Spinal fusion procedures US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Spinal fusion procedures. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Spinal fusion procedures US Medical PG Question 1: A 14-year-old girl is brought to the physician for a follow-up examination. She has had frequent falls over the past two years. During the past six months, the patient has been unable to walk or stand without assistance and she now uses a wheelchair. Her mother was diagnosed with a vestibular schwannoma at age 52. Her vital signs are within normal limits. Her speech is slow and unclear. Neurological examination shows nystagmus in both eyes. Her gait is wide-based with irregular and uneven steps. Her proprioception and vibration sense are absent. Muscle strength is decreased especially in the lower extremities. Deep tendon reflexes are 1+ bilaterally. The remainder of the examination shows kyphoscoliosis and foot inversion with hammer toes. This patient is most likely to die from which of the following complications?
- A. Aspiration pneumonia
- B. Leukemia
- C. Renal cell carcinoma
- D. Heart failure (Correct Answer)
- E. Posterior fossa tumors
Spinal fusion procedures Explanation: ***Heart failure***
- This patient's presentation with progressive ataxia, nystagmus, dysarthria, kyphoscoliosis, foot deformities, sensory deficits, and decreased deep tendon reflexes is highly suggestive of **Friedreich ataxia**.
- **Cardiomyopathy** and **congestive heart failure** are the leading causes of death in patients with Friedreich ataxia, affecting approximately 60% of patients and often leading to premature mortality.
*Aspiration pneumonia*
- While patients with **neurological deficits** like dysarthria and ataxia are at increased risk for aspiration, it is not the most common or direct cause of death in Friedreich ataxia compared to cardiac complications.
- Aspiration pneumonia is a serious complication, but **cardiac involvement** typically dictates the prognosis and survival in this condition.
*Leukemia*
- There is **no established link** between Friedreich ataxia and an increased risk of developing leukemia.
- The patient's symptoms are characteristic of a primary neurological and systemic disorder, not a hematological malignancy.
*Renal cell carcinoma*
- This type of cancer is **not associated** with Friedreich ataxia.
- The presented symptoms do not point towards any renal pathology or an increased risk for renal cell carcinoma.
*Posterior fossa tumors*
- While the mother had a vestibular schwannoma, which is a **posterior fossa tumor**, the patient's symptoms are not consistent with a tumor of the posterior fossa.
- The **progressive, diffuse neurological deficits** affecting both motor and sensory systems, along with systemic manifestations like kyphoscoliosis, are characteristic of a genetic ataxia rather than a focal tumor.
Spinal fusion procedures US Medical PG Question 2: A 23-year-old man complains of lower back pain that began approximately 6 months ago. He is unsure why he is experiencing this pain and notices that this pain is worse in the morning after waking up and improves with physical activity. Ibuprofen provides significant relief. He denies bowel and bladder incontinence or erectile dysfunction. Physical exam is notable for decreased chest expansion, decreased spinal range of motion, 5/5 strength in both lower extremities, 2+ patellar reflexes bilaterally, and an absence of saddle anesthesia. Which of the following is the most appropriate next test for this patient?
- A. HLA-B27
- B. Slit-lamp examination
- C. MRI sacroiliac joint
- D. Radiograph sacroiliac joint (Correct Answer)
- E. ESR
Spinal fusion procedures Explanation: **Radiograph sacroiliac joint**
- Plain **radiographs of the sacroiliac (SI) joints** are typically the **initial imaging modality** for suspected **ankylosing spondylitis** due to affordability and diagnostic value.
- They can reveal characteristic changes such as **sacroiliitis (joint erosion, sclerosis, fusion)**, which are common in early-stage disease.
*HLA-B27*
- While a **positive HLA-B27** is associated with ankylosing spondylitis, it is **not diagnostic** on its own, as many HLA-B27 positive individuals never develop the disease.
- Its use is more in **confirming suspicion** or in cases where imaging is equivocal, but it's not the primary diagnostic test.
*Slit-lamp examination*
- A slit-lamp examination is used to detect **uveitis**, which can be an **extra-articular manifestation** of ankylosing spondylitis.
- However, it is not a primary diagnostic test for the condition itself, and its utility arises once the diagnosis is strongly considered or established.
*MRI sacroiliac joint*
- **MRI of the sacroiliac (SI) joints** is more sensitive than radiographs for detecting **early inflammatory changes** (e.g., bone marrow edema) that may not be visible on plain films.
