Full Question & Answer Text (for Search Engines)
Question 1:
When an osteoblastoma occurs in the spine, it can involve all of the following except:
Options:
- Facets
- Transverse processes
- Pedicles
- Lamina
- Vertebral body
Correct Answer: Vertebral body
Explanation:
When an osteoblastoma occurs in the spine, involvement of the posterior elements of the vertebra is typical and includes: Lamina Pedicles Transverse processes Facets Rib heads adjacent to thoracic vertebrae
Question 2:
The proper treatment of a vertebral osteoblastoma includes:
Options:
- Chemotherapy
- En-bloc resection
- Marginal excision/curettage of the tumor
- Radiation
- Radiofrequency ablation
Correct Answer: Chemotherapy
Explanation:
Treatment of spinal osteoblastomas usually consists of marginal excision or curettage of the tumor. Local recurrence rates of up to 10% have been observed from some osteoblastomas, however, malignant degeneration is rare. There is no role for radiation or chemotherapy. Radiofrequency ablation has been used successfully for the treatment of osteoid osteomas, but not osteoblastomas.C orrect Answer: Marginal excision/curettage of the tumor
Question 3:
Typical histologic features of an osteoblastoma include all of the following except:
Options:
- Vascularized spindle cell stroma
- Nidus composed of haphazardly arranged network of osteoid trabeculae
- Occasional areas of aneurysmal bone cyst formation
- Osteoblasts rimming the trabeculae
- C hondrocytes arranged in a zonal pattern
Correct Answer: C hondrocytes arranged in a zonal pattern
Explanation:
Histologically osteoblastoma is similar to an osteoid osteoma; its features include: Irregular osteoid arranged haphazardly with rimming by round osteoblasts Loose fibrovascular connective tissue between trabeculae Osteoblasts rimming the trabeculae Vascularized spindle cell stroma Areas of aneurysmal bone cyst formation can be seen
Question 4:
What percentage of osteoblastomas occur in the spine:
Options:
- 20% to 30%
- 30% to 40%
- 40% to 50%
- 50% to 60%
- 60% to 70%
Correct Answer: 40% to 50%
Explanation:
Osteoblastomas are: Osteoblastic bone-forming lesions measuring more than 2 cm in size characterized by marked growth potential Similar in histology and presentation to osteoid osteoma with the main difference being the size of the tumor Most common in the 2nd and 3rd decades of life Twice as common in men than in women Common in the spine: Spinal osteoblastomas account for 40% to 45% of all osteoblastomas Over half of spinal osteoblastomas occur in the lumbar spine
Question 5:
Primary spinal tumors account for:
Options:
- 0.4% of all tumors and 1% of all bone tumors
- 0.4 % of all tumors and 10% of all bone tumors
- 0.4 % of all tumors and 25% of all bone tumors
- 0.04% of all tumors and 10% of all bone tumors
- 0.04 % of all tumors and 25% of all bone tumors
Correct Answer: 0.4% of all tumors and 1% of all bone tumors
Explanation:
Neoplasms of the spine can be broadly categorized into metastatic tumors and primary tumors. Primary spinal tumors are rare and account for 0.04% of all tumors and 10% of all bone tumors.
