SANS VII Flashcards
general
1
Q
A 28 year-old healthy woman who delivered her second child 10 days ago presents with new onset headache. lethargy. and confusion. She has no focal deficits. A non-contrast head CT Is obtained and shown below. What is the most appropriate definitive treatment for this patient?
A Endovascular embolization
B Recombinant activated Factor VII
C Intravenous heparin infusion
D craniotomy for hematoma evacuation
E. Observation only
A
(C)
2
Q
a 47 year old woman presented with a frost seizure and underwent magnetic resonance imaging of the brain with multi voxel spectroscopy. The spectroscopy shown in figure 1 is MOST consistent with what diagnosis :
A. bacterial abcess
B. Glial Neoplasm
C. Toxoplasmosis
D. Demyelinating Plaque
E. Meningioma
A
(B)
3
Q
A 48 year-old man with a right middle cerebral artery distribution infarction. Despite aggressive medical and endovascular therapy, the artery remains occluded. Two days later he has a decline in mental status. His head CT is shown. What is the most likely explanation for the patient’s new neurological deterioration?
A. Occlusive Hyperemia B. Reperfusion syndrome
C. Hemorrhagic conversion
D. Cerebral Edema
E. Normal perfusion pressure breakthrough
A
(?)
4
Q
The appropriate maintenance rate for IV fluid in a 2 week old child is: A. 4 ml/kg/hr B. 10 ml/kg/hr C. 2 ml/kg/hr D. 20 ml/kg/hr E. 1 ml/kg/hr
A
(?)
5
Q
What factor MOST indicates the need for enhanced screening for coronary ischemia prior to general anesthesia for a neurosurgical procedure: A. male sex B. orthostatic intolerance C. age > 60 years D. surgical urgency E. neoplastic disease
A
(?)
6
Q
A patient presenting for resection of a small parietal meningioma has a preoperative INR of 1.5. What is the likellh<5% D. 75%E. 95%
A
(?)
7
Q
During the creation of a burr hole for a deep brain stimulator, an awake, sedated patient develops the sudden onset of coughing, hypotension, and hypoxia. The clinical presentation suggest which of the following complications: A. Intracranial hemorrhage B. Aspiration pneumonia C. Air embolism D. Tension pneumocephalus
A
(C)
8
Q
In a Nationwide lnpatient Sample, the most common cause of perioperative visual loss (POVL) In 465,345 patients undergolng spinal fusion was: A Anterior ischemic optic neuropathy B Corneal abrasion C Cortical blindness D Posterior ischemic optic neuropathy E. Retinal vascular occlusion
A
(C)
9
Q
In a 2009 study of 5.6 million patients who underwent the principal procedures of knee arthroplasty, cholecystostomy, hip/femur surgical treatment, spinal fusion, appendectomy, colorectal resection, laminectomy without fusion, coronary artery bypass grafting, and cardiac valve procedures from 1996 to 2005, cardiac and spinal fusion surgery had the highest rates of POVL. The national estimate in cardiac surgery was 8.64/10000. The American society of Anesthesiologists (ASA) class is designed to estimate what parameter: A. Patient physical status B. Age maximum of surgery C. Tolerable blood loss D. Surgical risk E. Operative mortality
A
(?)
10
Q
The use of Intensive Insulin therapy to reduce blood glucose In critically Ill patients with aneurismal subarachnoid hemorrhage has teen associated with an increase In the Incidence of what complication? A. Myocardial ischemia and Infarction B. Hypoglycemic episodes C. All-cause in-hospit31 mortality D. seizures E. Surgical site infection
A
(?)
11
Q
What is the BEST estimate of blood volume in a thirteen month old child weighing 10 kilograms? A. 700 ml B. 1000 ml C. 800 ml D 9OOml E. 600 ml
A
(?)
12
Q
What is the maximal reduction in the cerebral metabolic requirement for oxygen (CMR02) achievable exclusively through the use of high-dose barbiturates? A. 50% B. 25% C.15% D. 75% E. 90%
A
(?)
13
Q
What is the most concerning side effect or dexmedetomidine Infusion In ICU patients? A. Inhibition or the locus ceruleus B. Bradycardia c Systolic hypertension D. Respiratory depression E. Intracranial hypertension
A
(?)
14
Q
Which anesthetic agent is least likely to precipitate EEG evidence or seizure activity? A Lidocaine B. Isoflurane C. Enflurane D. Propofol E. Sevoflurane
A
(?)
15
Q
A 23 year old woman with complex partial seizures was Initially treated with phenytoin, then switched to carbamazepine, and is currently on levetiracetam after failing the first two therapies. After a seizure-free period of six months upon starting levetiracetam, she now has recurrence of 2-3 seizures/month. What is the most appropriate next step in her management? A. Evaluation for vagus nerve stimulation. B. Add-on therapy with oxcarbazepine. C. Switch to therapy with oxcarbazepine. D Evaluation for resective epilepsy surgery
A
(D)
16
Q
A 32 yr old male with intractable seizures and a normal MRI scan undergoes a non Invasive evaluation. Based on scalp EEG and seu:ure semiology, he had subdural electrodes placed and seizures were localized to the left language dommant supplementary motor area Following surgical resectioo the patient will MOST likely exhibit : A. Temporary paresis on the left. B. Left inferior quadrantopsia C. Temporary Mutism D. Anosmia and Finger agnosia
A
(C)
17
Q
Patients with subcortical band heterotopia are characterized by: A. Male predominance. B. Subependymal giant cell astrocytomas. C. Infantile spasms. D. X-linked migrational disorder
A
(D)
18
Q
The MOST common clinical feature of medial temporal lobe seizures is: A. Visual aura. B. Ictal Oral Automatism C. Ictal bicycling movements D. Ipsilateral dystonic posturing
A
(B)
19
Q
West’s syndrome is BEST characterized by which of the following seizure type : A. Primary and secondarily generalized B. Generalized tonic clonic C. Complex partial D. Infantile Spasm E. Atonic
A
(D)
20
Q
West’s syndrome is best characterized by which of the following seizure type : A. Primary and secondarily generalized B. Generalized tonic clonic C. Complex partial D. Infantile Spasm E. Atonic
A
(D)
21
Q
Which of the following structures is BEST described as lateral to the hippocampal complex (hippocampus, subiculum and parahippocampal gyrus)? A. Brain stem. B. Ambient cistern. C. Posterior cerebral artery. D. Fusiform gyrus E. Occulomotor nerve
A
(D)
22
Q
A 27 year old male construction worker had the on set of new head aches. which began suddenIy while doing heavy lifting at work. He was seen at a local emergency room shortly after his symptoms began. Neurological examination. head CT and spinal fluid were said to be normal. Now he returns to the ER with persistent headaches and a left abducens palsy. The remainder of the neurological examination is normal. An MRI with gadolinium is shown. Spinal fluid has 95 lymphocytes. CSF protein is slightly elevated but the glucose is normal. The MOST likely diagnosis is:
A. Carcinomatous meningitis
B. spontaneous intracranial hypotension
C. Hypertrophic interstitial pachymeningitis
D. sarcoidosis
E. Lymphoma
A
(?)
