Neurospine Flashcards
When placing bicortical sacral pedicle screws, which structure is at most risk with a laterally placed screw that perforates the anterior cortex?
a. S1 nerve root
b. L5 nerve root
c. Lumbosacral plexus
d. Internal Iliac artery
e. Aorta
b. L5 nerve root
A diabetic patient with known peripheral vascular disease undergoes an anterior cervical discectomy at C4-5. The operative course is unremarkable; however, in the recovery room the patient is noted to have decreased sensation in the 4th and 5th digits of the left hand and decreased grip. What is the MOST likely diagnosis?
a. Residual muscle relaxation
b. Brachial plexus stretch injury
c. Embolic stroke
d. Surgical trauma
e. Positioning nerve injury
e. Positioning nerve injury
A 68 year-old male with a history of prostatic cancer presents with low-grade fever and severe low back pain progressing to include lower extremity numbness. Thoracic CT shows extensive destruction of the T11 and T12 vertebral bodies with relative sparing of the T11-12 disc space, as well as a large paraspinous abscess with calcification. Thoracic MRI shows a kyphotic deformity with enhancing soft tissue and bone extending into the anterior spinal canal and resulting in moderate stenosis and spinal cord compression. The MOST likely pathologic process is:
a. Discitis - Staph epidermidis
b. Osteoporotic compression fracture
c. Pathologic fracture
d. Spinal tuberculosis
e. Discitis - Staph aureus
d. Spinal tuberculosis
A 12 year-old with Down syndrome has abnormal flexion-extension cervical spine x-rays. The child has no significant neurologic complaints or neck pain. On exam, the child has full range of motion and no tenderness to palpation. The flexion-extension x-rays show a 7-8 mm atlantodental interval in flexion which reduces to 4 mm in extension. What is the most appropriate next step?
a. C1-2 wiring with halo placement and autologous fusion
b. Occipital cervical fusion with sublaminar wires
c. Observation with no repeat imaging necessary
d. C1-2 transarticular screw placement and autologous fusion
e. Observation with repeat flexion-extension in the future
e. Observation with repeat flexion-extension in the future
What characteristic imaging finding on MRI would best differentiate neuromyelitis optica from multiple sclerosis?
a. Multiple enhancing intramedullary spinal lesions spanning 1-2 segments.
b. Presence of high burden of periventricular, juxtacortical and infratentorial demyelinating lesions.
c. Multiple non-enhancing intramedullary spinal lesions spanning 1-2 segments.
d. Optic nerve enhancement.
e. An intramedullary spinal cord lesion spanning 3 or more segments.
e. An intramedullary spinal cord lesion spanning 3 or more segments.
The radiographic and magnetic resonance imaging findings at L2-L3 (shown in Figures 1-3) are most consistent with a diagnosis of:
a. fracture.
b. metastatic carcinoma.
c. degenerative disc disease.
d. chordoma.
e. discitis/osteomyelitis.
e. discitis/osteomyelitis.
A 47 year-old woman underwent a C5-6 ACDF via a left sided approach. Postoperatively, she has a weak, drooping eyelid and a constricted pupil. What technique reduces risk of this complication?
a. Minimize excessive traction on the shoulders when positioning
b. Deflate and re-inflate the endotracheal balloon after retractor placement
c. Place retractors under the medial edge of the longus colli muscles during periosteal dissection
d. Minimize distraction of the vertebral bodies
e. Perform surgical approach from the patient’s right side
c. Place retractors under the medial edge of the longus colli muscles during periosteal dissection
A 60 year old man presents with 3 months of worsening diffuse severe unremitting left upper extremity pain, parasthesias, and hand weakness. Exam shows 4/5 weakness of hand muscles including abductor pollicus brevis and all intrinsics, scattered sensory loss on the ulnar side of the forearm, normal deep tendon reflexes and no evidence of myelopathy. MRI of the cervical spine shows mild degenerative changes throughout the neck. What imaging study would assist in the diagnosis?
a. Thermogram
b. Scoliosis survey
c. Chest CT
d. Bone scan
e. Cervical spine flexion-extension x-rays
c. Chest CT
What is the most common indication for surgical treatment of Scheuermann’s thoracic kyphosis?
a. Radiculopathy from disc herniation
b. Painful kyphosis
c. Severe compression fractures
d. Pulmonary compromise
e. Progressive scoliosis
b. Painful kyphosis
Failure to account for which radiographic measurement is associated with delayed treatment failure after surgical treatment of positive sagittal imbalance?
a. Central Sacral Vertical Line
b. Pelvic Incidence
c. Sacral Slope
d. Thoracic kyphosis
e. Lumbar coronal Cobb angle
b. Pelvic Incidence
A 55 year-old female presents with back pain, progressive right leg pain, atrophy and weakness. Exam reveals bilateral non-dermatomal lower extremity hypalgesia and a hemangioma with hypertrichosis over the lumbar spine. Imaging reveals a 10 degree thoracic scoliosis, right sided disc bulge at L1/2, conus terminating at L4, and a fatty filum terminale (3mm). What is the treatment of choice for this patient?
a. Spinal deformity correction
b. Monitoring with serial imaging
c. Conservative therapy (PT, NSAIDS, etc)
d. Release of filum terminale
e. L1/L2 microdiscectomy
d. Release of filum terminale
A 35-year-old woman presents with an L1 burst fracture after a motor vehicle accident. Which of the following characteristic(s) predicts likelihood of instrumentation failure with short segment posterior instrumented fusion?
