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8
Pediatric Spine
Christopher Sy, Alexander Villahermosa, Jonathan Fisher,
Molly Farrell, Ryan McDermott, and Daniel Smerin
Question 1
A 6-month-old male child is referred to your clinic with a
dimple that the mother noticed on his lower back. There is
no obvious tract or drainage. It lies below the gluteal fold
and overlies the coccyx. On examination, the patient has no
other lesions and appears to have a grossly intact neuro-
logical exam for his age. The mother reports that he has been
meeting usual milestones. What is the next best step?
a. MRI
b. Ultrasound
c. CT
d. Observation
Preferred answer: (d) Observation [1]
Question 2
You were consulted on an 11-year-old female who was
found to have an intramedullary lesion at the level of T2.
The decision was made to undergo surgical biopsy/resection
while utilizing intra-operative neuromonitoring including
MEPs and SSEPs. As soon as you make a midline myelo-
tomy, the SSEPs bilaterally completely disappear. There are
no changes with MEPs. What is the next best step?
a. Abort the procedure and close the patient. Get a prompt
neurological exam and MRI.
b. Check positioning and vital signs. Ask anesthesia to
increase the patient’s mean arterial pressure.
c. Proceed with surgery as planned.
d. Perform additional laminectomies above the level of the
lesion due to concern for stenosis/compression.
Preferred answer: (c) Proceed with surgery as planned [2].
Question 3
The following radiographic findings in pediatric patients can
be considered normal variants EXCEPT for:
a. 3-year-old female.Anterior wedging of the vertebral bodies.
b. 4-year-old male. C1 lateral masses displaced up to 6mm
with respect to dens on open mouth x-ray.
c. 9-year-old female. Atlanto-dens interval up to 10mm on
lateral x-ray.
d. 6-year-old male. About 1mm anterior displacement of C2
on C3 on lateral x-ray.
Preferred answer: (c) 9-year-old female. Atlanto-dens
interval up to 10mm on lateral x-ray [3].
Question 4
A 10-year-old male presents to the ED with severe, wors-
ening low back pain and a grossly intact neurological exam.
CT scan demonstrates an expansile, radiolucent lesion
involving the left pedicle and vertebral body of L1. MRI
demonstrates fluid levels. What is the most likely diagnosis
and best course of treatment?
A. Villahermosa J. Fisher M. Farrell R. McDermott
D. Smerin
Department of Neurosurgery, University of Texas Health Science
Center at San Antonio, San Antonio, TX, USA
e-mail: villahermosa@uthscsa.edu
J. Fisher
e-mail: fisherj1@uthscsa.edu
M. Farrell
e-mail: farrelm1@uthscsa.edu
R. McDermott
e-mail: McDermottRA@uthscsa.edu
D. Smerin
e-mail: smerin@uthscsa.edu
C. Sy (&)
Department of Neurosurgery, Houston Methodist Sugar Land
Hospital, Sugar Land, TX, USA
e-mail: casy@houstonmethodist.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
C. Gragnaniello et al. (eds.), MCQs in Spine Surgery,
https://doi.org/10.1007/978-3-031-69332-8_8
149
a. Osteoid Osteoma: conservative management and
observation.
b. Aneurysmal Bone Cyst: curettage, high-speed burr,
electrocautery, phenolization.
c. Hemangioma: surgical excision.
d. Osteoblastoma: surgical excision and instrumented fusion.
Preferred answer: (b) Aneurysmal Bone Cyst: curettage,
high-speed burr, electrocautery, phenolization [4].
Question 5
A 4-year-old female presents to your clinic with a diagnosis
of tethered cord syndrome based on a recent MRI ordered by
her pediatrician. She is here for evaluation and to establish
multidisciplinary care. All of the following additional con-
sults are commonly needed for these patients EXCE PT:
a. Neurology: due to weakness and spasticity.
b. Urology: due to urinary dysfunction and fecal
incontinence.
c. Ophthalmology: due to papilledema.
d. Orthopedics: due to leg asymmetry and valgus deformity.
Preferred answer: (c) Ophthalmology: due to papilledem a
[5].
Question 6
There is a 15-year-old male with a history of cerebral palsy
at birth and known coronal and sagittal deformity that you
have been following with serial exams and imaging. He is
non-ambulatory at baseline and uses a wheelchair. What is a
commonly accepted indication for surgical intervention in
regard to this patient’s deformity?
a. Curvature progressing beyond 10 degrees
b. Curvature change of more than 5 degrees per year
c. Recurrent urinary tract infections
d. Inability to maintain upright posture and a comfortable
sitting position
Preferred answer: (d) Inability to maintain upright posture
and a comfortable sitting position [6].
