2 lateral mass:

(A) The vertebral artery assumes a more lateral position at this level.

(B) The vertebral artery assumes a more medial position at this level.

(C) The vertebral artery is found outside of the transverse foramen at this level.

(D) The vertebral artery precludes placement of lateral mass screws at this level.

(E) None of the above

Explanation:

The vertebral artery assumes a more lateral position at the C2 level; therefore, screw
placement at this level should follow a medial trajectory to avoid injury to the vertebral
artery.

44) Which of the following pathogens is not typically implicated in diskitis:

(A) Staphylococcus aureus

(B) Staphylococcus albus

(C) Pseudomonas aeruginosa

(D) Staphylococcus epidermidis

(E) Gram-positive cocci

Explanation:

The gram-positive cocci are typical opportunistic pathogens that are capable of causing
infection in the vertebral disk space. Most commonly they seed via the hematogenous route
but local translocation has also been implicated. Unless a patient has been hospitalized for a
while and iatrogenesis is ruled out, Pseudomonas species usually do not cause diskitis.
45) Which of the following is characteristic of patients with Klippel-Feil syndrome:

(A) Absence of the vertebral pedicles

(B) Absence of intervertebral joints

(C) Shortened pedicles

(D) A narrow spinal canal

(E) Increased interpediculate distance

Explanation:

Klippel-Feil syndrome is a rare disorder characterized by the congenital fusion of any two of
the seven cervical vertebrae. The cause is a failure in the early segmentation during fetal
development. The fused segments show absence of intervertebral joints. Associated
abnormalities may include scoliosis; spina bifida; anomalies of the kidneys and ribs; and
other midline anomalies.

46) Typical C3 reflexes include which of the following:

(A) Sternocleidomastoid reflex

(B) Head retraction reflex

(C) Pectoralis reflex

(D) Biceps reflex

(E) None of the above

Explanation:

No reflexes are associated with the C3 spinal nerve.

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

(A) A lumbar puncture may reveal cerebral spinal fluid (CSF) with an increased number of neutrophils, decreased
glucose content, and increased protein levels.
(B) A CSF culture may reveal Haemophilus influenzae.

(C) Radiographic findings for whiplash-related trauma may be negative in this patient.

(D) The patient should be admitted to the pediatric intensive care unit (PICU) and started on an intravenous
antibiotic regimen.
(E) All of the above

Explanation:

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

48) A patient with slipped capital femoral epiphysis (SCFE) should have an endocrine workup
if presenting with which of the following features:

(A) Bilateral involvement

(B) Body mass index greater than the 95th percentile for age

(C) Age <10 or >15 years

(D) Negative family history

(E) Female gender

Explanation:

Endocrine workup is only indicated for age ,10 or .15 years, or stature less than the 10th
percentile. Bilaterality, obesity, and negative family history are common findings in idiopathic
SCFE. Although SCFE is more common in males, it is not uncommon in females.
49) Occipitocervical fusion is often technically difficult in patients with rheumatoid arthritis
due to all of the following reasons except:

(A) Reduced bone quality

(B) Subaxial cervical instability

(C) Persistent steroid use

(D) Occipital condyle fracture

(E) Frequent combination of both occipitocervical deformity and subaxial subluxation necessitating more extensive
constructs

Explanation:

Reduced bone quality is common in patients with rheumatoid arthritis. Steroid use may
contribute to poor bone quality, impair bony fusion, and impede wound healing. The
combination of occipitocervical deformity and subaxial subluxation may make individual
patient constructs more extensive.

50) Approximately what percentage of individuals with rheumatoid arthritis will develop
basilar invagination:

(A) 1%

(B) 3%

(C) 5%

(D) 10%

(E) 20%

Explanation:

As per Sandhu and researchers, approximately 11% of patients with rheumatoid arthritis will
eventually develop basilar invagination.
 SPINE
356 Q
7/7 (56Q )

COLLECTED BY
DR. A. AWAJI
Figure 1
1) This patient has a wide-based gait and hyper-reflexia in his lower extremities. His magnetic resonance image is
presented. Other physical findings in this patient would likely include:

(A) Negative Hoffman sign

(B) Negative Babinski sign

(C) Carpal tunnel syndrome

(D) Hand intrinsic wasting

(E) Thoracic outlet syndrome

Explanation:

This patient’s clinical presentation is suggestive of cervical spondylotic myelopathy. The T2

sagittal magnetic resonance image shows multiple areas of spinal cord compression due to
spondylosis. In this situation, one sees evidence of upper motor neuron dysfunction in the
lower extremites such as hyper-reflexia, Hoffman sign, clonus, wide-based gait, and sexual
or bladder dysfunction. The upper extremities may demonstrate upper and lower motor
neuron findings, hypo-reflexia or hyper-reflexia, crossed radial reflex, Hoffman sign, and
hand intrinsic wasting.
2) After an anterior cervical discectomy and fusion with autogenous iliac crest bone graft, the
patient reports numbness in the lateral thigh. This is due to:

(A) Nerve root injury

(B) Intraoperative positioning

(C) Lateral femoral cutaneous nerve injury

(D) Genitofemoral nerve injury

(E) Sciatic nerve injury

Explanation:

The lateral femoral cutaneous nerve emerges from the lateral border of the psoas major
muscle and crosses the ilium as it runs toward the anterior superior iliac spine. The course of
the nerve is variable. The nerve is at risk of injury, with resulting meralgia paresthetica, in
approximately 10% of patients.

3) A type 3 Anderson and Montensano fracture of the occipitocondyle is best described as:

(A) An impacted comminuted fracture of the occipital condyle

(B) An occipital condyle fracture associated with a basilar skull fracture

(C) An occipital condyle-axial dislocation`

(D) An occipital condyle avulsion fracture from the alar ligament

(E) A crush injury to the occipital condyle in the face of underlined osteoarthritis

Explanation:

A type 3 fracture of the occipital condyle is an avulsion fracture from traction of the alar
ligament. This usually results from a rotation, lateral bending moment, or combined injury. If
the injury is severe, both alar ligaments may be involved and occipitocervical instability may
occur. Treatment for a type 3 injury would include a rigid or collar orthosis for 8 to 12 weeks,
possible halo mobilization, and, if ligamentous instability has occurred, posterior cervical
fusion.
4) An 8-year-old boy has had torticollis for approximately 5 weeks. He has undergone
immobilization with a cervical collar without success. The patient has not undergone traction
and now has atlantoaxial rotatory subluxation. The best treatment for this patient should be:

(A) Continued treatment in hard cervical orthosis

(B) Manipulation and closed reduction of his deformity

(C) Hospitalization with cervical traction

(D) Posterior C1-C2 fusion

(E) Application of halo vest and reduction

Explanation:

The treatment protocol for atlantoaxial rotatory subluxation is based on the onset and length
of time of deformity. Soft collar treatment for this deformity is best if treated within 1 week
of onset. For deformities lasting up to 1 month, in-house hospitalization with traction is
warranted. However, the success of this treatment declines markedly after 1 month, at
which time posterior C1-C2 fusion is warranted.

5) A 12-year-old boy with Duchenne muscular dystrophy has a 25� curve in the
thoracolumbar spine with moderate pelvic obliquity. His pulmonary function tests are 70% of
predicted function. He uses a wheelchair for ambulation, but is able to stand for transfers.
Management should include:

(A) Observation, with repeat radiograph and pulmonary function tests in 6 months

(B) Thoracolumbosacral orthosis

(C) Wheelchair seat pressure mapping and lateral trunk support modifications

(D) Posterior spinal fusion with instrumentation

(E) Anterior spinal release and posterior spinal fusion with instrumentation

Explanation:

Scoliosis in patients with Duchenne muscular dystrophy typically becomes progressive when
ambulation ceases. For curves >20�, posterior spinal fusion with instrumentation is
indicated. Fixation to the pelvis is necessary to improve sitting if pelvic obliquity is present.
Severe, collapsing scoliosis can result without operative intervention and can result in
diminishing pulmonary function and loss of sitting ability. Surgery can be safely undertaken if
pulmonary function remains >40% of predicted function, but anterior surgery causes
morbidity on an already compromised pulmonary system. Nonoperative treatment such as
orthoses or trunk supports offer little in the way of controlling progression and are generally
not well tolerated by these patients.
6) A 13-year old boy presents to the emergency department with back pain of 5 days�
duration. The pain is exacerbated by sitting or standing. He has a low-grade fever. He has
pain on percussion of the lumbar spine. He has no tension signs. White blood cell count is
8000/mm3 and the erythrocyte sedimentation rate is 40 mm/hr. Plain radiographs of the
spine demonstrate a narrowed intervertebral space at L3-L4. The most likely diagnosis is:

(A) Epidural abscess

(B) Diskitis

(C) Vertebral osteomyelitis

(D) Pott disease

(E) Iliopsoas abscess

Explanation:

The symptoms of diskitis are often vague and insidious. This hematogenous infection of the
disk space acts differently than other musculoskeletal infections. The presentation is often
that of a patient with low back pain or refusal to ambulate. Fever is usually low or absent.
The white blood cell count is usually normal, but the erythrocyte sedimentation rate or C-
reactive protein levels may be elevated. Blood cultures are frequently negative. Radiographs
of the spine may be normal initially, but may show intervertebral disk space narrowing or
end plate irregularities. Bone scan and magnetic resonance imaging are also helpful in the
diagnosis.