a. Spinal canal compromise > 50%
b. Comminuted fracture with fragment displacement and kyphosis
c. Involvement of both vertebral endplates
d.Incomplete neurologic deficit
e. Disrupted posterior ligamentous complex
b. Comminuted fracture with fragment displacement and kyphosis
A 76 year-old man presents with worsening back pain unresponsive to conservative measures. 36-inch radiographs were performed at his office visit (Figure 1). What Schwab grade osteotomy (Figure 2) will provide the best correction of his sagittal plane deformity over one segment?
a. Grade 1
b. Grade 5
c. Grade 4
d. Grade 3
e. Grade 2
e. Grade 2
What is the first priority in the overall assessment of a trauma patient with an acute cervical spine fracture?
a. Spinal stability
b. Blood pressure
c. Neurological deficit
d. Airway integrity
e. Ongoing hemorrhage
d. Airway integrity
What is the definitive treatment of atlanto-occipital dislocation (AOD)?
a. Observation with serial radiographs
b. Cervical traction
c. Halo vest immobilization
d. Cranio-cervical internal fixation and fusion
e. Rigid cranio-cervico-thoracic orthosis
d. Cranio-cervical internal fixation and fusion
A 6 year-old girl presents with progressive scoliosis. Physical examination reveals a club foot and a midline hairy nevus in the lumbar region. MRI is shown (Figure 1). What is the most likely diagnosis?
a. Diastematomyelia
b. Dermal sinus tract
c. Neurenteric cyst
d. Myelomeningocele
e. Lipomyelomeningocele
a. Diastematomyelia
A 46-year-old IV drug abuser presents with a 2 week history of fever and progressive low back pain. He is neurologically intact. MRI reveals increased T2 signal in the L3-4 disc space with endplate destruction without an appreciable fluid collection. There is no evidence of instability or segmental kyphosis. Blood cultures are negative. What is the most appropriate next step in management?
a. Needle biopsy of disc space
b. Laminectomy for surgical debridement
c. Empiric antibiotics
d. Posterior instrumentation and fusion without laminectomy
e. Anterior discectomy and interbody fusion
a. Needle biopsy of disc space
In a patient with traumatic quadriparesis and difficulty breathing, vertical displacement of the occipital condyles from the lateral masses of C1 is most consistent with rupture of what soft tissue structures?
a. Rupture of the anterior longitudinal ligament.
b. Rupture of ligamentum flavum.
c. Rupture of the transverse ligament.
d. Rupture of the tectorial membrane and alar ligaments.
e. Rupture of the posterior longitudinal ligament.
d. Rupture of the tectorial membrane and alar ligaments.
A patient awakens from left-sided costotransversectomy at T10 for resection of a ventral metastatic tumor with complete paraplegia and loss of pain and temperature sensation. His sensation to light touch in the lower extremities is spared. Post operative MRI reveals no evidence of spinal cord compression or hematoma. What is the most likely diagnosis?
a. Weber’s Syndrome
b. Posterior cord syndrome.
c. Central cord syndrome.
d. Anterior cord syndrome.
e. Brown-Sequard syndrome.
d. Anterior cord syndrome.
Which of the following is considered a major risk factor for osteoporosis by the National Osteoporosis Foundation?
a. Current smoking
b. Prior falls
c. Alcohol use of 1 drink per day
d. High body mass index (BMI)
e. Use of NSAIDS
a. Current smoking
Approximately what percentage of cervical rotation occurs at the C1-2 level?
a. 10%
b. 75%
c. 25%
d. 90%
e. 50%
e. 50%
A patient presents with bilateral nondisplaced fractures through the C2 pars interarticularis (Hangman’s fracture). Flexion-extension dynamic cervical radiographs show 2 mm motion and no significant deformity. What is the most appropriate treatment modality?
a. External immobilization
b. Anterior odontoid screw fixation
c. Anterior C2-3 discectomy and fusion
d. C1-2 transarticular screw fixation
e. Posterior C1-C3 fixation
a. External immobilization
A 47 year-old diabetic woman presents with pain across her buttocks and bilateral lower extremities with ambulation, improved by leaning forward. She reports transient response to epidural injections and no response to NSAIDS and neuropathic pain medication. She has no neurologic deficit. Imaging is shown (figures). What intervention is most likely to best reduce her disability over 4 years?
a. L4-5 laminectomy
b. L4-5 decompression and fusion
c. Long term corticosteroids
d. L4-5 dynamic interspinous spacer placement
e. Bilateral L4-5 hemilaminotomies with preservation of midline structures
b. L4-5 decompression and fusion
A pedicle subtraction osteotomy (PSO) hinges on which anatomic region?
a. The anterior column of the spine
b. Anterior to the spinal column
c. The posterior column of the spine
d. The middle column of the spine
e. Posterior to the spinal column
a. The anterior column of the spine
A 42-year-old woman is referred with biopsy proven chordoma within the L3 vertebral body. MRI does not show any ventral epidural extension or involvement of the pedicles or posterior elements. Which treatment option is associated with decreased time to local recurrence?