Question 7
Myelomeningoceles are often associated with all of the
following EXCEPT:
a. Chiari I
b. Chiari II
c. Hydrocephalus
d. Paraplegia
Preferred answer: (a) Chiari I [7].
Question 8
The suboccipital triangle is made up of the obliquus capitis
superior, the rectus capitis posterior major, and the obliquus
capitis inferior. What important structure can be found
within it?
a. Cranial nerve XI
b. Vertebral artery
c. Occipital artery
d. C2 nerve root
Preferred answer: (b) Vertebral artery [8]
Question 9
The MOMS Trial (2011) demonstrated that there may be
potential benefits to prenatal treatment of myelomeningo-
celes. Which of the following was the significant finding?
a. Safer delivery with lower chance of complications
b. Reduction in rate of shunt insertion for hydrocephalus
c. Lower likelihood of developing a Chiari malformation
d. Preserved urinary/bowel function
Preferred answer: (b) Reduction in rate of shunt insertion
for hydrocephalus [9]
Question 10
All of the following radiographic findings are sugges tive of
atlanto-occipital dislocation (AOD) EXCEPT?
a. Basion-dens interval (BDI) > 15mm on lateral x-ray
b. Powers ratio > 1.0 on lateral x-ray
c. Condyle-C1 interval (CCI) > 4mm on CT
d. Atlanto-dens interval (ADI) > 1mm on CT
Preferred answer: (d) Atlanto-dens interval (ADI) > 1mm
on CT [10]
Question 11
A patient who had a baclofen pump for spasticity placed
years ago presents to the ED with worsening spasticity,
tachycardia, hyperthermia, and seizures. What is likely
happening and what is the best course of treatment?
150 C. Sy et al.
a. Baclofen overdose - > turn off pump, CSF aspiration,
ICU admission
b. Pump infection - > pan-cultures and broad-spectrum
antibiotics
c. Pump infection - > emergent OR for pump explantation
d. Baclofen withdrawal - > intrathecal administration of
baclofen
Preferred answer: (d) Baclofen withdrawal - > intrathecal
administration of baclofen [11]
Question 12
Pediatric patients with achondroplasia are more likely to
develop each of the following EXCEPT?
a. Spinal stenosis
b. Hydrocephalus
c. Foramen magnum stenosis
d. Recurrent spine fractures
Preferred answer: (d) Recurrent spine fractures [12]
Question 13
A 10-year-old female presents to the ED with worsening arm
weakness and inability to walk. She was found to have an
intramedullary spinal cord lesion at C4-C5. What is the most
likely diagnosis?
a. Meningioma
b. Neurofibroma
c. Astrocytoma
d. Myxopapillary ependymoma
Preferred answer: (c) Astrocytoma [13]
Question 14
An 8-year-old male with bilateral lower extremity weakness
was found to have a type 2 split cord malformation. What is
the primary goal of surgery in cases of progressive neuro-
logical deficit?
a. Repositioning both hemicords within the same dural
sleeve
b. Resection of the midline septum
c. Decompression via laminectomies or laminoplasties
d. Release of intradural arachnoid adhesions
Preferred answer: (b) Resection of the midline septum [14]
Question 15
Selective dorsal rhizotomy is a technique that is most
effective at which of the following:
a. Decreasing neuropathic type pain in the lower extremities
after trauma
b. Decrease in frequency of seizures in epilepsy patients
c. Decrease in spasticity in cerebral palsy patients
d. Decrease in urinary frequency in tethered cord patients
Preferred answer: (c) Decrease in spasticity in cerebral
palsy patients [15]
Question 16
A 2-year old child who was developing normally has
recently regressed and has only very weak movement in his
legs. He was found to have a spinal cord lipoma on MRI.
