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c. Radiation and chemotherapy
d. Observation
Preferred answer: (d) Observation [59]
Question 65
Which of the following is not a characteristic MRI finding
for pediatric intramedullary hemangioblastoma?
a. Isointense on T1-weighted MRI and hyperintense on T2
if tumor is less than 10 mm
b. Presence of flow void
c. Deep location of intramedullary tumor
d. Large size of associated syrinx compared to intrame-
dullary portion of tumor
Preferred answer: (c) Deep location of intramedullary
tumor [60]
Question 66
Following removal of a thoracic cavernous malformation in
a 14-year-old patient, there is persistent venous bleeding
from the surgical bed despite application of gentle pressure
with cotton pledges. This bleeding is most likely indicative
of which intraoperative complication?
a. Iatrogenic fistula
b. Incomplete resection of cavernous malformation
c. Damage to vertebral venous plexus
d. Damage to perilesional gliotic layer
Preferred answer: (b) Incomplete resection of caverno us
malformation [61]
Question 67
A 12-year-old patient with a history of retinoblastoma pre-
sents with new-onset lumbar back pain and peri-lumbar soft
tissue swelling. Where is this patient most likely to have
metastatic lesions?
a. Lung
b. Brain
c. Liver
d. Adrenal gland
Preferred answer: (a) Lung [62]
Question 68
When is surgical stabilization of scoliotic deformity com-
monly performed in children with Duchenne Muscular
Dystrophy (DMD)?
a. When vital capacity falls below 1 L
b. When a child transitions from ambulating to wheelchair use
c. Before 5 years of age
d. Surgery is not indicated; bracing alone is adequate
Preferred answer: (b) When a child transitions from
ambulating to wheelchair use [63]
Question 69
In the surgical management of pediatric scoliotic deformity,
consideration of which of the following should be consid-
ered for the prevention of postoperative incision dehiscence?
a. Nutrition assessment and metabolic demand
b. Presence of spasticity and limb contractures
c. Availability of sufficient subcutaneous tissue
d. All of the above
Preferred answer: (d) All of the above [64]
Question 70
Spasticity is primarily mediated by which of the following
fibers?
a. Ia fibers
b. Ib fibers
c. II fibers
d. Alpha-motor fibers
e. Gamma-motor fibers
Preferred answer: (a) Ia fibers [
65]
Question 71
When should selective dorsal rhizotomy be considered in the
management of cerebral palsy?
a. When hypertonia is present
b. For spasticity implicated in functional impairment
c. Significant motor weakness with standing
d. When dyskinesia is present
8 Pediatric Spine 159
Preferred answer: (b) For spasticity implicated in func-
tional impairment [66]
Question 72
A pediatric trauma patient presenting with subarachnoid
hemorrhage at the craniocervical junction, prevertebral soft
tissue edema, and lower cranial nerve deficits is most con-
cerning for which of the following?
a. Traumatic aneurysm rupture
b. Grade 3 diffuse axonal injury
c. Basilar skull fracture
d. Atlanto-occipital dissociation
Preferred answer: (d) Atlanto-occipital dissociation [67]
Question 73
Neural arches typically fuse to form a solid posterior ring at
C1 by the age of:
a. 32 weeks gestational age
b. 1 month
c. 1 year
d. 3 years
Preferred answer: (d) 3 years [68]
Question 74
The atlanto-dental interval is used to assess the integrity of
which of the following ligaments?
a. Tectorial membrane
b. Transverse ligament
c. Alar ligaments
d. Apical odontoid ligament
Preferred answer: (b) Transverse ligament [69]
Question 75
When should myelomeningocele repair be undertaken?
a. 20 weeks gestational age
b. Within 72 h of birth
c. Not before 1 week
d. Not before 1 month
Preferred answer: (b) Within 72 h of birth [70]
Question 76
The goals of myelomeningocele repair include all of the
following except:
a. Improved urodynamics
b. Reducing risk of meningitis
c. Minimize CSF loss
d. Protect the functional spinal cord tissue
Preferred answer: (a) Improved urodynamics [71]
Question 77
Which occipital sclerotome differentiates into the apical
ligament and apex of the dens?