a. Debulking of tumor and L2-4 fusion
b. Radiation therapy alone
c. L3 en bloc spondylectomy and L2-4 fusion
d. L3 corpectomy and fusion plus chemotherapy
e. L3 corpectomy and fusion plus radiation therapy
c. L3 en bloc spondylectomy and L2-4 fusion
A 71 year-old man with cervical myelopathy underwent C4-6 laminoplasty. On postoperative day 2, he develops deltoid and biceps 3/5 weakness and sensory loss in a C5 dermatomal pattern. Postoperative CT and MRI are unremarkable. What is the most likely outcome?
a. Recovery of motor function but permanent sensory deficit
b. Chronic C5 neuropathic pain
c. Permanent motor and sensory deficit
d. Complete resolution of motor and sensory deficit
e. Recovery of sensory function but permanent motor deficit
d. Complete resolution of motor and sensory deficit
What radiographic finding is most commonly associated with Chiari I malformations?
a. Hydrocephalus.
b. Scoliosis.
c. Synringomyelia.
d. “Pigeon Breast” deformity of the brainstem.
e. Spina Bifida
c. Synringomyelia.
What is the most likely diagnosis demonstrated by the findings in the MRI images shown (see figures)?
a. Basilar invagination
b. Chiari 1 malformation with syrinx
c. Multiple sclerosis
d. Chordoma
e. Pilocytic astrocytoma
b. Chiari 1 malformation with syrinx
A 56 year-old man presents with rheumatoid arthritis and a several month history of progressively severe neck pain and numbness in all four extremities as well as gait disturbance. Cervical MRI reveals myelomalacia at C1-2. Dynamic radiographs reveal an atlanto-dental interval of 3 mm in extension and 12 mm in flexion. Which of the following is the MOST appropriate surgical intervention:
a. C1-2 fixation
b. Transoral odontoid resection
c. C2-3 Lateral mass fixation
d. Anterior odontoid screw fixation
e. Posterior C1 ring resection
a. C1-2 fixation
If pelvic alignment is not addressed during spinal deformity surgery, what clinical outcome is most likely to occur?
a. Hardware failure
b. Spinal misalignment
c. Acetabular fracture
d. Piriformis syndrome
e. Hip dislocation
b. Spinal misalignment
A 47 year-old woman with a history of multiple prior lumbar spine surgeries with temporary relief of back and leg pain after each, now presents with severe low back pain. Her pain worsens throughout the day, requiring her to use a walker in the evening. She denies new radicular symptoms and is neurologically intact on exam. X-rays are obtained (Figure 1). What is the likely etiology of her pain and disability?
a. Positive sagittal imbalance
b. Residual lumbar stenosis
c. Pseudarthrosis
d. Adjacent level foraminal stenosis
e. Sacroiliac joint dysfunction
a. Positive sagittal imbalance
A 50 year old man presents with progressive gait and micturition difficulty from a spinal dural AV fistula. What is the most reliable predictor of postoperative recovery of function?
a. Spinal level of dural AV fistula
b. Degree of preoperative disability
c. Patient age
d. Treatment modality
e. Number of arterial feeders
b. Degree of preoperative disability
A patient presents with a classic type II odontoid fracture. A magnetic resonance image and flexion-extension dynamic radiographs of the cervical spine are consistent with disruption of the transverse ligament. The MOST appropriate treatment is:
a. Occipital-cervical fusion
b. Posterior C1-C2 fixation
c. Hard cervical collar
d. Anterior odontoid screw fixation
e. Halo immobilization
b. Posterior C1-C2 fixation
What is the recommended treatment of an isolated unilateral occipital condylar fracture (OCF) without associated atlanto-occipital ligamentous injury or evidence of instability?
a. Physical therapy
b. Foramen magnum decompression
c. Cranio-cervical instrumentation and arthrodesis
d. Cervical immobilization
e. Observation with serial radiographs
d. Cervical immobilization
Vertebral artery injury during C1-2 transarticular screw placement is most likely to result when the screw is misplaced in which direction?
a. caudally
b. medially
c. cranially
d. laterally
e. anteriorly
a. caudally
A 27 year old patient presents following a trauma that involved an axial load to the spine. He has undergone CT imaging. He notes neck pain but otherwise has a normal neurological examination. What does the following coronal CT scan of the cervical spine depict (figure)?
a. C2 Hangman’s Fracture
b. Type 1 odontoid fracture
c. C1-2 Rotatory Subluxation
d. Occipital condyle fracture
e. Unstable C1 (Jefferson) fracture
e. Unstable C1 (Jefferson) fracture
A 78 year-old man with a 10-year history of intermittent chronic neck pain has cervical spine X-rays (Figure 1) and MRI (Figure 2). The patient denies any current neck pain, radiculopathy or subjective symptoms of myelopathy. His exam is normal. What is the recommended management for this patient?
a. Serial MRI
b. Clinical observation
c. High-dose steroids and cervical traction
d. Surgery
e. Immobilization with cervical collar
b. Clinical observation
A 42 year old male is undergoing L5-S1 anterior lumbar interbody fusion for spondylolisthesis. What anatomic structure overlying the disc space is potentially at risk during exposure for discectomy?:
a. iliolumbar vein
b. genitofemoral nerve
c. vena cava
d. hypogastic plexus
e. distal aorta
d. hypogastic plexus
Immediately after closing the osteotomy for correction of a thoracolumbar scoliosis, the intraoperative monitoring technician informs you that there has been a sudden > 50% decrease in amplitude on the motor evoked potentials. What is the first step in management?
