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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5259_Библиотеки_им_академика_М_И_Перельмана.pdf
D. Failed fusion after disc placement leading to
formation of aberrant posterior bridges of bone
impinging the dural sac
E. None of the above
Preferred Response: A: Subsidence is generally defined
as 3 mm loss of height comparing the immediate post-
operative intervertebral height with the intervertebral height
at the last follow-up moment [79].
(136) Which of the following sentences is false about cage
subsidence in anterior spinal approaches?
A. Subsidence rate in ACDF using cages is
approximately 21%
B. It is still not clear if radiologic occurrence of
subsidence affects clinical outcome
C. Risk for subsidence is increased when a PEEK or
titanium cage is used
D. Risk of subsidence is reduced when a cage with
integrated screws is used
E. B + C
Preferred Response: C: A recent review showed that sub-
sidence rate is approximately of 21%. Using PEEK or tita-
nium cages or cages with integrated screws lowers the risk of
subsidence. The actual literature is not able to provide any
relevant data about the impact of cage subsidence on clinical
outcomes [55].
(137) Which of the following sentences is true regarding
loss of disc height after discectomy?
A. Loss of disc height causes delayed onset of
recurrent radiculopathy in the same or rostral root
distribution
B. Discectomy results in an average 26% loss of
height 2 years after surgery.
C. Disc height loss can lead to foraminal stenosis,
annular bulging, and lateral recess stenosis.
D. A + B
E. A + B + C
Preferred response: E: Height loss after discectomy can
determine foraminal stenosis, annular bulging, and lateral
recess stenosis, which may lead to delayed onset of recurrent
radiculopathy with the same distribution. Discectomy
resulted in a mean 18% loss of height at 3 months and a 26%
loss of height at 2 years [80].
(138) Which of the following is not a risk factor for recur-
rent lumbar disc herniation?
A. configuration of the initial disc herniation
B. smoking
C. diabetes
D. Isolated trauma
E. Duration of initial symptoms
Preferred Response: D: Among the several risk factors
identified for recurrent lumbar disc herniation a major con-
troversy surrounds isolated trauma. In fact, an association
between isolated trauma and recurrent disc herniation has
been reported from 0,1 to 10%. All the other answers are
recognized as clear factors increasing the risk of recurrences
of lumbar disc herniation [81].
(139) What is the rate of post-operative cauda equina syn-
drome following lumbar spine surgery?
A. < 1%
B. 1–2%
C. 2–4%
D. 4–6%
E. > 6%
Preferred Response: B: The reported incidence of cauda
equina syndrome following lumbar spine surgery is
approximately 1–2% [38].
(140) Which of the following are risk factors for recurrent
laryngeal nerve palsy during anterior approaches to
the cervical spine?
A. Direct traction on recurrent laryngeal nerve
B. Duration of surgery
C. Number of treated levels
D. A + B
E. A + B + C
Preferred Response: A: Several metanalysis and retro-
spective cohort studies proved that the risk for recurrent
laryngeal nerve palsy depends only on direct manipulation
of the nerve. Factors like duration of the surgery and number
of treated levels are not associated with an increased risk of
this occurrence. Moreover, no association has been found
between recurrent laryngeal nerve palsy and patients’ char-
acteristics such as, age, sex, body mass index [38].
(141) Which of the following sentences is true regarding
anterior approaches to the thoracolumbar junction?
A. Right sided approaches are safer because dam-
aging the liver carries less consequences than
splenic injuries
B. The diaphragm should not be sutured because the
pleural pressure is equal to pression inside the
peritoneum and risk of herniation is negligible
C. Revision surgery should be performed from the
contralateral side
230 A. Bocchetti et al.
D. A + C
E. None of the above
Preferred Respon se: E: Anterior approaches to the thora-
columbar spine should be performed from the left side
whenever possible as right sided approaches carry the risk of
mobilizing the liver. The diaphragm should be always closed
with a proper suture in order to avoid herniation. If the latter
occurs, revision surgery is needed. Revision surgery should
be carried out always from the same side and has higher risk
of complications [82].
