Neurospine Flashcards
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. Decompression of the spinal cord via expansile duraplasty
B. Coagulate the abnormal dilated pial veins
C. Gross total resection of the nidus
D. Divide the arteriovenous connection at the nerve root sleeve
E. Sacrifice the feeding vessel to the anterior spinal artery
D. Divide the arteriovenous connection at the nerve root sleeve
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. Decrease inhalant anesthetic
B. Check MEP leads and connections
C. Reverse the osteotomy closure
D. Perform a wake-up test
E. Fluoroscopy to confirm pedicle screw position
C. Reverse the osteotomy closure
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. Sympathetic trunk
B. Ilioinguinal nerve
C. Genitofemoral nerve
D. Ureter
E. Aorta
A. Sympathetic trunk
The radiographic and magnetic resonance imaging findings at L2-L3 (shown in Figures 1-3) are most consistent with a diagnosis of:
A. Metastatic carcinoma
B. Chordoma
C. Degenerative disc disease
D. Discitis/osteomyelitis
E. Fracture
D. Discitis/osteomyelitis
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. Apply Gelfoam and pressure
B. Call interventional radiology
C. Order blood for transfusion
D. Explore the vertebral artery
E. Abort the procedure
A. Apply Gelfoam and pressure
What is the definitive treatment of atlanto-occipital dislocation (AOD)?
A. Cervical traction
B. Halo vest immobilization
C. Observation with serial radiographs
D. Rigid cranio-cervico-thoracic orthosis
E. Cranio-cervical internal fixation and fusion
E. Cranio-cervical internal fixation and fusion
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. 65-80%
C. 50-65%
D. 80-95%
B. 65-80%
A 60-year-old man presents with 3 months of worsening diffuse severe unremitting left upper extremity pain, paresthesias, and hand weakness. Exam shows 4/5 weakness of hand muscles including abductor pollicis 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
A 56-year-old man presents with rheumatoid arthritis and a several-month history of progressively severe neck pain, numbness in all four extremities, and gait disturbance. Cervical MRI reveals myelomalacia at C1-2. Dynamic radiographs reveal an atlanto-dental interval of 3mm in extension and 12mm in flexion. Which of the following is the MOST appropriate surgical intervention?
A. C2-3 lateral mass fixation
B. C1-2 fixation
C. Posterior C1 ring resection
D. Anterior odontoid screw fixation
E. Transoral odontoid resection
B. C1-2 fixation
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. Halo immobilization
B. Posterior C1-C2 fixation
C. Occipital-cervical fusion
D. Anterior odontoid screw fixation
E. Hard cervical collar
B. Posterior C1-C2 fixation
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 the risk of this complication?
A. Minimize excessive traction on the shoulders when positioning
B. Perform surgical approach from the patient’s right side
C. Place retractors under the medial edge of the longus coli muscles during periosteal dissection
D. Minimize distraction of the vertebral bodies
E. Deflate and re-inflate the endotracheal balloon after retractor placement
C. Place retractors under the medial edge of the longus coli muscles during periosteal dissection
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. Kyphoplasty
B. Corpectomy and instrumented fusion
C. Antibiotic therapy and external orthosis
D. Percutaneous aspiration
E. Thoracic laminectomy
B. Corpectomy and instrumented fusion
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. Anterior discectomy and interbody fusion
B. Empiric antibiotics
C. Needle biopsy of disc space
D. Laminectomy for surgical debridement
E. Posterior instrumentation and fusion without laminectomy
C. Needle biopsy of disc space
A 50-year-old male has 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. C5 and C6 corpectomies, C4-C7 anterior reconstruction and fusion with cage and plating, with supplemental posterior instrumented fusion from C4-C7
B. Anterior cervical discectomy and fusion at C4-5, C5-6, C6-7
C. C5 and C6 corpectomies and C4-C7 anterior reconstruction and fusion with cage and plating
D. C4-C6 laminectomies and C4-C7 posterior instrumented fusion/fixation
E. C4-C6 laminectomies and decompression
D. C4-C6 laminectomies and C4-C7 posterior instrumented fusion/fixation
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. Thoracic laminectomy and posterior fusion
B. Thoracotomy for thoracic discectomy
C. Intradural exploration and detethering of ventral spinal cord
D. Observation and physical therapy
E. Fenestration of dorsal arachnoid cyst
C. Intradural exploration and detethering of ventral spinal cord
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. Observation with no repeat imaging necessary
B. C1-2 wiring with halo placement and autologous fusion
C. Observation with repeat flexion-extension in the future
D. C1-2 transarticular screw placement and autologous fusion
E. Occipital cervical fusion with sublaminar wires
C. Observation with repeat flexion-extension in the future
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 paracentral disc herniation
B. L3-4 central disc herniation
C. L4-L5 far lateral disc herniation
D. L3-L4 paracentral disc herniation
E. L5-S1 foraminal disc herniation
E. L5-S1 foraminal disc herniation
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. Sacroiliac joint injection
C. Facet joint injection
D. Selective nerve root block
E. Provocative discography
D. Selective nerve root block
A 28-year-old male presents to the Emergency Department with complaints of severe low back and right leg pain after an injury while working as a carpenter the previous day. He denies weakness, numbness, gait, or bowel/bladder disturbance. Examination reveals trace weakness of dorsiflexion on the right associated with pain. What is the best initial management strategy for this patient?