a. 1st
b. 2nd
c. 3rd
d. 4th
Preferred answer: (c) 3rd [72]
Question 78
Inflammatory, spontaneous subluxation of the atlantoax-
ial joint following parapharyngeal infection is also known
as:
a. Grisel syndrome
b. Apert syndrome
c. Scheuermann’s disease
d. Pfeiffer syndrome
Preferred answer: (a) Grisel syndrome [73]
Question 79
Symptomatic incidence of atlantoaxial instability in Down
syndrome is estimated to be:
a. Less than 1%
b. 14–24%
c. 50%
d. Atlantoaxial instability is not associated with Down
syndrome
Preferred answer: (a) Less than 1% [74]
160 C. Sy et al.
Question 80
The NF2 suppressor gene on 22q12.2 is found in 50% of
which pediatric spinal cord tumors?
a. Astrocytoma
b. Ganglioglioma
c. Ependymoma
d. Hemangioblastoma
Preferred answer: (c) Ependymoma [75]
Question 81
The most important oncogene associated with
neuroblastoma:
a. MYCN
b. RAS
c. EGFR
d. NF1
Preferred answer: (a) MYCN [76]
Question 82
In the evaluation of a pediatric patient presenting with axial
back pain and finding of “vertebra plana” (pancaked verte-
bral body) on imaging studies, the most likely diagnosis is:
a. Osteochondroma
b. Aneurysmal bone cyst
c. Chordoma
d. Langerhans cell histiocytosis
Preferred answer: (d) Langerhans cell histiocytosis [77]
Question 83
In the pediatric population, chordoma should be suspected
with lesions found in the:
a. Craniocervical junction
b. Thoracic spine
c. Lumbar spine
d. Sacrococcygeal region
e. Both A and D
f. Chordoma is found only in the adult population
Preferred answer: (e) Both A and D [77]
Question 84
The presence of C3-C4 anterolisthesis and smooth spino-
laminar lines on dynamic imaging is most consistent with:
a. Pseudosubluxation
b. Posterior longitudinal ligament instability
c. Down syndrome
d. Incomplete endochondral ossification
Preferred answer: (a) Pseudosubluxation [78]
Question 85
A 12-year-old male patient with von Hippel-Lindau disease
presents with frequent falls and difficulty ambulating. He is
found to have an intramedullary spinal cord lesion. On MRI
thoracic spine, the mass has a cystic component, enhances
with gadolinium, and there is significant spinal cord edema
at T8. What is the most appropriate management for this
patient’s most likely diagnosis?
a. Spinal angiogram with embolization of the draining vein
b. Total surgical resection, followed by chemotherapy and
radiation
c. Radiation alone
d. Total surgical resection followed by observation
e. Observation
Preferred answer: (d) Total surgical resection followed by
observation [52]
Question 86
Which of the following is true regarding intrauterine repair
of myelomeningocele?
a. Decreased rate of post-natal shunt placement
b. Improved motor function at 30 months
c. Decreased rate of tonsillar herniation on imaging studies
d. A and C
e. All of the above
Preferred answer: (e) All of the above [79]
Question 87
An 8-year-old female with Down syndrome presents to the
ER complaining of neck pain. Her mother states that she has
been having increased difficulty with activities of daily
8 Pediatric Spine 161
living. On exam, the patient has generalized weakness in all
extremities, 3 + hyperreflexia throughout, and an upgoing
plantar reflex bilaterally. Lateral x-rays reveal an atlanto-
dental interval of 6 mm. Which of the following is the most
appropriate management for this patient?
a. Occiput to C2 fusion and C1-2 laminectomy
b. C1 laminectomy and posterior C1-C2 fusion
c. Rigid cervical orthosis
d. Halo placement
e. Cervical laminectomy alone
Preferred answer: (b) C1 laminectomy and posterior
C1-C2 fusion [52]
Question 88
A patient presents with progressive scoliosis, at what degree
does a patient typically begin to experience respiratory
compromise:
a. 45 degrees
b. 60 degrees
c. 90 degrees
d. 100 degrees
e. 120 degrees
Preferred answer: (c) 90 degrees [52]
Question 89
A 9-year-old patient with cerebral palsy undergoes selective
dorsal rhizotomy. The patient returns to a four-week post op
check and the patient’s spasticity is the same as
pre-operatively. The patient is complaining of mild lower
back pain in the region of the surgery. Which of the fol-
lowing is the most appropriate management?