Question 6:
Pain is the most common complaint in patients presenting with a primary spine tumor and is present in which percentage of patients:
Options:
Correct Answer: 85%
Explanation:
I. Pain is the most common complaint in patients presenting with a primary spine tumor A. Present in up to 85% of patients B. Typically localized to the site of lesion but can be radicular C . C haracterized as: 1. Progressive 2. Gradual in onset 3. Worse at night 4. Non-mechanical D. Loosely associated with trauma II. Weakness can be seen in up to 42% of patients III. Mass is evident in up to 16% of patients IV. Three percent of patients are asymptomatic V. Other symptoms can include: A. Sensory loss B. Loss of sphincter control
Question 7:
Patients presenting with a primary spine tumor most often characterize their pain as:
Options:
- Constant, sudden in onset, worse at night, mechanical, and loosely associated with trauma
- Constant, gradual in onset, worse at night, non-mechanical, and loosely associated with trauma
- Progressive, gradual in onset, worse at night, non-mechanical, and loosely associated with trauma
- Progressive, sudden in onset, worse at night, mechanical, and loosely associated with trauma
- Progressive, gradual in onset, worse at night, mechanical, and loosely associated with trauma
Correct Answer: Progressive, gradual in onset, worse at night, non-mechanical, and loosely associated with trauma
Explanation:
I. Pain is the most common complaint in patients presenting with a primary spine tumor A. Present in up to 85% of patients B. Typically localized to the site of lesion but can be radicular C . Characterized as: 1. Progressive 2. Gradual in onset 3. Worse at night 4. Non-mechanical a. Loosely associated with trauma D. Weakness can be seen in up to 42% of patients E. Mass is evident in up to 16% of patients F. Three percent of patients are asymptomatic G. Other symptoms can include: 1. Sensory loss 2. Loss of sphincter control
Question 8:
What percentage of trabecular bone must be destroyed before changes can be seen on plain radiographs:
Options:
- 20% to 40%
- 30% to 50%
- 40% to 60%
- 60% to 80%
- 70% to 90%
Correct Answer: 30% to 50%
Explanation:
I. Imaging studies used most frequently in the diagnosis of primary spine tumors include: A. Plain radiographs 1. Initial imaging study 2. Recommended for any patient with prolonged back pain (>6 weeks) 3. Identify 30% to 70% of spine tumors at presentation 4. Early lesions difficult to detect because 30% to 50% of trabecular bone must be destroyed before changes can be seen 5. Absence of the pedicle is usually the earliest radiographic sign of vertebral 6. Cortical bone loss easier to detect than destruction of trabecular bone 7. "Winking owl" sign 8. Disk space generally preserved 9. Geographic lesions with well-circumscribed borders suggest a benign tumor 10. Permeative lesions suggest a malignant tumor B. Bone scan 1. Technetium (Tc)-99m 2. C an identify lesions 3 to 18 months before plain radiographs 3. Sensitivity 74%, specificity 81% 4. False negative in up to 60% of patients with multiple myeloma 5. Single photon emission computerized tomography scan can improve both sensitivity (87%) and specificity (91%) 6. When used in combination with gallium scanning, Tc-99 bone scan can help to differentiate between tumors and infections C . Computed tomography/myelography 1. Best test to determine extent of bony destruction 2. Important in surgical planning 3. Myelography usually used only when magnetic resonance imaging (MRI) not possible (danger of complete myelographic block) D. MRI 1. Modality of choice in evaluating tumors of the spine 2. Noninvasive 3. Allows direct visualization of entire spinal cord 4. Visualization of soft tissues 5. Sensitivity 92%, specificity 90% 6. Additional lesions in 20% to 24%, and 10% will have multiple levels of cord compression
Question 9:
Which of the following is considered to be a malignant primary spine tumor:
Options:
- Osteoblastoma
- Eosinophilic granuloma
- Giant cell tumor
- C hordoma
- Aneurysmal bone cyst
Correct Answer: C hordoma
Explanation:
I. Primary benign tumors of the spine are: A. Slow-growing B. Well-circumscribed C . Usually occur in patients younger than 21 years of age D. Involve the vertebral body and posterior elements of the spine 1. Overall slight predilection for the posterior elements 2. Location of tumor is an important factor in determining the type of tumor E. Examples include: 1. Osteochondroma 2. Osteoid osteoma 3. Osteoblastoma 4. Aneurysmal bone cyst 5. Giant cell tumor 6. Eosinophilic granuloma II. Primary malignant tumors of the spine are: A. Fast-growing B. Permeative C . Usually occur in patients older than 21 years of age D. Examples include: 1. Multiple myeloma/solitary plasmacytoma 2. Osteosarcoma 3. C hondrosarcoma 4. Ewing's sarcoma/primitive neuroectodermal tumor 5. Chordoma 6. Lymphoma
Question 10:
Which of the following tumors is considered to be a benign primary spine tumor:
Options:
- Osteosarcoma
- C hordoma
- Multiple myeloma
- Osteoblastoma
- Lymphoma
Correct Answer: Osteoblastoma