(142) Which of the following sentences is true about
post-thoracotomy pain?
A. Post-thoracotomy pain can be a cause of
pneumonia
B. Paravertebral block, interpleural block and
intrathecal opioids can be performed in patients
with normal coagulation profile.
C. Serratus Anterior Plane Block under ultrasound
guidance may be performed in patients with
deranged coagulation profile
D. A + B + C
E. A + B
Preferred Response: D: Post-thoracotomy pain may lead to
restriction of chest movements in order to minimize pain.
Consequently, pulmonary function is reduced leading to
higher predisposition for pooled secretions and pneumonia.
Among the analgesic options for post-thoracotomy pain,
thoracic epidural anesthetic delivery is the gold standard. This
technique, as well as paravertebral blocks, interpleural blocks
and intrathecal opioids require normal coagulation parameters
to be used. Contrarywise, serratus anterior plane block can be
performed in patient with altered coagulation parameters [83].
(143) Translaminar screws of the axis…
A. carry more risk because of the more demanding
technique for placement
B. have less stability and fusion rates than C2
pedicle screws but lower risk of vertebral artery
injury
C. can be used as an alternative technique when
pedicle screw placement is contraindicated or not
possible
D. B + C
E. A + B + C
Preferred Response: C: Translaminar screws are an alterna-
tive technique in cases of upper cervical spine instability when
pedicle screw placement is contraindicated or not possible.
They have comparable biomechanical stability and fusion rates
(up to 93%) compared to other posterior fixation techniques.
Moreover, translaminar screw placement is technically less
demanding and reduces the risk of vertebral artery injury.
(144) Which of the following sentences is false about
management of cervical spondylotic myelopathy in
Parkinson’s disease (PD) patients?
A. The most performed approach is ACDF
B. The safest route is the posterior
C. PD patients have higher risk of dysphagia after
ACDF than non-PD patients
D. ACDF is associated with higher risk of pneu-
monia than posterior surgery in PD patients.
E. None of the above
Preferred Response: E: ACDF is the most common pro-
cedure for cervical spondylotic myelopathy in PD. Never-
theless, it is associated with higher incidence of
postoperative dysphagia and postprocedural pneumonia as
compared with posterior cervical procedures [84].
(145) What is the crankshaft phenomenon?
A. Implant failure occurring after less than 24 h
from the surgery
B. Occipito-cervical fusion failure leading to sudden
death
C. Rib fracture during thoracoscopic approach
D. Progression of spinal deformity despite a solid
posterior arthrodesis due to skeletal immaturity
E. None of the above
Preferred Response: E: Crankshaft phenomenon is defined
as the progression of a preexisting spinal deformity despite a
solid posterior arthrodesis. It can occur in the skeletally
immature patient and it is due to the growth of the unfused
anterior vertebral segments [85].
(146) Which of the following is not a contraindication for
lumbar total disc arthroplasty?
A. Prior surgery
B. Obese patient
C. Osteoporotic bone
D. Smoking
E. None of the above
Preferred Response: D: Contraindications for total disc
arthroplasty are: Obese patients, facet disease, skeletal
anomalies, high narcotic intake, osteoporotic bone, insta-
bility, spondylolysis, vascular calcification, prior infection,
severely collapsed disc, unrealistic expectations, spinal
stenosis, spinal deformity. Among these, smoking is not a
contraindication of total disc arthroplasty [86].
10 Complications of Surgery of the Spine 231
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234 A. Bocchetti et al.
11
Biomechanics of the Spine
Luke Antonio Silveira, Anvitha Sathya, and Ryan Jewell
1. The change in unit length (linear) or change in unit
angle (shear) in a body subjected to a force is defined
as?
a) Coupling
b) Burst load
c) Strain
d) Rigidity
e) Bending Moment
Response: (C) Strain refers to the change in unit length
(linear) or change in unit angle (shear) in a body subjected to
a force (vector). When a deformable body is subjected to a
load vector, the resulting deformations yield strains. The
deformation along the direction of force application is ter-
med axial strain, while the deformation transverse to the
direction of applied force is termed transverse strain. The
ratio of transverse to axial strain is termed Poisson’s ratio.