a. Observation and follow-up in 1–2 months
b. Repeat surgery and possible further root sectioning
c. MRI lumbar spine to assess for infection
d. Intrathecal baclofen administration for possible intrathe-
cal baclofen pump placement
e. Flexion–extension x-rays of L spine to assess for
instability
Preferred answer: (a) Observation and follow-up in 1–2
months [80]
Question 90
An infant is found to have a fatty filum terminale. At what
stage did this patient have failure of embryological
development?
a. Primary neuralation
b. Secondary neuralation
c. Gastrulation
d. Cranial neuropore closure
e. Caudal neuropore closu re
Preferred answer: (b) Secondary neuralation[52]
Question 91
A 3-year-old male presents to the ER with fatigue, mild back
pain and failure to thrive. MRI of the spine does not reveal
any spinal cord compression. The patient is found to have a
ventral T10-11 paravertebral mass. Urine testing reveals
elevated urine catecholamines. Radionucleotide MiBG test-
ing shows uptake at the same location. What is the best
treatment for this patient?
a. Observation
b. Chemotherapy
c. Radiation and Chemotherapy
d. Surgical excision followed by observation
e. Surgical excision followed by chemotherapy
Preferred answer: (b) Chemotherapy. The patient has
neuroblastoma. Chemotherapy is first line treatment, espe-
cially in absence of neurological deficit or cord compression
[81]
Question 92
Approximately what percentage of spinal myelomeningoceles
occur outside of the lumbosacral spine?
a. 1%
b. 5%
c. 15%
d. 35%
e. 50%
Preferred answer: (c) 15% [
52]
162 C. Sy et al.
Question 93
A 14-year-old female with history of spinal cord lipoma
resection presents to establish care with a screening MRI of
the lumbar spine. On the MRI, the conus medullaris termi-
nates at L3. The patient has no back pain, has stable motor
exam, and has not had any change in bowel or bladder habits.
What is the most appropriate management for this patient?
a. Redo surgery for release of retethering
b. Follow up in MRI in 6 months
c. CT myelogram
d. Urodynamicse. Flexion–extension x-rays
Preferred answer: (b) Follow up in MRI in 6 months [52]
Question 94
A 15-year-old patient sustains a C5 burst fracture with asso-
ciated spinal cord injury. The patient undergoes surgical
decompression stabilization. At the patient’s 3 month follow
up visit, upright cervical x-rays show bony fusion and stable
alignment. However, the patient is reporting radiating pain
from the neck into both hands. The pain is worsened during
defecation. The patient also reports that his baclofen dose has
been increasing due to worsening spasticity. What is the next
step in management for the patient’s most likely condition?
a. Flexion–extension X-rays of Cervical spine
b. CT scan of the cervical spine
c. MRI Cervical spine without contrast
d. Observation and follow up in 6 weeks
e. Occupational therapy for worsening spasticity
Preferred answer: (c) MRI Cervical spine without contrast
to assess for the presence of a syrinx [82]
Question 95
After an MVC, a 6-year-old male patient is found to have a
fracture through the C2 synchondrosis. The patient is neu-
rologically intact. MRI shows no spinal canal stenosis or
spinal cord injury. Based on 2013 CNS guidelines, how
should this fracture be managed?
a. C1-2 posterior spinal fusion
b. Odontoid screw fixation
c. Miami J collar at all times
d. Closed reduction and halo immobilization
e. Occiput to C3 fusion
Preferred answer: (d) Closed reduction and halo immobi-
lization [83 ]
Question 96
What is the incidence of scoliosis in patients who sustained a
spinal cord injury at < 10 years of age?
a. < 10%
b. 10–25%
c. 25–50%
d. 50–75%
e. > 90%
Preferred answer: (e) > 90% [84]
Question 97
Which of the following is true regarding surgery on
myelomeningoceles?
a. Preserves all neural elements
b. Complete removal of all skin from the neural elements
c. Cauterization and sectioning of large vessels passing near
the placode
d. All of the above
e. A and B
Preferred answer: (e) A and B [52]
Question 98
An 11-year-old patient presents with an intramedullary
lipoma. The patient is having progressive weakness and the
patient is taken to the OR for resection. Which of the fol-
lowing is important regarding perioperative management?