23
Q
A 29-year-old man comes to the emergency department after awakening that morning with deep, boring pain in the right ear and sagging of the right side of his face. Examination shows normal sensation in the affected area and there are no lesions on the pinna. Hearing is normal but he complains of increased sensitivity to sound in the right ear. A MR scan shows enhancement of the right facial nerve in the petrous bone. A photograph of him attempting to smile is shown. The MOST appropriate initial therapy should be: A. Oral prednison B. Oral Levaquin C. Observation only D. Oral acyclovir E. Surgical decompression of the right facial nerve
A
(?)
24
Q
A 34 year old male who is 8 years post liver transplantation is seen in the emergency department complaining of blurred vision. He has visual hallucinations. He has no paresis but there is bilateral asterixes. His pupils and optic discs are normal. He is hypertensive. He has a grand mal seizure. His MRI scan is shown. Which of the following is the mOST likely diagnosis: A. Lymphoma B. Diffuse glioma C. Reversible posterior leukoencephalopathy D. Progressive multifocalleukoencephalopathy E. Ammonia intoxication with secondary cerebral edema
A
(?)
25
A 6-year-old boy is struck in the right temple by a baseball but does not lose consciousness. His older brother walks him home. He complains of headache and takes acetaminophen for the pain. He soon becomes delirious: screaming, fighting, and biting his parents who try to restrain him. When seen shortly thereafter in the local emergency department, he has normal pupils and no paresis. His mother has a history of migraine headaches. The MOST likely diagnosis is: A. Subclinical Seizure. B. Bitemporal Contusion. C. EPIDURAL HEMATOMA D. Metabolic Encephalopathy. E. MIGRAINE
?
26
A 65 year old presents with gradual onset: asymmetric weakness with proximal and distal atrophy. He has had multiple falls. Biopsy of the vastus latera lis is shown. What is the most likely diagnosis? A. amyotrophic lateral sclerosis B. Inclusion body myositis C. Polymyositis D. Dermatomyositis E. Toxic myopathy
?
27
A 7 year-old child of migrant farm workers presents with to the emergency room with a seizure. Parents describe 60 seconds of unresponsiveness with twitching movements of the right leg. Last month they noted several similar episodes when the child was sick with an ear infection. On examination in the EDI he is sleepy but arousal, with a moderate right hemiparesis! most prominent in the leg. An MRI of the brain is shown in the figure. Which of the following is the MOST appropriate diagnostic step? A. TB skin test B. needle biopsi C. 0pen resection D. Serum/CSF immunologic testing
?
28
A 74 year old man presents with progressive cognitive decline over one year. Occasional visual hallucinations. poor attention. short-term memory loss! and bilateral upper extremity rigidity. What is the most likely diagnosis? A. Alzheimer disease B. Dementia with Lew Bodies C. Multi-infarct dementia D. Wilson's disease E. Pick's disease
?
29
According to the World Federation of Neurology, amytrophic lateral sclerosis is diagnosed by which pattern of neurological dysfunction? A. Upper or lower motor neuron dysfunction without progression B. Isolated lower motor neuron dysfunction with progression C. Isolated upper motor neuron dysfunction with progression D. Both upper and lower motor neuron dysfunction with progression E. Both upper and lower motor neuron dysfunction without regression
?
30
This 7 year old boy has had difficulty with ambulation and gross motor skills since early childhood. He did not walk until age 17 months. His symptoms are getting progressively worse. Mental status is unimpaired, and cognitive development is normal. Based on this video clip. his MOST likely diagnosis is: A. Muscular Dystrophy B. Myelodysplasia C. Tethered cord syndrome D. McArdle's disease E. Spinal cord tumor
?
31
What is the pathophysiological etiology of isolated unilateral weakness of dorsiflexion and ankle inversion? A. Peroneal mononeuropathy B. L5 Radiculopathy C. S 1 radiculopathy D. L4 radiculopathy E. Tibial mononeuropathy
?
32
What is the pathophysiological etiology of isolated unilateral weakness of dorsiflexion and ankle inversion? A. Peroneal mononeuropathy B. L5 Radiculopathy C. S 1 radiculopathy D. L4 radiculopathy E. Tibial mononeuropathy
?
33
Which of the following anti-epileptic agents would be BEST to use in a patient receiving multiple other medications extensively metabolized by the liver? A. Phenobarbital (Luminal) B. Levetiracetam (keppra) C. Carbamazepin (Tegretol) D. Phenytoin (Dilantin) E. Oxcarbazepine (Trileptal)
?
34
.5 year old child presents with macrocephaly and poor height and weight gain. He has just begun to walk, but has age appropriate language development. A head CT scan and MRI show a large pineal region lesion. Serum beta HCG and AFP are negative. The MOST appropriate procedures is: A. Endoscopic biobsy and CSF shunt placement B. Cerebral angiogram C. Stereotactic Biopsy D. Open biopsy and possible resection
D
35
A 10 year old boy with a history of aqueductal stenosis and CFS shunt present with nausea, vomitting and headache and a temperature of 100.5 he had a shunt revision for similiar symptoms 3 month ago. His brother has been sick lately too, with diarrhea and abdominal pain. His CT scan shows a ventricular catheter in good position and normal ventricular size. A shunt series is norma. The MOST appropriate diagnotic test is : A. None B. Shunt exploration C. Shunt tap D. ICP monitoring
C
36
What is the pathophysiological etiology of isolated unilateral weakness of dorsiflexion and ankle inversion? A. Peroneal mononeuropathy B. L5 Radiculopathy C. S 1 radiculopathy D. L4 radiculopathy E. Tibial mononeuropathy
?
37
What is the pathophysiological etiology of isolated unilateral weakness of dorsiflexion and ankle inversion? A. Peroneal mononeuropathy B. L5 Radiculopathy C. S 1 radiculopathy D. L4 radiculopathy E. Tibial mononeuropathy
?
38
Which of the following anti-epileptic agents would be BEST to use in a patient receiving multiple other medications extensively metabolized by the liver? A. Phenobarbital (Luminal) B. Levetiracetam (keppra) C. Carbamazepin (Tegretol) D. Phenytoin (Dilantin) E. Oxcarbazepine (Trileptal)
?
