Full Question & Answer Text (for Search Engines)
Question 1:
Which of the following statements concerning neck pain is incorrect:
Options:
- Patients with traumatic neck injury and pain must be stabilized and assessed with a full neurologic examination while immobilized.
- Elderly patients may have symptoms of traumatic neck injury without a history of trauma.
- Rest, physical therapy, and prolonged immobilization of the neck with a collar are effective in managing patients with neck pain.
- Surgery for neck pain may be indicated for patients with a cervical spine fracture with evidence of instability, neoplastic disorders, spinal stenosis, and nerve root compression.
- Rest and physical therapy
Correct Answer: Patients with traumatic neck injury and pain must be stabilized and assessed with a full neurologic examination while immobilized.
Explanation:
Choices A, B, D, and E are correct and are important considerations with managing a patient with neck pain. Rest and physical therapy are important and effective in treating neck pain. Prolonged immobilization of the neck with a collar, however, can result in deconditioning of the cervical paraspinal musculature, which can increase the patientâ s risk for further neck injury.
Question 2:
Schmorlâ s nodes may be seen on radiographic studies in all of the following disorders except:
Options:
- Spina bifida
- Scheuermannâ s kyphosis
- Degenerative disk disease
- Trauma
- Osteoporosis
Correct Answer: Spina bifida
Explanation:
Schmorls nodes are seen in association with several disorders including Scheuermanns kyphosis, degenerative disk disease, trauma, and osteoporosis. Schmorlâ s nodes are not commonly seen in patients with spina bifida.
Question 3:
All of the following are possible treatments for congenital or acquired torticollis except:
Options:
- No treatment because spontaneous resolution is possible in cases of congenital torticollis
- Active and passive stretching therapies in patients with congenital torticollis until puberty
- Holding infants so that chin is rotated toward the affected side
- Physical therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) and use of a soft collar
- Use botulinum toxin, hard collars, or braces in severe cases
Correct Answer: Active and passive stretching therapies in patients with congenital torticollis until puberty
Explanation:
Several treatment options exist for congenital and acquired torticollis. In very mild cases of congenital torticollis, the deformity may be self-limited and no therapy needs to be administered. Sometimes active and passive stretching of the neck can work well if performed before 1 year of life. Parents may hold the babys head so that the chin is rotated toward the affected side. Acquired torticollis can also be managed by physical therapy using NSAIDs and a soft collar. The use of botulinum toxin or braces can be a form of therapy in recalcitrant cases.
Question 4:
What is the incidence of congenital torticollis in the general population:
Options:
- 0.1% to 0.3%
- 0.5% to 0.8%
- 0.3 to 1.0%
- 0.3% to 1.9%
- 2% to 5%
Correct Answer: 0.3% to 1.9%
Explanation:
Epidemiological studies have shown that the incidence of congenital torticollis is approximately 0.3% to 1.9% in the general population.
Question 5:
Which of the following is a contraindication to kyphoplasty:
Options:
- Local osteomyelitis
- Osteoblastic lesions
- Sepsis
- Bleeding diathesis
- All of the above
Correct Answer: All of the above
Explanation:
It is important to properly evaluate a patient prior to any surgical procedure. If a patient presents with osteomyelitis, osteoblastic lesions, sepsis, or bleeding diathesis, then surgery should be postponed until the underlying condition is corrected.
Question 6:
Approximately how many vertebral compression fractures occur in the United States annually:
Options:
- 70,000
- 500,000
- 700,000
- 1 million
- 1.5 million
Correct Answer: 70,000
Explanation:
There are approximately 700,000 reported vertebral compression fractures annually in the United States.
Question 7:
It is important to distinguish between acute or subacute vertebral compression fractures and old healed fractures radiographically. Which of the following can help distinguish an acute fracture from a chronic fracture:
Options:
- T1-weighted magnetic resonance image (MRI)
- T2-weighted MRI
- Fat-suppressed T2-weighted MRI
- Dual energy X-ray absorptiometry (DEXA) scan
- C omputed tomography (C T)
Correct Answer: T2-weighted MRI
Explanation:
One can distinguish an acute or subacute vertebral compression fracture from an old, healed fracture by evaluating the fatsuppressed T2-weighted MRI or short tau inversion recovery (STIR) images. These images will show increased signal intensity suggesting an acute fracture. All of the other forms of imaging mentioned may also be used to evaluate the patient but are not the best techniques for differentiating an acute from a subacute fracture. DEXA scans are used to evaluate for osteoporosis. Although CT imaging provides excellent osseous detail, it may not allow for differentiation of an acute from a chronic fracture unless evidence of fracture healing is seen. Another method for evaluating the acuity of a vertebral compression fracture is a threephase bone scan, which will demonstrate increased radiotracer activity at the site of an acute or subacute fracture.