a. Total resection is needed to prevent recurrence
b. Subtotal resection to decompress the spinal cord is
adequate
c. Post-operative adjuvant radiotherapy
d. Bony decompression alone is adequate
Preferred answer: (b) Subtotal resection to decompress the
spinal cord is adequate [52]
Question 99
A 12-year-old patient is undergoing a 2nd intramedullary
neoplasm resection. After dural opening and prior to
8 Pediatric Spine 163
myelotomy, SSEP signals are lost. There is no suspicion for
blunt injury to the spinal cord. The patient has been hemo-
dynamically stable throughout the case. EEG monitoring is
normal. What is the most likely cause?
a. Acute spinal hemor rhage
b. Cerebral infarct
c. Spinal cord infarct
d. Ventral arachnoid cyst
e. Spinal cord hypoperfusion
Preferred answer: (d) Ventral arachnoid cyst [85]
Question 100
A 15-year-old patient presents with acute back pain and
quadriparesis with diminished reflexes. MRI with contrast
reveals a contrast enhancing non expansile lesion in the
thoracic spinal cord. What is the next best step in
management?
a. CSF analysis
b. IR biopsy
c. Laminectomy and biopsy
d. Laminectomy and gross total resection
e. Observation
Preferred answer: (a) CSF analysis with high suspicion for
transverse myelitis [86]
Question 101
A newborn male is found to have a tethered cord on
screening imaging, otherwise spinal imaging is normal.
Additionally, the child has tetralogy of Fallot, syndactyly,
tracheoesophageal fistula and one kidney. What is the most
likely diagnosis?
a. CHARGE SYNDROME
b. VACTERL syndrome
c. 22q11 deletion syndrome
d. Down syndrome
e. Klippel-Feil Syndrome
Preferred answer: (b) VACTERL syndrome [87]
Question 102
When exposing the spinous processes during a posterior
approach to the pediatric cervical spine, it is important to
stay within which structure to avoid excessive blood loss and
post-operative pain?
a. Ligamentum nuchae
b. Prevertebral fascia
c. Alar fascia
d. Trapezius muscle
Preferred answer: (a) Ligamentum nuchae [88]
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8 Pediatric Spine 165
9
Tumors, Infections, Inflammatory
and Vascular Lesions of the Spine
Ravi Nunna, Michael Torres, Wesley Chen, and Sasidhar Karuparti
1. Which of the following most commonly presents with
nocturnal back pain in children and adolescents?
a. Chondrosarcoma
b. Osteoid osteoma
c. Hemangioma
d. Chordoma
Answer: B, osteoid osteoma are non-malignant tumors that
often present in the 1st two decades of life, usually involving
the posterior elements. They can cause significant pain and
sometimes muscle spasms but are not malignant tumors.
2. A patient with intractable neck pain is found to have a
vertebra plana at C5. Which of the following lesions is
most likely responsible in a patient with no oncological
history?
a. Osteoid osteoma
b. Prostate cancer
c. Eosinophilic granuloma
d. Osteoblastoma
Answer: C, Eosinophilic granuloma of the spine often pre-
sents with vertebra plana
3. Which lesion is depicted in the picture (see Fig. 9.1)?
a. Osteoid osteoma
b. Chrondrosarcoma
c. Osteoblastoma
d. Hemangioma
Answer: D, hemangioma often appears as a spongy
appearing vertebral body lesion on CT scan.
4. Which lesion is depicted in the picture below (see
Fig. 9.2)?
a. Chordoma
b. Chondroma
c. Osteoid osteoma
d. Hemangioma
Answer: A, the picture depicts a classic sacral chordoma [4].
5. Which lesion is depicted in the picture below (see
Fig. 9.3)?
a. Chordoma
b. Chondroma
c. Osteoid osteoma
d. Hemangioma
Answer: C, the picture depicts osteoid osteoma, with classic
hypodense center with hyperdense rim.