39
.5 year old child presents with macrocephaly and poor height and weight gain. He has just begun to walk, but has age appropriate language development. A head CT scan and MRI show a large pineal region lesion. Serum beta HCG and AFP are negative. The MOST appropriate procedures is: A. Endoscopic biobsy and CSF shunt placement B. Cerebral angiogram C. Stereotactic Biopsy D. Open biopsy and possible resection
D
40
A 10 year old boy with a history of aqueductal stenosis and CFS shunt present with nausea, vomitting and headache and a temperature of 100.5 he had a shunt revision for similiar symptoms 3 month ago. His brother has been sick lately too, with diarrhea and abdominal pain. His CT scan shows a ventricular catheter in good position and normal ventricular size. A shunt series is norma. The MOST appropriate diagnotic test is : A. None B. Shunt exploration C. Shunt tap D. ICP monitoring
C
41
A 10 year-old girl presents with signs of accelerated pubertal stage, convergence-retraction nystagmus, and impaired upward gaze. Which of the following lesions would likely be the cause of the findings described? A. Pontine glioma B. Pineal region tumor C. Acqueductal stenosis D. Multiple sclerosis
B
42
A 10-year-old boy presents compalining of headache and imbalance. Examination discloses mild pailedema, right-sided dysmetria, and taxia. Magnetic resonance imaging with gadolinium enhancememnt is shownin figure 1. The MOST important prognostic factor this patient is : A. The extent of resection of the enhancing mass B. The extent of resecion of the cyst walls C. The presence of endothelial proliferation of histology D. The presence of mitoses on histology E. The presence of hydrocephalus at presentation
A
43
A 15 year old male presents with severe low back pain. The pain responds poorly to ..... but responds well to aspirin. CT demonstrates a 1.5 cm dense lytic lesion of with a calcified nidus and circumferential sclerosis. What is the diagnosis? A. Osteochondroma B. Osteoid osteoma C. Hemangioma D. Oteoblastoma
B
44
A 15 year old patient with a history of prematurity and post-hemorrhagic hydrocephalus presents to the emergeny department with an intermittent fever of no higher than 100.2 deg . F, anorexia, and mild headache. His peripheral WBC is normal, at 9.3. The patient and his mother both deny the possibility of VP shunt malfunction. He states that “this is totally different than the symptoms i had 8 months ago when my shunt was blocked”. The MOST likely diagnos is : A. Gastroenteritis B. Pseudotumor cerebri C. Proximal shunt obstruction D. Bowel perforation E. Abdominal pseudocyst
E
45
A- 2-year-old child undergoes computed tomography for the preliminary complaint of macrocephaly (figure 1). He is developmentally normal and has normal results of the neurological examination without papilledema. Six months later, routine follow-up magnetic resonance imaging shows enlargement of the left middle fossa abnormality (figure 2) and repeat tasting reveals mild developmental delay and early papilledema. Which diagnosis is MOST likely: A. Arachnoid cyst B. Epidermoid C. Abscess D. astrocytoma
A
46
A year old presents with headache and vomitting. CT and MR imaging reveals the presence of a 4th ventricular tumor. A suboccipital craniotomy is performed for total resection of a medulloblastoma. Resection is followed protocol based chemotherapy and total neuroaxis radiotherapy. With a boost to the posterior fossa. Which endocrinological complication is the MOST likely after radiotherapy for a posterior fossa tumor in childhood? A. Diabetes insipidus B. Cushing’s syndrome C. Growth hormone deficiency D. Addison’s syndrome
C
47
A 6 year old child with a traumatic brain injury is intubated and appears agitated. His CT scan obtained within the last hour shows a left parietal contusion. Intracranial pressure monitoring via ventriculostomy shows sustained pressure above 20 mmHg, despite bucking againts the ventilator with minimal stimulation. His vital signs are within age appropriate limits and he apprears well hydrated. What is the most appropriate pharmacological management of this patient? A. Morphine and versed B. Pentobarbital C. Vecuronium D. Propofol
A
48
A 9-year-old male presented to his pediatrian with headaches and growth delay. Pathological specimens of his tumor obtained at operation are shown in the photomicrographs. What is the MOST likely diagnosis: A. Colloid cyst B. Craniopharyngioma C. Pilocytic astrocytoma D. Hypothalamic hamartoma E. Pituitary adenoma
B
49
A term infant is born with a cranial malformation in the occipital region (fig 1). Which diagnosis is MOST likely? A. Dermal sinus tract B. Chiari III malormation C. Myelomeningocele D. Anencephaly E. Encephalocele
E
50
An 8 year old girl present with years of chronic headaches that have worsened during the past 6 months and prgressive difficulty in school. She had previously been an ‘A student’ but her grades have dropped to Cs, and she complains of problems with memory, attention, and coordination. She has mild papilledema. You recommend endoscopic treatment of her obstructive triventricular hydrocephalus rather than VP shunt placement. During endoscopic exploration of the ventricular system, the MOST appropriate site for surgical fenestration is: A. Septum pellucidum superior to the fornices B. 3rd ventricle floor anterior to the infundibular recess C. 3rd ventricle floor anteior to the mammillary bodies D. Lamina terminalis above the suprachiasmatic recess
C
51
Children of mothers with diabetes mellitus have an increased insidence of which spinal disorder? A. Meningocele manque B. Sacral agenesis C. Spinal dysraphism D. Thoracic hemivertebrae E. Intraspinal lipomas
B
52
Current pediatric head injury guidelines suggest maintenance of the minimum cerebral perfusion pressure above 40 to 65 mmHg, depending on : A. Skull thickness B. Patient age C. Status of fontanelle D. Core temperature E. Time since injury
B
53
The incidence of myelomeningocele has decreased during the past decade. Before the 1980s, the incidence was 1 to 2 per 1000 live births. The current incidence is 3 per 10.000 live births. One reason for this decline may be the recommendation by physicians and obstetricians for women to supplement their folic acid intake. The american college of obstetrics and gynecology recommends the following supplementation guideline to all women from menarche to menopause: A. 400 micrograms every day B. 800 microgramsduring first trimester C. 4 gram every day D. 4 gram every week E. 400 micrograms after positive pregnancy test
A
54
1. A PGY -2 resident has worked 75 hours In the current week. The resident began his call shift yesterday at 06:00. The resident had 2 days completely off work in the previous two weeks. During the call day, the resident admits a pediatric patient with a rare brain tumor. The next day, the resident hands off call responsibilities to another resident. However, he then stays to assist with a rare pediatric brain tumor resection until noon. Which ACGME duty hour rule applies? A. Adequate rest between duty periods B. Minimum days off C. Maximum duty period length D. In house call limitation E. 80 hour work week
C
55
A Type 2 error (false negative) in interpreting clinical trials occurs when: A. Inadequate informed consent was obtained in over half the cases. B. A treatment is found to be ineffective but the sample size is too small. C. A positive result relies on an incorrect statistical test D. The test is not randomized or controlled. E. Gender makeup of the experimental and control populations are not equal.