What is the primary goal of surgery for spinal cord lipomas
in patients with neurologic deficit?
a. Untethering of the spinal cord
b. Decompression and debulking of the lipoma only
c. Gross total resection of lipoma
d. Biopsy for diagnosis followed by adjuvant therapies
Preferred answer: (a) Untethering of the spinal cord [16]
Question 17
A child with cerebral palsy and severe spastic quadriparesis
presents to your clinic for evaluation and he is deemed a good
candidate for intrathecal baclofen pump placement. What is
the appropriate level shown to have the best efficacy?
a. C1-C2
b. C5-T2
c. T10-T12
d. L3-L4
Preferred answer: (b) C5-T2 [17]
Question 18
Primary neurulation, or the enfolding of the lateral edges of
the neural plate to form the neural tube, happens approxi-
mately at what time?
a. Days 14–18, forming the most caudal part of the neural
tube
8 Pediatric Spine 151
b. Days 18–28, forming the most rostral part of the neural
tube
c. Days 25–35, forming the most rostral part of the neural
tube
d. Days 10–15, forming the most caudal part of the neural
tube
Preferred answer: (b) Days 18–28, forming the most rostral
part of the neural tube [18]
Question 19
The pediatrics team calls you for an inpatient consult on a
newborn patient with a large cystic sac on the lumbar spine,
noticeable lower extremity weakness, and clubfeet. Of note,
the mother’s alpha fetoprotein was significantly elevated
during pregnancy. This is an example of what sort of spinal
dysraphism?
a. Primary neurulation
b. Secondary neurulation
c. Gastrulation
d. Resegmentation
Preferred answer: (a) Primary neurulation [19]
Question 20
A 4-year-old male is referred to your office after falling from
standing, with initial concern of a type 3 odontoid fracture.
The patient denies any neck pain and does not seem to be
acting abnormally. He has normal alignment on upright
imaging, and no evidence of instability of flexion/ extension
x-rays. What would you recommend as management?
a. Observation. This is a normal anatomical finding of a
non-ossified dentocentral synchondrosis
b. Repeat Xrays in 6 weeks
c. MRI of the cervical spine
d. Posterior cervical fixation
Preferred answer: (a) Observation. This is a normal
anatomical finding of a non-ossified dentocentral synchon-
drosis [20]
Question 21
The os terminale of the odontoid fuses by what age
approximately?
a. 3 years
b. 5 years
c. 9 years
d. 13 years
Preferred answer: (d) 13 years [20]
Question 22
A pediatric patient is referred to you with concern for dif-
ficulty swallowing and paresis of tongue movement. On
exam, the patient has a noticeably short neck, low hairline,
and decreased range of neck motion. Imaging demonstrates
basilar invagination and compression of the mesencephalon.
What is the likely diagnosis?
a. McArdle’s syndrome
b. Odontoid insufficiency
c. Down Syndrome
d. Klippel-Feil Syndrome
Preferred answer: (d) Klippel-Feil Syndrome [21]
Question 23
A 15 years old female presents for evaluation of her scol-
iosis. She states her grandmother also had scoliosis. On
exam, she has a rightward thoracic curve with mild cosmetic
deformity. She has noticed a worsening of her pain over the
last few years, however she describes the pain as mild. She
denies breathing issues. What is the first form of treatment
you would recommend?
a. Surgical fusion
b. Conservative observation and repeat imaging
c. Pain management wi th no further follow up
d. Bracing
Preferred answer: (b) Conservative observation and repeat
imaging [22]
Question 24
A 7-year-old male presents with progressive back pain over
a few months and frequent urinary tract infections to the ER.
On X-ray imaging, he is noted to have a major left thoracic
curve with a kyphotic component. What is your recom-
mendation for management?
a. Pain management
b. MRI imaging with gadolinium to evaluate for intraspinal
neoplasm or Chiari malformation
c. CT imaging for evaluation of fractures
152 C. Sy et al.
d. Ultrasound of bladder to assess for urinary outlet
obstruction
Preferred answer: (b) MRI imaging with gadolinium to
evaluate for intraspinal neoplasm or Chiari malformation
[23]
Question 25
The rostral neuropore closes around what day?
a. Day 14–16
b. Day 18–21
c. Day 23–25
d. Day 25 to 27
Preferred answer: (c) Day 23–25 [24]
Question 26
A 2-year-old patient is brought to the trauma bay after a low
impact car accident where the patient was restrained, com-
plaining of neck pain. On CT imaging, the trauma surgeon
notices three discontinuities in the arch of C1- one anteri-
orly, and two posteriorly, adjacent bilaterally to the lateral
masses. What is your recommendation?