Treatment is usually conservative, and outcomes are aided by the fact that this condition is
usually self-limiting. Rest and immobilization provide symptomatic relief, and many authors
favor intravenous antibiotics. After an initial response in 72 hours or less, the patient can be
switched to oral antibiotics for 3 to 5 weeks. A biopsy is indicated if the patient does not
improve quickly, or if a tumor or abscess formation is suspected.

Patients with vertebral osteomyelitis or abscesses are typically more ill-appearing, have high
fevers and white blood cell counts, and a markedly elevated erythrocyte sedimentation rate.
Furthermore, a patient with an epidural abscess may have neurological symptoms or a
positive straight leg raising test, due to nerve root irritation or spinal cord compression.

7) The patient's clinical diagnosis is degenerative spondylolithesis. In what patient population

is this condition most commonly symptomatic?

(A) Pre-teen males

(B) Females 40- to 70-years-old

(C) Males over 70-years-old

(D) Females 20- to 30-years-old

Explanation:

Degenerative spondylolithesis is most frequently symptomatic in the 40- to 70-year-old age

range and is six times more common in females than in males. This population appears to
have enough disc degeneration and motion to become symptomatic, whereas the older
population tend to have acquired enough ankylosis at the level to prevent instability
symptoms.
Slide 1
8) 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

Explanation:

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.
9) On physical examination, a patient with a weak extensor hallucis longus muscle might be
expected to have a far-lateral disk herniation at what level in the spine:

(A) L2/L3

(B) L3/L4

(C) L4/L5

(D) L5/S1

(E) S1/S2

Explanation:

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 irritate the L5 nerve root, which would affect the extensor hallucis longus muscle

10) When testing the range of motion in the lumbar spine, which maneuver involves
stretching of the interspinous and supraspinous ligaments, ligamentum flavum, and posterior
longitudinal ligament while relaxing the anterior longitudinal ligament:

(A) Flexion

(B) Extension

(C) Lateral bending

(D) Lateral bending

(E) None of the above

Explanation:

Flexion of the lumbar spine creates stretching or tension of the posterior spinal structures
including the interspinous and supraspinous ligaments, ligamentum flavum, and posterior
longitudinal ligament. Flexion also allows relaxation of the anterior longitudinal ligament. This
is often elicited by having a patient bend forward in attempt to touch the floor with the
fingertips. If the patient cannot touch the floor, the distance from the floor to fingertips is
measured in fingerbreadths or inches.
11) Which orthopedic test, designed to apply tension to the spinal cord producing pain,
involves having the patient lie supine while the examiner flexes the patient's head to his
chest:

(A) Kernig sign

(B) Hoover test

(C) Milgram test

(D) Naffziger test

(E) Gaenslen test

Explanation:The Kernig test involves the patient lying supine while the examiner forcibly
flexes the head to the chest applying tension to the spinal cord. The test is positive if pain is
elicited and indicates meningeal irritation in conditions such as meningitis.

 The Hoover test can help identify a patient who is malingering. This test involves
having the patient lie supine with the examiner's hands placed under both of the
patient's heels. The patient is asked to lift the affected leg. If a true effort is made,
the examiner should feel downward pressure in the patient's opposite foot as he
attempts to lift the affected leg. If no downward pressure is felt, the patient
purposely may not be trying and might be malingering.
 The Milgram test may be used in conditions with suspected intrathecal pathology.
While lying supine, the patient is asked to perform bilateral straight leg lifts. If the
patient can sustain his feet 2 inches off the ground for more 30 seconds,
intrathecal pathology is less likely.
 The Naffziger test is designed to increase intrathecal pressure and thus pain by
compressing the jugular veins.
 The Gaenslen test is used to determine sacroiliac joint pathology.

12) 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

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

(A) Persistent back pain and elevated c-reactive 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

Explanation:

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.