B
56
A medical device company is sponsoring a presentation regarding a new implant they have developed for treatment of spinal instability. The presentation is followed by a modest meal at a local restaurant. At the conclusion of the meal, the company representative passes out gifts to the attending physicians, as a "thank you" for taking time out of their personal lives to attend a work meeting. Which of the following gifts would be acceptable under the AMA code of ethics and Advamed guidelines? A. Tickets to professional basketball game the following week B. Textbook of spinal anatomy with company logo Imprinted on cover C. $100 gift certificate to restaurant D. Golf shirt with company logo displayed on sleeve
B
57
A physician chooses to utilize a questionnaire-based outcome measure in his/her practice The questionnaire is administered to a core group of patients and then readministered to the same patients within a few days. The purpose of this exercise is to confirm that the replies to the same questions by the same patients do not change after a few days. A statistical analysts is completed to assess the degree of similarity between the first and second replies In this setting. This type of analysis for an outcome measure is a reflection of its: A. Responsiveness B. Integrity C. Reliability D. Sensitivity E. Validity
C
58
An appropriate way for a neurosurgeon working in a complex team environment to mitigate stress and fatigue would be to: A. Not acknowledge stress and fatigue, therefore reducing its effect on performance. B Recognize stress and fatigue, thereby increasing the use of threat and error management strategies. C. Rely on previous experience of chronic stress and fatigue during residency training to overcome these factors D. Deny the existence of stress
B
59
Certain medical conditions are subject to mandatory physician reporting. You evaluate a recent immigrant from Mexico complaining of occasional back pain. He has not been previously evaluated by a physician in the United states. Which of the following diagnoses are required by law to report, if the patient reveals it to you as part of their medical history? A.inactive TB B. Assault C. Polio D. Cysticercosis E. AIDS
E
60
Company X offers surgeons $100 for each time they implant their patented deviced. Which federal statue has been violated? A. EMTALA B. Anti-Kickback C. Stark D. HIPAA E. This is not a violation
B
61
Dr. Carter is investing with a group of surgeons who want to open an ambulatory surgery center (ASC). In order for this investment to pass Anti-Kickback statutes, what should Dr. Carter’s admitting status be at the proposed ASC? A. Nonadmitting B. Consult only C. Active status D. Emeritus
C
62
Dr. Jones designed a new instrument, obtained a patent, and sold the device to Company X. Dr. Jones then became an employee of Company X and draws a fair market value annual salary for marketing the instrument. Under what conditions can Dr. Jones give a presentation about this Instrument at a CNS or MNS sanctioned meeting? A. In a break-out session B. Only if he is rot the first author C. in poster form only D. with disclosures on the first slide
D
63
Dr. Jones is presenting a paper she co-authored at a CNS/AANS CME sanctioned meeting. She has disclosed a conflict of interest (COl) w1th Company Z prior to the meeting. Her presentation will include information about products made by Company Z. In order for the paper to be presented, Dr. Jones must: A. Limit her comments to research data and results. B. Disclose COI without limiting comments. C. Eliminate her COI with Company Z within one month prior to the meeting. D. Have the paper presented by a co-author without COL
A
64
During performance of a lumbar discectomy, there is a delay in radiology availability. The spinal surgeon elects to proceed with laminotomy and disc space exploration but finds no herniated disc material. A subsequent intra-operative radiograph demonstrates that the neurosurgeon is operating at the wrong level. The spinal surgeon adjusts the level of approach and successfully completes the procedure. In this circumstance, of the following. The neurosurgeon should: A. Consult risk management committee and ask them to disclose the error B. Disclose the error to a quality assurance committee, but not to the patient C. Request that the patient advocate disclosure the error to the patient D. Not disclosure the error because the patient was not harmed E. Disclose the error to the patient in a timely fashion
E
65
Federal health care insurance agencies including Medicaid and Medicare have established spesific standards for medical coding, biling , and reimbursement. Under these systems, primary responsibility for accurate coding and biling rests with : A. The surgical practice manager B. The surgical coding specialist C. The hospital biling departement D. The operative surgeon E. The hospital compliance officer
D
66
In order to provide useful, high quality medical evidence, a clinical study should employ an outcome measure that has the following characteristics : A. published, peer review, and objective B. Subjective, straightforward, and simple to employ C. Reproducible, nonbiased, and comprehensive D. Parametric, nonbiased, and comprehensive E. Reliable, valid, and responsive
E
67
Steep gradients In authority can negatively impact patient safety when: A. Fear or litigation results in physician migration out or a community. B. Surgical instruments are incorrectly counted at the beginning of a case. c. An incomplete medical record results in a missed drug allergy. D. Overcrowded operating rooms create delays in scheduling. E. A nurse who is unable to reach a resident and does not call an attending
E
68
The agencies for Healthcare Research and Quality (AHRQ) is charged in part with promoting evidence-based medical practice. AHRO reports recommend standards, Guidelines and Options for practice that are based on a scale of evidence class (or quality) from the peerreviewed, clinical literature. In the case of a retrospective. Case-controlled study of craniotomy plus whole brain radiation therapy versus stereotactic radiosurgery plus whole brain radiation therapy for solitary lung cancer brain metastasis. The evidence class is: A. Not classifiable B. Class III C. Class I D. Class II
D
69
The Joint Commission on the Accreditation of Health Care Organizations (JCAHO) has issued a set of National Patient Safety Goals to be implemented by all hospitals and hospitalbased practitioners by January 1st, 2005. One of JCAHO's 2005 national patient safety goals is: A. Include the use of the patient room number as a patient identifier whenever administering medications or performing procedures. B.Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organizatlon C. Assure that the full range of manufactured drug concentrations and Intravenous solutions are readily available within the hospital. D. Implement a process to mark the surgical site involving nursesiO.R. technicians. E. For verbal telephone orders, verify the order by having the person receiving the order readback the key portions
B
70
The class of evidence associated with a controlled study of severe closed head injury demonstrating reduced brain parenchymal loss and enhanced residual motor function in rodents treated with hypertonic saline versus mannitol after injury is: A. Class I B. Class II c. Class Ill d. not classifiable
D
71
. What is the ACGME definition of systems-based practice? A. Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment. B. Demonstrate an investigatory and anal~ic thinking approach to clinical situations. C. Know and apply the basic and clinically supportive sciences which are appropriate to their discipline. D. Partner with health care managers and providers to assess, coordinate. and improve health care. E. Demonstrate sensitivity and responsiveness to patients' culture, age, gender, and disabilities
D
72