a. Cervical MRI to evaluate for disc herniation
b. Upright AP/Lateral/Open mouth odontoid view x-ray
imaging and follow up in 6 weeks with repeat imaging
for cervi cal fractures of C1
c. Treatment in cervical collar for neck sprain only, as CT
imaging consistent with normal ossification centers of C1
Preferred answer: (c) Treatment in cervical collar for neck
sprain only, as CT imaging consistent with normal ossifi-
cation centers of C1 [25]
Question 27
A 15-year-old female presents with the primary complaint of
months of headache. These headaches are often exacerbated
by laughing, coughing or straining on the toilet. She recently
was taken to the hospital after she had a syncopal episode
following a coughing episode. Given this clinical scenario,
what is the most likely finding on imaging studies?
a. Supratentorial brain mass causing cerebral mass effect
b. Cervical stenosis with spinal cord compression
c. Cerebellar ectopia with syrinx formation
d. Basilar invagination
Preferred answer: (c) Cerebellar ectopia with syrinx for-
mation [26]
Question 28
A patient with neurofibromatosis type 1 presents with known
optic glioma and cerebellar gliomas for evaluation of
worsening bilateral hand weakness, numbness, and wors-
ening gait imbalance. MRI imaging demonstrates stable
intracranial gliomas, however of note there appear to be
dilations of the neural foramen of the cervical spine with
spinal cord compression in the spinal canal. What is your
diagnosis and management?
a. Decompression alone, with or without laminopl asty for
plexiform neurofibromas
b. Decompression and resection of plexiform neurofibromas
c. Conservative management with observ ation
d. Refer patient to physical and occupational therapy
Preferred answer: (a) Decompression alone, with or with-
out laminoplasty for plexiform neurofibromas [27]
Question 29
How long is it safe to postpone surgical closure of a newborn
with myelomeningocele while having its cardiopulmonary
and genitourinary systems investigated?
a. 24 h
b. 48 h
c. 72 h
d. 96 h
Preferred answer: (c) 72 h [28]
Question 30
During closure of a myelomeningocele, special attention to
separation of the fused neural placode to surrounding tissue
at the junctional zone is made circumferentially in order to
obtain a primary closure of the underlying dura. Why is it
important also to remove any residual epidermal or dermal
elements from the periphery of the neural placode?
a. Assists with water-tight closure to prevent CSF leak
b. Prevents CNS infection
c. Prevents future development of dermoids or lipomas
d. This step is not necessary during myelomeningocele
repair
8 Pediatric Spine 153
Preferred answer: (c) Prevents future development of
dermoids or lipomas [29]
Question 31
During intraoperative debulking of a lipomeningocele, the
neuromonitoring tech alerts you to a decrease in pudendal
sensory evoked potent ials. What does this information
indicate?
a. Over-stretch or damage of the lumbar plexus
b. Over-stretch or damage to S2-4 segments
c. Nothing, this is unrelated to your surgery
d. Motor damage to the iliopsoas
Preferred answer: (b) Over-stretch or damage to S2-4
segments [30]
Question 32
What is the best way to prevent post laminectomy kyphosis
following suboccipital decompression for Chiari 1 syndrome
in a child?
a. Decompressing C1 until you see the lateral dural edges
only
b. Decompressing further than the lateral dural edges
c. Leaving the paraspinal musculature and bone of C2 intact
d. Preventing excessive force on the C1 arch that could
cause breakdown of the anterior synchondrosis
Preferred answer: (c) Leaving the paraspinal musculature
and bone of C2 intact [31]
Question 33
A patient is referred for evaluation of dermal sinus tract. On
physical exam, his lower back area appears normal, with no
signs of hemangiomas, subcutaneous lipomas or focal hir-
sutism. The tract appears to be a dimple located deep in the
gluteal cleft, overlying the coccyx, has a downward incline,
and almost disappears when the skin is spread. What is the
most likely diagnosis?
a. Lipomeningocele
b. Dermal sinus tract
c. Benign sacrococcygeal dimple
d. Myelomeningocele
Preferred answer: (c) Benign sacrococcygeal dimple [32]
Question 34
A 7-year-old boy presents to the trauma bay following a car
accident and presents with significant paresis of thei r upper
and lower extremities. A stat MRI is done, demonstrating a
rupture of the anterior longitudinal ligament without mass
lesion or increased spinal cord signal, and a CTA performed
is normal. The child is diagnosed with Spinal Cord Injury
Without Radiographic Abnormality. What can you deter-
mine prognostically in terms of this child’s neurological
exam?