14) Risk factors implicated in postoperative wound infection following lumbar spine surgery
include all of the following except:

(A) Use of instrumentation

(B) Presence of spina bifida occulta

(C) History of smoking

(D) Longer operative duration

(E) Obesity

Explanation:

Instrumented cases, preoperative history of smoking or obesity, and longer operating room
duration have all been identified as possible risk factors for surgical site infection.
Additionally, patient age may be a risk factor or may be associated with a risk factor like
medical comorbidity or nutritional depletion.

15) The spinal surgical procedure associated with the highest rate of surgical site infection is:

(A) Neuromuscular scoliosis fusion

(B) Lumbar spondylolisthesis fusion

(C) Reduction and fusion of traumatic cervical facet fracture-dislocation

(D) Lumbar stenosis decompression and fusion

(E) Cervical laminectomy, foraminotomy, and arthrodesis

Explanation:

Postoperative infection rates reach 11% for neuromuscular disease indications. For muscular
dystrophy scoliosis surgery, the rate may be as high as 23%, for cerebral palsy 18%, and for
myelomeningocele 11%.
16) Which type of thoracolumbar fracture is associated with the highest incidence of intra-
abdominal visceral trauma:

(A) Burst fracture

(B) Compression fracture

(C) Flexion-distraction injury

(D) Fracture dislocation

(E) Pathologic fracture

Explanation:

The flexion-distraction injury was originally termed the �seatbelt injury� or in the case of a
fracture proceeding through bone, a �Chance fracture.� This injury is usually the result of
a severe flexion force to the lumbar spine with flexion moment anterior to the spine (e.g., at
a lap belt). Due to the severe energy dissipation at the level of the flexion moment, there is
a high incidence of intra-abdominal visceral trauma.

17) Which is the best indication for surgical treatment of a patient with a thoracolumbar
burst fracture:

(A) 60% canal compromise by a retropulsed bony fragment

(B) 25� of kyphosis on the lateral radiograph

(C) A fracture of the lamina present on a computerized tomography scan

(D) An incomplete neurologic deficit

(E) A polytrauma patient

Explanation:

The exact indications for surgery vs nonoperative management of thoracolumbar burst

fractures remains controversial. The best indication is an incomplete neurologic deficit with
spinal cord compression. Other considerations include the degree of deformity (greater than
30� is generally considered appropriate to consider surgery) and the other injuries.
Although much has been written about canal compromise, in the absence of a neurologic
deficit it is not clear that surgery is always indicated due to canal compromise alone. Large
canal fragments have been shown to resorb with conservative treatment.
18) Which patient is at the lowest risk for progression of spondylolisthesis:

(A) A 45-year-old man with grade II isthmic spondylolisthesis at L5-S1.

(B) A 5-year-old girl with grade I dysplastic spondylolisthesis at L5-S1.

(C) A 25-year-old man with a grade I isthmic spondylolisthesis at L4-5.

(D) A 16-year-old boy with Grade III isthmic spondylolisthesis at L5-S1.

(E) A 12-year-old girl with Grade II isthmic spondylolisthesis at L5-S1.

Explanation:
Young age, dysplastic spondylolisthesis, and spondylolisthesis above L5-S1 are all risk factors
for progression. Adults with isthmic spondylolisthesis at L5-S1 (85% of cases) are at a low
risk for progression of the slippage.

19) 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

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

20) If the C5 cervical spine nerve root is injured during a decompression of the cervical
spine, then sensation is lost over which of the following areas:

(A) The lateral aspect of the arm from the shoulder to the elbow

(B) The medial aspect of the arm from the shoulder to the elbow

(C) The lateral border of the forearm including the thumb

(D) The middle finger

(E) The medial border of the forearm including the little finger

Explanation:
The C5 cervical spine nerve root supplies sensation from the lateral aspect of the arm from
the shoulder to the elbow.

 C5 � Lateral aspect of the arm from the shoulder to the elbow

 C6 � Lateral border of the forearm including the thumb
 C7 � Middle finger
 C8 � Medial border of the forearm including the little finger
 T1 � Medial aspect of the arm from the shoulder to the elbow
21) If the brachioradialis reflex is diminished after a posterior spinal decompression, then
which of the following nerve roots is injured:

(A) C5

(B) C6

(C) C7

(D) C8

(E) T1

Explanation:

The brachioradialis reflex is mediated by the C6 cervical spine nerve root.