When looking at the total cost of medical malpractice in the U.S., what fraction of the total money involved (including legal expenditures, settlements, and judgemenets) ends up going to the plaintiff (patient)? A. 1/5 B. 3/4 C. 112 D. 1/3
D
73
Which of the following activities must be submitted to institutional review board (IRS) for supervision? A. You investigate the relationship between socioeconomics and post-concussion syndrome by reviewing hospital records to correlate return visits with residential Zip Code. B. In response co an elevated CSF shunt infection race. the hospital infection control service prospectively observes 20 shunt operations and discover that holes in gloves correlate with infection Double gloving is adopted C. A school-age child suffers a gun shot wound to the brachial plexus and subsequently develops a neuropathic pain syndrome. You prescribe an off label use of gabapentin. D. An 11 year old harbors an incidentally discovered internal carotid aneurysm. You treat this lesion with endovascular placement of coils approved by the FDA for use in patients 18 years old and older. E. All neurosurgeon at your institution shave the scalp for cranial surgery. In response to an article about shaveless neurosurgery, you adopt this practice
A
74
A 23 year old male with a remote history of facial fractures presents with progressive headaches over 4 days, low grade fever and confusion. His neurologic examination is otherwise on-focaL A head CT with contrast is shown below. The MOST likely diagnosis is: A. Subarachnoid/subdural hemorrhage. B. Chronic subdural hematoma. C. Arachnoid cyst D. Subdural empyema
B
75
A patient presents with a single level lumbar discitislosteomylitis without associated abcess. Bone destruction, neurologic defecit, or deformity. Blood cultures are positive for staphylococcus aureus. What is the most appropriate next step in management? A. Needle biopsy B. Debridement and internal fixation C. Debridement D. Antibiotic Therapy E. Tagged WBG scan
B
76
Prophylactic intravenous antibiotics for a surgical procedure are BEST administered: A. Within twenty-four hours of surgery. B. Within one hour of making incision. C. Six hours prior to incision. D. One hour prior to incision
B
77
The following CSF lab values are MOST consistent with which diagnosis: Opening pressure: 40 cmH20 Appearance: Turbid White Cells (per mm3): 1500 Differential: 95% PMNs 5% Lymphs Protein: 110 mg/dl Glucose: 15 mgldL A. bacterial meningitis B. Normal CSF C. Fungal meningitis D. TB meningitis E. ViraI meningitis
A
78
. A 15 year old boy presents with neck pain. He is neurologically intact. A CT of the cervical spine reveals an osteolytic lesion with multiple fluid-filled cavities involving the body of C4. What is the most likely diagnosis? A. Ewings sarcoma B. Aneurysmal bone cyst C. Osteosarcoma D. Eosinophilic granuloma E. Fibrous dysplasia
B
79
A 19 year old male presents with tussive headaches located at me posterior base of the skull. NeuroIogic examination reveals weakness of the hands bilaterally with hypesthesia. MR of the brain and cervical spine are shown in the figures. What Is the BEST initial management strategy for this presentation? A. Posterior cervical decompression B. Posterior fossa decompression C. Syringo-subarachnoid shunt D. Ventriculoperitoneal shunt E. Anterior transoral odontoid resection
B
80
A 26 year old male presents after motor vehicle crash with absent right and partially preserved left lower extremity motor function (more than half of left leg muscles have less than antigravity strength). Sensation to pain and temperature Is markedly diminished In the left leg. Proprioception is markedly diminished in the right leg. Neuro-imaging studies are obtained and depicted in Figures 1 and 2. Which spinal cord syndrome BEST describes the injury: A. Cauda equina B. Brown-Sequard C. Anterior spinal D. Central cord
B
81
A 27 year old sustains a Type II odontoid fracture. He is complaining of upper cervical pain, but his neurologic exam is normal. Which of the following factors would increase his risk for nonunion? A. Age less than 30 years B. Comminution of the dens C. Anterior displacement of 3 mm D. Basilar Skull fracture E. Vertebral artery injury
B
82
A 28 year old male presents to the Emergency Department with complaints of severe low back and right leg pain after injury while working as a carpenter the previous day. He denies weakness, numbness and gait or bowel/bladder disturbance. Examination reveals trace weakness of dorsi-flexion on the right associated with pain. The BEST Initial management strategy for this patient is: A. Epidural steroid injection B. Seven day course of bed rest C. Lumbar discectomy D. Nonsteroidal anti-inflammatory medications E. Posterior lumbar interbody fusion
D
83
A 33 year-old man with known metastatic breast carcinoma presents with a one day history of paraparesis and bladder incontinence. Her lower extremity motor strength is 2/5 in all groups. An MRI of her thoracic spine reveals an isolated dorsal metastasis with cord compression at T9-T1O and preserved alignment. After administering steroids, the next step in her course of treatment should be: A. Single session spinal radiosurgery B. Spinal radiation therapy C. T9-1O spondytectomny with instrumentation D. No additional treatment E. T9-10 laminectomy
E
84
A 35 year old woman presents with progressive upper and lower extremity myelopathy. MR imaging reveals a well defined, contrast enhancing lesion 2 cm in diameter in her cervical spinal cord. What is the most appropriate treatment for this patient? A. Open biopsy of the lesion followed by appropriate chemotherapy and radiotherapy B. CT guided biopsy followed by appropriate chemotherapy and radiotherapy C. Serial MR imaging every three months D. Complete surgical excision of the lesion, if possible
D
85
A 35-year-old man presents with a several week history of left calf weakness and urinary retention. The MRI scan of the lumbar spine is most consistent with a myxopapillary ependymoma of the conus medullaris. What is the most appropriate initial management of this patient? A. Laminectomy and tumor resection B. Laminectomy and biopsy C. CT-guided biopsy D. Spinal radiosurgery E. Clinical observation with early repeat imaging
A
86
A 36 y/o restrained driver presented after a MVC. He complained of leg numbness and weakness. Examination revealed him to have 4-/5 strength in his proximal and 3/5 strength in his distal lower extremities and an L1 sensory level. Lumbar spine radiographs and axial CT through the level of Injury are shown in the figures. What is the BEST definitive management strategy for this type of Injury: A. TLSO brace B. Kyphoplasty C. Posterior spinal fusion D. Anterior spinal fusion
C
87
A 38 year old man presents with severe left leg pain. The pain came on spontaneously and he cannot remember any antecedent trauma or illness. The pain is severe and has prevented him from working as a carpenter since its onset two weeks ago. His examination Is notable for a positive straight leg raising test on the left and paresthesias in the S1 distribution on the left. The remainder of his physical and neurologal examination is normal. An MRI was ordered by his primary care physician, and it reveals a left sided herniated disc. The next appropriate management strategy for this patient is: A. Posterior lumbar interbody fusion B. Minimally incisional endoscopic discectomy C. Analgesics and Physical Therapy D. Percutaneous Chymopapain injection E. Traditional open discectomy
C
88
