Neurosurgery Flashcards
1
Q
Identify the follow ing structures. The gure illustrates a right
transcallosal approach to the third ventricle.
1. Caudate nucleus
A
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H
I. I
2
Q
identify the follow ing structures. The gure illustrates a right
transcallosal approach to the third ventricle.
2. Choroid plexus
A
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H
I. I
3
Q
identify the follow ing structures. The gure illustrates a right
transcallosal approach to the third ventricle.
3. Foram en of Monro
A
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H
I. I
4
Q
identify the follow ing structures. The gure illustrates a right transcallosal approach to the third ventricle.
4. Colum ns of the fornix
A
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H
I. I
5
Q
identify the follow ing structures. The gure illustrates a right
transcallosal approach to the third ventricle.
5. Septum pellucidum
A
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H
I. I
6
Q
identify the follow ing structures. The gure illustrates a right
transcallosal approach to the third ventricle.
6. Thalam ostriate vein
A
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H
I. I
7
Q
identify the follow ing structures. The gure illustrates a right
transcallosal approach to the third ventricle.
7. Thalam us
A
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H
I. I
8
Q
identify the follow ing structures. The gure illustrates a right
transcallosal approach to the third ventricle.
8. Body of the fornix
A
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H
I. I
9
Q
identify the follow ing structures. The gure illustrates a right
transcallosal approach to the third ventricle.
9. Anterior caudate vein
A
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H
I. I
10
Q
Surgical procedures utilized in the treatm ent of spasm odic torticollis include
I. Upper cervical ventral rhizotom ies and spinal accessory neurectomy
II. Stereotactic thalam otomy
III. Microvascular decom pression of the spinal accessory nerve
IV. Myotomy
A
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of the above
11
Q
- Which surgical approach for thoracic disk herniations is associated w ith the
highest rate of neurologic injury?
A. Costotransversectomy
B. Lateral extracavitary
C. Midline laminectomy
D. Transpedicular
E. Transthoracic
A
A. Costotransversectomy
B. Lateral extracavitary
C. Midline laminectomy
D. Transpedicular
E. Transthoracic
12
Q
Most patients with intrinsic brainstem gliomas initially present with
A. Cranial neuropathies
B. Headache
C. Hydrocephalus
D. Nausea and vom iting
E. Papilledema
A
A. Cranial neuropathies
B. Headache
C. Hydrocephalus
D. Nausea and vom iting
E. Papilledema
13
Q
Each of the follow ing is characteristic of com plex regional pain syndrom e II
(causalgia) except
A. Atrophic changes in the lim b
B. Hypesthesia
C. Increased sweating
D. Lack of m ajor m otor de cit
E. Good relief w ith sympathetic block
A
A. Atrophic changes in the lim b
B. Hypesthesia
C. Increased sweating
D. Lack of m ajor m otor de cit
E. Good relief w ith sympathetic block
14
Q
For questions 14 to 18, match the description w ith the structure
14. Bacterial m eningitis
A. Derm oid cyst
B. Epiderm oid cyst
C. Both
D. Neither
A
A. Derm oid cyst
B. Epiderm oid cyst
C. Both
D. Neither
15
Q
match the description w ith the structure.
15. Aseptic m eningitis
A. Derm oid cyst
B. Epiderm oid cyst
C. Both
D. Neither
A
A. Derm oid cyst
B. Epiderm oid cyst
C. Both
D. Neither
16
Q
match the description w ith the structure.
16. Associated congenital m alform ations
A. Derm oid cyst
B. Epiderm oid cyst
C. Both
D. Neither
A
A. Derm oid cyst
B. Epiderm oid cyst
C. Both
D. Neither
17
Q
match the description w ith the structure.
17. Most often midline
A. Derm oid cyst
B. Epiderm oid cyst
C. Both
D. Neither
A
A. Derm oid cyst
B. Epiderm oid cyst
C. Both
D. Neither
18
Q
match the description w ith the structure.
18. Responsive to radiation therapy
A. Derm oid cyst
B. Epiderm oid cyst
C. Both
D. Neither
A
A. Derm oid cyst
B. Epiderm oid cyst
C. Both
D. Neither
19
Q
Ventricular enlargem ent from choroid plexus papillom as can be secondary to
I. Entrapm ent of cerebrospinal uid (CSF)
II. Decreased absorption of CSF from hem orrhage-induced arachnoiditis
III. Tum or grow th
IV. Excessive production of CSF
A
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of the above
20
Q
- Which approach is favored for a patient w ith an 8-m m acoustic neurom a in
w hich hearing preservation is a goal?
A. Middle fossa
B. Suboccipital
C. Translabyrinthine
A
A. Middle fossa
B. Suboccipital
C. Translabyrinthine
21
Q
Uncinate seizures typically produce
A. Auditory hallucinations
B. Gustatory hallucinations
C. Olfactory hallucinations
D. Vertiginous sensations
E. Visual seizures
A
A. Auditory hallucinations
B. Gustatory hallucinations
C. Olfactory hallucinations
D. Vertiginous sensations
E. Visual seizures
22
Q
For questions 22 to 25, match the description w ith the structure.
22. Separates the P1 and P2A segm ents of the posterior cerebral artery
A. Calcarine sulcus
B. Lateral m esencephalic sulcus
C. Posterior communicating artery
D. Tectal plate
A
A. Calcarine sulcus
B. Lateral m esencephalic sulcus
C. Posterior com m unicating artery
D. Tectal plate
23
Q
match the description w ith the structure.
23. Separates the P2A and P2P segm ents of the posterior cerebral artery
A. Calcarine sulcus
B. Lateral mesencephalic sulcus
C. Posterior com m unicating artery
D. Tectal plate
A
A. Calcarine sulcus
B. Lateral m esencephalic sulcus
C. Posterior com m unicating artery
D. Tectal plate
24
Q
match the description w ith the structure
24. Separates the P2P and P3 segm ents of the posterior cerebral artery
A. Calcarine sulcus
B. Lateral m esencephalic sulcus
C. Posterior com m unicating artery
D. Tectal plate
A
A. Calcarine sulcus
B. Lateral m esencephalic sulcus
C. Posterior com m unicating artery
D. Tectal plate
25
match the description w ith the structure
25. Separates the P3 and P4 segm ents of the posterior cerebral artery
A. Calcarine sulcus
B. Lateral m esencephalic sulcus
C. Posterior com m unicating artery
D. Tectal plate
**A. Calcarine sulcus**
B. Lateral m esencephalic sulcus
C. Posterior com m unicating artery
D. Tectal plate
26
The radial nerve or one of its branches innervates each of the follow ing except the
A. Abductor pollicis longus
B. Adductor pollicis
C. Brachioradialis
D. Extensor pollicis brevis
E. Supinator
A. Abductor pollicis longus
**B. Adductor pollicis**
C. Brachioradialis
D. Extensor pollicis brevis
E. Supinator
27
Each of the follow ing is true of intraventricular hem orrhage (IVH) in the new born except
A. Periventricular hem orrhagic infarction is one sequela.
B. Posthem orrhagic hydrocephalus can result in persistent bradycardia and apneic spells.
C. The capillary bed of the germinal matrix is composed of large irregular vessels.
D. The germ inal matrix is the most common site of IVH in the full-term neonate.
E. The risk of IVH is greater in the preterm than in the term infant.
A. Periventricular hem orrhagic infarction is one sequela.
B. Posthem orrhagic hydrocephalus can result in persistent bradycardia and
apneic spells.
C. The capillary bed of the germ inal m atrix is composed of large irregular
vessels.
**D. The germ inal m atrix is the m ost common site of IVH in the full-term neonate.**
E. The risk of IVH is greater in the preterm than in the term infant.
28
The ossification centers of the odontoid consist of
A. One prim ary and two secondary centers
B. One secondary and three prim ary centers
C. Three secondary and one prim ary center
D. Two prim ary centers
E. Two prim ary and one secondary center
A. One prim ary and two secondary centers
B. One secondary and three prim ary centers
C. Three secondary and one prim ary center
D. Two prim ary centers
**E. Two prim ary and one secondary center**
29
The most common single-suture synostosis is
A. Coronal
B. Lam bdoid
C. Metopic
D. Sagittal
E. Sphenozygom atic
A. Coronal
B. Lam bdoid
C. Metopic
**D. Sagittal**
E. Sphenozygom atic
30
The most sensitive method for detecting carpal tunnel syndrome is
A. Needle examination of the abductor pollicis brevis
B. Needle examination of the rst and second lumbricals
C. Motor amplitude of the median nerve
D. Motor distal latency of the median nerve
E. Palmar sensory conduction tim e of the m edian nerve
A. Needle exam ination of the abductor pollicis brevis
B. Needle examination of the rst and second lumbricals
C. Motor amplitude of the median nerve
D. Motor distal latency of the median nerve
**E. Palmar sensory conduction time of the median nerve**
31
Coup contusions most commonly occur at the
A. Cerebral convexities
B. Frontal and temporal poles
C. Orbital surface of the frontal lobes
D. Posterior fossa
E. Ventral surface of the temporal lobe
**A. Cerebral convexities**
B. Frontal and temporal poles
C. Orbital surface of the frontal lobes
D. Posterior fossa
E. Ventral surface of the temporal lobe
32
For questions 32 to 36, match the aneurysm w ith the sign or sym ptom it is m ost likely
to produce. Each response m ay be used once, m ore than once, or not at all.
32. Pupil-involving third nerve palsy
A. Anterior com m unicating artery aneurysm
B. Intracavernous carotid artery aneurysm
C. Middle cerebral artery aneurysm
D. Ophthalm ic artery aneurysm
E. Posterior com m unicating artery aneurysm
A. Anterior com m unicating artery aneurysm
B. Intracavernous carotid artery aneurysm
C. Middle cerebral artery aneurysm
D. Ophthalm ic artery aneurysm
**E. Posterior com m unicating artery aneurysm**
33
match the aneurysm w ith the sign or sym ptom it is m ost likely
to produce. Each response m ay be used once, m ore than once, or not at all.
33. Seizures
A. Anterior com m unicating artery aneurysm
B. Intracavernous carotid artery aneurysm
C. Middle cerebral artery aneurysm
D. Ophthalm ic artery aneurysm
E. Posterior com m unicating artery aneurysm
A. Anterior com m unicating artery aneurysm
B. Intracavernous carotid artery aneurysm
**C. Middle cerebral artery aneurysm**
D. Ophthalm ic artery aneurysm
E. Posterior com m unicating artery aneurysm
34
match the aneurysm w ith the sign or sym ptom it is m ost likely
to produce. Each response m ay be used once, m ore than once, or not at all.
34. Diabetes insipidus
A. Anterior com m unicating artery aneurysm
B. Intracavernous carotid artery aneurysm
C. Middle cerebral artery aneurysm
D. Ophthalm ic artery aneurysm
E. Posterior com m unicating artery aneurysm
**A. Anterior com m unicating artery aneurysm**
B. Intracavernous carotid artery aneurysm
C. Middle cerebral artery aneurysm
D. Ophthalm ic artery aneurysm
E. Posterior com m unicating artery aneurysm
35
match the aneurysm w ith the sign or sym ptom it is m ost likely
to produce. Each response m ay be used once, m ore than once, or not at all.
35. Inferior nasal quadrantanopia
A. Anterior com m unicating artery aneurysm
B. Intracavernous carotid artery aneurysm
C. Middle cerebral artery aneurysm
D. Ophthalm ic artery aneurysm
E. Posterior com m unicating artery aneurysm
A. Anterior com m unicating artery aneurysm
B. Intracavernous carotid artery aneurysm
C. Middle cerebral artery aneurysm
**D. Ophthalmic artery aneurysm**
E. Posterior com m unicating artery aneurysm
36
match the aneurysm w ith the sign or sym ptom it is m ost likely
to produce. Each response m ay be used once, m ore than once, or not at all.