Question 8:
What is the prevalence of Schmorls nodes in the general population:
Options:
Correct Answer: 10%
Explanation:
Approximately 10% of the population has Schmorlâ s nodes, which are often completely benign.
Question 9:
A 34-year-old man presents to the emergency department after sustaining a low-velocity gunshot wound to the upper back. Radiologic studies reveal bullet fragments scattered throughout the T6 to T8 levels. No evidence of instability is present on conventional radiographs and computed tomography. The patient was stabilized and a full neurologic examination was performed, revealing no major neurologic deficits. Management of this patient should consist of:
Options:
- Removal of the bullet fragments from the T6 to T8 vertebral bodies
- Removal of the bullet fragments from the T6 to T8 vertebral bodies and instrumented fusion from T4 to T10
- High-dose intravenous methylprednisolone administration for 24 hours
- Broad-spectrum antibiotic administration for 7 days
- Nonoperative treatment (eg, thoracolumbosacral bracing) and regular observation for progression of any neurologic deficits
Correct Answer: Nonoperative treatment (eg, thoracolumbosacral bracing) and regular observation for progression of any neurologic deficits
Explanation:
Removal of the bullet fragments from the T6 to T8 levels is not indicated because the patient does not have neurologic deficits and therefore does not require spinal cord decompression via bullet removal. Decompression via bullet removal for neural deficits in the thoracic spine has been shown to result in higher rates of complications compared with nonoperative management. High-dose steroid administration is not indicated in patients with gunshot wounds to the spine because the benefits of steroids are outweighed by the risks. The administration of broad-spectrum antibiotics is not indicated in this patient because the bullet did not pass through the gastrointestinal tract. Nonoperative management and regular observation for progression of neurologic deficits is important in this patient because of the localization of the bullet fragments to the thoracic spine, the lack of neurologic deficits, and the lack of instability.
Question 10:
A patient with slipped capital femoral epiphysis (SC FE) should have an endocrine workup if presenting with which of the following features:
Options:
- Bilateral involvement
- Body mass index greater than the 95th percentile for age
- Age <10 or >15 years
- Negative family history
- Female gender
Correct Answer: Age <10 or >15 years
Explanation:
Endocrine workup is only indicated for age ,10 or .15 years, or stature less than the 10th percentile. Bilaterality, obesity, and negative family history are common findings in idiopathic SC FE. Although SC FE is more common in males, it is not uncommon in females.
Question 11:
Occipitocervical fusion is often technically difficult in patients with rheumatoid arthritis due to all of the following reasons except:
Options:
- Reduced bone quality
- Subaxial cervical instability
- Persistent steroid use
- Occipital condyle fracture
- Frequent combination of both occipitocervical deformity and subaxial subluxation necessitating more extensive constructs
Correct Answer: Occipital condyle fracture
Explanation:
Reduced bone quality is common in patients with rheumatoid arthritis. Steroid use may contribute to poor bone quality, impair bony fusion, and impede wound healing. The combination of occipitocervical deformity and subaxial subluxation may make individual patient constructs more extensive.
Question 12:
The majority of studies confirm the presence of atlanto-axial subluxation (AAS) when:
Options:
- Anterior atlantodental intervals (AADI) > 0 mm or posterior atlantodental intervals (PADI) < 18 mm
- AADI > 1 mm or PADI ≤ 14 mm
- AADI > 2 mm or PADI ≤ 16 mm
- AADI > 3 mm or PADI ≤ 14 mm
- AADI > 4 mm or PADI ≤ 18 mm
Correct Answer: AADI > 3 mm or PADI ≤ 14 mm
Explanation:
As described by Puttlitz and colleagues, AAS is defined as an AADI greater than 3 mm or a PADI less than 14 mm.
Question 13:
The most common traumatic indications for occipitocervical fusion include type III occipital condyle fractures and:
Options:
- Basilar invagination
- Atlanto-axial subluxation
- Odontoid fracture
- Atlanto-axial dissociation
- C 1-C 2 instability
Correct Answer: Atlanto-axial subluxation
Explanation:
Basilar invagination and atlanto-axial subluxation are more commonly present in degenerative disorders and less in trauma. Odontoid fractures are usually treated via C 1-C 2 fusion or odontoid screw fixation, although less commonly occipitocervical fusion is required. C 1-C 2 instability, similarly, is usually treated via C 1-C 2 stabilization. A more common traumatic indication for occipitocervical fusion is atlanto-axial dissociation.