A 38 year old man presents with severe left leg pain. The pain came on spontaneously and he cannot remember any antecedent trauma or illness The pain was very severe and has prevented him from working as a carpenter since its onset eight weeks ago. He has improved somewhat over the last month but still has substantial pain. His examination is notable for a positive straight leg raising test on the left and paresthesias in the S1 distribution on the left. The remainder of his physical and neurological examination is normal. An MRI was ordered by his primary care physician and demonstrates a disc hemiation on the left at L5-S1. He is referred to you for consideration of a lumbar discectomy. You counsel the patient that surgery is: A. Indicated as pain relief is faster with surgery than with conservative care B. Not indicated as the risks of surgery outweigh any jxential benefits C. Should be delayed as long as possible in order to avoid adjacent segment disease D. Indicated promptly in order to avoid long term disabltiy due to nerve damage E. Not Indicated as his symptoms are improving
A
89
A 42-year-old woman is referred with biopsy proven chordoma within the L3 vertebral body. MRI does not show any ventral epidural extension or involvement of the peddes or posterior elements, The BEST management option for this patient Is: A. L3 spondylectomy and L2-4 fusion B. DebuIking of tumor and L2-4 fusion C. L3 corpectomy and fusion plus chemotherapy D. Radiation therapy alone E. L3 corpectorny and fusion plus radiation therapy
A
90
A 43 year old man with a 3 month history of numbness and tingling in bilateral lower extremities, diffioulty ambulating, and weakness in both hands and arms undergoes MR imaging of his cervical spine revealing a homogeneously enhancing intramedullary spinal cord tumor. The tumor diffusely and symmetrically enlarges the involved portion of the spinal cord without cyst formation. At surgery, intraoperative frozen section yields ependymoma. The MOST appropriate treatment strategy is: A. Attempted gross total resection B. Biopsy and external beam radiation C. Tumor debulking and duraplasty D. Subtotal resection and radiotherapy
A
91
A 45 year old gentleman is seen in the PACU after undergoing an anterior cervical discectomy and fusion with plating at C6-7. He is noted to have a constricted pupil and ptosis. What is the most likely explanation of this condition? A. Recurrent laryngeal nerve injury B. Over distraction of the disc space C. Vertebral artery injury D. Stretch injury of the sympathetic trunk E. Myastenia gravis exacerbation
D
92
A 48 y/o female with a history of breast caronoma presents with severe neck pain for several days. The neck pain resolves with recumbency and worsens with movement. Her neurological examination is normal except for symmetric hyper-reflexia in all four extremities. Her primary disease Is wellcontrolled and she is otherwise healthy. MR imaging is shown below (Figure 1) In addition to appropriate adjuvant chemotherapy and radiation, the BEST treatment option is: A. Occipito-cervical fusion B. Posterior C1-2 transarticular screw fixation C. transoral resection and posterior fusion D. External orthosis only
A
93
A 48 year old men presents with progressive complaints of hand paresthesias, loss of fine motor control, gait instability, and urinary urgency (MR imaging is shown below). She undergoes a posterior decompression via an open-door laminoplasty from C3 to C7. On postoperative day number 3, she complains of bilateral shoulder pain and demonstrates mild weakness of her right deltoid. The MOST appropflate next step in the management of this patient is: A. Bilateral upper extremity EMG B. Bilateral selective nerve root injections C. Emergent surgery for laminectomy/foraminotomy D. Administration of corticosteroids E. Orthopedic/Physiatry consult for “frozen shoulder”
D
94
A 50 year ol male presents with a 2 week history of low back pain radiating down the posterolateral thigh, lateral shin, dorsum of the foot and great toe on the right side. His neurologic exam is intact except for a (+) right straight leg raise at 30 degrees and 4+/5 EHL strength on the right. The most appropriate initial step in the management of this patient is: A. Intradiscal Electrothermy (IDET) B. Epidural steroid injection C. Microdiscectomy/foraminotomy D. EMG/Nerve conduction studies E. Education/Counseling
E
95
A 50 year old male presents with a 2 week history of low back pain radiating down the postero-lateral thigh, lateral shin, dorsum of the foot and great toe on the right side. His neurologic exam is intact except for a (+) right straight leg raise at 30 degrees and 4-/5 EHL strength on the right. The most likely diagnosis is: A. L4-L5 far lateral disc herniation B. L5-S1 foraminal disc herniation C. L3-L4 paracentral disc herniation D. L3-4 central disc herniatlon E. L5-S1 paracentral disc herniation
B
96
A 54 year old male with non-small cell lung cancer (NSCLC) presents with progressive myelopathy over the past 2 months along with incontinence and an inability to ambulate over the past 48 hours. Imaging is as shown. What Is the most accurate statement regarding surgical decision making in this patient? A. Regardless of surgery, performance status, serum calcium and albumin levels are the most important prognostic factors. B. The presence of a spinal metastasis carries an extremely poor prognosis, therefore no surgery should be pursued. C. Aggressive surgical decompression and reconstruion should be performed, as life expectancy in this patient is \> 2 years. D. Surgical decompression should be pursued in the face of neurologic deterioration during radiotherapy given its clear benefit relative to risk
A
97
A 54 year-old female presents 18 months after undergoing instrumented ACDF at C5-6 via a left-sided approach. She has neck pain and radiculopathy with pseudoarthrosis and instrumentation failure. She denies hoarseness or swallowing difficulties with the initial surgery. Being right-handed, you prefer a right-sided approach for her recommended revision surgery. What is the MOST appropriate management of the surgical approach in this case: A. Intra-operatve EMG monitoring of the laryngeal muscles B. Modified barium swallow prior to surgery C. Right-sided approach without further work-up D. Laryngoscopic screening prior to surgery
D
98
A 54 yo male presents with 10 years of progressive back and bilateral radicular L5 leg pain. The pain is worse when upright and refractory to conservative management. Examination reveals full strength in his distal lower extremities. Lumbar spine radiographs and MRI are shown in the figures. Flexion/extension radiographs show 4 mm of motion of L4 on L5. According to the ‘Guidelines for Management of Degenerative Lumbar Disease’, hat is the BEST surgical management strategy: A. Lumbar decompression B. Lumbar decompression and fusion C. Spinal cord stimulator D. Lumbar fusion E. Morphine pain pump
B
99
A 55 year-old female presents with back pain, progressive right leg pain, atrophy and weakness. Exam reveals bilateral non-dermatomal lower extremity hypalgesia and a hemangioma with hirsuitism over the lumbarspine. Imaging reveals a 10 degree thoracic scoliosis, right sided disc bulge at L1/2, conus terminating at L4, and a fatty filum terminale (3mm). The treatment of choice is: A. Conservative therapy (PT, NSAIDS, etc) B. Spinal deformity correction C. Realease of filum terminale D. L1/L2 microdiscectomy E. Monitoring with serial imaging
C
100
A 58 year old woman presents with neurogenic claudication, MRI demonstrates moderate to severe stenosis associated with spondylolisthesis at L4-5. She presents for a surgical opinion. Regarding surgery. which of the foIlowing is true? A. It prevents potentially catastrophic neurological deterioration B. It leads to significantly worse long term outcomes due to adjacent segment disease C. It affords significant short and long term benefits compared to non-surgical treatment D. It does not influence the clinical outcome in patients with more severe symptoms E. It must include the use of pedicle screw fusion to improve patient outcomes
C
101
A 58 year-old female presents with a six-month history of progressive mid-back pain. She reports several falls secondary to her nght lower extremity ‘giving out’. Physical examination reveals normal strength except for 4+/5 in the right lower extremity. There is sustained, threebeat donus on the right MRI with and without contrast reveals a partially enhancing intradural, intramedullary mass at T8. The MOST likely diagnosis is: A. Glioblastoma B. Astrocytoma C. Schwannoma D. Ependymoma E. Meningloma