36. Exophthalmos
A. Anterior com m unicating artery aneurysm
B. Intracavernous carotid artery aneurysm
C. Middle cerebral artery aneurysm
D. Ophthalm ic artery aneurysm
E. Posterior com m unicating artery aneurysm
A. Anterior com m unicating artery aneurysm
**B. Intracavernous carotid artery aneurysm**
C. Middle cerebral artery aneurysm
D. Ophthalm ic artery aneurysm
E. Posterior com m unicating artery aneurysm
37
The essential diference between a syringomyelic and a hydromyelic cavity is
that the cavity in
A. Hydromyelia is lined w ith ependym al cells, and in syringomyelia is not
B. Hydromyelia is lined w ith choroid plexus, and in syringomyelia is not
C. Syringomyelia contains CSF, and in hydromyelia contains serum
D. Syringomyelia is focal, and in hydromyelia is m ore extensive
E. Syringomyelia is an enlargem ent of the central canal, and in hydromyelia is
an enlargem ent of the anterior m edian septum
**A. Hydromyelia is lined w ith ependym al cells, and in syringomyelia is not**
B. Hydromyelia is lined w ith choroid plexus, and in syringomyelia is not
C. Syringomyelia contains CSF, and in hydromyelia contains serum
D. Syringomyelia is focal, and in hydromyelia is m ore extensive
E. Syringomyelia is an enlargem ent of the central canal, and in hydromyelia is
an enlargem ent of the anterior m edian septum
38
For questions 38 to 45, identify the follow ing structures. The gure illustrates the
structures exposed through the right opticocarotid triangle.
38. Basilar artery
A. A
B. B
C. C
D. D
E. E
**F. F**
G. G
H. H
39
identify the follow ing structures. The gure illustrates the
structures exposed through the right opticocarotid triangle.
39. Pituitary stalk
A. A
B. B
C. C
D. D
E. E
F. F
**G. G**
H. H
40
identify the follow ing structures. The gure illustrates the
structures exposed through the right opticocarotid triangle.
40. Right oculom otor nerve
A. A
B. B
C. C
D. D
E. E
F. F
G. G
**H. H**
41
identify the follow ing structures. The gure illustrates the
structures exposed through the right opticocarotid triangle.
41. Right posterior cerebral artery
A. A
B. B
**C. C**
D. D
E. E
F. F
G. G
H. H
42
identify the following structures. The gure illustrates the
structures exposed through the right opticocarotid triangle.
42. Internal carotid artery
**A. A**
B. B
C. C
D. D
E. E
F. F
G. G
H. H
43
identify the follow ing structures. The gure illustrates the
structures exposed through the right opticocarotid triangle.
43. Left duplicated superior cerebellar artery
A. A
B. B
C. C
**D. D**
E. E
F. F
G. G
H. H
44
identify the follow ing structures. The gure illustrates the
structures exposed through the right opticocarotid triangle.
44. Right superior cerebellar artery
A. A
**B. B**
C. C
D. D
E. E
F. F
G. G
H. H
45
identify the follow ing structures. The gure illustrates the
structures exposed through the right opticocarotid triangle.
45. Right anterior cerebral artery (A1 segm ent)
A. A
B. B
C. C
D. D
**E. E**
F. F
G. G
H. H
46
Each of the follow ing is true of basilar impression except
A. Cerebellar and vestibular com plaints typically overshadow m otor and
sensory com plaints.
B. McGregor’s line is helpful in routine screening.
C. McRae’s line is helpful in clinical assessm ent.
D. Short necks and torticollis are common.
E. Vertebral artery anom alies are common.
**A. Cerebellar and vestibular com plaints typically overshadow m otor and
sensory com plaints.**
B. McGregor’s line is helpful in routine screening.
C. McRae’s line is helpful in clinical assessm ent.
D. Short necks and torticollis are com m on.
E. Vertebral artery anom alies are com m on.
47
Which of the follow ing fractures has the poorest prognosis for healing w ithout
surgical intervention?
A. Hangm an’s
B. Je erson’s fracture w ith 4 m m displacem ent of lateral m asses
C. Type I odontoid
D. Type II odontoid
E. Type III odontoid
A. Hangm an’s
B. Je erson’s fracture w ith 4 m m displacem ent of lateral m asses
C. Type I odontoid
**D. Type II odontoid**
E. Type III odontoid
48
Sprengel’s deform ity refers to a(n)
A. Congenital elevation of the scapula
B. Congenital fusion of the upper cervical vertebrae
C. Intravertebral disk herniation
D. Postlam inectomy kyphosis
E. Scoliosis resulting from tethering of the spinal cord
**A. Congenital elevation of the scapula**
B. Congenital fusion of the upper cervical vertebrae
C. Intravertebral disk herniation
D. Postlam inectomy kyphosis
E. Scoliosis resulting from tethering of the spinal cord
49
For questions 49 to 55, m atch the fracture type w ith the m echanism . Each response
m ay be used once, m ore than once, or not at all.
Force Neck Posture
49. Hangm an’s fracture
A. Flexing exed
B. Com pressing exed
C. Compressing neutral
D. Distracting extended
E. Flexing axially rotated
F. Com pressing laterally bent
A. Flexing exed
B. Com pressing exed
C. Compressing neutral
**D. Distracting extended**
E. Flexing axially rotated
F. Com pressing laterally bent
50
m atch the fracture type w ith the m echanism . Each response
m ay be used once, m ore than once, or not at all.
Force Neck Posture
50. Burst fracture
A. Flexing exed
B. Com pressing exed
C. Compressing neutral
D. Distracting extended
E. Flexing axially rotated
F. Com pressing laterally bent
A. Flexing exed
B. Com pressing exed
**C. Compressing neutral**
D. Distracting extended
E. Flexing axially rotated
F. Com pressing laterally bent
51
m atch the fracture type w ith the m echanism . Each response
m ay be used once, m ore than once, or not at all.
Force Neck Posture
51. Unilateral facet dislocation
A. Flexing exed
B. Com pressing exed
C. Compressing neutral
D. Distracting extended
E. Flexing axially rotated
F. Com pressing laterally bent
A. Flexing exed
B. Com pressing exed
C. Compressing neutral
D. Distracting extended
E. Flexing axially rotated
**F. Com pressing laterally bent**
52
m atch the fracture type w ith the m echanism . Each response
m ay be used once, m ore than once, or not at all.
Force Neck Posture
52. Teardrop fracture
A. Flexing exed
B. Com pressing exed
C. Compressing neutral
D. Distracting extended
E. Flexing axially rotated
F. Com pressing laterally bent
A. Flexing exed
**B. Com pressing exed**
C. Compressing neutral
D. Distracting extended
E. Flexing axially rotated
F. Com pressing laterally bent
53
m atch the fracture type w ith the m echanism . Each response
m ay be used once, m ore than once, or not at all.
Force Neck Posture
53. Bilateral facet dislocation
A. Flexing exed
B. Com pressing exed
C. Compressing neutral
D. Distracting extended
E. Flexing axially rotated
F. Com pressing laterally bent
**A. Flexing exed**
B. Com pressing exed
C. Compressing neutral
D. Distracting extended
E. Flexing axially rotated
F. Com pressing laterally bent
54
m atch the fracture type w ith the m echanism . Each response
m ay be used once, m ore than once, or not at all.
Force Neck Posture
54. Horizontal facet fracture
A. Flexing exed
B. Com pressing exed
C. Compressing neutral
D. Distracting extended
E. Flexing axially rotated
F. Com pressing laterally bent
A. Flexing exed
B. Com pressing exed
C. Compressing neutral
D. Distracting extended
E. Flexing axially rotated
**F. Com pressing laterally bent**
55
m atch the fracture type w ith the m echanism . Each response
m ay be used once, m ore than once, or not at all.
Force Neck Posture
55. Jefferson’s fracture
A. Flexing exed
B. Com pressing exed
C. Compressing neutral
D. Distracting extended
E. Flexing axially rotated
F. Com pressing laterally bent
A. Flexing exed
B. Com pressing exed
**C. Compressing neutral**
D. Distracting extended
E. Flexing axially rotated
F. Com pressing laterally bent
56
Lateral recess stenosis in spondylosis is most commonly caused by
A. Disk herniation
B. Hypertrophied pedicles
C. Inferior articular facet hypertrophy
D. Ligam entum avum hypertrophy
E. Superior articular facet hypertrophy
A. Disk herniation
B. Hypertrophied pedicles
C. Inferior articular facet hypertrophy
D. Ligam entum avum hypertrophy
**E. Superior articular facet hypertrophy**
57
In the treatm ent of chronic pain, the undesirable e ect(s) that is/are m ore
com m on in stim ulation of the periaqueductal gray than the periventricular gray
region is/are
I. Diplopia
II. Oscillopsia
III. Reduction of upgaze
IV. Sense of im pending doom
A. I, II, III
B. I, III
C. II, IV
D. IV
**E. All of the above**
58
“Trilateral retinoblastom a” describes bilateral ocular retinoblastom as and a(n)
A. Astrocytom a
B. Medulloblastom a
C. Neuro brom a
D. Optic nerve sheath tum or
E. Pineoblastoma
A. Astrocytom a
B. Medulloblastom a
C. Neuro brom a
D. Optic nerve sheath tum or
**E. Pineoblastoma**
59
Carotid artery ligation is absolutely contraindicated in patients w ith (a)
A. Bilateral intracavernous carotid aneurysm s
B. Giant ophthalm ic artery aneurysm and evidence of vasospasm on
arteriogram
C. Giant ophthalm ic artery aneurysm and extracranial atherosclerotic
disease
D. Intracavernous carotid artery aneurysm and sudden loss of extraocular
m otility
E. Traum atic dissecting aneurysm of the petrous carotid artery
A. Bilateral intracavernous carotid aneurysm s
**B. Giant ophthalm ic artery aneurysm and evidence of vasospasm on
arteriogram**
C. Giant ophthalm ic artery aneurysm and extracranial atherosclerotic
disease
D. Intracavernous carotid artery aneurysm and sudden loss of extraocular
m otility
E. Traum atic dissecting aneurysm of the petrous carotid artery
60
The syndrom e of weakness in one upper extrem ity followed by lower extrem -
ity weakness on the sam e side, then contralateral lower extrem ity weakness, is
m ost characteristic of a m eningiom a involving the
A. Clivus
B. Falx
C. Foramen magnum
D. Olfactory groove
E. Tuberculum sella
A. Clivus
B. Falx
**C. Foram en m agnum**
D. Olfactory groove
E. Tuberculum sella
61
For questions 61 to 70, the gure illustrates a lateral view of the left cavernous sinus.
Match the follow ing triangles w ith the descriptions/structures. Each response m ay be
used once, m ore than once, or not at all.
61. Clinoidal segment of the internal carotid artery
A. Clinoidal
B. Oculom otor
C. Supratrochlear
D. Infratrochlear or Parkinson’s
E. Anterom edial
F. Anterolateral
G. Posterolateral or Glasscock’s
H. Posterom edial or Kawase’s
**A. Clinoidal**
B. Oculom otor
C. Supratrochlear
D. Infratrochlear or Parkinson’s
E. Anterom edial
F. Anterolateral
G. Posterolateral or Glasscock’s
H. Posterom edial or Kawase’s
62
the gure illustrates a lateral view of the left cavernous sinus.
Match the follow ing triangles w ith the descriptions/structures. Each response m ay be
used once, m ore than once, or not at all.
62. Intracavernous carotid artery
A. Clinoidal
B. Oculom otor
C. Supratrochlear
D. Infratrochlear or Parkinson’s
E. Anterom edial
F. Anterolateral
G. Posterolateral or Glasscock’s
H. Posterom edial or Kawase’s
A. Clinoidal
B. Oculom otor
C. Supratrochlear
**D. Infratrochlear or Parkinson’s**
E. Anterom edial
F. Anterolateral
G. Posterolateral or Glasscock’s
H. Posterom edial or Kawase’s
63
the gure illustrates a lateral view of the left cavernous sinus.
Match the follow ing triangles w ith the descriptions/structures. Each response m ay be
used once, m ore than once, or not at all.
63. Intrapetrous carotid artery
A. Clinoidal
B. Oculom otor
C. Supratrochlear
D. Infratrochlear or Parkinson’s
E. Anterom edial
F. Anterolateral
G. Posterolateral or Glasscock’s
H. Posterom edial or Kawase’s
A. Clinoidal
B. Oculom otor
C. Supratrochlear
D. Infratrochlear or Parkinson’s
E. Anterom edial
F. Anterolateral
G. Posterolateral or Glasscock’s
**H. Posterom edial or Kawase’s**
64
the gure illustrates a lateral view of the left cavernous sinus.
Match the follow ing triangles w ith the descriptions/structures. Each response m ay be
used once, m ore than once, or not at all.
64. Meningohypophyseal trunk origin
A. Clinoidal
B. Oculom otor
C. Supratrochlear
D. Infratrochlear or Parkinson’s
E. Anterom edial
F. Anterolateral
G. Posterolateral or Glasscock’s
H. Posterom edial or Kawase’s
A. Clinoidal
B. Oculom otor
C. Supratrochlear
**D. Infratrochlear or Parkinson’s**
E. Anterom edial
F. Anterolateral
G. Posterolateral or Glasscock’s
H. Posterom edial or Kawase’s
65
the gure illustrates a lateral view of the left cavernous sinus.