Question 14:
Occipitocervical fusion is indicated in all of the following situations except:
Options:
- Diseased C 1-C 2 facet joints
- C 1-C 2 instability with decompressive laminectomy
- C 1-C 2 instability with intact posterior arch of the atlas
- C 1-C 2 instability with fractured posterior arch of the atlas
- Atlanto-occipital instability
Correct Answer: C 1-C 2 instability with decompressive laminectomy
Explanation:
An unstable C 1-C 2 segment, with intact posterior elements, may be treated via a C 1-C 2 fusion. If decompression is necessary or the posterior elements at C 1-C 2 are involved, then extension to the occiput may be necessary.
Question 15:
Approximately what percentage of individuals with rheumatoid arthritis will develop basilar invagination:
Options:
Correct Answer: 1%
Explanation:
As per Sandhu and researchers, approximately 11% of patients with rheumatoid arthritis will eventually develop basilar invagination.
Question 16:
Which approach(es) will provide access to the middle and anterior columns of the thoracic spine:
Options:
- Posterior
- Anterior (thoracotomy)
- Anterior and posterolateral (costotransversectomy)
- Interlaminar
- None of the above
Correct Answer: Anterior and posterolateral (costotransversectomy)
Explanation:
The anterior and posterolateral approaches provide access to the vertebral body (the anterior and middle columns of the spine) for performance of a corpectomy procedure, for example.
Question 17:
A 30-year-old man underwent an anterior lumbar discectomy and fusion at L4-L5 and L5-S1 through an anterior retroperitoneal approach 1 month ago. He now reports that he is unable to obtain and maintain an erection. The most likely cause of this condition is:
Options:
- Disruption of the sympathetic nerves during anterior lumbar exposure
- Traction on the parasympathetic nerve at the L4-L5 level
- Not related to the surgical dissection
- Injury to the pudendal nerves in the anterior sacral region during dissection at the L5-S1 level
- Sexual dysfunction secondary to retrograde ejaculation
Correct Answer: Not related to the surgical dissection
Explanation:
Sexual dysfunction is a common condition after extensive anterior lumbar surgical dissection. Erectile dysfunction is often nonorganic but may be related to parasympathetic injury. The parasympathetic nerves are deep in the pelvis at the level of S2-S3 and S3-S4 and are not usually involved in the surgical field for anterior L4-L5 and L5-S1 procedures. Retrograde ejaculation is the result of injury to the sympathetic chain on the anterior surface of the major vessels crossing the L4-L5 level and at the L5-S1 interspace. Erectile function and orgasm are not affected by sympathetic injury. The pudendal nerve is primarily a somatic nerve and is not located in the surgical field.
Question 18:
What percentage of patients with cervical myelopathy living in North America exhibit ossification of the posterior longitudinal ligament:
Options:
Correct Answer: 5%
Explanation:
Although ossification of the posterior longitudinal ligament is considered most common in the Japanese population, 25% of North Americans with cervical myelopathy exhibit signs of this condition.
Question 19:
A 46-year-old patient with cervical myelopathy undergoes a multilevel posterior cervical laminectomy from C 3 to C 7. The risk of post laminectomy kyphosis is greatest with removal of which of the following structures:
Options:
- More than 80% of the lamina
- More than 50% of each facet joint
- Interspinous ligament
- Facet joint capsules
- Ligamentum flavum
Correct Answer: More than 50% of each facet joint
Explanation:
Post laminectomy kyphosis is often seen in patients who have removal of more than 50% of each facet joint or 100% of one facet joint. It is not commonly seen with removal of the ligamentum flavum or interspinous ligament. Less frequently, post laminectomy kyphosis is seen with removal of more than 80% of the lamina or excision of the facet joint capsules.
Question 20:
Which of the following variables is the most reliable predictor of poor outcome following arthroscopic debridement of an arthritic knee:
Options:
- Presence of mechanical symptoms
- Outerbridge grade IV chondromalacia
- Varus malalignment
- Patient age
- Duration of symptoms
Correct Answer: Varus malalignment
Explanation:
The presence of mechanical symptoms is a reliable predictor of successful outcome. Age has not been shown to reliably predict outcome following knee debridement. Although a prolonged duration of symptoms correlates with poor outcome, the presence of varus malalignment has a far more dismal prognosis.