- However, given the duration of symptoms (6 months) and the characteristic inflammatory back pain, **radiographs are typically the first-line imaging** due to cost-effectiveness, reserving MRI for cases with normal radiographs but high clinical suspicion.
*ESR*
- **Erythrocyte sedimentation rate (ESR)** is a **non-specific marker of inflammation** and can be elevated in various inflammatory conditions, including ankylosing spondylitis.
- It is not diagnostic for ankylosing spondylitis and cannot differentiate it from other inflammatory or infectious conditions.
Spinal fusion procedures US Medical PG Question 3: A 57-year-old woman presents to her primary care physician with a concern for joint pain. She states that she often feels minor joint pain and morning stiffness in both of her hands every day, particularly in the joints of her fingers. Her symptoms tend to improve as the day goes on and she states they are not impacting the quality of her life. She lives alone as her partner recently died. She smokes 1 pack of cigarettes per day and drinks 2-3 alcoholic drinks per day. Her last menses was at age 45 and she works at a library. The patient has a history of diabetes and chronic kidney disease with her last GFR at 45 mL/min. Her temperature is 97.5°F (36.4°C), blood pressure is 117/58 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical examination is within normal limits. Which of the following interventions is appropriate management of future complications in this patient?
- A. Methotrexate
- B. Ibuprofen
- C. Prednisone
- D. Alendronate (Correct Answer)
- E. Infliximab
Spinal fusion procedures Explanation: ***Alendronate***
- This patient, a 57-year-old postmenopausal woman with **early menopause (age 45)**, **smoking**, **alcohol use**, and **chronic kidney disease**, is at **significantly increased risk for osteoporosis**. Alendronate, a **bisphosphonate**, is an appropriate intervention to prevent future osteoporotic fractures.
- While her joint pain is likely **osteoarthritis** and currently mild, the question targets **future complication management**, highlighting her significant risk factors for bone density loss.
- Her **GFR of 45 mL/min** (Stage 3a CKD) is at the lower acceptable range for bisphosphonate use; alendronate is generally avoided when GFR < 30-35 mL/min, but can be used with monitoring at GFR 45 mL/min given her high fracture risk.
*Methotrexate*
- Methotrexate is a **disease-modifying antirheumatic drug (DMARD)** typically used for inflammatory arthropathies like **rheumatoid arthritis** or **psoriatic arthritis**.
- The patient's symptoms (mild, improving with activity, no significant exam findings) are not consistent with an inflammatory arthritis requiring methotrexate, and her **chronic kidney disease** makes its use more complex due to renal elimination and toxicity risk.
*Ibuprofen*
- Ibuprofen, a **nonsteroidal anti-inflammatory drug (NSAID)**, could be used for symptomatic relief of her mild osteoarthritis.
- However, the question asks about **"future complications"** and her history of **chronic kidney disease** makes long-term NSAID use potentially harmful due to the risk of worsening renal function and increased cardiovascular risk.
*Prednisone*
- Prednisone is a powerful **corticosteroid** used for acute flares of inflammatory conditions or severe autoimmune diseases.
- Her current joint pain is mild and not indicative of an inflammatory process requiring prednisone; furthermore, long-term corticosteroid use is a significant **risk factor for osteoporosis**, which would worsen her already elevated fracture risk.
*Infliximab*
- Infliximab is a **biologic agent** (TNF-alpha inhibitor) used for severe, refractory inflammatory conditions such as **rheumatoid arthritis**, **ankylosing spondylitis**, or **inflammatory bowel disease**.
- Her symptoms are mild and do not suggest a severe inflammatory arthropathy that would warrant the use of a high-risk biologic medication, which also carries risks like increased infection susceptibility and significant cost.
Spinal fusion procedures US Medical PG Question 4: A 54-year-old man presents to his primary care physician for back pain. His back pain worsens with standing for a prolonged period of time or climbing down the stairs and improves with sitting. Medical history is significant for hypertension, type II diabetes mellitus, and hypercholesterolemia. Neurologic exam demonstrates normal tone, 5/5 strength, and a normal sensory exam throughout the bilateral lower extremity. Skin exam is unremarkable and dorsalis pedis and posterior tibialis pulses are 3+. Which of the following is the best next step in management?
- A. Surgical spinal decompression
- B. MRI of the lumbosacral spine (Correct Answer)
- C. Ankle-brachial index
- D. Radiography of the lumbosacral spine
- E. Naproxen
Spinal fusion procedures Explanation: ***MRI of the lumbosacral spine***
- The patient's symptoms of back pain worsening with standing/climbing downstairs and improving with sitting are classic for **neurogenic claudication** due to **lumbar spinal stenosis**.