A. Seven-day course of bed rest
B. Posterior lumbar interbody fusion
C. Epidural steroid injection
D. Nonsteroidal anti-inflammatory medications
E. Lumbar discectomy
D. Nonsteroidal anti-inflammatory medications
For which spinal disorder are children of mothers with diabetes mellitus at risk?
A. Intraspinal lipomas
B. Spinal dysraphism
C. Sacral agenesis
D. Meningocele manque
E. Thoracic hemivertebrae
C. Sacral agenesis
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. Complete resolution of motor and sensory deficit
B. Chronic C5 neuropathic pain
C. Recovery of sensory function but permanent motor deficit
D. Recovery of motor function but permanent sensory deficit
E. Permanent motor and sensory deficit
A. Complete resolution of motor and sensory deficit
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 a headache when she sits up or stands. What is the most likely etiology of her fluid collection?
A. Wound seroma
B. Cerebrospinal fluid leak
C. Wound infection
D. Subcutaneous foreign body
E. Wound hematoma
B. Cerebrospinal fluid leak
What radiographic finding is most commonly associated with Chiari I malformations?
A. Spina bifida
B. Hydrocephalus
C. Scoliosis
D. Syringomyelia
E. “Pigeon breast” deformity of the brainstem
D. Syringomyelia
What lateral plain film measurements of the cervical spine are used to make the diagnosis of atlanto-occipital dislocation (AOD)?
A. Combined C1 lateral mass displacement
B. Atlanto-dens interval
C. Basion-posterior axial line and basion-dens interval
D. Chamberlain’s line
E. McGregor’s line
C. Basion-posterior axial line and basion-dens interval
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. L1/L2 microdiscectomy
B. Spinal deformity correction
C. Release of filum terminale
D. Conservative therapy (PT, NSAIDs, etc.)
E. Monitoring with serial imaging
C. Release of filum terminale
What is the most common cause of perioperative visual loss (POVL) in patients undergoing spinal fusion?
A. Cortical blindness
B. Corneal abrasion
C. Posterior ischemic optic neuropathy
D. Retinal vascular occlusion
E. Anterior ischemic optic neuropathy
A. Cortical blindness
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. She is neurologically intact. What is the most important next step to determine further management?
A. Formal urodynamic studies
B. MRI of the skull base
C. MRI with contrast of the pelvis
D. CT-guided biopsy of the mass
E. Proctoscopic examination to assess the consistency of the lesion
D. CT-guided biopsy of the mass
What clinical finding best characterizes cauda equina syndrome?
A. Saddle anesthesia
B. Sciatica
C. Ankle plantar flexion weakness
D. Foot drop
E. Decreased patellar tendon reflex
A. Saddle anesthesia
A 19-year-old man presents after a helmeted ATV accident. On examination, the patient is neurologically intact and denies any midline tenderness. Trauma survey and labs are normal. What imaging test should be ordered before clearing his collar?