a. No improvement after 6 months
b. Permanent neurological decline following injury
c. Significant improvement in neurological condition after 6
months
Preferred answer: (c) Significant improvement in neuro-
logical condition after 6 months [33]
Question 35
What is generally considered the most reliable diagnostic
criteria for atlanto-occipital dislocation (AOD) for pediatric
patients?
a. Dens-Basion (DB) distance > 12.5 mm
b. Basion-Axial Interval (BAI) > 12 mm
c. Powers Ratio of > 1
d. Condyle-C1 interval (CCI) > 4.0 mm
Preferred answ er: (d) Condyle-C1 interval (CCI) > 4.0
mm [34]
Question 36
A 3-year-old female with no past medical history, meeting
developmental milestones presents after being involved in a
motor vehicle accident. Patient’s neurological exam is non
focal except for some neck pain. Radiology report returns
with a reading concerning for a type II odontoid fracture.
This radio logy finding is less likely due to the fact that
dentocentral synchondrosis occurs during the ages:
a. 1–2 years of age
b. 2–3 years of agec
c. 4–8 years of age
d. 11
–14 years of age
Preferred answer: (c) 4–8 years of age [20]
154 C. Sy et al.
Question 37
A 12-year-old female with dextroscoliosis that is followed
closely by her PCP was noted to have progressive abnor-
mality and worsening back pain. Patient also notes that she
had one episode of bladder incontinence. On exam, she is
noted to have weakness in her left lower extremity. On MRI,
the patient is found to have a tumor with a “meniscus sign”
at T12. What kind of tumor do you expect with this radio-
logical finding?
a. Intradural, intramedullary
b. Intradural, extramedullary
c. Extradural
Preferred answer: (b) Intradural, extramedullary [35]
Question 38
Which of the following tumors listed below would you
anticipate this patient to have?
a. Neuroblastoma
b. Astrocytoma
c. Dermoid
d. Sarcoma
e. Teratoma
f. Ependymoma
Preferred answer: (c) Dermoid [36]
Question 39
After surgical resection of this patient’s spinal tumor which
included posterior approach with laminectomies, what
postoperative complication should be considered especially
in the pediatric population?
a. Increased infection rates
b. Delayed spinal deformity
c. Development of cerebrospinal fluid fistulas
d. Aseptic meningitis
Preferred answer: (b) Delayed spinal deformity [37]
Question 40
After removal of a dermoid spinal tumor, what type of
post-operative care should this patient have in particular?
a. Chemotherapy
b. Radiation therapy
c. Proton beam therapy
d. Serial MRI to monitor for recurrence
Preferred answer: (d) Serial MRI to monitor for recurrence
[38]
Question 41
A 5-year-old male patient presented to the ER with acute back
pain. Patient was found to have a pathologic fracture of T3 on
XR. On furt her imaging, a mass is visualized within the bone
and noted to have a fluid level with a thin “eggshell” rim
surrounding it. What is this patient’s like ly diagnosis?
a. Osteochondroma
b. Osteosarcoma
c. Aneurysmal Bone Cys t
d. Eosinophilic Granuloma
Preferred answer: (c) Aneurysmal Bone Cyst [39]
Question 42
The patient with an aneurysmal bone cyst (ABC) should
follow up closely with their physician because other condi-
tions are often associated with his diagnosis. What are those
other conditions?
a. Osteoblastoma or giant cell tumor
b. Neuroblastoma
c. NF1 or NF2
d. Chordoma
Preferred answer: (a) Osteoblastoma or giant cell tumor
[40]
Question 43
An incidental, single, dumbbell shaped tumor through the
neural foramina is found in an 8-year-old patient. An MRI
shows that the lesion is hypointense to the spinal cord on T1
weighted imaging, hyperintense on T2 weighted imaging,
and with homogenous enhancement on postcontrast studies.