a. fluoroscopy to confirm pedicle screw position
b. check MEP leads and connections
c. decrease inhalant anesthetic
d. perform a wake up test
e. reverse the osteotomy closure
e. reverse the osteotomy closure
Two days after performing heavy manual labor, your patient awakens with severe left shoulder pain, severe enough to require narcotics for relief. Ten days later, he notices rapidly progressive weakness of his left shoulder girdle muscles and biceps. Examination reveals a normal sensory exam. MRI of the cervical spine is unremarkable. What is the most likely diagnosis?
a. Thoracic outlet syndrome
b. Parsonage-Turner syndrome
c. Amyotrophic lateral sclerosis
d. Acute left C5-C6 disc herniation
e. Brachial plexus stretch injury
b. Parsonage-Turner syndrome
A 42 year old woman suffers a gunshot injury to the abdomen. A CT scan shows intraperitoneal free air as well as a bullet lodged within the L3 vertebral body with minimal retropulsion of the posterior wall. She is neurologically intact. What is the most appropriate next step in management?
a. Exploratory laparotomy to repair intraperitoneal injury with L3 corpectomy and fusion.
b. L3 laminectomy, removal of all loose bone fragments, and antibiotic washout.
c. Administration of prophylactic antifungal coverage.
d. Gunshot wound cultures.
e. Administration of tetanus prophylaxis.
e. Administration of tetanus prophylaxis.
A 68 year-old man presents to the office with neck pain and right upper extremity paresthesias. He reports mild difficulty with buttoning his shirt and initiating micturition. He has decreased sensation in the right first and second digit and loss of the right biceps reflex. He also has mild loss of balance with tandem gait. His cervical spine MRI is depicted (Fig 1). What is the most appropriate management?
a. Electrodiagnostic studies (EMG/NCV) to assess for carpal tunnel syndrome
b. Surgical decompression of the cervical spinal cord
c. Right C5-C6 transforaminal epidural injection
d. Medrol dose pack and soft cervical collar for 6 months
e. Structured physical therapy with gait training
b. Surgical decompression of the cervical spinal cord
A 37 year-old man presents with worsening low back pain and right L5 radicular pain and a normal examination. Lumbar spine MRI (Figure 1) and CT (Figure 2) are shown. Work-up revealed this solitary lesion. What is the most appropriate next step in management?
a. Open surgical biopsy
b. Observation with serial imaging
c. CT-guided biopsy
d. Surgical excision and stabilization
e. External beam radiotherapy
c. CT-guided biopsy
A 19 year old male presents with tussive headaches located at the posterior base of the skull. Neurologic examination reveals weakness of the hands bilaterally with hypesthesia. MR of the brain and cervical spine are shown in the figures. What is the best initial management strategy for this presentation?
a. Posterior cervical decompression
b. Anterior transoral odontoid resection
c. Ventriculoperitoneal shunt
d. Posterior fossa decompression
e. Syringo-subarachnoid shunt
d. Posterior fossa decompression
A 51 year-old woman presents to the ED with a subcutaneous fluid collection in the lumbar area two days after undergoing a redo L4-5 laminectomy/discectomy at another institution. She is afebrile and has no neurological deficits but complains of headache when she sits up or stands. What is the most likely etiology of her fluid collection?
a. cerebrospinal fluid leak
b. wound infection
c. subcutaneous foreign body
d. wound hematoma
e. wound seroma
a. cerebrospinal fluid leak
What clinical finding best characterizes cauda equina syndrome?
a. foot drop
b. decreased patellar tendon reflex
c. sciatica
d. saddle anesthesia
e. ankle plantar flexion weakness
d. saddle anesthesia
For which spinal disorder are children of mothers with diabetes mellitus at risk?
a. Intraspinal lipomas
b. Meningocele manque
c. Spinal dysraphism
d. Sacral agenesis
e. Thoracic hemivertebrae
d. Sacral agenesis
An 8 year-old child with a history of myelomeningocele presents with progressive back pain, scoliosis, right calf numbness, right leg weakness, incontinence, and bladder spasticity. Which of her symptoms is most likely to improve following a third untethering procedure?
a. Leg weakness
b. Bladder spasticity
c. Back pain
d. Leg numbness
e. Scoliosi
c. Back pain
A 56-year old man presents with a 4-year history of progressive lower extremity numbness, paresthesias, weakness and spastic gait. MRI and CT Myelogram of the thoracic spine is shown (Figure 1 & 2). What is the most appropriate treatment option?
a. Fenestration of dorsal arachnoid cyst
b. Intradural exploration and detethering of ventral spinal cord
c. Thoracotomy for thoracic discectomy
d. Observation and physical therapy
e. Thoracic laminectomy and posterior fusion
b. Intradural exploration and detethering of ventral spinal cord
Which of the following pedicle screw characteristics increases pullout strength?
a. smaller inter-thread distance
b. unicortical purchase
c. increased minor - major diameter ratio
d. bilateral screw triangulation with crosslink
e. tapered screw shape
d. bilateral screw triangulation with crosslink
During lateral osteophyte removal in an anterior decompressive discectomy, you encounter brisk bleeding in the region of the nerve root. What is the best next step?
a. Order blood for transfusion
b. Abort the procedure
c. Call interventional radiology
d. Explore the vertebral artery
e. Apply gelfoam and pressure
e. Apply gelfoam and pressure
What is the most common spinal cord anomaly in a 6 month-old male with an area of focal hirsutism located just above the gluteal crease?
a. Atretic meningocele.
b. Split cord malformation.
c. Dermal sinus tract.
d. Fatty filum.
e. Lipomyelomeningocele
b. Split cord malformation.
