Chapter 9 – Spine II Structured SBA

Abstract

Spine II Structured SBA Questions

Chapter 9 Spine II Structured SBA

Prasad Karpe

Spine II Structured SBA Questions

1. A 40-year-old patient with a background of ankylosing spondylitis with spinal deformities has arrived at the ED after an RTA at 70 miles per hour. He is conscious and speaking, with a blood pressure of 90 and HR of 120.

Which of the following is likely to negatively affect the outcome of this patient?

Assess airway and breathing and start high-flow oxygen

FAST scan

Pass 2 large IV bore lines and assess for sites of bleeding

Trauma CT scan

Triple immobilisation of the cervical spine with rigid collar

2. Which of the following statement is true regarding pelvic incidence?

It changes with posture like other parameters of pelvic morphology

It is pelvic tilt minus the sacral slope

It is the angle formed between a line drawn from the centre of the S1 end plate to the centre of the femoral head and a second line drawn perpendicular to the S1 end plate, intersecting it at the centre

Lower pelvic incidence necessitates more lumbar lordosis to maintain sagittal balance

There is no correlation between pelvic incidence and the Meyerding Newman grade of spondylolisthesis

3. A 13-year-old girl is seen in the paediatric clinic with scoliosis. It was noticed by her mother 18 months ago that it is gradually getting worse.

Which of the following is not an indication of MRI scan of the full spine?

Asymmetric abdominal reflexes on examination.

Axillary and inguinal freckling on examination

Left-sided curve on x-rays

Rib prominence on forward bending

Right-sided short angular curve on x-rays

4. An 8-year-old boy has come to the orthopaedics clinic with back pain and scoliosis. The boy’s mum mentions that the pain is more prevalent at night and has responded to anti-inflammatory agents.

Which of the following is the only TRUE statement about this condition?

Fine cuts of CT and MRI scan help best in determining treatment plan

It is larger than 2cm in diameter

It is most often present with neurological deficit.

Radiofrequency is the first line of treatment in all lesions.

The lesion is typically present on the convex side of the scoliosis

5. A 40-year-old man has arrived in the ED with penetrating injury to his upper abdomen. His BP is 100, HR 110 and RR 20. He has 15/15 GCS and normal neurology in all four limbs.

His CT shows minimal tear to his descending aorta with no bony injuries. He undergoes laparotomy with repair of the descending aorta. His surgery lasts for 4 hours under general anaesthesia, with his blood pressure always above 110mm Hg. Post-op he wakes up with weakness of the muscles in his foot, reduced sensations in both lower limbs but intact proprioception. His power, sensations and proprioception are normal in both upper limbs. His blood pressure now is 120mm Hg, HR 90, SaO₂ 100% on 2 litres of oxygen, RR 18.

Which of the following is the MOST likely cause of the patient’s weakness?

Central cord syndrome

Damage to feeding vessel from the left side between T8 and L1

Neurogenic shock

Posterior cord syndrome

Spinal shock

6. A 60-year-old man with a background of hypertension has been referred by his GP with symptoms of low back pain, neurogenic claudication and gait disturbances. On examination, he has brisk reflexes in all four limbs and 4/5 power in all four limbs. He denies any symptoms of bowel or bladder dysfunction. His lumbar spine is tender in the region of the facets, and lumbar extension is painful. Both pedal pulsations are well felt. His GP has already performed an MRI of the lumbar spine that shows severe canal stenosis at L34, L45.

The NEXT most appropriate step in the management of this patient is which of the following?

Facet joint injections lumbar spine

Laminectomy L3–L5

Laminectomy, medial facetectomy and instrumented fusion

MRI of cervical and thoracic spine

Transforaminal interbody fusion L34, L45

7. Which of the following is a true statement regarding the Smith–Robinson (anterior cervical spine) approach?

Dissection of the longus colli muscle risks damage to the parasympathetic chain

Hyoid bone roughly lines up with C5

The location of the maxilla decides the ease of access to the C23 disc

The superficial fascia, pretracheal fascia and prevertebral fascia are encountered from superficial to deep

Utilises the plane between the carotid sheath laterally and the trachea with internal jugular medially

8. A 68-year-old female sustains an osteoporotic fracture. After failure of conservative treatment, she undergoes vertebroplasty.

Which of the following statements is correct regarding this procedure?