The patient has no neurological defi
cits but does have a
significant cardiac and pulmonary history. A biopsy is
completed and show s a high-grade malignant lesion con-
sistent with neuroblastoma. What treatment should be
offered to this patient?
a. Surgical resection of a malignant tumor
b. Chemotherapy
c. Radiation
8 Pediatric Spine 155
d. Surgical resection followed by chemotherapy
e. Surgical resection followed by radiation
Preferred answer: (b) Chemotherapy [38]
Question 44
What is the oncologic stage of this tumor according to
Enneking system?
a. Stage IA G1, T1, M0
b. Stage IB G1, T2, M0
c. Stage IIA G2, T1, M0
d. Stage IIB G2, T2, M0
e. Stage III G1/2, T1/2, M1
Preferred answer: (c) Stage IIA G2, T1, M0 [41]
Question 45
Maternal serum testing for detecting open neural tube
defects is associated with the following:
a. Elevated alpha fetoprotein
b. Low alpha fetoprotein, low inhibin A, low human
chorionic gonadotropin, low estriol
c. Low alpha fetoprotein, elevated inhibin A, elevated
human chorionic gonadotropin, low estriol
Preferred answer: (a) Elevated alpha fetoprotein [42]
Question 46
A 7-year-old male with past medical history of
myelomeningocele who is status post-surgical repair and
ventriculoperitoneal shunt placement presents with progres-
sive difficulties with walking and multiple urinary tract
infections. The patient denies any headaches, nausea, vom-
iting, or visual changes. The patient’s head CT ventricle size
appears stable, and his shunt is on the correct setting and
appears intact. What is the patient’s most likely diagnosis?
a. Tethered spinal cord
b. Ruptured spinal arteriovenous malformation
c. Large, herniated disc in the lower lumbar region
Preferred answer: (a) Tethered spinal cord [43]
Question 47
Which of the following is true regarding epidermoids, der-
moids, and teratomas of the spine?
a. Dermoid tumors consist of only desquamated cells
b. Epidermoid tumors hav e germ layers that include ele-
ments such as skin, hair, sweat, and sebaceous glands
c. Teratomas are made of one germ layer
d. Dermoid tumors are made up of two germ layers
Preferred answer: (d) Dermoid tumors are made up of two
germ layers [44]
Question 48
Newborn infant on exam was discovered to have a tuft of
hair and cutaneous midline changes at the lumbosacral
junction and a small opening. The etiology of this patient’s
particular diagnosis is due to incomplete separation of neural
ectoderm from epithelial ectoderm. This description is con-
sistent with,
a. Dermal sinus
b. Terminal syrinx
c. Meningocele Manque
d. Diastematomyelia
Preferred answer: (a) Dermal sinus [44]
Question 49
Widening of the atlantodental interval (ADI) is consistent
with injury to what structure?
a. Alar ligament
b. Transverse ligament
c. Deep accessory tectorial membrane
d. Anterior atlantoaxial ligament
Preferred answer: (b) Transverse ligament [45]
Question 50
A 5-year-old male with no significant past medical history
is involved in a motor vehicle accident. The patient reports
that his neck hurts and his hands are tingling. On a neu-
rological exam, the patient’s hands are decreased in
strength but otherwise he is neurologically intact. Work-up
and imaging for the patient are all normal. What is true of
spinal cord injury without radiographic abnormality
(SCIWORA)?
a. Suggested etiology due to the increased malleability of the
spinal column leading to less protection of the spinal cord
b. Patients < 8 years old experience this injury most com-
monly in the lower cervical region
156 C. Sy et al.
c. It is a functional phenomenon that is commonly seen in
children after a traumatic event
d. The rate of occurrence is similar for pediatric patients
compared with adult patients
Preferred answer: (a) Suggested etiology due to the
increased malleability of the spinal column leading to less
protection of the spinal cord [46]
Question 51
Many biomechanical factors contribute to the hypermobility
of the pediatric cervical spine, which makes this portion of
the spine particularly vulnerable to injury. While the adult
fulcrum for maximal flexion–extension is located at C5-C6,
an infant’ s fulcrum is located at:
a. C6-C7
b. C4-C5
c. C3-C4
d. C2-C3
e. C1-C2
Preferred answer: (d) C2-C3 [47]
Question 52
During a transoral approach to the cervical spine in a pedi-
atric patient, lateral exposure beyond 15 mm to the right of
midline in the posterior pharyngeal mucosa will most likely
lead to which post-operative complication?
a. Tongue deviation to the right
b. Tongue deviation to the left
c. Apnea
d. Bradycardia
Preferred answer: (a) Tongue deviation to the right [48]
Question 53
During subperiosteal dissection as part of the posterior
approach to the pediatric cervical spine, excessive pressure
on which spinous structure is most likely to cause a fracture
and leave the underlying cord vulnerable to injury?
