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A. Severe loss of disc space height
B. High-grade spondylolisthesis
C. Spinal infection
D. Isthmic spondylolisthesis at L5/S1
E. Solitary kidney on the side of exposure
Response (A)Severe loss of disc space height is not a con-
traindication for ALIF Procedure. In grade 3 and 4 spondy-
lolisthesis, the nerve roots are stretched, which places patients
at high risk for nerve root injury without first decompressing
the nerve roots. Spinal infection is a contraindication to
interbody fusion, given that a foreign body is being placed into
infected tissue. For isthmic spondylolisthesis, addition of
posterior fusion should strongly be considered because of the
inherent instability. Solitary kidney on the side of the exposure
would also be considered a contraindication because the
anterior approach poses a risk of injury to the ureter [35].
Question 59
A 19-year-old female is brought to the emergency room after
a motor vehicle collision. She complains of persistent neck
pain without any radiation. On examination, she is neuro-
logically intact. A CT scan of the spine shows bilateral
fracture of the C2 pars interarticular is with a displacement
of 5.5 mm, severe anterior angulation, and C2-3 facet sub-
luxation. Which of the following is the most rational man-
agement strategy for this patient?
A. Soft cervical collar
B. Hard cervical collar
C. Reduction with traction followed by halo immobilization
D. Open reduction and internal fixation
E. Halo-vest orthosis
Response (D)Traumatic spondylolisthesis of the axis, also
known as a Hangman's Fracture, is a fracture of the pedicles
or pars interarticularis of the C2 vertebra. This pati ent has a
type III Hangman’s fracture that is greater than 5mm dis-
placement with significant angulation and facet capsule
disruption, making reduction with surgical stabilization the
most ideal treatment strategy. Cervical collar, halo-vest
orthosis, and closed reduction with halo immobilization are
only indicated when the patient has either a type I Hang-
man’s fracture (< 3mm horizontal displacement) or type II
with 3 to 5 mm displacement [36].
Question 60
Which of the following is not an advisable indication for pos-
terior and transforaminal lumbar interbody fusion approach?
A. Degenerative scoliosis
B. Infection
C. Spondylolisthesis
D. Pseudarthrosis
E. Severe spinal instability
Response (B)Acceptable indications for PLIF and TLIF
include spondylolisthesis, failure of posterolateral fusion
(pseudarthrosis), and degenerative scoliosis. Relative indi-
cations for these approaches include degenerative disc dis-
ease, high-grade spinal instability, and recurrent disc
herniation. Active infection, on the contrary, is a con-
traindication to PLIF and TLIF due to the high risk of dural
tear and possible meningitis. Additionally placement of
foreign body in the setting of infection is avoided when able.
Question 61
A 30-year-old woman sustained a complete spinal cord
injury after a gunshot to her back. Following the acute phase
of injury, she regainedher patellar reflex. Which of the fol-
lowing component must have been intact?
A. Cell bodies in the lower thoracic spinal cord
B. Cell bodies in the lumbar prominence of the spinal cord
C. Corticospinal tract between the brain and lumbar spinal cord
D. Dorsal column–medial lemniscus pathway between the
brain and lumbar spinal cord
Response (B)A“reflex arc” is made up of five components:
a receptor (muscle spindle), an afferent fi
ber, an integration
center (lamina IX of the spinal cord), an efferent fiber (alpha
motor neuron), and an effector (muscle). It primarily occurs
without the involvement of the central nervous system; the
brain only works to suppress the reflex when all spinal cir-
cuitry is intact (see Fig. 2.6). This patient had a patellar reflex
Fig. 2.6 Schematic representation of the monosynaptic stretch reflex
46 A. Khan et al.
after the injury because her sensory nerves from the patellar
tendon, the cell bodies within the lumbar spinal cord, and the
motor neurons at the same level were all intact [37].
Question 62
A 41-year-old male was emergently transported to the
emergency room after a motor vehicle collision. He was
restrained in the front seat with a three-point belt. The patient
complained of severe lower back pain but was able to
ambulate at the scene. On physical examination, he was fully
conscious and vital signs were stable. He has normal motor
power in all extremities and no sensory deficit. An antero-
posterior radiograph revealed an empty vertebral body sign
at T12 level and widening of interspinous processes from
T11 to L1. Which of the following is an indication for spine
surgery in this patient?
A. Normal neurological exam
B. Additional intrabdominal injury
C. Kyphosis less than 15 degree
D. Ligamentous injury
E. Purely osseous injury
Response (D) Chance fracture is a transverse vertebral
splitting that extends from the posterior spinal complex to
the anterior vertebral body, with no rotation or lateral dis-
placement of the fracture fragments. Treatment options
include conservative management through immobilization
and surgical stabilization. Unstable posterior elements and
ligamentous chance fracture with neurological deficits are
indicative for emergent open reduction surgery followed by
rehabilitation. In a patient with a bony type of Chance
fractures, no neurological deficit, and less than 15-degree
kyphosis, conservative management is appropriate.