2. Which of the following substances has the highest
modulus of elasticity?
a) Cortical bone (femur/tibia)
b) Carbon fiber polymer
c) Polyether ether ketone (PEEK)
d) Titanium
e) Cancellous bone
Response: (D) Of the substances listed, titaniu m has the
highest modulus of elasticity (GPa > 100). Compar atively,
the other substances all have a modulus of elasticity less than
20 GPa [1].
3. The phenomenon by which a movement of the spine
along or about an axis obligates another movement
along or about another axis is referred to as?
a) Rotational Interfaces
b) Stress
c) Load sharing
d) Knurling
e) Coupling
Response: (E) Coupling refers to the relationship by which
a movement of the spine along or about one axis induces a
simultaneous movement along or about another axis of the
Cartesian coordinate system. This is illustrated in the cer-
vical spine, where lateral bending results in rotation of the
spinous processes away from the concave side of the curve.
The opposite occurs in the lumbar spine, where lateral
bending results in the spinous processes rotating in the same
direction as the concave side of the bend.
4. The slope of a stress–strain curve within the linear,
elastic phase of a particular material is referred to as?
a) The Modulus of Elasticity
b) The coarseness
c) The material velocity
d) The Rotational Equilibrium
e) The Object Turgor
Response: (A) The modulus of elasticity, synonymous with
an object’s stiffness, is defined as the stress-to-strain ratio,
which is a constant for a given material within that material
elastic zone [2].
L. A. Silveira (&) R. Jewell
Division of Neurosurgery, University of Vermont Medical Center,
Burlington, VT, USA
e-mail: luke.silveira@uvmhealth.org
R. Jewell
e-mail: ryan.jewell@uvmhealth.org
A. Sathya
Boston University School of Medicine, Boston, MA, USA
© 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_11
235
5. Which of the following statements coincides with
Hooke’s Law?
a) For solids deformed within their plastic zone, the size
of deformation is proportional to the deforming force
b) For solids deformed within their elastic zone, the size
of deformation is proportional to the deforming force
c) After a solid’s elastic limit is reached, the size of
deformation is proportional to the deforming force
d) After a solid’s yield point is reached, the size of
deformation is proportional to the deforming force
e) Between a solid’s yield point and point of failure,
deformation is proportional to the deforming force
Response (B) Hooke’s law states that for small deforma-
tions, within a solid object’s elastic zone, the size of defor-
mation is proportional to the deforming force. Elastic
deformation occurs when a strain totally recovers after a
stress is removed. For larger displacements, the elastic zone
may be exceeded. This occurs at a solid’s elastic limit, or
yield point, after which Hooke’s law no longer applies.
Beyond the yield point, the solid acquires a permanent set
such that the solid no longer assumes its undeformed con-
figuration following removal of external forces [2].
6. Which of the following terms describes the direc-
tionally variant compressive strength of the vertebral
body?
a) Anisotropic
b) Ballistic
c) Agoraphobic
d) Biomechanically Bilingual
e) Isotropic
Response (A) The vertebral bodies demonstrate highly
anisotropic architecture [3]. The spine is predominantly
vertically loaded and vertebral bodies are optimally struc-
tured to sustain the greatest load in the cephalo-caudal
direction, with vertebral trabecular bone aligned in the ver-
tical direction to provide maximal strength with minimal
mass.
7. A 64yo male with cervical myelopathy undergoes a
C6 corpectomy and placement of a fibular strut graft
with adjacent vertebral bodies plated to create axial
loading on the graft, as shown below in Fig. 11.1.