 C5 � Biceps
 C6 � Brachioradialis
 C7 � Triceps

22) 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

Explanation:

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.
23) A patient with radicular pain is experiencing skin numbness on the lateral aspect of the
leg and the dorsum of the foot between the second and fourth toes. Which of the following
nerve roots is being compressed:

(A) L1

(B) L2

(C) L3

(D) L4

(E) L5

Explanation:

The L5 dermatome covers the skin on the lateral leg and dorsum of the foot from the lateral
border of the great toe to the medial border of the little toe.

 L4 Medial aspect of leg, foot, and great toe

 L5 Lateral aspect of the leg and toes 2 through 4
 S1 Lateral aspect of the fifth toe

24) A patient with a fracture dislocation of the spine has a sensory level at the xiphoid
process. Which of the following nerve root levels indicates this finding:

(A) T2

(B) T4

(C) T7

(D) T10

(E) T12

Explanation:

The skin over the xiphoid process area is innervated by the T7 nerve root.

In addition to knowing the innervation of selected muscles and the deep tendon reflexes, the
clinician should also know the sensory levels to localize pathologic processes.

 T4 Nipple line
 T7 Xiphoid process
 T10 Umbilicus
 T12 Groin
25) A patient with a fracture dislocation of the spine has a sensory level at the umbilicus.
Which of the following nerve root levels indicates this finding:

(A) T2

(B) T4

(C) T7

(D) T10

(E) T12

Explanation:

The skin of the umbilicus is innervated by the T10 nerve root.br>

In addition to knowing the innervation of selected muscles and the deep tendon reflexes, the
clinician should also know the sensory levels to localize pathologic processes.

 T4 Nipple line
 T7 Xiphoid process
 T10 Umbilicus
 T12 Groin

26) Which of the following types of neural dysfunction is present with a cervical fracture-
dislocation, resulting in a Brown-Sequard neurological injury:

(A) Ipsilateral loss of pain, temperature recognition, and contralateral loss of motor function

(B) Ipsilateral loss of motor and contralateral loss of pain/temperature

(C) Bilateral loss of pain/temperature and unilateral loss of motor

(D) Bilateral loss of motor and unilateral loss of pain/temperature

(E) Bilateral upper extremity loss of motor and unilateral lower extremity loss of pain/temperature

Explanation:

A Brown-Sequard injury causes damage to half of the spinal cord. Brown-Sequard injuries
produce ipsilateral proprioceptive and motor loss and contralateral loss of sensitivity to pain
and temperature. Proprioceptive sensory fibers enter the spinal cord, travel in the dorsal
columns and lateral and ventral spinothalmic tracts, and decussate high in the thalamus.
Motor efferent nerves cross in the medulla and travel down in the lateral corticospinal
tracts.Spinthalamic fibers enter and decussate in the spinal cord. Hence, cord hemi-section
produces contralateral pain and temperature (spinothalamic) loss, and ipsilateral motor
(corticospinal) and, proprioceptive (dorsal columns) deficit. Often due to penetrating injuries,
Brown-Sequard injuries have the best prognosis of the cord injury complexes.
27) Acute thoracic compression fractures should have the following signal characteristics on
magnetic resonance imaging:

(A) High signal on T1 and T2

(B) Low signal on T1 and T2

(C) High signal on T1 and low signal on T2

(D) Low signal on T1 and high signal on T2

(E) Intermediate signal on both T1 and T2

Explanation:
Acute fractures produce local hematomas that displace the adipose tissue normally present
in the bone marrow and decrease the signal uptake from fat on T1-weighted sequences.
Fractures also produce edema, which is bright on T2-weighted sequences. Acute thoracic
compression fractures should be low signal intensity on T1 sequences and high on T2
sequences.

Slide 1
28) 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

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

(A) Epidermoid cyst

(B) Lymphoma

(C) Meningioma

(D) Ependymoma

(E) Astrocytoma

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

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

(A) L3

(B) L4

(C) L5

(D) S1

(E) None of the above

Explanation:
A far lateral herniated nucleus pulposus, which is less common, can lead to compression of
the nerve root that has already exited the supra-adjacent foramen. Therefore, a far lateral
L4-L5 herniated nucleus pulposus leads to L4 nerve root compression.
31) Which of the following is the most common type of spondylolisthesis seen in the adult
population:

(A) Degenerative

(B) Isthmic

(C) Congenital

(D) Traumatic

(E) Pathologic

Explanation:
The prevalence of degenerative spondylolisthesis is 2% to 5%; the prevalence increases with
age. Symptomatic patients usually present in the fourth decade of life or later. The disease is
five times more common in the female sex. The African American population, diabetics, and
patients with sacralization of the L5 vertebrae are also at increased risk for developing
symptomatic spondylolisthesis.