Chemical destruction of the nerve endings due to chemical composition of the cement has been proposed

Vertebroplasty has more advantages than kyphoplasty

Vertebroplasty is indicated in patients with ongoing pain after recent unhealed fracture, pain confirmed at the level of fracture by examination and MRI showing low signal on T2

It works by destruction of the nerve endings due to extreme low temperature reached by the polymerisation of the injected cement

It works by stabilisation of the fractured bone by forming a chemical bond

9. An 8-year-old boy presents with fever and low back pain. He is very tender in the L23 region. Hip and knee examinations are normal. His inflammatory markers are raised.

Which of the following is a true statement about this condition?

Disc space narrowing is the earliest radiographic sign

Batson plexus is the most common pathway of mode of spread to spine

Most common organism is Staphylococcus aureus

CT imaging is the investigation of choice

Vertebral end plates get infected first

10. Which of the following is not an imaging finding for spinal infection in adults?

Loss of disc height and abnormal disc signal

Loss of end plate definition on both sides of the disc

Paraspinal soft tissue or loculated fluid collection

Posterior elements are most commonly affected

Vertebral collapse

11. The root value of the ankle reflex is which of the following?

L34

L45

L5S1

S12

S23

12. An 11-year-old girl comes to the spinal clinic with recent onset of noticing deformity. She has no neurology in her legs and no generalised syndromic features. AP radiograph of her spine is as depicted in Figure 9.1.

Figure 9.1 AP radiograph spine

Which of the following is an ideal indication of a brace?

Curves greater than 40 degrees

Overweight adolescent patients with curve progression

Patients unable to cope emotionally with treatment

Thoracic lordosis

Skeletally immature patients

13. A 4-year-old boy is brought unconscious to the ED with a history of a motor vehicle accident.

Which of the following is true about paediatric spinal trauma?

Injury to the spinal cord can only happen with visible changes on rays and CT scan

CT scan is the investigation to diagnose injury to the cord and ligament injuries

Upper cervical trauma is more common in children younger than 8 years of age

The child should be immobilised on a standard spinal board

There can be a normal anterior translation between C5 and C6

14. A 30-year-old male ankylosing spondylitis patient with kyphosis needs a sagittal correction spinal procedure.

Which of the following statements correctly describes pedicle subtraction osteotomy?

Correction happens at the level of vertebral body and not the disc

It opens up the anterior column, closes the middle column somewhat and closes the posterior column

It is classically performed at T11/T12 vertebrae

It provides more correction than Smith-Petersen osteotomy and vertebral column resection

PSO is associated with fewer complications

15. All of the following are true about radiology in ankylosing spondylitis EXCEPT which answer?

50% of ankylosing spondylitis patients with fractures can have normal-looking x-rays

The earliest sign on pelvic x-rays is erosion on the iliac side of sacroiliac joint

Marginal syndesmophytes are present in the vertebrae

MRI is the modality for early detection of ankylosing spondylitis

Sacroiliac joint involvement is often asymmetric

16. A 40-year-old man visits a clinic, complaining of chronic back pain. There are no red flags on history and or abnormalities on examination.

Which of the following is the most appropriate method of treatment?

Acupuncture

Caudal epidural injection

Combined physical and psychological programmes

Lumbar corset or belt

Opioid analgesics

17. Which of the following statements about spine anatomy is true?

The cell bodies of the sympathetic nervous system are found in the lateral horn grey matter of spinal cord segments T7–T9

The preganglionic sympathetic preganglionic cell bodies lie in sacral segments S2, S3, S4

The C8 nerve exits the foramen superior to the pedicle of C7

The inferior limit of the spinal cord in adults is L1 or L2

The inferior limit of the dural sac and subarachnoid space is the L2 vertebra

18. A 30-year-old man has been brought to the ED after a motor vehicle accident. He appears drowsy and a trauma CT shows a small contusion in the brain with 50% subluxation of the C67 vertebrae. He has triple immobilisation in place. He is also seen by neurosurgeons who say he is able to undergo any cervical procedures.

The most appropriate next step in management of this patient is which of the following?

Anterior cervical fusion

Cervical orthosis for 6 weeks

Immediate closed reduction of the subluxation

MRI scan

Posterior cervical fusion

19. A patient with T4 spinal cord injury and paraplegia is not likely to have which of the following complications?

Autonomic dysreflexia

Major depressive episode

Orthostatic hypertension

Urosepsis

Venous thromboembolism

20. Which of the following pelvic parameters does not change on posture?

Lumbar lordosis

Pelvic incidence

Pelvic tilt

Sacral slope

Sagittal vertical axis

21. Which of the following is true regarding lumbar lordosis?

It is increased in patients with lytic spondylolisthesis

It is greater in proximal lumbar levels

It does not alter with posture

It is is linked with pelvic incidence

It should never be corrected in a patient with flat back syndrome

22. A 13-year-old boy with a background of cerebral palsy presents with the deformity as depicted in sitting spinal radiographs (Figure 9.2).