Axial loading upon the graft facilitates remodeling and
healing via which principle?
a) Hooke’s Law
b) Dalton’s Law
c) Subsidence
d) Wolff’s Law
e) Weiss’ Principle
Response (D) Wolff’s Law most literally states that every
change in form and function of a bone, as well as external
forces acting on a bone, lead to changes in the internal
structure of that bone. Wolff’s law suggests axial loading
alters bone integrity and healing in that trabecular structure
is hypothesized to be altered by remodeling resulting from
mechanical loading such that bone heals optimally under
loading forces. Thus, in the case described above, axial
loading upon the graft is thought to facilitate bone growth,
remodeling, and strengthening during healing [4].
8. Degree of axial rotation within the cervical spine is
greatest at which of the following levels?
a) C1-2
b) C2-3
c) C3-4
d) C4-5
e) C5-6
Response (A) The degree of axial rotation is greatest
between C1 and C2, occurring about the axis of the odontoid
process
9. Which of the following has the highest resistance to
screw pullout assuming use of an identical screw in
each scenario?
a) vertebral body
b) osteoporotic vertebral body
Fig. 11.1 Sagittal bone CT scan in patient that underwent C6
corpectomy and C5-C7 arthrodesis
236 L. A. Silveira et al.
c) osteoporotic large pedicle (sacrum pedicle)
d) healthy large pedicle (sacrum pedicle)
e) smaller pedicle (thoracic and upper lumbar pedicles)
Response (E) The ratio of cortical to cancellous bone is
greater in the pedicles than in the vertebral bodies and
greater in the smaller pedicles (thoracic and upper lumbar)
than in the larger sacral pedicles. For each listed option,
osteoporosis would significantly decrease bone integrity and
thereby decrease resistance to screw pullout. Therefore, of
the options listed, smaller pedicles have the greatest resis-
tance to screw pullout [5].
10. Which of the following statements accurately details
the relationship between facet joint orientation and
spinal segmental movement?
a) Lumbar spine facet joints are oriented in a relatively
coronal plane, making them less resistant to rota-
tional movement than the cervical spine facet joints
b) Cervical spine facet joints are oriented in a relatively
coronal plane, making them less resistant to rota-
tional movement than the lumbar spine facet joints
c) Lumbar and cervical spine facet joints are similarly
oriented in a sagittal plane, making them equally
resistant to rotational movement
d) Lumbar and cervical spine facet joints are similarly
oriented in a coronal, making them equally resistant
to rotat ional movement
e) The cervical and thoracic facet joints are similarly
oriented in a sagittal plane, making them equally
resistant to rotational movement, while the lumbar
facet joints are oriented in a relatively coronal plane
and less resistant to rotational movement.
Response (B) The facet joints of the cervical spine are
primarily oriented in the coronal plane and the facet joint
orientation becomes more sagittal as one descends through
the thoracic and lumbar spine. As the lumbar facets are
oriented in the sagittal plane, their ability to resist rotational
movements is substantially greater than in the cervical spine.
The orientation of the facet joints in the coronal plane
most substantially inhibits extension.
11. Which of the following correctly identifies the rela-
tive vertebral body compression strengths?
a) Lumbar compression strength > thoracic compres-
sion strength > cervical compression strength
b) Thoracic compression strength > Lumbar compres-
sion strength > cervical compression strength
c) Thoracic compression strength > Cervical com-
pression strength > lumbar compression strength
d) Cervical compression strength > thoracic compres-
sion strength > lumbar compression strength
e) Cervical compression strength > lumbar compres-
sion strength > thoracic compression strength
Response (A) The progressive increase in size of the ver-
tebral bodies from the rostral to caudal direction along the
spine correlates with an increase in strength and load-bearing
ability [3]. The vertebral bodies’ dimensions are proportional
to the loading forces they support.
12. During which motion do the facets joints bear a
greater part of the axial load in the cervical and
lumbar regions?
a) Extension
b) Flexion
c) Rotation
d) Lateral bending
e) Neutral position
Response: (A). The facets bear a greater part of the axial
load during extension. The facet joints do not otherwise
significantly support axial loads.