A. Cervical CT scan
B. Cervical MRI
C. Cervical CTA
D. No imaging
E. Cervical X-ray
D. No imaging
A 52-year-old restrained driver presents 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. C
B. A
C. E
D. B
E. D
E. D
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. Acute left C5-C6 disc herniation
B. Amyotrophic lateral sclerosis
C. Brachial plexus stretch injury
D. Thoracic outlet syndrome
E. Parsonage-Turner syndrome
E. Parsonage-Turner syndrome
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 paresthesias 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. Cyst shunt
C. Cervical laminectomy and duraplasty
D. Suboccipital decompression
E. Cyst fenestration
A. VP shunt
An 18-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. Immobilization with cervical collar
B. High-dose steroids and cervical traction
C. Clinical observation
D. Serial MRI
E. Surgery
C. Clinical observation
If pelvic alignment is not addressed during spinal deformity surgery, what clinical outcome is most likely to occur?
A. Piriformis syndrome
B. Acetabular fracture
C. Hip dislocation
D. Spinal misalignment
E. Hardware failure
D. Spinal misalignment
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. Genitofemoral nerve
B. Hypogastric plexus
C. Distal aorta
D. Vena cava
E. Iliolumbar vein
B. Hypogastric plexus
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. Burst fracture
E. Teardrop fracture
B. Chance fracture
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. Surgical excision and stabilization
B. External beam radiotherapy
C. Open surgical biopsy
D. Observation with serial imaging
E. CT-guided biopsy
E. CT-guided biopsy
After a type II odontoid fracture, the function of which ligament/membrane most strongly influences treatment options?
A. Alar
B. Anterior longitudinal
C. Transverse
D. Apical
E. Interspinous
C. Transverse
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. Accessory ligament
B. Transverse ligament
C. Contralateral C1-C2 facet capsular ligament
D. Ipsilateral C1-C2 facet capsular ligament
E. Alar ligament
B. Transverse ligament
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. Bilateral L4-5 hemilaminotomies with preservation of midline structures
C. Long-term corticosteroids
D. L4-5 dynamic interspinous spacer placement
E. L4-5 decompression and fusion
E. L4-5 decompression and fusion
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. L5
B. L2
C. C1
D. T9
E. T11
D. T9
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. Structured physical therapy with gait training
B. Medrol dose pack and soft cervical collar for 6 months
C. Right C5-C6 transforaminal epidural injection
D. Electrodiagnostic studies (EMG/NCV) to assess for carpal tunnel syndrome
E. Surgical decompression of the cervical spinal cord
E. Surgical decompression of the cervical spinal cord
What is the most common adverse event following laminoplasty for cervical spondylotic myelopathy?
A. Loss of cervical range of motion
B. Progressive cervical kyphosis
C. Inadequate cord decompression
D. C5 root palsy
E. Accelerated adjacent level deterioration
A. Loss of cervical range of motion
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. Peroneal neuropathy
B. Lumbar plexopathy
C. Sciatic neuropathy
D. Tibialis anterior compression
E. L5 radiculopathy
A. Peroneal neuropathy
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. Subacute Combined System Disease
B. Amyotrophic Lateral Sclerosis
C. Cervical Spondylotic Myelopathy
D. Normal Pressure Hydrocephalus
E. Multiple Sclerosis
C. Cervical Spondylotic Myelopathy
What is the best method to screen for cervical spine injury in the unconscious, intubated multi-trauma patient?
A. AP, Lateral, Oblique, and Open Mouth Odontoid radiographs
B. Dynamic traction fluoroscopy
C. C-spine CT
D. C-spine MRI
E. Fluoroscopic Flexion/Extension Imaging
C. C-spine CT
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. Pseudarthrosis
B. Positive sagittal imbalance
C. Adjacent level foraminal stenosis
D. Sacroiliac joint dysfunction
E. Residual lumbar stenosis
B. Positive sagittal imbalance
A 35-year-old woman presents with an L1 burst fracture after a motor vehicle accident. Which of the following characteristic(s) predict the likelihood of instrumentation failure with short segment posterior instrumented fusion?
A. Disrupted posterior ligamentous complex
B. Incomplete neurologic deficit
C. Spinal canal compromise > 50%
D. Comminuted fracture with fragment displacement and kyphosis
E. Involvement of both vertebral endplates
D. Comminuted fracture with fragment displacement and kyphosis
What mechanism underlies the injury depicted in Figures 1 and 2?
A. Distractive extension
B. Compressive flexion
C. Torsional rotation
D. Distractive flexion
E. Compressive extension
B. Compressive flexion
What radiographic finding is a contraindication to cervical laminoplasty?