- An **MRI** is the gold standard for visualizing the spinal canal, nerve roots, and any potential compression, providing the most detailed imaging to confirm the diagnosis and guide further management.
*Surgical spinal decompression*
- This is a definitive treatment option for severe **spinal stenosis** but should only be considered after a confirmed diagnosis and failed conservative management.
- Jumping straight to surgery without proper imaging and assessment of the severity would be premature and potentially unnecessary.
*Ankle-brachial index*
- This test is primarily used to diagnose **peripheral artery disease (PAD)**, which causes **vascular claudication**.
- While it's important to differentiate vascular from neurogenic claudication, the patient's symptoms (pain relief with sitting, no mention of exertional leg pain specifically) and normal pulses make vascular claudication less likely, and an MRI is more directly indicated for the suspected neurogenic cause.
*Radiography of the lumbosacral spine*
- While X-rays can show bone anomalies and degenerative changes like **osteophytes** and decreased disc space, they do not visualize soft tissues (spinal cord, nerve roots) or the extent of spinal canal narrowing.
- Therefore, X-rays are insufficient for diagnosing **spinal stenosis** and its impact on neural structures.
*Naproxen*
- **Naproxen**, an NSAID, can provide symptomatic relief for musculoskeletal pain but does not address the underlying structural issue of **spinal stenosis**.
- It would be a component of conservative management but not the definitive "next step" for diagnosing the cause of neurogenic claudication as described.
Spinal fusion procedures US Medical PG Question 5: A patient undergoes spinal surgery at the L4-L5 level. During the procedure, which of the following ligaments must be divided first to access the spinal canal?
- A. Nuchal ligament
- B. Anterior longitudinal ligament
- C. Supraspinous ligament
- D. Ligamentum flavum (Correct Answer)
Spinal fusion procedures Explanation: ***Ligamentum flavum***
- The **ligamentum flavum** connects the laminae of adjacent vertebrae and forms the posterior boundary of the spinal canal, making it the first ligament encountered anteriorly after removing the lamina.
- While performing a posterior approach **laminectomy**, the ligamentum flavum is typically divided or removed to gain access to the neural structures within the spinal canal.
*Nuchal ligament*
- The **nuchal ligament** is located in the cervical spine and provides attachment for muscles, extending from the external occipital protuberance to the spinous process of C7.
- It is not present at the **L4-L5 level** and therefore plays no role in lumbar spinal surgery.
*Anterior longitudinal ligament*
- The **anterior longitudinal ligament** runs along the anterior surfaces of the vertebral bodies and intervertebral discs.
- It would be encountered during an **anterior surgical approach** to the spine, not a posterior approach to access the spinal canal.
*Supraspinous ligament*
- The **supraspinous ligament** connects the tips of the spinous processes and is the most superficial ligament posteriorly.
- While it is incised during a posterior approach, it is **superficial to the lamina** and ligamentum flavum; therefore, the lamina and ligamentum flavum must be removed or divided first to access the canal.
Spinal fusion procedures US Medical PG Question 6: A 45-year-old man undergoes elective vasectomy for permanent contraception. The procedure is performed under local anesthesia. There are no intra-operative complications and he is discharged home with ibuprofen for post-operative pain. This patient is at increased risk for which of the following complications?
- A. Prostatitis
- B. Seminoma
- C. Testicular torsion
- D. Sperm granuloma (Correct Answer)
- E. Inguinal hernia
Spinal fusion procedures Explanation: **Sperm granuloma**
- A **sperm granuloma** can occur after vasectomy due to the extravasation of sperm from the severed vas deferens, leading to a foreign body granulomatous reaction.
- This complication presents as a **palpable, tender nodule** at the vasectomy site and is a relatively common long-term issue.
*Prostatitis*
- **Prostatitis** is an inflammation of the prostate gland, and there is no direct mechanistic link or increased risk following a vasectomy.
- It is typically caused by bacterial infection or non-infectious inflammatory processes, unrelated to the **vas deferens** ligation.
*Seminoma*
- **Seminoma** is a type of testicular germ cell tumor, and extensive research has shown no increased risk of developing testicular cancer after vasectomy.
- The procedure does not alter the cellular processes or environment within the testicles that predispose to germ cell tumor formation.