13. Which of the following statements accurately
describes the movement of the annulus fibrosus
during forward flexion?
a) Flexion causes bulging of the annulus fibrosus
rostrally
b) Flexion has no effect on the annulus fibrosus
c) Flexion causes bulging of the annulus fibrosus
ventrally
d) Flexion causes bulging of the annulus fibrosus
dorsally
e) Flexion causes bulging of the annulus fibrosus
laterally
Response (C) Bulging of the annulus fibrosus occurs on
the concave side of a bending spine. The nucleus pulposus
moves in the opposite direction. Thus, flexion causes ventral
bulging of the annulus fibrosis and dorsal migration of the
nucleus pulposus.
14. Which of the following statements accurately
describes the movement of the nucleus pulposus in
relation to the annulus fibrosis bulge during appli-
cation an eccentric axial load?
11 Biomechanics of the Spine 237
a) The nucleus pulposus tends to migrate in the same
direction as the annulus fibrosus bulge
b) The nucleus pulposus tends to migrate in the
opposite direction as the annulus fibrosus bulge
c) The nucleus pulposus tends to remain stationary
during application of an eccentric axial load
d) The nucleus pulposus tends to migrate within the
annulus fibrosus bulge
e) The nucleus pulposus tends to migrate orthogonally
to the annulus fibrosus bulge
Response (B) Disk bulging, and therefore annulus fibrosus
bulge, occurs on the concave side of a bending spine. When
under eccentric axial loading, the nucleus pulposus migrates
away from the concave side of the bending spine and
therefore away from the annulus fibrosus bulge.
15. Which of the following levels has the highest inci-
dence of vertebral compression fractures?
a) Lower lumbar spine
b) Sacral spine
c) Mid-thoracic spine
d) Upper thoracic spine
d) Upper thoracic spine
e) Thoracolumbar spine
Response (E) The thoracolumbar spine represents the
lower terminus of the thoracic kyphosis, lacks the protective
support of the rib cage, and does not have the larger vertebral
bodies characteristic of the lower lumbar spine. These fac-
tors collectively contribute to an increased incidence of
compression fractures in this region.
16. Degree of flexion–extension in the spine is greatest at
which of the following levels?
a) L1-2
b) Occiput to C1
c) C2-3
d) C3-4
e) C4-5
Response (B) Of the spinal levels listed, degree of flexion–
extension is greatest at the Occiput to C1 interface.
17. Which of the following ligaments plays the most
critical role in holding the dens to the posterior
aspect of the C1 anterior arch in a configuration
permitting significant neck rotation but limiting
posterior migration of the dens into the spinal canal?
a) Alar ligament
b) Tectorial mem brane
c) C1-2 Interspinous Ligament
d) Transverse ligament
e) Posterior longitudinal ligament
Response (D) The transverse ligament inserts into the
medial tubercles of the C1 lateral masses crosses immedi-
ately behind the body of the dens, holding the dens in close
proximity to the posterior aspect of the C1 anterior arch. The
transverse ligament thereby plays a crucial role in permitting
a large degree of axial neck rotation, but limits pathologic
flexion and extension as well as posterior migration of the
dens into the spinal canal. Disruption of the transverse
ligament, therefore, leads to atlanto-axial instability.
18. Which of the following accurately describes the
relationship between rod diameter and its stiffness?
a) Rod stiffness is inversely proportional to rod diam-
eter squared
b) Rod stiffness is proportional to rod diameter squared
c) Rod stiffness is directly proportional to rod diameter
d) Rod stiffness is proportional to rod diameter to the
fourth power
e) Rod stiffness is inversely proportional to rod diam-
eter to the fourth power
Response (D) Rod stiffness is proportional to rod diameter
to the fourth power.
19. Which of the following accurately describes the
relationship between rod diameter and its strength?
a) Rod strength is inversely proportional to rod diam-
eter squared
b) Rod strength is proportional to rod diameter squared
c) Rod strength is directly proportional to rod diameter
d) Rod strength is proportional to rod diameter to the
fourth power
e) Rod strength is proportional to rod diameter cubed
Response (D) Rod strength is proportional to rod diameter
cubed.