Match the follow ing triangles w ith the descriptions/structures. Each response m ay be
used once, m ore than once, or not at all.
65. Optic strut
A. Clinoidal
B. Oculom otor
C. Supratrochlear
D. Infratrochlear or Parkinson’s
E. Anterom edial
F. Anterolateral
G. Posterolateral or Glasscock’s
H. Posterom edial or Kawase’s
**A. Clinoidal**
B. Oculom otor
C. Supratrochlear
D. Infratrochlear or Parkinson’s
E. Anterom edial
F. Anterolateral
G. Posterolateral or Glasscock’s
H. Posterom edial or Kawase’s
66
the figure illustrates a lateral view of the left cavernous sinus.
Match the follow ing triangles w ith the descriptions/structures. Each response m ay be
used once, m ore than once, or not at all.
66. Sphenoid sinus and lower margin of V1
A. Clinoidal
B. Oculom otor
C. Supratrochlear
D. Infratrochlear or Parkinson’s
E. Anterom edial
F. Anterolateral
G. Posterolateral or Glasscock’s
H. Posterom edial or Kawase’s
A. Clinoidal
B. Oculom otor
C. Supratrochlear
D. Infratrochlear or Parkinson’s
**E. Anterom edial**
F. Anterolateral
G. Posterolateral or Glasscock’s
H. Posterom edial or Kawase’s
67
the figure illustrates a lateral view of the left cavernous sinus.
Match the follow ing triangles w ith the descriptions/structures. Each response m ay be
used once, m ore than once, or not at all.
67. Two margins of this triangle are formed by the anterior and posterior petroclinoidal
dural folds.
A. Clinoidal
B. Oculom otor
C. Supratrochlear
D. Infratrochlear or Parkinson’s
E. Anterom edial
F. Anterolateral
G. Posterolateral or Glasscock’s
H. Posterom edial or Kawase’s
A. Clinoidal
**B. Oculom otor**
C. Supratrochlear
D. Infratrochlear or Parkinson’s
E. Anterom edial
F. Anterolateral
G. Posterolateral or Glasscock’s
H. Posterom edial or Kawase’s
68
the figure illustrates a lateral view of the left cavernous sinus.
Match the follow ing triangles w ith the descriptions/structures. Each response m ay be
used once, m ore than once, or not at all.
68. Located between V2 and V3
A. Clinoidal
B. Oculom otor
C. Supratrochlear
D. Infratrochlear or Parkinson’s
E. Anterom edial
F. Anterolateral
G. Posterolateral or Glasscock’s
H. Posterom edial or Kawase’s
A. Clinoidal
B. Oculom otor
C. Supratrochlear
D. Infratrochlear or Parkinson’s
E. Anterom edial
**F. Anterolateral**
G. Posterolateral or Glasscock’s
H. Posterom edial or Kawase’s
69
the figure illustrates a lateral view of the left cavernous sinus.
Match the follow ing triangles w ith the descriptions/structures. Each response m ay be
used once, m ore than once, or not at all.
69. Contains the foramen spinosum
A. Clinoidal
B. Oculom otor
C. Supratrochlear
D. Infratrochlear or Parkinson’s
E. Anterom edial
F. Anterolateral
G. Posterolateral or Glasscock’s
H. Posterom edial or Kawase’s
A. Clinoidal
B. Oculom otor
C. Supratrochlear
D. Infratrochlear or Parkinson’s
E. Anterom edial
F. Anterolateral
**G. Posterolateral or Glasscock’s**
H. Posterom edial or Kawase’s
70
the figure illustrates a lateral view of the left cavernous sinus.
Match the follow ing triangles w ith the descriptions/structures. Each response m ay be
used once, m ore than once, or not at all.
70. Contains the cochlea
A. Clinoidal
B. Oculom otor
C. Supratrochlear
D. Infratrochlear or Parkinson’s
E. Anterom edial
F. Anterolateral
G. Posterolateral or Glasscock’s
H. Posterom edial or Kawase’s
A. Clinoidal
B. Oculom otor
C. Supratrochlear
D. Infratrochlear or Parkinson’s
E. Anterom edial
F. Anterolateral
G. Posterolateral or Glasscock’s
**H. Posterom edial or Kawase’s**
71
Which of the follow ing findings is m ost consistent w ith adherence of a posterior
com m unicating artery aneurysm to the tem poral lobe?
A. Loss of consciousness
B. Absence of third nerve palsy
C. Projection of the aneurysm m edial to the carotid on the anteroposterior
(AP) angiogram
D. Third nerve involvem ent
E. Seizures
A. Loss of consciousness
**B. Absence of third nerve palsy**
C. Projection of the aneurysm m edial to the carotid on the anteroposterior
(AP) angiogram
D. Third nerve involvem ent
E. Seizures
## Footnote
Pat ients with posterior communication artery aneurysms who do not have
a third nerve palsy (B) or whose angiogram reveals the aneurysm project ing
laterally to the carotid are m ore likely to have aneurysm domes that are adherent
to the temporal lobe. Choices C and D are incorrect because they contradict
this statement. Neither loss of consciousness (A) nor seizures (E)
predict aneurysm adherence to the temporal lobe
72
72. Weakness of the deltoid m uscle is caused by injury to the
A. Axillary nerve
B. Dorsal scapular nerve
C. Musculocutaneous nerve
D. Suprascapular nerve
E. Thoracodorsal nerve
**A. Axillary nerve**
B. Dorsal scapular nerve
C. Musculocutaneous nerve
D. Suprascapular nerve
E. Thoracodorsal nerve
## Footnote
Weakness of the deltoid muscle could be caused by injury to the axillary
nerve (A), which innervates the deltoid. The dorsal scapular nerve (B)
innervates the rhomboid muscles as well as the levator scapulae. The musculocutaneous
nerve (C) innervates the m uscles of the anterior compartment
of the arm including the biceps brachii and the coracobrachialis muscles. The
suprascapular nerve (D) innervates the supraspinatus and infraspinatus
muscles. An injury to the thoracodorsal nerve (E) would cause weakness of
the latissimus dorsi muscle
73
Subdural empyem a resulting after m eningitis in an infant m ost commonly develops w ith
A.Escherichia coli
B.Haem ophilus influenzae
C.Listeria
D.Neisseria
E.Staphylococcus
**A.Escherichia coli**
B.Haemophilus inf uenzae
C.Listeria
D.Neisseria
E.Staphylococcus
## Footnote
E. coli (A) is the m ost common cause of subdural empyema in the infant following
meningit is. Streptococcus pneumoniae meningitis may also lead to
subdural empyemas. Lister ia (C), Neisser ia (D), and St a phylococcu s (E) are
incorrect responses
74
Sudeck’s atrophy, associated w ith re ex sym pathetic dystrophy, refers to atrophic changes occurring in each of the follow ing structures except
A. Bone
B. Joints
C. Muscle
D. Nerve
E. Skin
A. Bone
B. Joints
C. Muscle
**D. Nerve**
E. Skin
## Footnote
The manifestat ions of Sudeck’s at rophy are late changes of re ex sympathetic
dystrophy (CPRS I, RSD). This condition may involve at rophic changes in the
bone (A), joints (B), m uscle (C), and skin (E), but not the nerve (D). The diagnosis
of CRPS I, or re ex sympathet ic dyst rophy, is made only in the absence
of a known nerve injury (in contrast with CRPS II, or causalgia, which requires
a known nerve injury for diagnosis).
75
For questions 75 to 79, match the em bryologic event w ith the postovulatory day. Each
response m ay be used once, m ore than once, or not at all.
Postovulatory Day Number
75. Closure of the caudal neuropore
A. 13
B. 17
C. 22
D. 24
E. 26
A. 13
B. 17
C. 22
D. 24
**E. 26**
76
match the em bryologic event w ith the postovulatory day. Each
response m ay be used once, m ore than once, or not at all.
Postovulatory Day Number
76. Closure of the cranial neuropore
A. 13
B. 17
C. 22
D. 24
E. 26
A. 13
B. 17
C. 22
**D. 24**
E. 26
77
match the em bryologic event w ith the postovulatory day. Each
response m ay be used once, m ore than once, or not at all.
Postovulatory Day Number
77. Formation of the notochord
A. 13
B. 17
C. 22
D. 24
E. 26
A. 13
**B. 17**
C. 22
D. 24
E. 26
78
match the em bryologic event w ith the postovulatory day. Each
response m ay be used once, m ore than once, or not at all.
Postovulatory Day Number
78. Formation of the prim itive streak
A. 13
B. 17
C. 22
D. 24
E. 26
**A. 13**
B. 17
C. 22
D. 24
E. 26
79
match the em bryologic event w ith the postovulatory day. Each
response m ay be used once, m ore than once, or not at all.
Postovulatory Day Number
79. Fusion of the neural folds to form the neural tube
A. 13
B. 17
C. 22
D. 24
E. 26
A. 13
B. 17
**C. 22**
D. 24
E. 26
80
Factors that predispose to the subclavian steal syndrom e include
I. Occlusion of the left subclavian artery proxim al to the origin of the
left vertebral artery
II. Occlusion of the left subclavian artery distal to the origin of the left
vertebral artery
III. Active use of the left arm
IV. Occlusion of the left vertebral artery
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of the above
A. I, II, III
**B. I, III**
C. II, IV
D. IV
E. All of the above
## Footnote
The subclavian steal syndrome is associated with symptoms of vertebrobasilar
insu ciency. It occurs when increased activity of the left arm (III) results
in shunting of blood into the left subclavian that is occluded proximal to the
origin of the left vertebral artery (I). The blood ow in the vertebral artery
is reversed, result ing in part ial brainstem ischemia exacerbated by use of the
left arm. Occlusion of the left subclavian artery distal to the origin of the
left vertebral artery (II) would not cause reversal of ow in the left vertebral
artery, and therefore would not cause subclavian steal syndrome. Occlusion
of the left vertebral artery (IV) might cause symptoms of vertebrobasilar
insu ciency, but this would not be an example of subclavian steal.
81
The articular facet joint in the upper thoracic region is oriented
A. Axially
B. Coronally
C. Obliquely
D. Sagittally
A. Axially
**B. Coronally**
C. Obliquely
D. Sagittally
## Footnote
The coronal orientation of the facets in the upper thoracic spine leads to signi
cant resistance to anterior t ranslation but lit tle resistance to rotation. In
the lower thoracic spine, the facets become more sagit tally oriented, and less
resistance to anterior t ranslation is o ered.
82
The most com m on presenting symptom of a thoracic herniated disk is
A. Back pain
B. Leg num bness
C. Leg weakness
D. Thoracic num bness
E. Urinary incontinence
**A. Back pain**
B. Leg num bness
C. Leg weakness
D. Thoracic num bness
E. Urinary incontinence
## Footnote
While it is possible for a thoracic disk herniation to cause either thoracic
myelopathy, which may be characterized by leg numbness (B), leg weakness
(C), or urinary incontinence (E); or thoracic radiculopathy, which
could cause thoracic numbness (D); or thoracic pain in a dermatomal distribution,
the most common presenting symptom of a herniated thoracic
disk is back pain (A). Back pain is the presenting complaint of 57 to 88% of
patients with a thoracic herniated disk.
83
Neurologic de cits thought to result from occlusion of the thalam ostriate vein
during the subchoroidal transvelum interpositum approach to the third ventricle
include
I. Drowsiness
II. Hem iparesis
III. Mutism
IV. Seizures
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of the above
**A. I, II, III**
B. I, III
C. II, IV
D. IV
E. All of the above
## Footnote
Occlusion of the thalamostriate vein during the subchoroidal transvelum
interpositum approach to the third vent ricle may result in drowsiness (I),
hemiparesis (II), or mutism (III). Seizures (IV) have not been reported after
the ligation of the thalamostriate vein during this approach.
84
For questions 84 to 88, the figure illustrates the right internal auditory canal through a
middle fossa approach. Identify the following nerves.
84. Labyrinthine segment of the facial nerve
A. A
B. B
C. C
D. D
E. E
A. A
B. B
C. C
D. D
**E. E**
85
the figure illustrates the right internal auditory canal through a
m iddle fossa approach. Identify the follow ing nerves.
85. Meatal segm ent of the facial nerve
A. A
B. B
C. C
D. D
E. E
A. A
B. B
**C. C**
D. D
E. E
86
the figure illustrates the right internal auditory canal through a
m iddle fossa approach. Identify the follow ing nerves.