D
102
A 60 year old man presents with 6 months of worsening back pain. He denies any weakness or numbness. The patient describes the pain as deep and aching. It is located only in the back and does not radiate. It is worse with activity and improved with rest. He is not tender to palpation on physical exam. This type of pain may be classified as: A. Mechanical B. Malingering C. Myofascial D. Oncologic
A
103
A 60 year old man presents with progressive pain at the level of his sacrum over the course of 6 months. MR imaging reveals an 8 cm lesion within his sacrum most consistent with a chordoma. What is the most appropriate and best treatment option for this patient that is associated with the best long-term outcome? A. Intralesional tumor decompression to alleviate the pain and allow for a tissue diagnosis followed by referral for proton beam radiotherapy. B. CT guided biopsy of the lesion to confirm the diagnosis followed by en bloc resection of the lesion including resection of the biopsy tract C. CT guided biopsy of the lesion to confirm the diagnosis followed by referral for proton beam radiotherapy D. Proton beam radiotherapy alone without biopsy to avoid seeding tumor in the biopsy tract given that the MR appearance of chordomas is highly specific
B
104
A 61 year old previously healthy man presents with progressive hand weakness, tingling in his fingers, and gait instability. Examination reveals atrophy and weakness of the hands, impaired rapid alternating movements, diminished pinprick sensation in the fingers, diffuse hyper-reflexia, and lower extremity spasticity. What is the MOST likely diagnosis: A. Amytrophic Lateral Sclerosis B. Multiple Sclerosis C. Cervical Spondylotic Myelopathy D. Normal Pressure Hydrocephalus E. Subacute Combined System Disease
C
105
A 62 year old with known metastatic renal cell cancer presents with unbearable bad pain and lower extremity myelopathy after a fall. Her imaging is displayed in the accompanying figures, The best management strategy of this lesion would be: A. Kyphoplasty/Vertebroplasty followed by radiotherapy B. Stereotactic Radiosurgery C. Conventional external beam radiotherapy D. Laminectomy and resection of epidural disease followed by radiotherapy E. Vertebrecomy with posterior stabilization followed by radiotherapy
E
106
A 65-year old man complains of bilateral lower extremity pain, numbness, and weakness after standing or walking for 5 minutes. A brief period of sitting or lying down results in complete relief of symptoms, after which he can walk another 5 minutes. Magnetic resonance image is shown in Figure 1. The clinical syndrome is BEST described as: A. Neurogenic claudication B. Diabetic peripheral neuropathy C. Radiculopathy D. Sciatica E. Plexopathy
A
107
A 65-year-old man presents with progressive neck pain, bilateral numb, clumsy hands, spastic gait and a present Babinski sign. Tongue fasciculations are absent, MR imaging is shown in the figure. The MOST likely diagnosis is: A. Combined systems degeneration B. Parkinson’s disease C. Amyotrophic lateral sclerosis D. Cervical spondylotic myelopathy E. Cerebral palsy
D
108
A 65-year-old man presents 6 months after a motor vehide collision complaining of severe disabling neck pain. Cervical CT reveals a non-united type II odontold fraclure. The MOST appropriate management is: A. Posterior C1-C2 arthrodesis B. B. Halo immobilization C. Hard cervical collar D. Anterior odontoid screw fixation
A
109
A 65-year-old man presents 6 months after a motor vehide collision complaining of severe disabling neck pain. Cervical CT reveals a non-united type II odontold fraclure. The MOST appropriate management is: E. Posterior C1-C2 arthrodesis F. B. Halo immobilization G. Hard cervical collar H. Anterior odontoid screw fixation
E
110
A 65-year-old woman presents with severe, progressive back pain is found to have degenerative, thoracolumbar scoliosis as depicted in the pigures. Which radiographic parameter has the greatest impact on physical function and disability? A. Abnormal coronal balance B. Presence of apical rotation C. Scoliosis curbe magnitude D. Positive sagittal balance E. Presence of single curve
D
111
steps complaining of pain and weakness, worse in arms than legs. Plain radiographs, CT and MRI of the cervical spine are shown in the pigures. What underlying medical condition does this patient have: A. Severe Cervical Spondylosis B. Ankylosing Spondylitis C. Osteoporosis D. Diffuse Idiopathic Skeletal Hyperostosis
D
112
A 68 years-old male with a history of prostatic cancer present with low-grade fever and severe low back pain progressing to include lower extremity numbness. Thoracic CT shows extensive destruction of the T11 and T12 vertebral bodies with relative sparing of the T11-12 disc space, as well as a large paraspinous abscess with calcification. Thoracic MRI shows a kyphotic deformity with enhancing soft tissue and bone extending into the anterior spinal canal and resulting in moderate stenosis and spinal cord compresion. The MOST likely pathologic process is: A. Osteoporotic Compression Fracture B. Discitis – Staph Aureus C. Pott’s Disease – Tubercolosis D. Pathologic Fracture – Metastatic Tumor E. Discitis – Staph Apidermidis
C
113
A 68 years-old woman presents with progressive myelopathy with MRI shown. An isolated posterior approach is contraindicated in this patient in the presence of : A. Fixed kyphotic deformity B. Posterior ligamentous hypertrophy C. Subluxation at C3/4 and C4/5 D. Ventral compressive pathology E. Compressive pathology across multiple levels
A
114
A 70 years-old male with a type II dens fracture has non-union of the dens despite 6 month of halo fixation. His new cervical CT scan demonstrates non-union of the dens with 6 mm of posterior displacement. Cervical x-rays reveal that anatomic reduction of the fracture is not possibble. No other associated fractures are identified. He is otherwise neurologically intact and is in good medical condition. What is the most appropriate treatment option at this time? A. Continued halo management for an additional 3 months B. Management in a hard cervical collar for 3 month C. Removal of halo fixation and observation D. Anterior odontoid screw fixation E. Posterior C1-2 instrumented arthrodesis
E
115
A 72 years old woman has been diagnosed with osteoporosis, with a T-score of -2.6 on a recent central DXA scan. She has recently been started on supplemental calcium (1500 mg daily) and bisphosphonate. Which one of the following would be the most appropriate next step in management of her osteoporosis? A. Screening urinary calcium levels B. Doubling the calcium supplement C. Repeating bone density testing in 2 years D. Measuring hormonal levels E. Obtaining x-rays of the lumbar spine
C
116
A C1-2 transarticular screw is most likely to result in injury to the vertebral artery when misdirected: A. Medially B. Caudally C. Laterally D. Anteriorly E. Cranially
B
117
A 54 years old male presents with a three day history of bladder problems. He states that he does not feel his bladder filling, and that urine sometimes leaks out. Neurologic exam is normal with the exception of hypoactive reflexes. His CT myelogram is displayed below. What is the most appropriate treatment for this patient? A. Endovascular therapy with particulate embolic agents B. A ventral approach, carpectomy and recection of the lesion C. A posterior approach, laminectomy, durotomy, and ligation of draining vein D. Continued observation, physical therapy and lumbal strenghtening E. Endovascular embolization followed by radiosurgery
C
118
A normal intraoperative electromyographic study during lumbar fusion surgery has been shown to the BEST corelate with: A. Improved fusion rates B. Improved patient outcomes C. Lack of a neurological injury D. Pedicle fractures