20. The quantification of an angular deformity can be
accomplished by determining which angle?
a) Cobb angle- angle between neutral rostral and cau-
dal vertebrae associated with a curvature
b) Dutch angle -angle between plum line and rostral
neutral vertebral body associated with a curve
c) Hallstead’s angle—angle between C7 middle infe-
rior endplate and caudal neutral vertebral body
associated with a curve
238 L. A. Silveira et al.
d) Callahan’s angle—angle between apex of curvature
and center of S1 superior endplate
e) Trolley angle—angle between C7 middle inferior
endplate and apex of curvature under analysis
Response (A) An angular deformity can be quantified by
calculating the Cobb angle, the angle between the rostral
neutral vertebra and caudal neutral vertebra. In this case,
neutral vertebrae are referred to as those vertebrae located at
the junct ion between two opposite curvatures.
21. Which of the following best describes the pressure
within the disc space in youth versus with
age-related degeneration?
a) In youth, the pressures within the central disc are
generally high and relatively evenly distributed
across the disc space during axial loading.
b) In youth, the pressures within the central disc are
generally low and the annulus fibrosus bears a
greater portion of axial loading
c) With degenerative aging, the pressures within the
central disc become higher during axial loading and
pressure on the peripheral annulus fibrosus is
diminished
d) Pressure borne by the central disc remains unchan-
ged in the aged degenerative spine during axial
loading as compared to the youthful spine
e) Pressure borne by the peripheral annulu s fibrosus
remains unchanged in the aged degenerative spine
during axial loading as compared to the youthful
spine
Response (A) Aging and degeneration within the interver-
tebral disc is associated with pressure distribution changes
across the disc space. In youth, the pressures within the
central disc are generally high and relatively evenly dis-
tributed across the disc space during axial loading. As the
spine ages and degenerative processes take place, the desic-
cated central nucleus pulposus can no longer bear axial loads
as in youth. Therefore, axial loads are borne more peripherally
by the fibrocartilaginous equivalent of the nucleus pulposus,
and the central disc pressure is diminished [2].
22. How do the ribs and sternum effect stability of the
middle and upper thoracic spine?
a) An intact sternum-ribcage plays no role in stability
of the middle and upper thoracic spine
b) The sternum-ribcage makes the upper and middle
thoracic spine particularly unstable
c) Sternal attachments are not required to achieve the
full stabilization potential of the ribcage
d) The sternum and ribcage function together to
enhance stability of the upper and middle thoracic
spine
e) An intact sternum with or without the ribcage aug-
ments stability of the middle thoracic spine
Response (D) The sternum and ribcage function together to
enhance stability of the upper and mid dle thoracic spine,
providing an additional degree of stiffness to that portion of
the spine and augmenting its axial load resisting ability. The
removal or detachment of the ribs to an intact sternum
detracts significantly from this added stability.
23. A burst fracture is characterized by which of the
following?
a) Anterior column compression only
b) Anterior column compression and middle column
compression
c) Middle column distraction and posterior column
distraction
d) Anterior column compression, middle column dis-
traction, and posterior column distraction
e) Posterior column compression only
Response (B) A burst fracture is characterized by anterior
and middle column compression. A compression fracture is
characterized by an anterior column compression only or
anterior column compression and posterior column distrac-
tion. A “seat belt” fracture is characterized by middle col-
umn distraction and posterior column distraction.
A fracture-dislocation is characterized by anterior column
compression, middle column distraction, and posterior col-
umn dist raction with a rotational shear.
24. The 30-degree orientation of the annular collagen
fi
bers to the vertebral endplates provides the annu-
lus fibrosis with the greatest resistance to which of
the following movements?
a) Torsion/rotation
b) Distraction
c) Compression
d) lateral bending
e) Equal degree of resistance to rotation and
compression
Response (A) Annular fibers, laminated bands of fibrous
tissue predominantly composed of collagen, are oriented in
11 Biomechanics of the Spine 239