A 36 year old restrained driver presented after a motor vehicle collision. What is the classification of the spinal injury illustrated in the figure?
a. Fracture dislocation
b. Chance fracture
c. Compression fracture
d. Teardrop fracture
e. Burst fracture
b. Chance fracture
A 58 year old male presents with longstanding progressive neck and back pain and dysphagia. The following CT is obtained. What is the most likely diagnosis?
a. age-appropriate spine
b. Orheumatoid arthritis
c. ankylosing spondylitis
d. diffuse idiopathic skeletal hyperostosis
e. hypercalcemia
d. diffuse idiopathic skeletal hyperostosis
What proportion of pediatric patients who undergo temporal lobectomy for intractable epilepsy have a favorable outcome (seizure freedom or substantial decrease in seizure frequency)?
a. 35-50%
b. 80-95%
c. 50-65%
d. 65-80%
d. 65-80%
You are seeing a patient with left leg pain and foraminal stenosis at four lumbar levels on the left side. You are considering decompressive surgery, but want to identify the symptomatic level(s) prior to operating. Which procedure would be best suited to identify the nerve root(s) responsible for the pain?
a. Interlaminar epidural steroid injection
b. Selective nerve root block
c. Facet joint injection
d. Provocative discography
e. Sacroiliac joint injection
b. Selective nerve root block
A 65 year-old patient awakens from a left subcostal spinal infusion pump surgery done in the lateral position with complaints of painless right leg weakness. Examination shows weakness of ankle dorsiflexion and eversion and sensory loss limited to the dorsal foot. Ankle inversion, toe flexion and deep tendon reflexes are normal. Babinski response is normal. An urgent EMG/NCV is normal. What is the most likely cause of this man’s weakness?
a. Tibialis anterior compression
b. Lumbar plexopathy
c. Peroneal neuropathy
d. Sciatic neuropathy
e. L5 radiculopathy
c. Peroneal neuropathy
A 30 year-old woman presents with progressive difficulty using her hands and gait dysfunction. She has pain in the back of her neck that radiates into her head. She notes pain and pareasthesias in both arms that are refractory to neuropathic pain medication. Her imaging is shown in the figures. What is the most appropriate initial surgical management?
a. VP shunt
b. Cervical laminectomy and duraplasty
c. Cyst fenestration
d. Cyst shunt
e. Suboccipital decompression
a. VP shunt
A 60 year old male with type 2 diabetes presents with fever, back pain and < 24 hours of acute onset 2/5 motor weakness in the lower extremities. Thoracic MRI (Figure 1) and CT (Figure 2) imaging is performed. What is the most appropriate management for this patient’s acute neurologic deficits?
a. Corpectomy and instrumented fusion
b. Antibiotic therapy and external orthosis
c. Percutaneous aspiration
d. Kyphoplasty
e. Thoracic laminectomy
a. Corpectomy and instrumented fusion
A 19 year-old man presents after a helmeted ATV accident. On examination the patient is neurologically intact. He denies any midline tenderness. Trauma survey and labs are normal. What imaging test should be ordered before clearing his collar.
a. Cervical CTA
b. No imaging.
c. Cervical CT Scan
d. Cervical X-ray
e. Cervical MRI
b. No imaging.
A 62 year old with known metastatic renal cell cancer presents with unbearable back pain and lower extremity myelopathy after a fall. Her imaging is displayed in the accompanying figures. The best management strategy of this lesion would be:
a. Laminectomy and resection of epidural disease followed by radiotherapy
b. Vertebrectomy with posterior stabilization followed by radiotherapy
c. Kyphoplasty/Vertebroplasty followed by radiotherapy
d. Conventional external beam radiotherapy
e. Stereotactic Radiosurgery
b. Vertebrectomy with posterior stabilization followed by radiotherapy
A 61 year old previously healthy man presents with progressive hand weakness, tingling in his fingers, and gait instability. Examination reveals atrophy and weakness of the hands, impaired rapid alternating movements, diminished pinprick sensation in the fingers, diffuse hyper-reflexia, and lower extremity spasticity. What is the MOST likely diagnosis:
a. Cervical Spondylotic Myelopathy
b. Multiple Sclerosis
c. Subacute Combined System Disease
d. Normal Pressure Hydrocephalus
e. Amytrophic Lateral Sclerosis
a. Cervical Spondylotic Myelopathy
Amyotrophic lateral sclerosis (ALS) is diagnosed by which pattern of neurological dysfunction?
a. Upper or lower motor neuron dysfunction without progression
b. Both upper and lower motor neuron dysfunction with progression
c. Isolated upper motor neuron dysfunction with progression
d. Isolated lower motor neuron dysfunction with progression
e. Both upper and lower motor neuron dysfunction without progression
b. Both upper and lower motor neuron dysfunction with progression
What lateral plain film measurements of the cervical spine is used to make the diagnosis of atlanto-occipital dislocation (AOD)?