86. Superior vestibular nerve
A. A
B. B
C. C
D. D
E. E
A. A
B. B
C. C
**D. D**
E. E
87
the figure illustrates the right internal auditory canal through a
middle fossa approach. Identify the following nerves.
87. Greater super cial petrosal nerve
A. A
B. B
C. C
D. D
E. E
**A. A**
B. B
C. C
D. D
E. E
88
the figure illustrates the right internal auditory canal through a
middle fossa approach. Identify the following nerves.
88. Geniculate ganglion
A. A
B. B
C. C
D. D
E. E
A. A
**B. B**
C. C
D. D
E. E
89
In the suboccipital transmeatal approach to an acoustic neurom a, the location of
the facial nerve in relation to the tum or, in decreasing frequency of occurrence, is
A. Anterior, posterior, inferior
B. Anterior, superior, inferior
C. Superior, anterior, posterior
D. Posterior, superior, anterior
E. Anterior, posterior, superior
A. Anterior, posterior, inferior
**B. Anterior, superior, inferior**
C. Superior, anterior, posterior
D. Posterior, superior, anterior
E. Anterior, posterior, superior
## Footnote
In the series of Sugita and Kobayashi, the facial nerve was anterior to the
tumor in 50%, superior in 30%, and inferior in 15% of cases
90
Each of the follow ing features is usually minimal or absent in patients w ith
type 2 neuro brom atosis except
A. Axillary freckles
B. Café au lait spots
C. Lisch nodules
D. Multiple, typical skin neuro brom as
E. Skin plaques
A. Axillary freckles
B. Café au lait spots
C. Lisch nodules
D. Multiple, typical skin neuro brom as
**E. Skin plaques**
## Footnote
Skin plaques (E) are the m ost common skin lesions seen in neuro bromatosis
type 2. They are well-circumscribed, raised, rough areas of skin that may
be associated with excess hair. Axillary freckles (A), café au lait spots (B),
Lisch nodules (C), and multiple typical skin neuro bromas (D) are all characteristics
of neuro bromatosis type 1.
91
The single most im portant factor in the recurrence of m eningiom as is
A. Age of the patient
B. Bone invasion
C. Histologic type of benign m eningiom a
D. Postoperative tum or residual
E. Sex of the patient
A. Age of the patient
B. Bone invasion
C. Histologic type of benign m eningiom a
**D. Postoperative tum or residual**
E. Sex of the patient
## Footnote
Of the choices available, postoperative tumor residual (D) is the most important
factor in meningioma recurrence. Bone invasion (B) could in uence
recurrence rates as it may limit the extent of tumor resection, part icularly for
lesions at the skull base. Histologic type of benign meningioma (C) is incorrect
because this answer choice implies that the lesion is WHO grade I. Certainly
WHO grade II (atypical) and WHO grade III (anaplastic) meningiomas
have a higher recurrence rate than grade I (benign) lesions, but this is not an
answer choice. Patient age (A) and sex (E) are incorrect responses
92
For questions 92 to 98, match the cistern w ith the structure it contains. Each response
m ay be used once, more than once, or not at all.
92. Contains the anteroinferior cerebellar artery (AICA)
A. Am bient cistern
B. Cerebellopontine angle cistern
C. Interpeduncular cistern
D. Lateral cerebellom edullary cistern
E. Prepontine cistern
A. Am bient cistern
**B. Cerebellopontine angle cistern**
C. Interpeduncular cistern
D. Lateral cerebellom edullary cistern
E. Prepontine cistern
93
match the cistern w ith the structure it contains. Each response
m ay be used once, m ore than once, or not at all.
93. Contains the origin of the posteroinferior cerebellar artery (PICA)
A. Am bient cistern
B. Cerebellopontine angle cistern
C. Interpeduncular cistern
D. Lateral cerebellom edullary cistern
E. Prepontine cistern
A. Am bient cistern
B. Cerebellopontine angle cistern
C. Interpeduncular cistern
**D. Lateral cerebellom edullary cistern**
E. Prepontine cistern
94
match the cistern w ith the structure it contains. Each response
m ay be used once, m ore than once, or not at all.
94. Contains the superior cerebellar artery
A. Am bient cistern
B. Cerebellopontine angle cistern
C. Interpeduncular cistern
D. Lateral cerebellom edullary cistern
E. Prepontine cistern
**A. Am bient cistern**
B. Cerebellopontine angle cistern
C. Interpeduncular cistern
D. Lateral cerebellom edullary cistern
E. Prepontine cistern
95
match the cistern w ith the structure it contains. Each response
m ay be used once, m ore than once, or not at all.
95. Contains cranial nerve (CN) IV
A. Am bient cistern
B. Cerebellopontine angle cistern
C. Interpeduncular cistern
D. Lateral cerebellom edullary cistern
E. Prepontine cistern
**A. Am bient cistern**
B. Cerebellopontine angle cistern
C. Interpeduncular cistern
D. Lateral cerebellom edullary cistern
E. Prepontine cistern
96
match the cistern w ith the structure it contains. Each response
m ay be used once, m ore than once, or not at all.
96. Contains CN V
A. Am bient cistern
B. Cerebellopontine angle cistern
C. Interpeduncular cistern
D. Lateral cerebellom edullary cistern
E. Prepontine cistern
A. Am bient cistern
**B. Cerebellopontine angle cistern**
C. Interpeduncular cistern
D. Lateral cerebellom edullary cistern
E. Prepontine cistern
97
match the cistern w ith the structure it contains. Each response
m ay be used once, m ore than once, or not at all.
97. Contains the basal vein of Rosenthal
A. Am bient cistern
B. Cerebellopontine angle cistern
C. Interpeduncular cistern
D. Lateral cerebellom edullary cistern
E. Prepontine cistern
A. Am bient cistern
B. Cerebellopontine angle cistern
**C. Interpeduncular cistern**
D. Lateral cerebellom edullary cistern
E. Prepontine cistern
98
match the cistern w ith the structure it contains. Each response
m ay be used once, m ore than once, or not at all.
98. Contains the choroid plexus at the foram en of Luschka
A. Am bient cistern
B. Cerebellopontine angle cistern
C. Interpeduncular cistern
D. Lateral cerebellom edullary cistern
E. Prepontine cistern
A. Am bient cistern
B. Cerebellopontine angle cistern
C. Interpeduncular cistern
**D. Lateral cerebellom edullary cistern**
E. Prepontine cistern
99
The transverse crest separates the
A. Cochlear, facial, and superior vestibular nerves from the inferior vestibular
nerve
B. Cochlear and inferior vestibular nerves from the facial and superior vestibular nerves
C. Facial and cochlear nerves from the superior and inferior vestibular nerves
D. Facial, cochlear, and inferior vestibular nerves from the superior vestibular
nerve
E. Facial and inferior vestibular nerves from the cochlear and superior
vestibular nerves
A. Cochlear, facial, and superior vestibular nerves from the inferior vestibular
nerve
**B. Cochlear and inferior vestibular nerves from the facial and superior vestibular nerves**
C. Facial and cochlear nerves from the superior and inferior vestibular nerves
D. Facial, cochlear, and inferior vestibular nerves from the superior vestibular
nerve
E. Facial and inferior vestibular nerves from the cochlear and superior
vestibular nerves
## Footnote
This quest ion tests the examinee’s knowledge of the relationships of the
nerves in the internal acoust ic meatus. Anteriorly, the facial nerve is superior
to the cochlear nerve (“7-up, coke down”). Posteriorly, the superior and
inferior vestibular nerves are related to one another as their names imply.
The transverse crest runs horizontally separating the two superior st ructures
(facial nerve anteriorly and superior vestibular nerve posteriorly) from
the two inferior structures (cochlear nerve anteriorly and inferior vestibular
nerve posteriorly).
100
Which of the follow ing is true of hem ifacial spasm ?
A. Compression of the facial nerve by the superior cerebellar artery is the
m ost com m on operative nding.
B. Deafness is m ore com m on than perm anent facial weakness as a complication of m icrovascular decom pression.
C. Men are m ore frequently a ected than wom en.
D. Symptom s typically begin in the buccal m uscles and m ove cranially.
E. The cure rate at 1 m onth after m icrovascular decom pression is 95%
A. Compression of the facial nerve by the superior cerebellar artery is the
m ost com m on operative nding.
**B. Deafness is m ore com m on than perm anent facial weakness as a complication of m icrovascular decom pression.**
C. Men are m ore frequently a ected than wom en.
D. Symptom s typically begin in the buccal m uscles and m ove cranially.
E. The cure rate at 1 m onth after m icrovascular decom pression is 95%
## Footnote
Hemifacial spasm is more common in females (C is incorrect); it typically
begins in the orbicularis muscles and progresses caudally (D is incorrect).
At microvascular decompression the most common nding is compression
by the posteroinferior cerebellar artery (PICA) (A is incorrect); the cure rate
at 1 month is 86% (E is incorrect). Deafness occurs in 2.7% of patients, and
permanent facial weakness occurs in 1.5% of pat ients after microvascular
decompression (B is correct).
101
Each of the follow ing surgical approaches m ay be considered for an aneurysm of
the vertebrobasilar junction except the
A. Extended extrem e lateral inferior transcondylar approach
B. Lateral suboccipital approach
C. Presigm oid transtentorial approach
D. Retrolabyrinthine transsigm oid approach
E. Subtemporal approach
A. Extended extrem e lateral inferior transcondylar approach
B. Lateral suboccipital approach
C. Presigm oid transtentorial approach
D. Retrolabyrinthine transsigm oid approach
**E. Subtemporal approach**
## Footnote
Possible approaches to an aneurysm of the vertebrobasilar junction include
the extended extreme lateral inferior transcondylar approach (A), the lateral
suboccipital approach (B), the presigmoid transtentorial approach (C),
and the retrolabyrinthine transsigmoid approach (D). The subtemporal approach
(E) is best suited for aneurysms of the upper basilar trunk arising w ithin
2 cm below the tip of the posterior clinoid
102
The m ost com m on presenting sym ptom in patients w ith colloid cysts is
A. Headache
B. Dem entia
C. Seizures
D. Sudden attacks of leg weakness
E. Sudden death
**A. Headache**
B. Dem entia
C. Seizures
D. Sudden attacks of leg weakness
E. Sudden death
## Footnote
Headache (A) is the initial symptom in more than 75% of patients with colloid
cysts, and almost all patients with this lesion experience headache. “Drop
attacks,” possibly secondary to acute hydrocephalus that suddenly stretches
corticospinal leg bers (sudden leg weakness [D]), are associated with colloid
cysts. Dementia (B) m ay be prominent, and seizures (C) occur in 20% of
patients. An association with sudden death (E) has been reported.
103
For questions 103 to 106, the figure illustrates the nerves occupying the right internal
auditory canal through a m iddle fossa approach. Identify their relative positions.
103. Inferior and anterior
A. A
B. B
C. C
D. D
A. A
B. B
**C. C**
D. D
104
the gure illustrates the nerves occupying the right internal
auditory canal through a m iddle fossa approach. Identify their relative positions.
104. Inferior and posterior
A. A
B. B
C. C
D. D
A. A
B. B
C. C
**D. D**
105
the gure illustrates the nerves occupying the right internal
auditory canal through a m iddle fossa approach. Identify their relative positions.
105. Superior and anterior
A. A
B. B
C. C
D. D
**A. A**
B. B
C. C
D. D
106
the gure illustrates the nerves occupying the right internal
auditory canal through a m iddle fossa approach. Identify their relative positions.
106. Superior and posterior
A. A
B. B
C. C
D. D
A. A
**B. B**
C. C
D. D
107
The m ost com m on presenting sym ptom of neonates w ith vein of Galen
A. Congestive heart failure
B. Hydrocephalus
C. Intracerebral hem orrhage
D. Seizures
E. Subarachnoid hem orrhage
**A. Congestive heart failure**
B. Hydrocephalus
C. Intracerebral hem orrhage
D. Seizures
E. Subarachnoid hem orrhage
## Footnote
Neonates with congestive heart failure (A) usually have multiple stulas,
and over 25% of their cardiac output is shunted. Hydrocephalus (B) and
seizures (D) are more common in infants, whereas subarachnoid hemorrhage
(E), decreased cognition, and intraparenchymal hemorrhage (C) are
more common in older children and adults.
108
The m ost com m on upper thoracic spine injury is a
A. Burst fracture
B. Com pression fracture
C. Fracture-dislocation
D. Seat belt injury
A. Burst fracture
**B. Com pression fracture**
C. Fracture-dislocation
D. Seat belt injury
## Footnote
This t ype of fracture is generally stable because the middle column is intact ,
by de nition (ut ilizing the three-column spine model). Posterior column
failure can st ill occur, however, if the anterior body height is reduced by more
than half. The resulting kyphotic deformity can lead to neurologic deficit .