32) 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.

Explanation:

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.

33) Which of the following is the most common complaint in patients with degenerative
lumbar scoliosis:

(A) Radicular pain radiating to one or the other leg

(B) Mechanical pain during motion

(C) Low back pain and reduced tolerance for walking

(D) Urinary incontinence

(E) Sensory changes at the dorsal feet bilaterally

Explanation:

Patients with degenerative lumbar scoliosis typically complain of symptoms related to the
associated spinal stenosis. These symptoms commonly include (with approximate incidence
rates): low back pain (100%), reduced tolerance for standing and walking (85% to 100%),
neurogenic claudication (50%), and radicular or pseudoradicular pain radiating into the
buttocks or thighs (40% to 60%).
34) 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.

Explanation:

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.

35) A 73-year-old woman with a history of cervical stenosis who sustained a fall at home
yesterday is now complaining of �clumsy� fingers and weakness in her hands. She denies
any difficulty with ambulation or bowel and bladder dysfunction. She most likely has:

(A) Bilateral cervical radiculopathy

(B) Exacerbation of cervical stenosis

(C) Anterior cord syndrome

(D) Posterior cord syndrome

(E) Central cord syndrome

Explanation:

The most common incomplete spinal cord injury syndrome is most likely central cord
syndrome. Central cord syndrome often occurs as a result of a pinching of the spinal cord in
elderly patients who have a narrowed spinal canal as the result of degenerative spondylosis.
It is a pattern of disproportionately severe upper extremity motor and sensory changes as
compared to lower extremity findings.
36) A 27-year-old man was involved in a motor vehicle accident. He was resuscitated at the
scene but was noted to have a prolonged hypotensive period. Upon arrival at the medical
center, he is noted to be paraplegic but radiographic evaluation does not demonstrate any
fracture or soft tissue abnormality. Which of the following is the most likely diagnosis:

(A) Occult fracture with retropulsion into the cord

(B) Contusion of the cord at a high thoracic level

(C) Spinal shock

(D) Spinal cord ischemic injury at the low thoracic watershed zone

(E) Conversion disorder

Explanation:
A watershed zone refers to an area that is supplied purely by end arteries. Therefore, during
periods of hypoperfusion, it is the most likely region to sustain an ischemic injury. In the
spinal cord, this region lies in the T7-T9 region as it is a watershed zone between the rostral
anterior spinal artery distribution and the caudal dominant lumbar segmental artery.

37) 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

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

38) Which of the following descriptions applies to the sacroiliac joint:

(A) The sacroiliac joint accounts for 15% of lower back pain.

(B) Pain is referred most commonly to the groin.

(C) Focal pain over the sacral sulcus is rare.

(D) Focal neurological deficits are common.

(E) Provocative tests (Patrick and Gaenslens) are useful predictors of joint pathology.

Explanation:
Sacroiliac joint pathology accounts for 15% of lower back pain, and the sacroiliac joint is one
of the most common sites of referred pain. Patients with sacroiliac joint pathology commonly
experience pain above the posterior buttock and seldom have focal neurological deficits.
Physical examination tests are poor predictors of sacroiliac joint pathology.
39) Osteochondromas in the spine most commonly occur in:

(A) Posterior elements of the cervical spine

(B) Posterior elements of the thoracic spine

(C) Posterior elements of the lumbar spine

(D) Posterior elements of the sacral spine

(E) Vertebral body of the thoracic spine

Explanation:
Osteochondromas most commonly occur in the appendicular skeleton but can also occur in
the spine (<5% of cases). When present in the spine, solitary osteochondromas have a
predilection for the cervical spine. They can, however, also occur in the thoracic and lumbar
spine. Sacral involvement is rare.

40) The proper treatment of a vertebral osteoblastoma includes:

(A) Chemotherapy

(B) En-bloc resection

(C) Marginal excision/curettage of the tumor

(D) Radiation

(E) Radiofrequency ablation

Explanation:
Treatment of spinal osteoblastomas usually consists of marginal excision or curettage of the
tumor. Local recurrence rates of up to 10% have been observed from some osteoblastomas,
however, malignant degeneration is rare. There is no role for radiation or chemotherapy.
Radiofrequency ablation has been used successfully for the treatment of osteoid osteomas,
but not osteoblastomas.

41) Which of the following statements is true regarding minimally invasive posterior lumbar
interbody fusion:

(A) Minimally invasive fusion may be safely performed only with the assistance of endoscopy.

(B) Minimally invasive fusion increases the risk of nerve root injury.