a. Atlanto-dens interval
b. Basion-posterior axial line and basion-dens interval
c. Mcgregor’s line
d. Combined C1 Lateral mass displacement
e. Chamberlain’s line
b. Basion-posterior axial line and basion-dens interval
A 58 year old woman with a history of breast cancer presents with lower thoracic spine pain. The pain is worse at night and does not worsen with movement. She is neurologically intact. An MRI reveals a contrast-enhancing lytic lesion isolated to the T12 body without evidence of fracture. There are multiple smaller lesions noted throughout her entire spinal axis. She is currently undergoing systemic therapy for her bone only disease. What is the most appropriate treatment option for this patient?
a. Percutaneous biopsy and vertebroplasty followed by radiosurgery.
b. Percutaneous biopsy and vertebroplasty followed by conventional fractionated radiotherapy.
c. Fractionated external beam radiotherapy.
d. T12 vertebrectomy with pedicle screw instrumentation followed by radiotherapy.
e. Posterior T12 laminectomy with pedicle screw instrumentation followed by radiotherapy.
c. Fractionated external beam radiotherapy.
What mechanism underlies the injury depicted in Figures 1 and 2?
a. Compressive extension
b. Distractive extension
c. Distractive flexion
d. Compressive flexion
e. Torsional rotation
d. Compressive flexion
What is the most common cause of perioperative visual loss (POVL) in patients undergoing spinal fusion?
a. Cortical blindness
b. Retinal vascular occlusion
c. Posterior ischemic optic neuropathy
d. Anterior ischemic optic neuropathy
e. Corneal abrasion
a. Cortical blindness
According to the Guidelines for the Performance of Fusion Procedures for Degenerative Disease of the Lumbar Spine, the literature supports the use of fusion in lumbar decompression surgery for degenerative stenosis when associated with what imaging finding?
a. spina bifida.
b. conjoined nerve root.
c. focal disc herniation.
d. congenital stenosis.
e. spondylolisthesis.
e. spondylolisthesis.
What is the best method to screen for cervical spine injury in the unconscious, intubated multitrauma patient?
a. C-spine CT
b. Fluoroscopic Flexion/Extension Imaging
c. Dynamic traction fluoroscopy
d. A/P, Lateral, Oblique, and Open Mouth Odontoid radiographs
e. C-Spine MRI
a. C-spine CT
A 75 year-old healthy woman suffered a fall 3 months ago and immediately noticed neck pain. She has been treating her pain with over-the-counter medications, but the pain continues to worsen over time. On exam, she has no focal deficits. X-ray (Figure 1) and CT (Figure 2) are depicted. What is the optimal management for this patient?
a. Cervical collar
b. Halo-vest placement
c. Odontoid screw placement
d. C1-2 posterior fusion
e. Occipital-cervical fusion
d. C1-2 posterior fusion
A 50 year old male has a cervical myelopathy. Imaging shows cervical disc osteophyte complexes at C4-5, C5-6, and C6-7 with severe canal stenosis at these levels and cord signal. Standing x-rays show mild kyphosis of the cervical spine centered at C5-6. Which surgical approach would most likely result in a worsening clinical picture post-operatively?
a. C4-C6 laminectomies and decompression
b. C5 and C6 corpectomies, C4-C7 anterior reconstruction and fusion with cage and plating, with supplemental posterior instrumented fusion from C4-C7
c. C4-C6 laminectomies and C4-C7 posterior instrumented fusion/fixation
d. C5 and C6 corpectomies and C4-C7 anterior reconstruction and fusion with cage and plating
e. Anterior cervical discectomy and fusion at C4-5, C5-6, C6-7
a. C4-C6 laminectomies and decompression
The ventral cervical plate pictured below spans three vertebral levels, and reveals a pseudoarthrosis. It consists of two screws at each end that are rigidly affixed to the plate. Which of following biomechanical properties best describe the type of fixation pictured in the radiograph that lead to the pseudoarthrosis?
a. Constrained three-point bending.
b. Semi-constrained cantilever beam.
c. Semi-constrained four-point bending.
d. Constrained dynamic.
e. Constrained cantilever beam.
e. Constrained cantilever beam.
A 50 year old male presents with a 2 week history of low back pain radiating down the postero-lateral thigh, lateral shin, dorsum of the foot and great toe on the right side. His neurologic exam is intact except for a (+) right straight leg raise at 30 degrees and 4-/5 EHL strength on the right. The most likely diagnosis is:
a. L5-S1 foraminal disc herniation
b. L3-L4 paracentral disc herniation
c. L3-4 central disc herniation
d. L5-S1 paracentral disc herniation
e. L4-L5 far lateral disc herniation
a. L5-S1 foraminal disc herniation
Compared to posterior surgery, what risk is associated with Anterior cervical surgery for OPLL?
a. Kyphosis
b. C5 root palsy
c. OPLL growth
d. shoulder girdle pain
e. CSF leak
e. CSF leak
A 60 year old man presents with 10 weeks of back pain. ESR and CRP are elevated and WBC is normal. Blood cultures show no growth. The patient has normal strength and sensation and no bowel or bladder incontinence. The MRI reveals osteomyelitis and discitis of L3/4 without epidural abscess or canal compromise. What is the best next step in the management of this patient?