A. Cervical kyphosis
B. Multilevel cervical spondylosis
C. Ossified posterior longitudinal ligament (OPLL)
D. Spinal cord signal change
E. Congenital cervical stenosis
A. Cervical kyphosis
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. Narrowest diameter
B. 3-point bending
C. Greatest flexibility
D. Maximum strain application
E. Maximum stress application
E. Maximum stress application
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. Neurenteric cyst
C. Myelomeningocele
D. Dermal sinus tract
E. Lipomyelomeningocele
A. Diastematomyelia
What is the most likely diagnosis demonstrated by the findings in the MRI images shown?
A. Multiple sclerosis
B. Chiari I malformation with syrinx
C. Pilocytic astrocytoma
D. Chordoma
E. Basilar invagination
B. Chiari I malformation with syrinx
A 66-year-old male with a history of ACDF performed 3 months ago presents with a 6-week history of fever, dysphagia, and neck pain. The patient is 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. Tagged white blood-cell scan
D. Esophagoscopy
E. Echocardiogram
D. 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 S1 nerve root
C. Traversing S1 nerve root
D. Traversing L5 nerve root
E. Exiting L5 nerve root
C. Traversing S1 nerve root
A patient awakens from a 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. Postoperative MRI reveals no evidence of spinal cord compression or hematoma. What is the most likely diagnosis?
A. Anterior cord syndrome
B. Central cord syndrome
C. Weber’s syndrome
D. Brown-Sequard syndrome
E. Posterior cord syndrome
A. Anterior cord syndrome
What is the first priority in the overall assessment of a trauma patient with an acute cervical spine fracture?
A. Neurological deficit
B. Airway integrity
C. Blood pressure
D. Ongoing hemorrhage
E. Spinal stability
B. Airway integrity
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 a three-column injury without evidence of canal compromise. What is the most appropriate management?
A. Cervico-thoracic orthosis
B. Thoraco-lumbo-sacral orthosis
C. Posterior T4-9 instrumented fusion
D. T7 vertebroplasty
E. Transthoracic T6-7 discectomy and anterior instrumentation
C. Posterior T4-9 instrumented fusion
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. Anterior odontoid screw fixation
B. Anterior C2-3 discectomy and fusion
C. External immobilization
D. Posterior C1-C3 fixation
E. C1-2 transarticular screw fixation
C. External immobilization
Vertebral artery injury during C1-2 transarticular screw placement is most likely to result when the screw is misplaced in which direction?
A. Laterally
B. Caudally
C. Anteriorly
D. Medially
E. Cranially
B. Caudally
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 5
B. Grade 1
C. Grade 2
D. Grade 4
E. Grade 3
C. Grade 2
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. Spondylolisthesis
B. Spina bifida
C. Focal disc herniation
D. Conjoined nerve root
E. Congenital stenosis
A. Spondylolisthesis
For which type of lumbar fusion is the use of recombinant human bone morphogenetic protein 2 (rhBMP-2) FDA approved?
A. Non-instrumented posterolateral lumbar fusion procedures
B. Instrumented posterolateral lumbar fusion procedures
C. Anterior lumbar interbody fusion procedures
D. Posterior lumbar interbody fusion procedures
E. Transforaminal lumbar interbody fusion procedures
C. Anterior lumbar interbody fusion procedures
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, resulting in moderate stenosis and spinal cord compression. The MOST likely pathologic process is:
A. Osteoporotic compression fracture
B. Pathologic fracture
C. Spinal tuberculosis
D. Discitis - Staph epidermidis
E. Discitis - Staph aureus
C. Spinal tuberculosis
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 for this lesion would be:
A. Stereotactic radiosurgery
B. Laminectomy and resection of epidural disease followed by radiotherapy
C. Vertebrectomy with posterior stabilization followed by radiotherapy
D. Kyphoplasty/Vertebroplasty followed by radiotherapy
E. Conventional external beam radiotherapy
C. Vertebrectomy with posterior stabilization followed by radiotherapy
What is the most common complication of anterior cervical discectomy and fusion (ACDF)?