C
119
. A twenty four years old woman present with right arm and leg weakness and left cranial nerve VI palsy following a high-speed motor vehicle accident. Her lateral cervical spine x-ray shows upper cervical prevertebral soft tissue swelling and a basion-dental interval of 16 mm. Her head CT is negative for intracranial hemorrhage. What is the recommended treatment of this injury? A. In situ arthrodesis and immobilization in a 4-poster brace B. Traction followed by immobilization in a halo C. Immobilization in a hard collar D. Internal fixation and arthrodesis E. Emmobilization in a halo
D
120
According to the BEST medical evidence available regarding lumbar fusion, the addition of pedicle screw fixation to a single or double level posterolateral fusion performed for chronic low back pain due to degenerative disease without deformity or neurological deficit is associated with which of the following outcomes: A. Unchanged complication rate B. Higher fusion rate C. Lower overall cost D. Shorter hospital stay E. Improved patient outcomes
B
121
According to the guidlines for the Performance of Fusion Procedures for Degenerative Disease of the Lumbar Spine, the literature supports the use of fusion in lumbar decompression surgery for degenerative stenosis when associated with: A. Conjoined nerve root B. Focal disc herniation C. Spondylolisthesis D. Spina bifida E. Congenital stenosis
C
122
According to the guidlines for surgical management of degenerative spinal disease, the short and long term economic impact of lumbar fusion surgery for degeneratve spinal disease is: A. Positive in the short term and negative in the long term B. Negligible in the short term and positive in the long term C. Negative in the short term and negative in the long term D. Negative in the short term but positive in the long term E. Positive in the short term and positive in the long term
D
123
After a type II odontoid fracture, the function of which ligament/membrane most strongly influences treatment options: A. Alar B. Tectorial C. Apical D. Transverse E. Anterior longitudinal
D
124
An eleven years old boy is brought to clinic by his parents with a one week history of neck pain. On questioning, the boy denies any falls or other accidents. He has no significant past medical history. A review of system is non-contributory. On physical exam, he is well-develoved, well-nourishd young male with a normal posture. He is slightly tender to midline palpation of the servical spine. Cervical range of motion is somewhat limited. His neurological exam is normal. His vital signs are normal, and he is afebrile. An MRI of the servical spine was obtaine by the boy’s pediatrician. The lateral view is displayed. What is the most likely diagnosis? A. Paget’s disease B. Metastatic cancer C. Hurler’s syndrome D. Pott’s disease E. Eosinophilic granuloma
E
125
Based on published medical evidence review, discography may BEST be used as a diagnostic test for which clinical purpose? A. Functional Imaging relevant to patient selection for lumbar fusion B. Repair of annular tears C. Visualization of clinically relevant disc space abnormalities D. Prediction of outcome following lumbar interbody fusion E. Diagnosis of discogenic low back pain
A
126
Class I medical evidence supports the use of lumbar fusion in patients with degenerative low back pain, without stenosis or spondylolisthesis, under which of the following circumstances: A. Acute severe axial back pain B. Protracted pain responding to medical management C. Protracted pain arising from 3 or more levels D. Acute pain refractory to epidural injections E. Protracted pain refractory to multi-modality medical management
E
127
During a retroperitoneal approach to the lumbar spine, what structure runs along the medial aspect ot the psoas muscle ang lateral aspect of the spine? A. Ilioinguinal nerve B. Ureter C. Sympathetic trunk D. Genitofemoral nerve E. Aorta
C
128
Following anterior cervical discectomy and fusion (ACDF), which of the following complications is the most common? 1. Dyshagia 2. Homer’s syndrome 3. Thoracic duct injury 4. New radiculopathy 5. Hoarsness
1
129
Harrington distraction rods were commonly used for the correction and stabilization of scoliosis. At which of the following locations is a harington rod most likely to fracture: A. The upper hook/rod (point A) B. The middle of the shaft (point B) C. The lower hook/rod (point E) D. The middle ratchet (point D) E. The proximal ratchet (point C
E
130
In the spine, which tumor is most commonly located in an intradural/extremedullary location: A. Astrocytoma B. Hemangioblastoma C. Ependymoma D. Adenocarcinoma E. Schwannoma
E
131
The first priority in the overall assessment of a trauma patient with an acute cervical spine fracture is: A. Ongoing hemorrhage B. Neurological deficit C. Spinal instability D. Blood pressure E. Airway integrityd
E
132
The most likely cause of decreased fusion rates in smokers undergoing lumbar spinal arthrodesis is: A. Decreased overall nutritional health B. Cardiopulmonary complication from COPD C. Peripheral vascular disease D. Inhibition of bone formation by nicotine E. Greater noncompliance with postoperative treatment recomendations
D
133
The right vertebral artery is injured during posterior C1-2 transarticular screw fixation, while placing the first screw. The MOST appropriate surgical management strategy is: A. Place the left screw B. Remove the right screw C. Extend the fusion to the occiput D. Use only right sided instrumentation
D
134
The use of recombinant bone morphogenetic protein in the performace of a lumbar fusion is currently supported by randomized controlled clinical trials for which fusion approach/type: A. Posterior lumbar interbody fusion procedures B. Anterior lumbar interbody fusion procedures C. Non-instrumented posterolateral lumbar fusion procedures D. Instrumented posterolateral lumbar fusion procedures
B
135
What are the current evidence-based guidelines regarding posterolateral lumbar fusion for patient with radiculopathy due to intervertebral disc herniation? 1. Recomended in patient with recurrent disc herniation without evidence of instability, deformity, or chronic low back pain. 2. Not recomended because interbody fusions are associated with better outcomes. 3. Recomended for patients with large para-central disc herniation. 4. Do not recomended because simple decompression is associated with better outcomes. 5. Recomended for patient who fail to improve with six to eight weeks of conservative management.
4
136
What grade of spondylolithesis is depicted by the x-rays: A. V B. IV C. III D. II E. I
D
137
What is the most common adverse event following laminoplasty for cervical spondylotic myelophaty? 1. Loss of cervical range of motion 2. C5 root palsy 3. Inadequate cord decompression 4. Progressive cervical kyphosis 5. Accelerated adjacent level deterioration
1
138
What is the recomended insertion torque for halo pins in adults? A. 8 inch pounds B. 6 inch pounds C. 4 inch pounds D. 10 inch pounds
A
139
What radiographic finding is a contraindication to cervical laminoplasty? A. Spinal cord signal change B. Ossified posterior longitudinal ligament (OPPLL) C. Multilevel cervical spondylosis D. Cervical kyphosis E. Congenital cervical stenosis
D
140
Which of the following is considered a major risk factor for osteoporosis by the National Osteoporosis Foundation? 1. Prior falls 2. High body mass index (BMI) 3. Current smoking 4. Use of NSAIDs 5. Alcohol use of 1 drink per day
3
141
Which of the following is the most caudal level(s) effectively immobilized by a standard thoracolumbosacral orthosis (TLSO)? A. T9-10 B. L1-2 C. T11-12 D. L3-4 E. L5-S1
D
142
Which of the following most accurately defines, from a biomechanical perspective, the location of rod fracture as depicted in figure 1? The point of: A. Maximum stress application B. 3-point bending C. Narrowest diameter D. Greates flexibility E. Maximum strain application
A