a. Surgical Debridement
b. Lumbar Brace
c. Lumbar Puncture
d. Empiric antibiotics
e. Disc space biopsy
e. Disc space biopsy
A 22-year-old sustained a spinal cord injury after a fall with an L2 burst fracture and canal compromise. More than half of the muscles below the level of injury have astrength grade less than 3. There is impaired pain and temperature sensation below the middle of the thighs bilaterally, but preserved light touch and proprioception. There is bilateral Babinski sign and loss of anal tone and wink reflex. According to the 2000/2002 ASIA Standards, what (modified) ASIA Impairment Scale classification is this patient?
a. E
b. D
c. B
d. C
e. A
d. C
During a retroperitoneal approach to the lumbar spine, what structure runs along the medial aspect of the psoas muscle and lateral aspect of the spine?
a. Genitofemoral nerve
b. Ureter
c. Aorta
d. Ilioinguinal nerve
e. sympathetic trunk
e. sympathetic trunk
After a type II odontoid fracture, the function of which ligament/membrane most strongly influences treatment options:
a. anterior longitudinal
b. interspinous
c. alar
d. apical
e. transverse
e. transverse
A 68 year-old woman presents with progressive myelopathy with MRI shown. Why is an isolated posterior approach contraindicated in this patient?
a. Posterior ligamentous hypertrophy
b. Subluxation at C3/4 and C4/5
c. Ventral compressive pathology
d. Compressive pathology across multiple levels
e. Fixed kyphotic deformity
e. Fixed kyphotic deformity
A 24 year old male presents within 3 hours of a gunshot wound to the lower neck with progressive quadriparesis. A C-spine CT demonstrates an epidural hematoma from C6-T1. What is the most appropriate next step in management?
a. Initiation of high-dose methylprednisolone for a full 48 hours.
b. ICU management with fluid boluses and pressors to increase mean arterial pressure.
c. Repeat CT in 4 hours to evaluate if the epidural hematoma is expanding.
d. Emergent surgical decompression.
e. MRI of the C-spine to better evaluate for cervical disk hernation.
d. Emergent surgical decompression.
A patient complains of hip and thigh pain 2 months following thoracolumbar fusion surgery (figure). Based on the provided radiograph, what is the best treatment option to correct the primary problem producing pain and disability?
a. Extension of instrumented fusion to T10
b. Extension of instrumented fusion to the pelvis
c. T12 to L5 decompressive Laminectomy
d. Pedicle subtraction osteotomy
e. Re-arthrodesis to address pseudarthrosis
d. Pedicle subtraction osteotomy
A 50-year-old woman presents with a one-year history of progressive low back pain and constipation. Magnetic resonance imaging demonstrates a large sacral mass (figure). She is neurologically intact. What is the most important next step to determine further management?
a. Proctoscopic examination to assess the consistency of lesion
b. MRI of the skull-base
c. MRI with contrast of the pelvis
d. Formal urodynamics studies
e. CT-guided biopsy of the mass
e. CT-guided biopsy of the mass
A 26 year old male presents after motor vehicle crash with absent right and partially preserved left lower extremity motor function (more than half of left leg muscles have less than antigravity strength). Sensation to pain and temperature is markedly diminished in the left leg. Proprioception is markedly diminished in the right leg. Neuro-imaging studies are obtained and depicted in Figures 1 and 2. Which spinal cord syndrome BEST describes the injury?
a. Central cord
b. Cauda equina
c. Anterior spinal
d. Posterior cord
e. Brown-Sequard
e. Brown-Sequard
You are treating a patient with chronic, medically-refractory low back pain. You decide to proceed with a trial of spinal cord stimulation. What would be the most appropriate spinal level for electrode placement to achieve the best stimulation coverage of the patient’s painful area?
a. C1
b. L5
c. L2
d. T11
e. T9
e. T9
A 30 year old male with history of IV drug use presents to the ER with fever and low back pain. His MRI demonstrates a small sacral epidural abscess. He has blood cultures positive for methicillin resistant staph aureus. His erythrocyte sedimentation rate (ESR) on presentation is elevated at 110 mm/hr. He is neurologically intact. He is to undergo 8 weeks of vancomycin IV. What is the most appropriate test for determining that his sacral epidural abscess has resolved at the conclusion of antibiotic therapy?
a. Bone scan
b. CT guided biopsy
c. Repeat ESR
d. Repeat MRI with and without contrast
e. Repeat blood culture
c. Repeat ESR
A 65 year-old woman presents with progressively worsening gait instability over 4 weeks. She has 4/5 strength in bilateral iliopsoas, 3+ patellar tendon reflexes, and difficulty with tandem gait. MRI of the thoracic spine is depicted (Figure 1). Selective spinal angiography of the right T11 intercostal artery is shown in the early (Figure 2A) and delayed (Figure 2B) phases. What is the goal of surgery?
a. Coagulate the abnormal dilated pial veins
b. Gross total resection of the nidus
c. Sacrifice the feeding vessel to the anterior spinal artery
d. Divide the arteriovenous connection at the nerve root sleeve
e. Decompression of the spinal cord via expansile duraplasty
d. Divide the arteriovenous connection at the nerve root sleeve
What is a contraindication for posterior cervical foraminotomy as a treatment for cervical radiculopathy due to disc herniation?