A. Thoracic duct injury
B. Hoarseness
C. Dysphagia
D. Horner’s syndrome
E. New radiculopathy
C. Dysphagia
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. Empiric antibiotics
B. Lumbar brace
C. Surgical debridement
D. Lumbar puncture
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 a strength 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. A
B. D
C. C
D. E
E. B
C. C
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. Rheumatoid arthritis
B. Ankylosing spondylitis
C. Hypercalcemia
D. Age-appropriate spine
E. Diffuse idiopathic skeletal hyperostosis (DISH)
E. Diffuse idiopathic skeletal hyperostosis (DISH)
A pedicle subtraction osteotomy (PSO) hinges on which anatomic region?
A. Posterior to the spinal column
B. Anterior to the spinal column
C. The anterior column of the spine
D. The posterior column of the spine
E. The middle column of the spine
C. The anterior column of the spine
A 24-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. Traction followed by immobilization in a halo
B. In situ arthrodesis and immobilization in a 4-poster brace
C. Immobilization in a halo
D. Internal fixation and arthrodesis
E. Immobilization in a hard collar
D. Internal fixation and arthrodesis
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. Split cord malformation
B. Fatty filum
C. Dermal sinus tract
D. Atretic meningocele
E. Lipomyelomeningocele
A. Split cord malformation
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 fossa decompression
B. Anterior transoral odontoid resection
C. Posterior cervical decompression
D. Syringo-subarachnoid shunt
E. Ventriculoperitoneal shunt
A. Posterior fossa decompression
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. ICU management with fluid boluses and pressors to increase mean arterial pressure
B. Repeat CT in 4 hours to evaluate if the epidural hematoma is expanding
C. Emergent surgical decompression
D. Initiation of high-dose methylprednisolone for a full 48 hours
E. MRI of the C-spine to better evaluate for cervical disk herniation
C. Emergent surgical decompression
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 tectorial membrane and alar ligaments
B. Rupture of the transverse ligament
C. Rupture of the posterior longitudinal ligament
D. Rupture of the anterior longitudinal ligament
E. Rupture of the ligamentum flavum
A. Rupture of the tectorial membrane and alar ligaments
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 corpectomy and fusion plus chemotherapy
D. L3 corpectomy and fusion plus radiation therapy
E. L3 en bloc spondylectomy and L2-4 fusion
E. L3 en bloc spondylectomy and L2-4 fusion
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. Pedicle subtraction osteotomy
B. Extension of instrumented fusion to the pelvis
C. T12 to L5 decompressive laminectomy
D. Extension of instrumented fusion to T10
E. Re-arthrodesis to address pseudarthrosis
A. Pedicle subtraction osteotomy
A 27-year-old patient presents following 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?
A. Occipital condyle fracture
B. C2 Hangman’s fracture
C. C1-2 rotatory subluxation
D. Unstable C1 (Jefferson) fracture
E. Type 1 odontoid fracture
D. Unstable C1 (Jefferson) fracture
What is a contraindication for posterior cervical foraminotomy as a treatment for cervical radiculopathy due to disc herniation?
A. Kyphotic neck deformity
B. Degenerative changes at other levels
C. Central disc herniation
D. Associated osteophyte formation
E. Ipsilateral vocal cord palsy
C. Central disc herniation
A 68-year-old woman presents with progressive myelopathy with MRI shown. Why is an isolated posterior approach contraindicated in this patient?
A. Fixed kyphotic deformity
B. Ventral compressive pathology
C. Subluxation at C3/4 and C4/5
D. Posterior ligamentous hypertrophy
E. Compressive pathology across multiple levels
A. Fixed kyphotic deformity
Compared to posterior surgery, what risk is associated with anterior cervical surgery for OPLL?
A. C5 root palsy
B. OPLL growth
C. Shoulder girdle pain
D. CSF leak
E. Kyphosis
D. CSF leak
Amyotrophic lateral sclerosis (ALS) is diagnosed by which pattern of neurological dysfunction?
A. Upper or lower motor neuron dysfunction without progression
B. Isolated lower motor neuron dysfunction with progression
C. Isolated upper motor neuron dysfunction with progression
D. Both upper and lower motor neuron dysfunction without progression
E. Both upper and lower motor neuron dysfunction with progression
E. Both upper and lower motor neuron dysfunction with progression
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 the following biomechanical properties best describe the type of fixation pictured in the radiograph that led to the pseudoarthrosis?