*Testicular torsion*
- **Testicular torsion** is a urological emergency involving the twisting of the spermatic cord, which cuts off blood supply to the testis.
- This condition is not associated with vasectomy; it typically occurs due to an anatomical abnormality (e.g., **bell-clapper deformity**) or trauma.
*Inguinal hernia*
- An **inguinal hernia** is a protrusion of abdominal contents through a weakness in the abdominal wall, specifically in the inguinal canal.
- Vasectomy is a superficial procedure that does not involve manipulating or weakening the abdominal wall in a way that would increase the risk of an inguinal hernia.
Spinal fusion procedures US Medical PG Question 7: A 57-year-old man presents to the ED complaining of back and left leg pain. He was lifting heavy furniture while helping his daughter move into college when all of sudden he felt a sharp pain at his back. The pain is described as severe, worse with movement, and shoots down his lateral thigh. The patient denies any bowel/urinary incontinence, saddle anesthesia, weight loss, or weakness. He denies any past medical history but endorses a family history of osteoporosis. He has been smoking 1 pack per day for the past 20 years. Physical examination demonstrated decreased sensation at the left knee, decreased patellar reflex, and a positive straight leg test. There is diffuse tenderness to palpation at the lower back but no vertebral step-offs were detected. What is the most likely etiology for this patient’s pain?
- A. Vertebral compression fracture
- B. Disc herniation at the L4/L5 vertebra
- C. Spinal metastasis from lung cancer
- D. Disc herniation at the L3/L4 vertebra (Correct Answer)
- E. Lumbar muscle sprain
Spinal fusion procedures Explanation: ***Disc herniation at the L3/L4 vertebra***
- The patient's symptoms of **acute back pain radiating down the lateral thigh** after lifting, combined with **decreased sensation at the left knee** and a **decreased patellar reflex**, are classic signs of L3/L4 nerve root compression.
- A **positive straight leg test** also supports nerve root irritation, and the absence of red flag symptoms like incontinence or saddle anesthesia makes a simple disc herniation more likely than other serious conditions.
*Vertebral compression fracture*
- While lifting heavy objects can cause compression fractures, these usually present with more **severe, localized pain** that is not typically radiating with specific dermatomal or reflex changes.
- Absence of **vertebral step-offs** or significant predisposing factors for a fracture (e.g., severe osteoporosis, trauma) makes this less likely given the specific neurological findings.
*Disc herniation at the L4/L5 vertebra*
- An L4/L5 disc herniation would typically cause symptoms related to the **L5 nerve root**, such as pain radiating down the **lateral leg into the foot**, **weakness in dorsiflexion of the ankle** or **big toe**, and potentially a **decreased medial hamstring reflex**.
- The patient's reported symptoms (lateral thigh pain, decreased knee sensation, decreased patellar reflex) are more consistent with **L4 nerve root** involvement.
*Spinal metastasis from lung cancer*
- Although the patient has a **smoking history** and could be at risk for lung cancer, this diagnosis typically presents with more **insidious onset** of unexplained back pain, often with **weight loss**, and sometimes with more profound neurological deficits or bone pain not relieved by rest.
- The acute onset after an inciting event and specific neurological findings of a single nerve root are less suggestive of metastasis.
*Lumbar muscle sprain*
- A muscle sprain would typically present with **localized back pain**, often worsened by movement, but would **not involve radicular pain** shooting down the leg, nor would it cause specific **neurological deficits** like decreased sensation or reflex changes.
- The positive straight leg test and neurological findings rule out a simple muscle sprain.
Spinal fusion procedures US Medical PG Question 8: A 22-year-old man is brought to the emergency department after he was impaled by a metal rod during a work accident. The rod went into his back around the level of T9 but was removed before arrival. He has no past medical history and does not take any medications. On physical examination, he has significant muscle weakness in his entire left lower body. He also exhibits impaired vibration and proprioception in his left leg as well as loss of pain and temperature sensation in his right leg. Which of the following sections of the spinal cord was most likely damaged in this patient?
- A. Posterior cord
- B. Anterior cord
- C. Left hemicord (Correct Answer)
- D. Central cord
- E. Right hemicord
Spinal fusion procedures Explanation: ***Left hemicord***
- The combination of **ipsilateral motor weakness** and **loss of vibration/proprioception** (damage to the **corticospinal tract** and **dorsal column**) along with **contralateral loss of pain/temperature** (damage to the **spinothalamic tract**) is the classic presentation of **Brown-Séquard syndrome**, which results from a lesion affecting one side (hemicord) of the spinal cord.