a. Degenerative changes at other levels
b. Ipsilateral vocal cord palsy
c. Kyphotic neck deformity
d. Associated osteophyte formation
e. Central disc herniation
e. Central disc herniation
A sagittal, upright long-cassette radiograph is shown (figure) for a 54-year-old woman with a history of T12-L5 instrumented fusion 2 months ago who now presents with back and thigh pain. Which of the following diagnoses is most likely based on her history and imaging?
a. Pseudarthrosis
b. Instrumentation failure
c. Flatback syndrome
d. Sagittal spinal imbalance
e. Adjacent segment disease
c. Flatback syndrome
For which type of lumbar fusion is the use of recombinant human bone morphogenetic protein 2 (rhBMP-2) FDA approved?
a. Instrumented posterolateral lumbar fusion procedures
b. Non-instrumented posterolateral lumbar fusion procedures
c. Posterior lumbar interbody fusion procedures
d. Anterior lumbar interbody fusion procedures
e. Transforaminal lumbar interbody fusion procedures
d. Anterior lumbar interbody fusion procedures
What is the most common complication of anterior cervical discectomy and fusion (ACDF)?
a. New radiculopathy
b. Horner’s syndrome
c. Hoarseness
d. Thoracic duct injury
e. Dysphagia
e. Dysphagia
A 52 y/o restrained driver presented after a motor vehicle accident with an L2 sensory level, 4/5 strength in his proximal and 4-/5 strength in his distal lower extremities and a severe L2 fracture. What is this patient’s ASIA Impairment Scale score (modified Frankel score)?
a. A
b. D
c. E
d. B
e. C
b. D
During atlantoaxial rotatory subluxation with left axial hyper-rotation, several ligaments of the upper cervical spine can be torn. In rotatory subluxation, which ligament is most likely to retain its integrity?
a. Transverse ligament
b. Alar ligament
c. Accessory ligament
d. Ipsilateral C1-C2 facet capsular ligament
e. Contralateral C1-C2 facet capsular ligament
a. Transverse ligament
A 28-year old male presents to the Emergency Department with complaints of severe low back and right leg pain after injury while working as a carpenter the previous day. He denies weakness, numbness and gait or bowel/bladder disturbance. Examination reveals trace weakness of dorsi-flexion on the right associated with pain. What is the best initial management strategy for this patient?
a. Nonsteroidal anti-inflammatory medications
b. Posterior lumbar interbody fusion
c. Seven day course of bed rest
d. Lumbar discectomy
e. Epidural steroid injection
a. Nonsteroidal anti-inflammatory medications
Which of the following most accurately defines, from a biomechanical perspective, the location of rod fracture as depicted in Figure 1? The point of:
a. 3-point bending.
b. greatest flexibility.
c. narrowest diameter.
d. maximum strain application.
e. maximum stress application.
e. maximum stress application.
What is the most common adverse event following laminoplasty for cervical spondylotic myelopathy?
a. Accelerated adjacent level deterioration
b. C5 root palsy
c. Progressive cervical kyphosis
d. Inadequate cord decompression
e. Loss of cervical range of motion
e. Loss of cervical range of motion
A twenty-four year old woman presents with right arm and leg weakness and left cranial nerve VI palsy following a high-speed motor vehicle accident. Her lateral cervical spine x-ray shows upper cervical prevertebral soft tissue swelling and a basion-dental interval of 16mm. Her Head CT is negative for intracranial hemorrhage. What is the recommended treatment of this injury?
a. Immobilization in a halo.
b. Internal fixation and arthrodesis.
c. In situ arthrodesis and immobilzation in a 4-poster brace
d. Immobilization in a hard collar.
e. Traction followed by immobilization in a halo.
b. Internal fixation and arthrodesis.
After a ground level fall, a 62 year-old man with a history of ankylosing spondylitis reports persistent mid-back pain. CT reveals a fracture through the entire T7 vertebral body. STIR signal MRI reveals three column injury without evidence of canal compromise. What is the most appropriate management?
a. Cervico-thoracic orthosis
b. T7 Vertebroplasty
c. Thoraco-lumbo-sacral orthosis
d. Posterior T4-9 instrumented fusion
e. Transthoracic T6-7 discectomy and anterior instrumentation
d. Posterior T4-9 instrumented fusion
What radiographic finding is a contraindication to cervical laminoplasty?
a. Ossified posterior longitudinal ligament (OPLL).
b. Multilevel cervical spondylosis.
c. Spinal cord signal change.
d. Congenital cervical stenosis.
e. Cervical kyphosis
e. Cervical kyphosis
A 66-year old male with a history of ACDF performed 3 months ago presented with a 6 week history of fever, dysphagia, and neck pain. The patient was neurologically intact. MR imaging is consistent with cervical vertebral osteomyelitis and reveals a retropharyngeal abscess. What test is most helpful to diagnose the source of the infection?
a. Peripheral blood cultures
b. Bone scan
c. Esophagoscopy
d. Tagged white blood-cell scan
e. Echocardiogram
c. Esophagoscopy
This lumbosacral spine MRI (figure) is from a 23-year-old woman who presented with severe low back pain radiating to her right leg. Which nerve root is most likely compressed by the herniated disc?
a. Traversing L4 nerve root
b. Exiting L5 nerve root
c. Exiting S1 nerve root
d. Traversing L5 nerve root
e. Traversing S1 nerve root
e. Traversing S1 nerve root