(C) Internal fixation with pedicle screws is not possible via the minimally invasive approach.

(D) Intraoperative fluoroscopy is of great value in minimally invasive fusion.

(E) Minimally invasive surgery has improved fusion rates.

Explanation:

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

(A) True

(B) False

(C)

(D)

Explanation:

Approximately 75% of cervical radiculopathies occur as a result of direct compression of

nerve roots, with at least one study noting �a pressure of only 10 mm Hg produced
significant conduction block, the potential [of nerve impulses] falling under 60 percent of its
initial value in 15 minutes. With higher levels of pressure, we have observed incomplete
recovery after many hours of recording.� Disk protrusion, with the associative release of
inflammatory mediators, is responsible for up to 25% of cervical radiculopathies. One study
even suggests �chemical release from the nucleus pulposus into the nerve root epidural
space, without herniation of the nucleus pulposus and without direct nerve root compression,
caused radiculopathic pain in an animal model.�

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

(A) C3

(B) C4

(C) C5

(D) C6

(E) C7

Explanation:
Headaches observed with upper cervical pathology may be due, in part, to the convergence
of C1-, C2-, and C3-level pain fibers with second-order neurons of the descending sensory
tract of cranial nerve V.
44) It is important to distinguish between acute or subacute vertebral compression fractures
and old healed fractures radiographically. Which of the following can help distinguish an
acute fracture from a chronic fracture:

(A) T1-weighted magnetic resonance image (MRI)

(B) T2-weighted MRI

(C) Fat-suppressed T2-weighted MRI

(D) Dual energy X-ray absorptiometry (DEXA) scan

(E) Computed tomography (CT)

Explanation:
One can distinguish an acute or subacute vertebral compression fracture from an old, healed
fracture by evaluating the fat-suppressed T2-weighted MRI or short tau inversion recovery
(STIR) images. These images will show increased signal intensity suggesting an acute
fracture. All of the other forms of imaging mentioned may also be used to evaluate the
patient but are not the best techniques for differentiating an acute from a subacute fracture.
DEXA scans are used to evaluate for osteoporosis. Although CT imaging provides excellent
osseous detail, it may not allow for differentiation of an acute from a chronic fracture unless
evidence of fracture healing is seen. Another method for evaluating the acuity of a vertebral
compression fracture is a three-phase bone scan, which will demonstrate increased
radiotracer activity at the site of an acute or subacute fracture.

45) The majority of studies confirm the presence of atlanto-axial subluxation (AAS) when:

(A) Anterior atlantodental intervals (AADI) > 0 mm or posterior atlantodental intervals (PADI) < 18 mm

(B) AADI > 1 mm or PADI ≤ 14 mm

(C) AADI > 2 mm or PADI ≤ 16 mm

(D) AADI > 3 mm or PADI ≤ 14 mm

(E) AADI > 4 mm or PADI ≤ 18 mm

Explanation:As described by Puttlitz and colleagues, AAS is defined as an AADI greater

than 3 mm or a PADI less than 14 mm.
46) The most useful measurement for predicting neurological deficit in rheumatoid
arthritis involvement of the cervical spine is:

(A) Flexion angle

(B) Posterior atlantodens interval (PADI)
(C) Anterior atlantodens interval (AADI)
(D) Lordosis angle
(E) C2-C3 disk height

Explanation:The posterior atlantodens interval (PADI) is the distance between the

posterior surface of the dens and the anterior edge of the posterior ring of C1, as seen
on a lateral radiograph. A PADI < 14 mm was 97% sensitive in predicting the presence
of neurological deficit. Patients with a PADI >14 mm had a 94% chance of being
neurologically intact.

47) The following can be found in the examination and radiographs of a child with
Scheuermann disease:

(A) Schmorl nodes

(B) Back pain
(C) Anterior wedging 3 or more vertebrae
(D) Thoracic kyphosis
(E) All of the above

Explanation:Scheuermann disease is increased thoracic kyphosis, usually rigid,

occurring in adolescent males. The etiology is unknown, but has included theories
dealing with avascular necrosis of the ring apophysis, growth plate abnormalities,
biologic and mechanical causes. The classic definition is increased thoracic kyphosis
(>45°) with 5° or more of anterior wedging at 3 sequential vertebrae. Other radiographic
abnormalities include:

 Endplate irregularities
 Spondylolysis
 Compensatory lumbar hyperlordosis
 Schmorl’s nodes

Hamstring tightness and rigid thoracic kyphosis is noted on physical examination, and
neurological function is normal.