109
Which is true of thoracolum bar spine fractures?
A. Burst fractures are the m ost com m on.
B. Fracture-dislocations involve all three colum ns.
C. Seat belt type injuries are generally stable.
D. Wedge com pression fractures are generally unstable.
E. Wedge com pression fractures involve the m iddle colum n
A. Burst fractures are the m ost com m on.
**B. Fracture-dislocations involve all three colum ns.**
C. Seat belt type injuries are generally stable.
D. Wedge com pression fractures are generally unstable.
E. Wedge com pression fractures involve the m iddle colum n
## Footnote
Compression fract ures are the most common thoracolumbar spine fract ure
(A is incorrect). Seat belt injuries refer to exion-dist raction t ype injuries that
are often unstable (C is incorrect). Wedge compression fractures generally
involve the anterior column and are usually stable (D and E are incorrect)
110
Each of the follow ing is true of diffuse brain swelling except that it is
A. A result of cerebrovascular congestion
B. A result of cytotoxic edem a
C. Associated w ith a 50% m ortality rate in children w ith severe head injuries
D. Manifested on computed tom ography (CT) scan by a com pression of the
perim esencephalic cistern
E. More com m on in children than in adults
A. A result of cerebrovascular congestion
**B. A result of cytotoxic edem a**
C. Associated w ith a 50% m ortality rate in children w ith severe head injuries
D. Manifested on computed tom ography (CT) scan by a com pression of the
perim esencephalic cistern
E. More com m on in children than in adults
## Footnote
Diffuse brain swelling is a vasoactive post traumatic phenomenon occurring
within hours of head injury. It is thought to be a result of cerebrovascular
congestion (A) and can be m anifested on CT scan by a compression of the
perimesencephalic cistern (D). This pathologic process is more common in
children than adults (E), and may be associated with a 50% mortality rate
in severely head injured children (C). It is distinct from the vasogenic or
cytotoxic edema (B) that occurs later.
111
Which of the follow ing is least suggestive of child abuse?
A. Acute and healing long bone fractures
B. Interhem ispheric subdural hem atom a
C. Parietal skull fracture
D. Retinal hem orrhages
E. Tentorial subdural hem atom a
A. Acute and healing long bone fractures
B. Interhem ispheric subdural hem atom a
**C. Parietal skull fracture**
D. Retinal hem orrhages
E. Tentorial subdural hem atom a
## Footnote
Of the choices listed, an isolated parietal skull fracture (C) is the least suggestive
of child abuse, or nonaccidental t rauma. Acute and healing long bone
fractures (A), retinal hemorrhages (D), and the presence of subdural hematomas
(B and E) should be t reated as nonaccidental trauma until proven
otherwise. When associated with abuse, skull fractures tend to be multiple or
complex, depressed, and nonparietal.
112
Trigonocephaly results from prem ature closure of the
A. Coronal suture bilaterally
B. Coronal suture unilaterally
C. Frontosphenoidal suture
D. Lam bdoid suture
E. Metopic suture
A. Coronal suture bilaterally
B. Coronal suture unilaterally
C. Frontosphenoidal suture
D. Lam bdoid suture
**E. Metopic suture**
## Footnote
Premature closure of the metopic suture (E) results in trigonocephaly. The
incidence of trigonocephaly ranges from 10 to 16%.7
113
The cleft in the spinal cord associated w ith diastem atomyelia is m ost com m only
located in the
A. Cervical region
B. Lum bar region
C. Sacral region
D. Thoracic region
A. Cervical region
**B. Lum bar region**
C. Sacral region
D. Thoracic region
## Footnote
The cleft is located in the lumbar region (B) in 47%, thoracolumbar region
in 27%, thoracic region (D) in 23%, and sacral (C) or cervical region (A) in
1.5% of cases.3
114
Up to w hat percentage of patients w ith bacterial arterial (mycotic) aneurysm s
carry an underlying diagnosis of subacute bacterial endocarditis?
A. 10%
B. 20%
C. 40%
D. 60%
E. 80%
A. 10%
B. 20%
C. 40%
D. 60%
**E. 80%**
## Footnote
Up to 80% of patients with mycotic aneurysms carry an underlying diagnosis
of subacute bacterial endocarditis
115
Each is true of bacterial intracranial aneurysm s except
A. Infected em boli lodge in the vasa vasorum .
B. The m iddle cerebral artery is m ost com m only a ected.
C. The peripherally located branches are m ost com m only a ected.
D. Typical subarachnoid hem orrhage occurs in 18% of patients.
E. Staphylococcus aureus and b-hem olytic streptococci are m ost com m only
involved.
**A. Infected em boli lodge in the vasa vasorum .**
B. The m iddle cerebral artery is m ost com m only a ected.
C. The peripherally located branches are m ost com m only a ected.
D. Typical subarachnoid hem orrhage occurs in 18% of patients.
E. Staphylococcus aureus and b-hem olytic streptococci are m ost com m only
involved.
## Footnote
Bacterial (mycot ic) int racranial aneurysms are t ypically located in the peripheral
branches (C) of the middle cerebral artery territory (B). St a phylococcu s
aureus and b-hemolytic streptococci species (E) are the m ost common offending
agents. The observat ion that vasa vasorum are found only on the rst
segment of the internal carotid artery (ICA), an unusual site of the development
of bacterial aneurysms, has discredited the notion that infected emboli
lodge in the vasa vasorum (A). Although these aneurysms have a high tendency
to bleed, typical subarachnoid hemorrhage occurs in less than 20%
of patients (D).
116
Each of the follow ing is true of grow ing skull fractures except that they
A. Can cross suture lines
B. May be associated w ith underlying brain injury
C. Occur if the edges of the initial fracture are separated by m ore than 3 m m
D. Occur m ost com m only in the parietal bone
E. Occur m ost com m only between the ages of 2 and 5 years
A. Can cross suture lines
B. May be associated w ith underlying brain injury
C. Occur if the edges of the initial fracture are separated by m ore than 3 m m
D. Occur m ost com m only in the parietal bone
**E. Occur m ost com m only between the ages of 2 and 5 years**
## Footnote
Growing skull fractures may cross suture lines (A), may be associated with
an underlying brain injury (B), tend to occur if the initial fracture is separated
by more than 3 mm (C), and occur most commonly in the parietal
bone (D). Up to 75% of patients with growing skull fractures are , 1 year old
(E is false, and therefore the correct answer choice).7
117
Approxim ately w hat percentage of infants w ith myelom eningocele have m ag-
netic resonance im aging (MRI) evidence of a Chiari II m alform ation?
A. 20%
B. 40%
C. 60%
D. 80%
E. 100%
A. 20%
B. 40%
C. 60%
D. 80%
**E. 100%**
## Footnote
One hundred percent (E) of infants with myelomeningocele have MRI
evidence of a Chiari II malformation, the mechanism of which is thought to
be due to CSF leaking through the myelomeningocele during development.
118
Cardiovascular disease involving the heart and great vessels gives rise to w hich of
the follow ing types of em boli in the retina?
I. Cholesterol
II. Calci c
III. Platelet- brin
IV. Fat
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of the above
**A. I, II, III**
B. I, III
C. II, IV
D. IV
E. All of the above
## Footnote
Cholesterol emboli (I) (Hollenhorst plaques) are associated with ulcerated
atheromatous plaques of the ICA. Calci c emboli (II) originate from the cardiac
valves. Platelet- brin emboli (III) are thought to arise from large-vessel
mural thrombi. Fat emboli (IV) result after trauma to marrow-containing
bones and therefore are not due to cardiovascular disease of the heart and
great vessels.4
119
In the infratentorial supracerebellar approach to the pineal region, w hich of the
follow ing veins are usually sacrificed?
I. Superior verm ian vein
II. Posterior pericallosal vein
III. Precentral cerebellar vein
IV. Basal vein of Rosenthal
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of the above
A. I, II, III
**B. I, III**
C. II, IV
D. IV
E. All of the above
## Footnote
The superior vermian vein (I) and precentral cerebellar vein (III) are usually
sacri ced during the infratentorial supracerebellar approach to the pineal
region. The basal vein of Rosenthal (IV) and posterior pericallosal vein (II)
are not sacri ced during this approach
120
Each of the follow ing is characteristic of an acoustic neurom a except
A. Békésy type III or IV audiogram
B. Loudness recruitm ent
C. Low short-increm ent sensitivity index
D. Poor speech discrim ination
E. Pronounced tone decay
A. Békésy type III or IV audiogram
**B. Loudness recruitm ent**
C. Low short-increm ent sensitivity index
D. Poor speech discrim ination
E. Pronounced tone decay
## Footnote
An absence of loudness recruitment (B is incorrect) is characterist ic of a
nerve t runk lesion, including an acoustic neuroma. Recruiting deafness
occurs with a lesion in the organ of Corti (e.g., Ménièreʼs disease). The other
responses (Békésy type III or IV audiogram [A], low short-increment
sensitivity index [C], poor speech discrimination [D], and pronounced
tone decay [E]) are all characteristic of a retrocochlear (nerve) lesion such as
an acoustic neuroma
121
For questions 121 to 128, the figure illustrates the right retrosigm oid approach. Identify
the follow ing structures.
121. Subarcuate artery
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H (Not labeled)
A. A
**B. B**
C. C
D. D
E. E
F. F
G. G
H. H (Not labeled)
122
the gure illustrates the right retrosigm oid approach. Identify
the follow ing structures.
122. Anteroinferior cerebellar artery
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H (Not labeled)
A. A
B. B
C. C
D. D
E. E
**F. F**
G. G
H. H (Not labeled)
123
the gure illustrates the right retrosigm oid approach. Identify
the follow ing structures.
123. Cochlear nerve
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H (Not labeled)
**A. A**
B. B
C. C
D. D
E. E
F. F
G. G
H. H (Not labeled)
124
the gure illustrates the right retrosigm oid approach. Identify
the follow ing structures.
124. Facial nerve
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H (Not labeled)
A. A
B. B
C. C
D. D
**E. E**
F. F
G. G
H. H (Not labeled)
125
the gure illustrates the right retrosigm oid approach. Identify
the follow ing structures.
125. Glossopharyngeal nerve
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H (Not labeled)
A. A
B. B
**C. C**
D. D
E. E
F. F
G. G
H. H (Not labeled)
126
the gure illustrates the right retrosigm oid approach. Identify
the follow ing structures.
126. Spinal accessory nerve
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H (Not labeled)
A. A
B. B
C. C
D. D
E. E
F. F
**G. G**
H. H (Not labeled)
127
the gure illustrates the right retrosigm oid approach. Identify
the follow ing structures.
127. Posteroinferior cerebellar artery
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H (Not labeled)
A. A
B. B
C. C
D. D
E. E
F. F
G. G
**H. H (Not labeled)**
128
the gure illustrates the right retrosigm oid approach. Identify
the follow ing structures.
128. Vagus nerve
129. A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H (Not labeled)
A. A
B. B
C. C
**D. D**
E. E
F. F
G. G
H. H (Not labeled)
129
Which of the follow ing structures provides a m arker for the m ost dorsal extent
of the incision for anterolateral cordotomy for pain control?
A. Dentate ligam ent
B. Dorsal root entry zone
C. Posterior interm ediate sulcus
D. Posterior m edian sulcus
E. Zone of Lissauer
**A. Dentate ligam ent**
B. Dorsal root entry zone
C. Posterior interm ediate sulcus
D. Posterior m edian sulcus
E. Zone of Lissauer
## Footnote
The dentate ligament (A) is a paired structure that is an extension of pia
that connects the lateral aspect of the spinal cord to the dura bilaterally—
it marks the most dorsal extent of the incision for anterolateral cordotomy,
a funct ional procedure for chronic pain. Lesioning at the dorsal root entry
zone (B) is a useful technique particularly in cases of pain related to nerve
root avulsion. The posterior intermediate sulcus (C) separates the fasciculus
gracilis from the fasciculus cuneatus. The posterior median sulcus (D) runs
in the dorsal midline separat ing the right and left dorsal columns. A erent
pain bers enter the spinal cord and may ascend or descend up to three spinal
levels in the zone of Lissauer (E) prior to terminating in the dorsal horn
130
Occlusion of the anterior choroidal artery results in
I. Contralateral hem iplegia
II. Hem ihypesthesia
III. Hom onym ous hem ianopsia
IV. Im paired cognition
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of the above
**A. I, II, III**
B. I, III
C. II, IV
D. IV
E. All of the above
## Footnote
The anterior choroidal artery is an intracranial branch of the internal carotid
artery that comes o the ICA just distal to the origin of the posterior communicating
artery. The anterior choroidal artery can be thought of as the most
medial of the lateral lenticulostriate arteries, supplying the globus pallidus
interna, the posterior limb of the internal capsule, and the optic tract. Occlusion
of the anterior choroidal artery may lead to contralateral hemiplegia (I),
hemihypesthesia (II), and a homonymous hemianopsia (III). Cognitive
function (IV) is unimpaired after occlusion of the anterior choroidal artery
131
Which of the follow ing sym ptom s of Parkinson’s disease is m ost likely to respond to a stereotactic lesion in the posterior ventral oval (VOP)/ventral intermediate (VIM) (ventrolateral) thalam us?