Figure 9.2 Sitting radiographs spine

Which of the following statements is true regarding this type of scoliosis?

It usually presents later than most cases of idiopathic scoliosis

It responds well to orthotic treatment

Surgical treatment is rarely needed

It tends to exhibit longer curves as compared to idiopathic scoliosis

It is less likely to progress in severity

23. A 15-year-old boy presents with Duchenne’s muscular dystrophy. He has a scoliotic curve measuring 35 degrees with apex at T11 and pelvic obliquity.

Which of the following is the most appropriate next step in management?

Bracing

Combined anterior and posterior fusion

Long segment posterior fusion

Observation

Short segment posterior fusion

24. Which of the following is not a criterion for recommending surgery for thoracolumbar burst fractures?

CT evidence of canal compromise with no neurology

Disruption of posterior column

Greater than 50% loss of vertebral body height

Inability to immobilise patient in brace due to associated injuries

Kyphosis greater than 25–30 degrees at the level of fracture

25. Which of the following is true regarding compression fractures of the thoracic or lumbar spine?

More than 40–50% loss of anterior body height may be considered as unstable

There is break of posterior aspect of the vertebral body on lateral x-rays

There is loss of posterior body height on lateral x-rays

There is widening of the pedicles on AP x-rays

X-rays alone can differentiate them from burst fractures

26. Which of the following is not a component of Thoracolumbar Injury Classification and Severity (TLICS) score for thoracolumbar fractures?

Canal compromise on axial CT scan

Injury morphology

MRI signal change in region of interspinous ligaments.

Neurology

Widening of interspinous distance

27. A 36-year-old man is involved in a motor vehicle accident. He is a seat belt–restrained car passenger. He sustains a flexion distraction type of injury of the thoracolumbar spine.

Which of the following is true about this injury?

It will always need surgical stabilisation.

Injury pattern is always through posterior ligamentous complex, facet capsules and intervertebral discs

It will involve the middle and posterior column of the spine

There is a low incidence of intra-abdominal injuries

Progressive kyphosis is a known complication in unrecognised injuries

28. Which of the following is not a cause of myelopathy?

Bilateral cervical facet dislocation

Prolapsed cervical disc

Multiple sclerosis

Myasthenia gravis

Vitamin B₁₂ deficiency

29. A 70-year-old man with a background of poorly controlled diabetes and prostate cancer with skeletal metastases presents with gait disturbances. There are no abnormalities in upper limb examination, but he has brisk lower limb reflexes and upgoing plantar reflex.

Which of the following is most likely to explain his findings and will need to be investigated further?

Brain metastases

Cervical spondylotic myelopathy

Lumbar spine metastases

Peripheral neuropathy

Thoracic spine metastases

30. Which of the following levels is most likely to be injured following trauma in adults?

Lower cervical spine

Lumbosacral spine

Thoracic spine

Thoracolumbar spine

Upper cervical spine

31. Return of the bulbocavernous reflex after spinal trauma could mean which of the following?

Complete spinal cord lesion

Incomplete spinal cord lesion

Neurogenic shock

Reversal of spinal shock

Sacral nerve root injury

32. A 40-year-old man is brought to the ED with a history of a heavy object falling on his head while performing construction work. He was wearing a helmet and had no signs or symptoms of head injury. He complains of neck pain and is in a collar. He has no neurology. CT scan confirms anterior and posterior arch fracture. Open mouth view x-ray shows a combined lateral displacement of 5mm.

Which of the following is true regarding this injury?

There is a high risk of associated spinal injury at another level

It is associated with a high risk of neurological injury

It is an unstable injury

Patient needs surgery in the form of C12 or occipitocervical fusion

Transverse and alar ligaments are ruptured in this case

33. Which of the following is true regarding a hangman’s fracture?

May be due to unilateral fracture of pars interarticularis

Is traumatic posterior spondylolisthesis of C2

Always unstable injury

High incidence of neurological injury

Caused by hyperextension with secondary flexion

34. A 30-year-old rugby player gets involved in a tackle. He complains of unilateral pain along C5 and C6 dermatomes along with transient weakness of deltoid and biceps, with normal cervical range of motion.

Which of the following fits this pattern of injury?

Brachial plexus axonotmesis

Cervical disc herniation

Cervical fracture

Scapula fracture

Stinger

35. Which of the following mechanisms is the least likely injury pattern responsible for stinger or burner?

Axial compression of the cervical spine

Direct blow to a point just above the clavicle

Hyperextension, compression and rotation towards the involved arm

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