6. What is the first line of treatment for pain related to
osteoid osteoma?
a. Surgery
b. NSAIDS
c. Narcotics
d. Physical therapy
R. Nunna (&) M. Torres W. Chen
Department of Neurosurgery, University of Missouri, Columbia,
MO, USA
e-mail: ravisnunna@gmail.com
M. Torres
e-mail: ortiztorresm@health.missouri.edu
W. Chen
e-mail: wesley.chen@health.missouri.edu
S. Karuparti
School of Medicine, University of Missouri, Columbia, MO, USA
e-mail: srkdg2@health.missouri.edu
© 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_9
167
Answer: B, NSAIDS are first line therapy for pain from
osteoid osteoma, and a good portion of patients are able to
manage the pain with these medications.
7. For sacral chordomas, what is the only independent
factor that influences prognosis?
a. Extent of resection
b. Radiation
c. Chemotherapy
d. Pre-operative symptoms
Answer: A. Wide en-bloc resection is the only independent
factor that contributes to reducing tumor recurrence and
tumor related death.
8. A patient with axial back pain has MRI imaging showing
a bony lesion at L4 with various fluid–fluid levels. What
is the lesion most likely to be?
a. Osteoblastoma
b. Chordoma
c. Aneurysmal bone cyst
d. Hemangioma
Answer: C, the description fits the characteristic appearance
of aneurysmal bone cysts.
9. Which of the following is NOT a benign lesion?
a. Osteoblastoma
b. Osteoid osteoma
Fig. 9.1 Axial and sagittal CT of
the midthoracic spine
Fig. 9.2 Sagittal T1 post gadolinium image of the sacral spine
Fig. 9.3 Axial CT of lumbar vertebra [5]
168 R. Nunna et al.
c. Aneurysmal bone cyst
d. Chordoma
Answer: D, Chordoma is a malignant lesion.
10. A nerve sheath tumor is resected from a patient with
known neurofibromatosis type 2. What is the lesion
most likely to be?
a. Neurofibroma
b. Schwannoma
c. Oligodendroglioma
d. Lymphoma
Answer: B, Patients with NF2 and nerve sheath tumors often
have schwannomas, whereas NF1 patients with nerve sheath
tumors often have neurofibromas.
11. A patient with back pain presents with imaging show-
ing a mass that protrudes from the T12 spinous process
with a cartilaginous cap. Which of the following lesions
is this most likely?
a. Osteochondroma
b. Osteoblastoma
c. Osteoid osteoma
d. Chordoma
Answer: A, Description fits osteochondroma of the spine.
12. A patient with a known osteochondroma has continued
back pain and is found on repeat imaging to have
widening of the cartilaginous cap, and additional oste-
olytic activity around the growing lesion. What will a
biopsy of the lesion most likely reveal?
a. Transformation to osteosarcoma
b. Transformation to chordoma
c. Transformation to chondrosarcoma
d. No change in osteochondroma
Answer: C, transformation of osteochondroma to chon-
drosarcoma is typically indicated with widening of carti-
laginous cap, increasing size and osteolytic activity, and
size > 2.5cm.
13. A bony mass on the T11 lamina is resected from a
16-year-old and pathology is confirmed as Ewing’s
sarcoma. What is the pathological appearance of this
mass?
a. Large GFAP staining cells with high mitotic activity
b. Small blue cells
c. Spindle cells
d. Layers of cuboidal cells
Answer: B, Ewing’s sarcoma is among the lesions with
small blue cells on pathology that can be isolated from
bone, which include neuroblastoma, PNET, lymphoma,
rhabdomyosarcoma.
14. What is the defining characteristic between osteoblas-
toma and osteoid osteoma?
a. Pathology
b. Location
c. Size
d. Shape
Answer: C, osteoblastoma is typically > 2cm in size. The
remainder of the characteristics are similar between the two
lesions.
15. What does this picture most likely depict (see Fig. 9.4)?
a. Chondrosarcoma
b. Chordoma
c. Hemangioma
d. Enostosis
Answer: D, vertebral enostosis is characteristically hyper-
dense round areas that do not have signal change on MRI or
increased metabolic activity on PET scans.
16. Of the below, all are common primary pathologies that
metastasize to the spine except
Fig. 9.4 Axial CT of thoracic vertebra
9 Tumors, Infections, Inflammatory and Vascular Lesions of the Spine 169