A. Bradykinesia
B. Gait disturbance
C. Rigidity
D. Speech disturbance
E. Tremor
**E. Tremor**
## Footnote
The symptom of Parkinson’s disease that is most likely to respond to a stereotact
ic lesion of the VIM of the thalamus is tremor (E)
132
For questions 132 to 136, m atch the description w ith the syndrom e or disease.
132. Autosom al recessive inheritance
A. Apert’s syndrom e
B. Crouzon’s disease
C. Both
D. Neither
A. Apert’s syndrom e
B. Crouzon’s disease
C. Both
**D. Neither**
133
m atch the description w ith the syndrom e or disease.
133. Exorbitism
A. Apert’s syndrom e
B. Crouzon’s disease
C. Both
D. Neither
A. Apert’s syndrom e
B. Crouzon’s disease
**C. Both**
D. Neither
134
m atch the description w ith the syndrom e or disease.
134. Syndactyly
A. Apert’s syndrom e
B. Crouzon’s disease
C. Both
D. Neither
**A. Apert’s syndrom e**
B. Crouzon’s disease
C. Both
D. Neither
135
m atch the description w ith the syndrom e or disease.
135. The m ajorit y of patients have preoperative intelligence quotients (IQs) greater
than 90
A. Apert’s syndrom e
B. Crouzon’s disease
C. Both
D. Neither
A. Apert’s syndrom e
**B. Crouzon’s disease**
C. Both
D. Neither
136
m atch the description w ith the syndrom e or disease.
136. Anterior open bite is com m on
A. Apert’s syndrom e
B. Crouzon’s disease
C. Both
D. Neither
**A. Apert’s syndrom e**
B. Crouzon’s disease
C. Both
D. Neither
137
For questions 137 and 138, m atch the description w ith the sym ptom .
137. Occurs prim arily in wom en.
A. Prim ary empt y sella syndrom e
B. Secondary empty sella syndrom e
C. Both
D. Neither
**A. Prim ary empt y sella syndrom e**
B. Secondary empty sella syndrom e
C. Both
D. Neither
138
m atch the description w ith the sym ptom .
138. Visual disturbance m ay occur.
A. Prim ary empt y sella syndrom e
B. Secondary empty sella syndrom e
C. Both
D. Neither
A. Prim ary empt y sella syndrom e
B. Secondary empty sella syndrom e
**C. Both**
D. Neither
139
The most common etiology of os odontoideum is
A. Congenital
B. Iatrogenic
C. Infectious
D. Neoplastic
E. Traumatic
A. Congenital
B. Iatrogenic
C. Infectious
D. Neoplastic
**E. Traumatic**
## Footnote
Os odontoideum is a segment of odontoid that is well-corticated and is not
fused with the body of the dens. The condition may be congenital (A) or
traumatic (E); trauma is the more common cause
140
The m ost com m on m echanism of translational C1–C2 subluxation is
A. Axial loading
B. Distraction
C. Extension
D. Flexion
A. Axial loading
B. Distraction
C. Extension
**D. Flexion**
## Footnote
Translat ional C1–C2 sublu xat ion is associated with exion (D) injuries, rheumatoid
arthritis, and tonsillitis (Grisel’s syndrome).
141
The factor or substance w ith the least im portant role in the pathogenesis of cere-
bral vasospasm is probably
A. Bilirubin
B. Endothelin
C. Intim al proliferation
D. Lipid peroxides
E. Oxyhem oglobin
A. Bilirubin
B. Endothelin
**C. Intim al proliferation**
D. Lipid peroxides
E. Oxyhem oglobin
## Footnote
While the mechanism of cerebral vasospasm has yet to be elucidated, studies
indicate that intimal proliferation (C) is too m ild and occurs too long after
subarachnoid hemorrhage to play a signi cant role in vasospasm
142
For questions 142 to 148, the gure illustrates the right presigm oid, retrolabyrinthine
approach. Identify the follow ing structures.
142. Internal acoustic m eatus
A. A
B. B
C. C
D. D
E. E
F. F
G. G
A. A
B. B
C. C
**D. D**
E. E
F. F
G. G
143
the gure illustrates the right presigm oid, retrolabyrinthine
approach. Identify the follow ing structures.
143. Posterior inferior cerebellar artery
A. A
B. B
C. C
D. D
E. E
F. F
G. G
A. A
B. B
C. C
D. D
**E. E**
F. F
G. G
144
the gure illustrates the right presigm oid, retrolabyrinthine
approach. Identify the follow ing structures.
144. Chorda tym pani nerve
A. A
B. B
C. C
D. D
E. E
F. F
G. G
A. A
B. B
C. C
D. D
E. E
F. F
**G. G**
145
the gure illustrates the right presigm oid, retrolabyrinthine
approach. Identify the follow ing structures.
145. Facial nerve
A. A
B. B
C. C
D. D
E. E
F. F
G. G
A. A
B. B
C. C
D. D
E. E
**F. F**
G. G
146
the gure illustrates the right presigm oid, retrolabyrinthine
approach. Identify the follow ing structures.
146. Superior cerebellar artery
A. A
B. B
C. C
D. D
E. E
F. F
G. G
A. A
**B. B**
C. C
D. D
E. E
F. F
G. G
147
the gure illustrates the right presigm oid, retrolabyrinthine
approach. Identify the follow ing structures.
147. Trigem inal nerve
A. A
B. B
C. C
D. D
E. E
F. F
G. G
A. A
B. B
**C. C**
D. D
E. E
F. F
G. G
148
the gure illustrates the right presigm oid, retrolabyrinthine
approach. Identify the follow ing structures.
148. Trochlear nerve
A. A
B. B
C. C
D. D
E. E
F. F
G. G
**A. A**
B. B
C. C
D. D
E. E
F. F
G. G
149
For questions 149 to 155, m atch the descriptions w ith the type of arteriovenous
m alform ation (AVM).
149. Most com m on type of spinal AVM
A. Type I spinal AVMs
B. Type II spinal AVMs
C. Type III spinal AVMs
D. Type IV spinal AVMs
E. Types II and III spinal AVMs
**A. Type I spinal AVMs**
B. Type II spinal AVMs
C. Type III spinal AVMs
D. Type IV spinal AVMs
E. Types II and III spinal AVMs
150
Match the descriptions w ith the type of arteriovenous
m alform ation (AVM).
150. Etiology believed to be acquired
A. Type I spinal AVMs
B. Type II spinal AVMs
C. Type III spinal AVMs
D. Type IV spinal AVMs
E. Types II and III spinal AVMs
**A. Type I spinal AVMs**
B. Type II spinal AVMs
C. Type III spinal AVMs
D. Type IV spinal AVMs
E. Types II and III spinal AVMs
151
Match the descriptions w ith the type of arteriovenous
m alform ation (AVM).
151. Also know n as juvenile m alform ations
A. Type I spinal AVMs
B. Type II spinal AVMs
C. Type III spinal AVMs
D. Type IV spinal AVMs
E. Types II and III spinal AVMs
A. Type I spinal AVMs
B. Type II spinal AVMs
**C. Type III spinal AVMs**
D. Type IV spinal AVMs
E. Types II and III spinal AVMs
152
Match the descriptions w ith the type of arteriovenous
m alform ation (AVM).
152. Also know n as glom us AVMs
A. Type I spinal AVMs
B. Type II spinal AVMs
C. Type III spinal AVMs
D. Type IV spinal AVMs
E. Types II and III spinal AVMs
A. Type I spinal AVMs
**B. Type II spinal AVMs**
C. Type III spinal AVMs
D. Type IV spinal AVMs
E. Types II and III spinal AVMs
153
Match the descriptions w ith the type of arteriovenous
m alform ation (AVM).
153. Low ow and high pressure dynam ics can be seen in type IV and this type
A. Type I spinal AVMs
B. Type II spinal AVMs
C. Type III spinal AVMs
D. Type IV spinal AVMs
E. Types II and III spinal AVMs
**A. Type I spinal AVMs**
B. Type II spinal AVMs
C. Type III spinal AVMs
D. Type IV spinal AVMs
E. Types II and III spinal AVMs
154
Match the descriptions w ith the type of arteriovenous
m alform ation (AVM).
154. High ow and high pressure dynam ics can be seen in type IV and this type
A. Type I spinal AVMs
B. Type II spinal AVMs
C. Type III spinal AVMs
D. Type IV spinal AVMs
E. Types II and III spinal AVMs
A. Type I spinal AVMs
B. Type II spinal AVMs
C. Type III spinal AVMs
D. Type IV spinal AVMs
**E. Types II and III spinal AVMs**
155
Match the descriptions w ith the type of arteriovenous
m alform ation (AVM).
155. Type IV and this type typically present w ith progressively worsening sym ptom s
w ithout signi cant clinical im provem ent
A. Type I spinal AVMs
B. Type II spinal AVMs
C. Type III spinal AVMs
D. Type IV spinal AVMs
E. Types II and III spinal AVMs
**A. Type I spinal AVMs**
B. Type II spinal AVMs
C. Type III spinal AVMs
D. Type IV spinal AVMs
E. Types II and III spinal AVMs
156
Which of the follow ing represents the correct sequence of rem oval of clam ps
from the arteries follow ing carotid endarterectomy?
A. Com m on carotid, external carotid, internal carotid
B. Com m on carotid, internal carotid, external carotid
C. External carotid, com m on carotid, internal carotid
D. External carotid, internal carotid, com m on carotid
E. Internal carotid, com m on carotid, external carotid
**C. External carotid, common carotid, internal carotid**
## Footnote
The correct sequence of removal of clamps from the arteries following carotid
endarterectomy is the external carotid artery first, followed by the common
carotid artery, with the removal of the clamp from the internal carotid artery
last. This sequence ensures that any embolic material will be ushed into the
external carotid circulation
157
For questions 157 to 163, the gure illustrates the subchoroidal transvelum interposi-
tum approach to the third ventricle. Identify the follow ing structures.
157. Anterior caudate vein
A. A
B. B
C. C
D. D
E. E
F. F
G. G
A. A
B. B
**C. C**
D. D
E. E
F. F
G. G
158
the gure illustrates the subchoroidal transvelum interposi-
tum approach to the third ventricle. Identify the follow ing structures.
158. Colum n of the fornix
A. A
B. B
C. C
D. D
E. E
F. F
G. G
A. A
**B. B**
C. C
D. D
E. E
F. F
G. G
159
the gure illustrates the subchoroidal transvelum interposi-
tum approach to the third ventricle. Identify the follow ing structures.
159. Internal cerebral vein
A. A
B. B
C. C
D. D
E. E
F. F
G. G
A. A
B. B
C. C
**D. D**
E. E
F. F
G. G
160
the gure illustrates the subchoroidal transvelum interposi-
tum approach to the third ventricle. Identify the follow ing structures.
160. Septal vein
A. A
B. B
C. C
D. D
E. E
F. F
G. G
**A. A**
B. B
C. C
D. D
E. E
F. F
G. G
161
the gure illustrates the subchoroidal transvelum interposi-
tum approach to the third ventricle. Identify the follow ing structures.
161. Tela choroidea
A. A
B. B
C. C
D. D
E. E
F. F
G. G
A. A
B. B
C. C
D. D
E. E
F. F
**G. G**
162
the gure illustrates the subchoroidal transvelum interposi-
tum approach to the third ventricle. Identify the follow ing structures.
162. Thalam ostriate vein
A. A
B. B
C. C
D. D
E. E
F. F
G. G
A. A
B. B
C. C
D. D
**E. E**
F. F
G. G
163
the gure illustrates the subchoroidal transvelum interposi-
tum approach to the third ventricle. Identify the follow ing structures.