Explanation:
I. Primary benign tumors of the spine are: A. Slow-growing B. Well-circumscribed C . Usually occur in patients younger than 21 years of age D. Involve the vertebral body and posterior elements of the spine 1. Overall slight predilection for the posterior elements 2. Location of tumor is an important factor in determining the type of tumor E. Examples include: 1. Osteochondroma 2. Osteoid osteoma 3. Osteoblastoma 4. Aneurysmal bone cyst 5. Giant cell tumor 6. Eosinophilic granuloma II. Primary malignant tumors of the spine are: A. Fast-growing B. Permeative C . Usually occur in patients older than 21 years of age D. Examples include: 1. Multiple myeloma/solitary plasmacytoma 2. Osteosarcoma 3. C hondrosarcoma 4. Ewing's sarcoma/primitive neuroectodermal tumor 5. Chordoma 6. Lymphoma
Question 11:
Primary malignant tumors of the spine have which of the following characteristics:
Options:
- Slow-growing, well-circumscribed, and usually occur in patients older than 21 years of age
- Slow-growing, well-circumscribed, and usually occur in patients younger than 21 years of age
- Fast-growing, permeative, and usually occur in patients older than 21 years of age
- Fast-growing, permeative, and usually occur in patients younger than 21 years of age
- Fast-growing, permeative, and usually occur in patients older than 40 years of age
Correct Answer: Fast-growing, permeative, and usually occur in patients older than 21 years of age
Explanation:
I. Primary benign tumors of the spine are: A. Slow-growing B. Well-circumscribed C . Usually occur in patients younger than 21 years of age D. Involve the vertebral body and posterior elements of the spine 1. Overall slight predilection for the posterior elements 2. Location of tumor is an important factor in determining the type of tumor E. Examples include: 1. Osteochondroma 2. Osteoid osteoma 3. Osteoblastoma 4. Aneurysmal bone cyst 5. Giant cell tumor 6. Eosinophilic granuloma II. Primary malignant tumors of the spine are: A. Fast-growing B. Permeative C . Usually occur in patients older than 21 years of age D. Examples include: 1. Multiple myeloma/solitary plasmacytoma 2. Osteosarcoma 3. C hondrosarcoma 4. Ewing's sarcoma/primitive neuroectodermal tumor 5. C hordoma 6. Lymphoma
Question 12:
All of the following are elements of the lateral mass of cervical spinal segments except:
Options:
- Inferior articulating process
- Superior articulating process
- Spinous process
- Transverse process
- Transverse foramen
Correct Answer: Inferior articulating process
Explanation:
The lateral mass of the cervical spinal segments includes the inferior and superior articulating processes, the transverse foramen, and the transverse process. The spinous process is not an element of the lateral mass.C orrect Answer: Spinous process
Question 13:
Advantages of minimally invasive lumbar interbody fusion over traditional open interbody fusion include:
Options:
- Minimal muscle dissection and trauma
- Wider surgical exposure
- Better fusion rates
- Lowered risk of nerve root injury
Correct Answer: Minimal muscle dissection and trauma
Explanation:
Minimally invasive lumbar interbody fusion involves less muscle dissection and trauma than traditional open approaches. The surgical exposure is more limited, though, and there is no evidence to date of minimally invasive techniques providing better fusion rates or lowered risk of nerve root injury.
Question 14:
Which of the following statements is true regarding minimally invasive posterior lumbar interbody fusion:
Options:
- Minimally invasive fusion may only be safely performed with the assistance of endoscopy.
- Minimally invasive fusion has increased risk of nerve root injury.
- Internal fixation with pedicle screws is not possible via the minimally invasive approach.
- Intraoperative fluoroscopy if of great value in minimally invasive fusion.
Correct Answer: Minimally invasive fusion may only be safely performed with the assistance of endoscopy.
Explanation:
Intraoperative fluoroscopy or radiography is vital for the proper identification of lumbar level and vertebral structures in minimally invasive posterior lumbar interbody fusions. While endoscopic assistance has been well described as a method of minimally invasive fusion, it is not vital to this technique. There is no evidence of increased risk of nerve root injury with minimally invasive techniques, and it is possible to internally fixate the lumbar segment with pedicle screws through minimally invasive techniques.
Question 15:
A 21-year-old man presented to the emergency department after sustaining a low-velocity gunshot wound to his midback resulting in grade 0 (out of 5) weakness in his quadriceps and tibialis anterior muscles. His extensor hallucis longus and gastrocnemius/soleus muscles were grade 3 (out of 5) bilaterally. His sensation remained intact. An intradural bullet fragment was seen at T12. No fracture was seen on computed tomography (C T) scan. Management should consist of:
Options:
- Administration of methylprednisolone 30 mg/kg bolus followed by an infusion of 5.4 mg/kg for 24 hours.