Treatment consists of bracing in skeletally immature patients with a thoracolumbosacral

orthosis, but many adolescent male patients are noncompliant with bracing. In the
skeletally mature patient with pain and severe deformity (>65° of kyphosis), posterior
spinal fusion with instrumentation is indicated. Occasionally, anterior diskectomy and
interbody fusion with posterior fusion and instrumentation are required for severe
deformity correction.

Postural kyphosis is also common in adolescent males, but the vertebral changes are
not present, and the deformities are usually more supple. Treatment is hyperextension
exercises.
48) Which of the following is a risk factor for neurological deficit associated with
tuberculoid spinal infection:

(A) Age
(B) Pulmonary involvement
(C) Erythrocyte sedimentation rate higher than 90
(D) History of smoking
(E) History of hypertension

Explanation:
Tuberculosis in the cervical spine of children younger than 10 years of age carries a
significantly lower risk of paralysis than in older patients (17% vs 81%).

49) Which of the following is a risk factor for neurological deficit associated with
tuberculoid spinal infection:

(A) Age
(B) Pulmonary involvement
(C) Erythrocyte sedimentation rate higher than 90
(D) History of smoking
(E) History of hypertension

Explanation:
Tuberculosis in the cervical spine of children younger than 10 years of age carries a
significantly lower risk of paralysis than in older patients (17% vs 81%).

50) A patient with a fracture dislocation of the spine has a sensory level at the nipple
line. Which of the following nerve root levels indicates this finding:

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

Explanation:
In addition to knowing the innervation of selected muscles and the deep tendon
reflexes, the clinician should also know the sensory levels to localize pathologic
processes.

 T4 Nipple line
 T7 Xiphoid process
 T10 Umbilicus
 T12 Groin
Slide 1

51) A 35-year-old man has neck pain following a motor vehicle accident. His axial
computed tomography scan is shown (Slide). The most likely diagnosis is:

(A) C4 compression fracture

(B) Clay shovelers fracture
(C) Bilateral facet dislocation
(D) Unilateral facet dislocation
(E) Pseudosubluxation of C4 on C5

Explanation:

The axial computed tomography scan of C4-C5 shows a unilateral facet dislocation.
Notice that 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.
52) What is the advantage of performing a magnetic resonance image (MRI) to
evaluate spinal tumors:

(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.

Explanation:

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.

53) 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

Explanation:

After a traumatic injury to peripheral nerves, early clinical examination is imperative.

The key is to test for motor function in the most distal aspect of the nerve and be able to
localize the site of injury. Imaging studies are far less sensitive than clinical
examinations. Electromyography and nerve conduction velocity studies are usually
performed during the follow-up examination to assess for residual, or recovery of,
function.
54) In relation to the lumbar pedicle, the exiting nerve root is found:

(A) Immediately superior to the pedicle

(B) Immediately inferior to the pedicle
(C) At the midpoint between the superior and inferior level pedicles
(D) Nerve root has no anatomic relationship to the pedicle
(E) None of the above

Explanation:

The exiting nerve root is found traversing immediately inferior to the pedicle

55) 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

Explanation:

It is appropriate to obtain an MRI in all of the above circumstances. Magnetic

resonance imaging allows a physician to evaluate the cerebrospinal fluid and spinal
cord to localize the cause of a neurologic deficit. The presence of back pain in a patient
with kyphosis and osteoporosis suggests the possibility of a vertebral compression
fracture; these fractures may not always be seen with conventional radiographs. The
use of MRI is recommended for the evaluation of a patient with congenital kyphosis to
evaluate the morphology of the malformed segment and to rule out associated
pathology.
56) All of the following disorders can result in thoracic kyphosis measuring >40 ‫ ؛‬except:

(A) Ankylosing spondylitis

(B) Osteoporosis
(C) Klippel-Feil syndrome
(D) Tuberculosis
(E) Juvenile osteochondrosis

Explanation:

Klippel-Feil syndrome is a congenital disorder characterized by cervical fusion and

malformation. It does not involve the thoracic spine. Conversely, ankylosing spondylitis,
a sero-negative spondyloarthropathy, results in excessive kyphosis of the thoracic
spine. Osteoporosis can result in kyphosis due to the presence of multiple vertebral
compression fractures. Tuberculosis is also known to cause kyphosis due to
involvement of the thoracic spine. Lastly, juvenile osteochondrosis, also known as
Scheuermann’s kyphosis, is often associated with thoracic kyphosis.