163. Thalam us
A. A
B. B
C. C
D. D
E. E
F. F
G. G
A. A
B. B
C. C
D. D
E. E
**F. F**
G. G
164
For questions 164 to 168, the gure illustrates the right retrocondylar, far lateral
approach. Identify the follow ing structures.
164. Dorsal ram us of C1
A. A
B. B
C. C
D. D
E. E
A. A
B. B
C. C
D. D
**E. E**
165
the gure illustrates the right retrocondylar, far lateral
approach. Identify the follow ing structures.
165. Glossopharyngeal nerve
A. A
B. B
C. C
D. D
E. E
**A. A**
B. B
C. C
D. D
E. E
166
the gure illustrates the right retrocondylar, far lateral
approach. Identify the follow ing structures.
166. Hypoglossal nerve
A. A
B. B
C. C
D. D
E. E
A. A
B. B
C. C
**D. D**
E. E
167
the gure illustrates the right retrocondylar, far lateral
approach. Identify the follow ing structures.
167. Spinal accessory nerve
A. A
B. B
C. C
D. D
E. E
A. A
B. B
**C. C**
D. D
E. E
168
the gure illustrates the right retrocondylar, far lateral
approach. Identify the follow ing structures.
168. Vagus nerve
A. A
B. B
C. C
D. D
E. E
A. A
**B. B**
C. C
D. D
E. E
169
For questions 169 to 174, the gure illustrates the pterional approach to aneurysm clip-
ping. Identify the follow ing structures.
169. Anterior cerebral artery
A. A
B. B
C. C
D. D
E. E
F. F
A. A
B. B
C. C
**D. D**
E. E
F. F
170
the gure illustrates the pterional approach to aneurysm clip-
ping. Identify the follow ing structures.
170. Anterior choroidal artery
A. A
B. B
C. C
D. D
E. E
F. F
A. A
B. B
C. C
D. D
**E. E**
F. F
171
the gure illustrates the pterional approach to aneurysm clip-
ping. Identify the follow ing structures.
171. Middle cerebral artery
A. A
B. B
C. C
D. D
E. E
F. F
A. A
B. B
C. C
D. D
E. E
**F. F**
172
the gure illustrates the pterional approach to aneurysm clip-
ping. Identify the follow ing structures.
172. Optic nerve
A. A
B. B
C. C
D. D
E. E
F. F
**A. A**
B. B
C. C
D. D
E. E
F. F
173
the gure illustrates the pterional approach to aneurysm clip-
ping. Identify the follow ing structures.
173. Posterior com m unicating artery
A. A
B. B
C. C
D. D
E. E
F. F
A. A
**B. B**
C. C
D. D
E. E
F. F
174
the gure illustrates the pterional approach to aneurysm clip-
ping. Identify the follow ing structures.
174. Superior hypophyseal artery
A. A
B. B
C. C
D. D
E. E
F. F
A. A
B. B
**C. C**
D. D
E. E
F. F
175
Which of the follow ing is m ost im portant in determ ining the propensity of a
dural AVM to an aggressive clinical course?
A. Duration of symptom s
B. Leptom eningeal venous drainage
C. Location
D. Presentation
E. Size
A. Duration of symptom s
**B. Leptom eningeal venous drainage**
C. Location
D. Presentation
E. Size
## Footnote
The risk of hemorrhage of dural AVMs seems related to the presence of
tortuous and aneurysmal leptomeningeal arterialized veins
176
For questions 176 and 177, refer to the image shown. The MRI shown is that of a 40-year-old patient with bitemporal hemianopia and a prolactin level of 89. The best m anagement of this lesion is
A. Bromocriptine
B. Bromocriptine, then surgery
C. Follow with serial MRIs
D. Radiation therapy
E. Surgery
A. Brom ocriptine
B. Brom ocriptine, then surgery
C. Follow w ith serial MRIs
D. Radiation therapy
**E. Surgery**
177
refer to the image shown. If the prolactin level of the sam e patient in question 176 was found to be 650, the best management is
A. Bromocriptine
B. Bromocriptine, then surgery
C. Follow with serial MRIs
D. Radiation therapy
E. Surgery
**A. Bromocriptine**
B. Follow w ith serial MRIs and prolactin levels
C. Radiation therapy
D. Surgery
E. Surgery, then radiation therapy
178
Of the follow ing, the least com m on location of intracranial m eningiom as is (the)
A. Intraventricular
B. Olfactory groove
C. Posterior fossa
D. Sphenoid ridge
E. Tuberculum sella
**A. Intraventricular**
B. Olfactory groove
C. Posterior fossa
D. Sphenoid ridge
E. Tuberculum sella
## Footnote
Lateral ventricular meningiomas account for 1 to 2% of intracranial meningiomas.
Olfactory groove (B), posterior fossa (C), sphenoid ridge (D), and
tuberculum sella (E) are all m ore common locat ions.
179
Each of the follow ing statem ents is true of AVMs except
A. Higher pressures have been m easured in the feeding arteries of sm aller as
com pared w ith larger AVMs.
B. Sm aller AVMs are m ore likely to bleed than larger AVMs.
C. The annual risk of death from a ruptured AVM is 1%.
D. The risk of bleeding from an unruptured AVM is 3 to 4% a year.
E. The risk of rebleed in the rst year after hem orrhage is highest in the rst
2 weeks.
A. Higher pressures have been m easured in the feeding arteries of sm aller as
com pared w ith larger AVMs.
B. Sm aller AVMs are m ore likely to bleed than larger AVMs.
C. The annual risk of death from a ruptured AVM is 1%.
D. The risk of bleeding from an unruptured AVM is 3 to 4% a year.
**E. The risk of rebleed in the rst year after hem orrhage is highest in the rst
2 weeks.**
## Footnote
The risk of rebleed from an AVM in the rst year after hemorrhage is as high
as 6 to 18%, but this risk is evenly dist ributed throughout the rst year.2
180
The m ost com m on com plication of percutaneous radiofrequency trigem inal
gangliolysis is
A. Anesthesia dolorosa
B. Decreased hearing
C. Keratitis
D. Masticatory weakness
E. Paresthesias or dysesthesias
A. Anesthesia dolorosa
B. Decreased hearing
C. Keratitis
D. Masticatory weakness
**E. Paresthesias or dysesthesias**
## Footnote
Paresthesias (E) occur in 20% of postoperative patients; dysesthesias (E)
occur in 5.2 to 24.2%.2
181
In the technique of percutaneous radiofrequency trigem inal gangliolysis, the
needle is inserted into the
I. Foram en rotundum
II. Trigem inal cistern
III. Foram en spinosum
IV. Foram en ovale
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of the above
A. I, II, III
B. I, III
**C. II, IV**
D. IV
E. All of the above
## Footnote
In the technique of percutaneous radiofrequency t rigeminal gangliolysis, the
needle is inserted into the trigeminal cistern (II) via the foramen ovale (IV).
The foramen rotundum (I) does t ransmit the maxillary division of the trigeminal
nerve, but is not used in this procedure. The foramen spinosum (III)
transmits the middle meningeal artery and is not used in percutaneous trigeminal
gangliolysis
182
For questions 182 to 189, the gure illustrates a lateral view of the contents of the right
orbit. The eyeball attachm ent of the lateral rectus m uscle has been divided. Identify the
follow ing structures.
182. Inferior rectus m uscle
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H
A. A
B. B
C. C
D. D
E. E
F. F
G. G
**H. H**
183
the gure illustrates a lateral view of the contents of the right
orbit. The eyeball attachm ent of the lateral rectus m uscle has been divided. Identify the
follow ing structures.
183. Inferior division of the oculom otor nerve
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H
A. A
B. B
C. C
**D. D**
E. E
F. F
G. G
H. H
184
the gure illustrates a lateral view of the contents of the right
orbit. The eyeball attachm ent of the lateral rectus m uscle has been divided. Identify the
follow ing structures.
184. Abducens nerve
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H
A. A
B. B
C. C
D. D
**E. E**
F. F
G. G
H. H
185
the gure illustrates a lateral view of the contents of the right
orbit. The eyeball attachm ent of the lateral rectus m uscle has been divided. Identify the
follow ing structures.
185. Frontal nerve
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H
**A. A **
B. B
C. C
D. D
E. E
F. F
G. G
H. H
186
the gure illustrates a lateral view of the contents of the right
orbit. The eyeball attachm ent of the lateral rectus m uscle has been divided. Identify the
follow ing structures.
186. Nasociliary nerve
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H
A. A
B. B
**C. C**
D. D
E. E
F. F
G. G
H. H
187
the gure illustrates a lateral view of the contents of the right
orbit. The eyeball attachm ent of the lateral rectus m uscle has been divided. Identify the
follow ing structures.
187. Superior division of the oculom otor nerve
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H
A. A
**B. B**
C. C
D. D
E. E
F. F
G. G
H. H
188
the gure illustrates a lateral view of the contents of the right
orbit. The eyeball attachm ent of the lateral rectus m uscle has been divided. Identify the
follow ing structures.
188. Optic nerve
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H
A. A
B. B
C. C
D. D
E. E
F. F
**G. G**
H. H
189
the gure illustrates a lateral view of the contents of the right
orbit. The eyeball attachm ent of the lateral rectus m uscle has been divided. Identify the
follow ing structures.
189. Trochlear nerve
A. A
B. B
C. C
D. D
E. E
F. F
G. G
H. H
A. A
B. B
C. C
D. D
E. E
**F. F**
G. G
H. H
190
For questions 190 to 195, m atch the condition w ith the m ost appropriate treatm ent
option. Each treatm ent option m ay be used once, m ore than once, or not at all.
190. Brachial plexus avulsion
A. Cingulotomy
B. Dorsal root entry zone (DREZ) rhizotomy
C. Morphine infusion
D. Pallidotomy
E. Sym pathectomy
F. Ventral rhizotomy
A. Cingulotomy
**B. Dorsal root entry zone (DREZ) rhizotomy**
C. Morphine infusion
D. Pallidotomy
E. Sym pathectomy
F. Ventral rhizotomy
191
m atch the condition w ith the m ost appropriate treatm ent
option. Each treatm ent option m ay be used once, m ore than once, or not at all.
191. Causalgia
A. Cingulotomy
B. Dorsal root entry zone (DREZ) rhizotomy
C. Morphine infusion
D. Pallidotomy
E. Sym pathectomy
F. Ventral rhizotomy
A. Cingulotomy
B. Dorsal root entry zone (DREZ) rhizotomy
C. Morphine infusion
D. Pallidotomy
**E. Sym pathectomy**
F. Ventral rhizotomy
192
m atch the condition w ith the m ost appropriate treatm ent
option. Each treatm ent option m ay be used once, m ore than once, or not at all.
192. Obsessive-com pulsive disorder
A. Cingulotomy
B. Dorsal root entry zone (DREZ) rhizotomy
C. Morphine infusion
D. Pallidotomy
E. Sym pathectomy
F. Ventral rhizotomy
**A. Cingulotomy**
B. Dorsal root entry zone (DREZ) rhizotomy
C. Morphine infusion
D. Pallidotomy
E. Sym pathectomy
F. Ventral rhizotomy
193
m atch the condition w ith the m ost appropriate treatm ent
option. Each treatm ent option m ay be used once, m ore than once, or not at all.
193. Nociceptive cancer pain above C5
A. Cingulotomy
B. Dorsal root entry zone (DREZ) rhizotomy
C. Morphine infusion
D. Pallidotomy
E. Sym pathectomy
F. Ventral rhizotomy
A. Cingulotomy
B. Dorsal root entry zone (DREZ) rhizotomy
**C. Morphine infusion**
D. Pallidotomy
E. Sym pathectomy
F. Ventral rhizotomy
194
m atch the condition w ith the m ost appropriate treatm ent
option. Each treatm ent option m ay be used once, m ore than once, or not at all.
194. Parkinson’s disease
A. Cingulotomy
B. Dorsal root entry zone (DREZ) rhizotomy
C. Morphine infusion
D. Pallidotomy
E. Sym pathectomy
F. Ventral rhizotomy
A. Cingulotomy
B. Dorsal root entry zone (DREZ) rhizotomy
C. Morphine infusion
**D. Pallidotomy**
E. Sym pathectomy
F. Ventral rhizotomy
195
m atch the condition w ith the m ost appropriate treatm ent
option. Each treatm ent option m ay be used once, m ore than once, or not at all.