a. C1 lateral mass
b. C2 lamina
c. C1 posterior tubercle
d. C2 transverse foramen
Preferred answer: (c) C1 posterior tubercle [49]
Question 54
Meticulous dissection and avoidance of unintended perios-
teal exposure is particularly important in pediatric spine
surgery due to the pediatric patient’s greater propensity for
what physiologic response?
a. Hematoma formation
b. Callus formation
c. Abscess formation
d. Seroma formation
Preferred answer: (b) Callus formation (causing bystander
fusion) [ 50]
Question 55
Incompetence of the cruciate ligament such as in pediatric
patients with Down syndro me or os odontoideum can lead to
pathologic predental space widening primarily due to load
placement on which structure(s)?
a. Apical and alar ligaments
b. Tectorial membrane
c. Atlanto-occipital joint
d. Atlanto-axial joint
Preferred answer: (a) Apical and alar ligaments [51 ]
Question 56
Which of the following structural aspects of the pediatric
cranio-vertebral junction is not a cause of increased mobility
at the junction relatively to adults?
a. Head to neck ratio
b. Horizontal orientation of cervical facets
c. Lack of uncovertebral joints
d. Strength of paracervical musculature
Preferred answer: (d) Strength of paracervical musculature
[51]
Question 57
Which imaging modality is most important to order prior to
posterior fossa decompression of a suspected Chiari 0
malformation?
a. XR lumbar spine
b. CT thoraco-lumbar spine
c. MRI neuro-axis
8 Pediatric Spine 157
d. CTA head and neck
Preferred answer: (c) MRI neuro-axis
Question 58
A twelve-year-old female is found to have a standing lateral
curvature of 12 degrees on plain radiograph. Which
accompanying structural abnormality will most likely be
found on ensuing MRI evaluation?
a. Cerebellar tonsillar herniation 6 mm below the foramen
magnum and syrinx
b. Spina bifida occulta and herniation of cerebellar vermis
c. Parietal bone hypoplasia
d. Dysgenesis of the corpus callosum
Preferred answer: (a) Cerebellar tonsillar herniation 6 mm
below the foramen magnum and syrinx [53]
Question 59
Which of the following is least likely to complicate a
pediatric Chiari II decompression?
a. Extension of cerebellar tissue into the lower cervical spine
b. Adherence of cerebellar tissue to the medulla
c. High-riding torcula
d. Pre-operative illness due to medullary dysfunction
Preferred answer: (c) High-riding torcula [54]
Question 60
Astrocytomas and ependymomas constitute 80% of pediatric
intramedullary tumors. All of the following are radiographic
differences that can help distinguish between astrocytoma
and ependymoma except:
a. Ependymomas tend to be centrally located within the
spinal cord while astrocytomas are more likely eccen-
trically located
b. Ependymomas have distinct margins while astrocytomas
have indistinct margins
c. Ependymomas demonstrate variable enhancement while
astrocytomas have uniform enhancement
d. Ependymomas are more likely to have calcification and
hemorrhage compared to astrocytomas
Preferred answer: (c) Ependymomas demonstrate variable
enhancement while astrocytomas have uniform enhancement
[55]
Question 61
Following repair of a myelomeningocele in a 24-week-old
patient, post-operative MRI demonstrates an intramedullary
lesion at T12. Which of the following radiographic findings
will help determine whether this lesion is more likely an
epidermoid cyst or arachnoid cyst?
a. Perifocal edema
b. Peripheral enhancement
c. Intensity on T1/T2 MRI
d. Diffusion restriction
Preferred answer: (d) Diffusion restriction [56]
Question 62
Which of the following pediatric neoplasms does not have a
well-defined surgical plane and therefore is usually not
amenable to gross total resection?
a. Lipoma
b. Juvenile pilocytic a strocytomas
c. Ependymoma
d. Epidermoid cyst
Preferred answer: (a) Lipoma [57]
Question 63
A 7-year-old patient is found to have primary intramedullary
oligodendroglioma. Which symptoms are most likely an
indication for additional imaging and radiation with adjuvant
chemotherapy?
a. Focal weakness
b. Focal sensory loss
c. Bowel incontinence
d. Nausea and blurry vision
Preferred answer: (d) Nausea and blurry vision
(Oligodendrogliomatosis-induced hydrocephalus) [58]
Question 64
A 12-month-old patient is found to have a rapidly growing
myofibroma of the trunk without visceral involvement or
compression of the spinal cord. Which of the following is
the appropr iate next step in management?
a. Gross total resection
b. Radiation
158 C. Sy et al.