- Application of a thoracolumbosacral orthosis (TLSO).
- Administration of broad-spectrum antibiotics for 14 days.
- Removal of the bullet fragment.
- Removal of the bullet fragment and instrumented fusion from T10 to L2.
Correct Answer: Removal of the bullet fragment.
Explanation:
In complete and incomplete lesions from T12 to L4, removal of the bullet fragment from the canal has been associated with significant motor recovery. This improvement is not seen in other regions of the spine. High-dose steroids have not been shown to offer improvement in patients with spinal cord injury after a gunshot wound, and the complications of high-dose steroids have been documented in this population. The majority of gunshot wounds to the spine are stable injuries. This patientâ s C T scan does not demonstrate any instability. Therefore, neither nonoperative (eg, TLSO bracing) nor operative (instrumented fusion) stabilization is indicated. While infection after transalimentary bullet wounds to the spine is a well-documented complication, this patientâ s injury was sustained from the back, thereby avoiding the alimentary canal and obviating the need for intravenous antibiotics.
Question 16:
In relation to the lumbar pedicle, the exiting nerve root is found:
Options:
- Immediately superior to the pedicle
- Immediately inferior to the pedicle
- At the midpoint between the superior and inferior level pedicles
- Nerve root has no anatomic relationship to the pedicle
- None of the above
Correct Answer: Immediately superior to the pedicle
Explanation:
The exiting nerve root is found traversing immediately inferior to the pedicle.
Question 17:
Regarding the anatomy of the lumbar pedicle, which of the following statements is true:
Options:
- The pedicle is located at the origin of the transverse process.
- The exiting nerve root is found immediately superior to the lumbar pedicle.
- The pedicle is located at the base of the superior facet, at the origin of the transverse process.
- The pedicle joins the vertebral body at its inferior border.
- There is no relationship between the pedicle and the superior facet.
Correct Answer: The pedicle is located at the origin of the transverse process.
Explanation:
The lumbar pedicle is the bony bridge that connects the posterior vertebral elements to the anterior body. The pedicle is located at the base of the superior facet, at the origin of the transverse process. The exiting nerve root traverses immediately inferior to the superior segment pedicle, and the pedicle joins the vertebral body at its superior half.
Question 18:
Which of the following serves as the best landmark for proper screw entry into the lumbar pedicle:
Options:
- The junction of the transverse process and inferior facet
- The junction of the transverse process and superior facet
- The articulating interface of the superior and inferior facets
- The medial border of the superior facet
- There is no relationship between the nerve root and the superior facet.
Correct Answer: The junction of the transverse process and inferior facet
Explanation:
The junction of the transverse process and the inferior facet represents the most appropriate entry point of the pedicle screw. This junction directly overlies the pedicle and ensures safe placement through the pedicle and into the vertebral body.
Question 19:
A potential major complication of lumbar pedicle screws is:
Options:
- Lateral screw breakout injuring the vertebral artery
- Lateral screw breakout injuring the exiting nerve root
- Medial screw breakout injuring the vertebral artery
- Medial screw breakout injuring the exiting nerve root
- Medial screw breakout causing vertebral fracture
Correct Answer: Medial screw breakout injuring the vertebral artery
Explanation:
The exiting nerve root traverses immediately medial then caudal to the lumbar pedicle. Therefore, a screw that breaks out medially or inferiorly from the pedicle is a potential risk to the nerve root.
Question 20:
Common indications for lumbar pedicle screw fixation include:
Options:
- Rigid stabilization for patients undergoing arthrodesis or interbody fusion
- Correction of lumbar spinal deformity
- Stabilization after trauma to the lumbar spine
- Rigid stabilization for patients undergoing arthrodesis or interbody fusion, and correction of lumbar spinal deformity
- Rigid stabilization for patients undergoing arthrodesis or interbody fusion, correction of lumbar spinal deformity and stabilization
Correct Answer: Rigid stabilization for patients undergoing arthrodesis or interbody fusion
Explanation:
after trauma to the lumbar spine Common indications for pedicle screw fixation include rigid stabilization for patients undergoing arthrodesis or interbody fusion, correction of deformity, and stabilization after trauma.