195. Spasm odic torticollis
A. Cingulotomy
B. Dorsal root entry zone (DREZ) rhizotomy
C. Morphine infusion
D. Pallidotomy
E. Sym pathectomy
F. Ventral rhizotomy
A. Cingulotomy
B. Dorsal root entry zone (DREZ) rhizotomy
C. Morphine infusion
D. Pallidotomy
E. Sym pathectomy
**F. Ventral rhizotomy**
196
Donor nerves that m ay be used for neurotization after brachial plexus avulsion
include
I. Intercostal nerves
II. Spinal accessory nerve
III. Cervical plexus
IV. Phrenic nerve
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of the above
A. I, II, III
B. I, III
C. II, IV
D. IV
**E. All of the above**
## Footnote
These options (intercostal nerves, spinal accessory nerves, cervical plexus,
and phrenic nerve) have all been used with varying degrees of success. Intercostal
nerves are most commonly used for neurotizat ion procedures involving
the upper extremity
197
The pterion is form ed by w hich of the follow ing bones?
A. Frontal, greater w ing of the sphenoid, parietal, and squam ous part of the
temporal
B. Frontal, lesser w ing of the sphenoid, parietal, and squam ous part of the
temporal
C. Frontal, greater w ing of the sphenoid, parietal, and zygom atic arch
D. Frontal, lesser w ing of the sphenoid, parietal, and zygom atic arch
E. Frontal, lesser w ing of the sphenoid, squam ous part of the tem poral, and
zygom atic arch
**A. Frontal, greater w ing of the sphenoid, parietal, and squam ous part of the temporal**
B. Frontal, lesser w ing of the sphenoid, parietal, and squam ous part of the
temporal
C. Frontal, greater w ing of the sphenoid, parietal, and zygom atic arch
D. Frontal, lesser w ing of the sphenoid, parietal, and zygom atic arch
E. Frontal, lesser w ing of the sphenoid, squam ous part of the tem poral, and
zygom atic arch
## Footnote
B is incorrect; the lesser wing of the sphenoid does not contribute to the
pterion. C is incorrect; the zygomat ic arch does not contribute to the pterion.
D and E are incorrect because neither the lesser w ing of the sphenoid nor the
zygomat ic arch contributes to the pterion
198
The m ost com m on external beam radiation therapy regim en for brain m etasta-
ses is
A. 30 Gy in 2 weeks
B. 30 Gy in 4 weeks
C. 60 Gy in 2 weeks
D. 60 Gy in 4 weeks
E. 45 Gy in 4 weeks
**A. 30 Gy in 2 weeks**
B. 30 Gy in 4 weeks
C. 60 Gy in 2 weeks
D. 60 Gy in 4 weeks
E. 45 Gy in 4 weeks
## Footnote
The most common external beam radiation therapy regimen for brain metastasis
is 30 Gy given over 2 weeks (A).
199
The m ost appropriate radiation treatm ent protocol for glioblastom a is
A. 8,000 cGY in 400 cGY daily fractions
B. 6,000 cGY in 200 cGy daily fractions
C. 6,000 cGy in 100 cGy daily fractions
D. 4,000 cGy in 400 cGy daily fractions
E. 4,000 cGy in 200 cGy daily fractions
A. 8,000 cGY in 400 cGY daily fractions
**B. 6,000 cGY in 200 cGy daily fractions**
C. 6,000 cGy in 100 cGy daily fractions
D. 4,000 cGy in 400 cGy daily fractions
E. 4,000 cGy in 200 cGy daily fractions
## Footnote
The most appropriate radiat ion protocol for glioblastoma is 6,000 cGy in
200 cGy daily fractions (B).
200
Cerebral salt wasting and syndrom e of inappropriate antidiuretic horm one
(SIADH) m ay best be distinguished by m easuring
A. Plasm a arginine vasopressin (AVP)
B. Serum osm olality
C. Serum sodium
D. Urine sodium
E. Volum e status
A. Plasm a arginine vasopressin (AVP)
B. Serum osm olality
C. Serum sodium
D. Urine sodium
**E. Volum e status**
## Footnote
Pat ients with cerebral salt wasting are volume depleted, whereas those with
syndrome of inappropriate antidiuretic hormone (SIADH) are euvolemic or
volume expanded
201
A patient presents status post a high speed m otor vehicle collision w ith a cervical
5/6 fracture dislocation. Power in the deltoid, biceps, and w rist extensors is 5/5,
and all other m uscle groups are 2/5 including triceps, grips, and lower extrem i-
ties. Rectal tone and perianal sensation are intact. What is the appropriate grade
of this acute spinal cord injury?
A. ASIA A
B. ASIA B
C. ASIA C
D. ASIA D
E. ASIA E
A. ASIA A
B. ASIA B
**C. ASIA C**
D. ASIA D
E. ASIA E
## Footnote
The ASIA impairment scale is used for the grading of acute spinal cord injuries.
ASIA A (A) represents a complete spinal cord injury with no sensory or m otor
sparing in the sacral dermatomes. ASIA B (B) corresponds to a sensory incomplete
spinal cord injury, with sparing of sensat ion but not motor function distal
to the level of injury—this may include sensation in the sacral dermatomes
only (perianal sensat ion or deep anal pressure). ASIA C (C) represents m otor
incomplete injuries where . 50% of the muscles below the level of injury have
, grade 3 power—such as the patient in the vignet te. ASIA D (D) is ascribed
to patients with grade 3 power in . 50% of the m uscle groups below the
neurologic level. ASIA E (E) corresponds to pat ients who have sustained a
documented spinal cord injury, but are now neurologically intact.
202
What is the likelihood that the patient in the previous question (201) w ill be
am bulatory at long-term follow-up?
A. , 3%
B. 50%
C. 75%
D. 95%
E. 100%
A. , 3%
B. 50%
**C. 75%**
D. 95%
E. 100%
## Footnote
The ASIA impairment scale can help to predict ambulatory outcomes. The
patient in the quest ion stem has an ASIA C spinal cord injury. Please see the
table below.14
Grade % Ambulatory
A ,3
B 50
C 75
D 95
E 100
203
A patient presents w ith facial trichilemmomas, fibromas of the oral m ucosa,
ham artom as of the GI tract and breast, and a thyroid m ass. Further workup re-
veals Lherm itte-Duclos disease in this patient, as well. What is the m ost likely
genetic abnorm ality?
A. CAG trinucleotide repeat
B. m TOR ampli cation
C. p53 deletion
D. PTEN m utation
E. Trisomy 21
A. CAG trinucleotide repeat
B. m TOR ampli cation
C. p53 deletion
**D. PTEN m utation**
E. Trisomy 21
## Footnote
The diagnosis for the patient in the question stem is Cowden’s syndrome,
which is characterized by facial trichilemmomas, bromas of the oral mucosa,
hamartomas of the GI tract and breast , and thyroid tumors. There is
also an association with Lhermit te-Duclos disease, a hamartomatous lesion
of the cerebellum. Cowden’s disease is due to mutations of the PTEN gene
on chromosome 10q (D). CAG trinucleotide repeats (A) are associated w ith
Hunt ington’s disease. The mTOR pathway (B) has been implicated in the
pathogenesis of tuberous sclerosis. Germline mutations of p53 (C) are seen
in the Li-Fraumeni syndrome. Trisomy 21 (E) is seen in Down’s syndrome
204
Which of the follow ing best describes the standing radiograph seen here?
A. Major lum bar dextroscoliosis and m inor
thoracic levoscoliosis
B. Major lum bar levoscoliosis and m ajor
thoracic dextroscoliosis
C. Major lum bar levoscoliosis and m inor
thoracic dextroscoliosis
D. Minor lum bar dextroscoliosis and m ajor
thoracic levoscoliosis
E. Minor lum bar levoscoliosis and m ajor
thoracic dextroscoliosis
A. Major lum bar dextroscoliosis and m inor
thoracic levoscoliosis
B. Major lum bar levoscoliosis and m ajor
thoracic dextroscoliosis
**C. Major lum bar levoscoliosis and m inor
thoracic dextroscoliosis**
D. Minor lum bar dextroscoliosis and m ajor
thoracic levoscoliosis
E. Minor lum bar levoscoliosis and m ajor
thoracic dextroscoliosis
## Footnote
The curve is named based on the direction of the convexit y of the curve. If the
convexity of the curve is to the right, it is labeled dextroscoliosis. If the convexity
of the curve is to the left, it is labeled levoscoliosis (A and D are incorrect).
The major and minor curves are determined by the Cobb angles; the curve
with the larger Cobb angle is the major curve. Conversely, the curve with the
smaller Cobb angle is the minor curve (E is incorrect). In this case, the thoracic
curve has its convexity pointed to the right with a Cobb angle of 33 degrees.
The lumbar curve has its convexit y pointed to the left and has a Cobb angle of
48 degrees. Therefore, the best description is choice C, major lumbar levosco -
liosis and minor thoracic dextroscoliosis.
205
Which nerve(s) is (are) at risk during harvesting of iliac crest bone graft via an
anterior approach?
A. Iliohypogastric nerve
B. Ilioinguinal nerve
C. Lateral fem oral cutaneous nerve
D. All of the above
E. None of the above
A. Iliohypogastric nerve
B. Ilioinguinal nerve
C. Lateral fem oral cutaneous nerve
**D. All of the above**
E. None of the above
## Footnote
Iliac crest bone graft is harvested from a point at least 3 cm behind the anterior
superior iliac spine to avoid ilioinguinal ligament disruption. Nerves at risk
during this procedure (from lateral to medial) include the iliohypogastric (A),
ilioinguinal (B), and lateral femoral cutaneous nerves (C). The correct answer
is D, all of the above.
206
Which of the follow ing features is suggestive of ulnar nerve com pression at the
w rist (Guyon’s canal)
A. Aching along the m edial proxim al forearm
B. “Claw ” hand
C. Paresthesias in an ulnar distribution
D. Sparing of dorsal hand sensation
E. Weakness of the third and fourth lum bricals
A. Aching along the m edial proxim al forearm
B. “Claw ” hand
C. Paresthesias in an ulnar distribution
**D. Sparing of dorsal hand sensation**
E. Weakness of the third and fourth lum bricals
## Footnote
A sensory de cit over the dorsoulnar aspect of the hand is seen in ulnar
nerve compression at the elbow. With ulnar nerve compression at the wrist in
Guyon’s canal, this dorsal sensation is spared as the dorsal sensory branch of
the ulnar nerve branches o proximal to the wrist. Therefore, D is the correct
response. The other features can be seen in ulnar nerve compression at the
elbow or the wrist
207
All of the following are true of SCIWORA except
A. Acronym for “spinal cord injury without radiographic abnormality”
B. More common in children
C. MRI is always unremarkable
D. No evidence of spinal fracture is seen
E. Thought to be due to ligamentous laxity
A. Acronym for “spinal cord injury without radiographic abnormality”
B. More common in children
**C. MRI is always unremarkable**
D. No evidence of spinal fracture is seen
E. Thought to be due to ligamentous laxity
## Footnote
SCIWORA refers to spinal cord injury without radiographic abnormality (A)
and is more often seen in the pediatric population (B). Pat ients will present
with signs and symptoms of spinal cord injury without radiographic (X-ray
or CT) evidence of a fracture (D). SCIWORA was rst described before MRI
was rout inely used in the evaluat ion of spine trauma, and the mechanism is
thought to be related to ligamentous laxity in children (E). MRI scans in children
with SCIWORA may reveal disruption of the discoligamentous complex
and injury to the cord itself (C is false).
208
A patient presents status post fall with an acute type II odontoid fracture. Good
spinal alignment is maintained. The patient has good bone quality, is otherwise
healthy, and is neurologically intact. An MRI reveals disrupt ion of the t ransverse
ligament. Which of the following is the most appropriate treatment?
A. C-collar immobilization
B. No treatment
C. Occiput to C2 posterior fusion
D. Odontoid screw placement
E. Posterior C1–C2 instrumented fusion
A. C-collar immobilization
B. No treatment
C. Occiput to C2 posterior fusion
D. Odontoid screw placement
**E. Posterior C1–C2 instrumented fusion**
## Footnote
Type II odontoid fractures have a high rate of nonunion, and therefore, surgical intervention
is usually recommended (A and B are incorrect). Generally, odontoid
screw placement (D) and posterior C1– C2 fusion (E) either w ith transarticular
screws or a screw/rod construct are acceptable options. In this case, the transverse
ligament is disrupted, which is a contraindication to odontoid screw placement
(the patient would have ongoing atlantoaxial instability even if the odontoid was
stabilized due to ligamentous disruption between the dens and C1). Therefore, a
posterior C1– C2 fusion (E) is the most appropriate treatment for this patient.
Inclusion of the occiput would be unnecessary and introduces additional complexity
and morbidity to the procedure (C is incorrect).