- The injury at **T9** is consistent with lower body symptoms, as tracts for the legs would be affected at this level.
*Posterior cord*
- Damage to the **posterior cord** primarily affects the **dorsal columns**, leading to **ipsilateral loss of vibration and proprioception**.
- It would not explain the **ipsilateral motor weakness** or the **contralateral loss of pain and temperature sensation**.
*Anterior cord*
- **Anterior cord syndrome** typically presents with **bilateral loss of motor function** (due to damage to the corticospinal tracts) and **bilateral loss of pain and temperature sensation** (due to damage to the spinothalamic tracts).
- **Vibration and proprioception** are usually preserved because the dorsal columns are spared.
*Central cord*
- **Central cord syndrome** most commonly results from hyperextension injuries, particularly in the cervical spine, affecting the central gray matter.
- It typically causes greater **weakness in the upper extremities** than the lower extremities and a variable sensory loss, often in a **"cape-like" distribution**.
*Right hemicord*
- A **right hemicord** lesion would cause **right-sided motor weakness** and **loss of vibration/proprioception**, along with **left-sided loss of pain/temperature sensation**.
- The patient's symptoms are on the **left side for motor/proprioception** and the **right side for pain/temperature**, indicating a left hemicord lesion.
Spinal fusion procedures US Medical PG Question 9: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?
- A. "Does the diarrhea typically precede the constipation, or vice-versa?"
- B. "Is the diarrhea foul-smelling?"
- C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
- D. "Are the symptoms worse in the morning or at night?"
- E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)
Spinal fusion procedures Explanation: ***Can you tell me more about the symptoms you have been experiencing?***
- This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis.
- In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions.
*Does the diarrhea typically precede the constipation, or vice-versa?*
- While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience.
- It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture.
*Is the diarrhea foul-smelling?*
- Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions.
- However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed.
*Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life*
- Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time.
- However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially.
*Are the symptoms worse in the morning or at night?*
- Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related.
- This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.
Spinal fusion procedures US Medical PG Question 10: A 63-year-old female with known breast cancer presents with progressive motor weakness in bilateral lower extremities and difficulty ambulating. Physical exam shows 4 of 5 motor strength in her legs and hyper-reflexia in her patellar tendons. Neurologic examination 2 weeks prior was normal. Imaging studies, including an MRI, show significant spinal cord compression by the metastatic lesion and complete erosion of the T12 vertebrae. She has no metastatic disease to the visceral organs and her oncologist reports her life expectancy to be greater than one year. What is the most appropriate treatment?
- A. Palliative pain management consultation
- B. Surgical decompression and postoperative radiotherapy (Correct Answer)
- C. High-dose corticosteroids and clinical observation
- D. Radiation therapy alone
- E. Chemotherapy alone
Spinal fusion procedures Explanation: ***Surgical decompression and postoperative radiotherapy***
- There is **spinal cord compression** by a metastatic lesion in a patient with a good prognosis (>1 year life expectancy) and rapidly progressive neurological deficits. **Surgical decompression** offers immediate relief of compression, while **postoperative radiotherapy** helps local tumor control.
- This combined approach is superior in preserving neurological function and improving quality of life for patients with **epidural spinal cord compression (ESCC)** in this clinical context.
*Palliative pain management consultation*
- While pain management is important in cancer care, this option alone does not address the **progressive neurological deficits** due to spinal cord compression.
- This patient's condition requires active treatment to prevent further neurological compromise and is not solely focused on comfort measures at this stage given her prognosis.
*Spinal dose corticosteroids and clinical observation*
- **Corticosteroids** can temporarily reduce edema around the spinal cord, but they do not resolve the mechanical compression caused by the eroded T12 vertebrae.
- **Clinical observation** without definitive intervention risks irreversible neurological damage given the rapid progression of symptoms.
*Radiation therapy alone*
- While radiation therapy is effective for local tumor control, it may not provide **rapid enough decompression** for acute or rapidly progressing neurological deficits due to significant mechanical compression.
- In cases of severe compression, such as bone erosion and cord involvement, surgery is usually needed prior to or in combination with radiation.
*Chemotherapy alone*
- **Chemotherapy** for breast cancer is a systemic treatment and may take time to reduce tumor burden, which is not suitable for urgent relief of **spinal cord compression**.
- It does not provide immediate mechanical decompression and is generally not the primary treatment for acute ESCC, especially with bone involvement.
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