A. Constrained three-point bending
B. Constrained cantilever beam
C. Semi-constrained cantilever beam
D. Constrained dynamic
E. Semi-constrained four-point bending
B. Constrained cantilever beam
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. Halo-vest placement
B. Occipital-cervical fusion
C. C1-2 posterior fusion
D. Odontoid screw placement
E. Cervical collar
C. C1-2 posterior fusion
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. L3 laminectomy, removal of all loose bone fragments, and antibiotic washout
B. Exploratory laparotomy to repair intraperitoneal injury with L3 corpectomy and fusion
C. Administration of prophylactic antifungal coverage
D. Administration of tetanus prophylaxis
E. Gunshot wound cultures
D. Administration of tetanus prophylaxis
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. An intramedullary spinal cord lesion spanning 3 or more segments
D. Optic nerve enhancement
E. Multiple non-enhancing intramedullary spinal lesions spanning 1-2 segments
C. An intramedullary spinal cord lesion spanning 3 or more segments
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. Bladder spasticity
B. Scoliosis
C. Leg weakness
D. Back pain
E. Leg numbness
D. Back pain
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. Flatback syndrome
C. Instrumentation failure
D. Sagittal spinal imbalance
E. Adjacent segment disease
B. Flatback syndrome
A 26-year-old male presents after a 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. Neuroimaging studies are obtained and depicted in Figures 1 and 2. Which spinal cord syndrome BEST describes the injury?
A. Anterior spinal syndrome
B. Brown-Sequard syndrome
C. Cauda equina syndrome
D. Central cord syndrome
E. Posterior cord syndrome
B. Brown-Sequard syndrome
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. Fractionated external beam radiotherapy
B. Posterior T12 laminectomy with pedicle screw instrumentation followed by radiotherapy
C. T12 vertebrectomy with pedicle screw instrumentation followed by radiotherapy
D. Percutaneous biopsy and vertebroplasty followed by radiosurgery
E. Percutaneous biopsy and vertebroplasty followed by conventional fractionated radiotherapy
A. Fractionated external beam radiotherapy
Which of the following is considered a major risk factor for osteoporosis by the National Osteoporosis Foundation?
A. Current smoking
B. High body mass index (BMI)
C. Alcohol use of 1 drink per day
D. Prior falls
E. Use of NSAIDs
A. Current smoking
Approximately what percentage of cervical rotation occurs at the C1-2 level?
A. 90%
B. 25%
C. 10%
D. 75%
E. 50%
E. 50%
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. Number of arterial feeders
B. Degree of preoperative disability
C. Spinal level of dural AV fistula
D. Patient age
E. Treatment modality
B. Degree of preoperative disability
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. Cranio-cervical instrumentation and arthrodesis
C. Foramen magnum decompression
D. Cervical immobilization
E. Observation with serial radiographs
D. Cervical immobilization
A 30-year-old male with a 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 Staphylococcus aureus. His erythrocyte sedimentation rate (ESR) on presentation is elevated at 110 mm/hr. He is neurologically intact and 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. Repeat ESR
C. Repeat MRI with and without contrast
D. Repeat blood culture
E. CT-guided biopsy
B. Repeat ESR
What is the most common indication for surgical treatment of Scheuermann’s thoracic kyphosis?
A. Radiculopathy from disc herniation
B. Pulmonary compromise
C. Painful kyphosis
D. Severe compression fractures
E. Progressive scoliosis
C. Painful kyphosis
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. Positioning nerve injury
B. Brachial plexus stretch injury
C. Residual muscle relaxation
D. Surgical trauma
E. Embolic stroke
A. Positioning nerve injury
Which of the following pedicle screw characteristics increases pullout strength?
A. Tapered screw shape
B. Unicortical purchase
C. Bilateral screw triangulation with crosslink
D. Increased minor-major diameter ratio
E. Smaller inter-thread distance
C. Bilateral screw triangulation with crosslink
When placing bi-cortical sacral pedicle screws, which structure is at most risk with a laterally placed screw that perforates the anterior cortex?
A. Lumbosacral plexus
B. Internal iliac artery
C. L5 nerve root
D. S1 nerve root
E. Aorta
C. L5 nerve root
Failure to account for which radiographic measurement is associated with delayed treatment failure after surgical treatment of positive sagittal imbalance?
A. Sacral Slope
B. Lumbar coronal Cobb angle
C. Central Sacral Vertical Line
D. Thoracic Kyphosis
E. Pelvic Incidence
E. Pelvic Incidence