Question 63
A 61-year-old male with a history of intravenous drug use
and diabetes mellitus presents to the clinic with fevers,
chills, neck pain, and worsening gait instability. His symp-
toms have been persistent for more than two weeks. On
exam, he has bilateral upper and lower extremity weakness.
An MRI of the spine shows anterior cervical epidural access
with spinal stenosis. What is the most appropriate next step
for this patient?
A. Broad-spectrum intravenous antibiotics
B. CT-guided biopsy and culture
C. Cervical collar with intravenous methylprednisolone
D. Posterior decompressive laminectomy
E. Anterior debridement and interbody fusion with strut
grafting
Response (E) This patient presents with risk factors (IV
drug use, diabetes) and exam findings (fever, motor
weakness) concerning spinal epidural abscess. Access
draining, necrotic bone debridement, and instrumentation
and fusion are necessary for this patient, as he has multiple
risk factors. Prophylactic antibiotics should not be given
until intraoperative cultures are obtained. Surgical delay for
IV steroids is also not supported because this patient has
neurological symptoms. The posterior approach is not the
best option, given that the cervical abscess is anterior in
this patient [38].
Question 64
At which of the following spinal cord levels can the cil-
iospinal center of Budge be found?
A. C5
B. T1
C. T6
D. L4
E. S1
Response (B) The ciliospinal center is located in the
intermediolateral horn between C8 and T2. It is a sympa-
thetic nucleus that receives input from the pretectum and
sends output to the superior cervical ganglion. It innervates
the iris dilator muscle.
Question 65
A 20-year-old student was sent to the emergency room after
hitting a sandbank as he dived into the waves. A CT scan of
the spine was ordered and found a complete spinal cord
injury at the C7 level. Which of the following sets of
motions is most likely to still be working in this student?
A. Wrist extension, shoulder abduction, finger flexion,
tricep reflex
B. Wrist flexion, elbow extension, thumb extension, bicep
reflex,
C. Wrist extension, elbow fl
exion, forearm supination,
brachioradialis reflex
D. Wrist flexion, elbow flexion, thumb extens ion, bicep
reflex
Response (C) Patients with a complete injury at C7 level
cannot move their legs or trunk. They have weakness in
2 Surgical Anatomy and Techniques to the Spine 47
breathing and coughing and have limited use of their hands
and fingers. Motions, including finger flexion (C8), wrist
flexion (C7), elbow extension (C7), thumb extension (C8),
and finger abduction (T1), may be affected by such injury.
Question 66
Which of the following is not an indication for surgical
management of rheumatoid arthritis in the cervical spine?
A. A cervico-medullary angle between 135 and 175
degrees
B. Atlantoaxial impaction represented by odontoid
migration 5 mm rostral to McGregor’s line
C. Progressive neurological deficit
D. Sagittal canal diameter 14 mm in patients with sub
axial subluxation
E. Posterior atlantodental interval 14 mm in the setting
of atlantoaxial subluxation
Response (A) The cervico-medullary angle can be mea-
sured on MRI by drawing a line along the anterior aspect of
the cervical spinal cord and the medulla. This angle is an
effective indicator of cord distortion from superior migration
of the odontoid. It is normally between 135 and 175 degrees.
With progressive craniocervical disease, the brainstem
angulates ventrally over the displaced odontoid process,
leading to increased obliquity of the cervicomedullary angle.
Therefore, when the cervicomedullary angle is less than 135
degrees, surgery is indicated in patients with rheumatoid
disease of the cervical spine [39].
Question 67
A 43-year-old male with a history of alcoholism presents to
the emergency room after collapsing while having a seizure.
He is conscious and reports severe low back pain coupled
with leg weakness that makes him unable to walk. On
examination, he is ASIA grade B. Initial CT scan reveal s a
burst fracture at L1 vertebra with 65% retropulsion into the
spinal canal and translation of L1 on L2. MRI spine with and
without contrast further shows significant edema disrupting
interspinous ligaments and ligamentum flavum. Which of
the following options is most likely recommended to this
patient?
A. Pain control and early mobilization in a turtle shell type
brace
B. Reassessment upon return of Osinski reflex
C. Posterior lumbar laminectomy
D. Corpectomy with interbody cage placement
E. Corpectomy with interbody cage placement and
instrumented fusion
Response (E) According to the Thoracolumbar Injury
Classification and Severity Score (TLICS), this patient has a
highly unstable burst fracture with a TLICS of 9 (translation,
injured posterior ligamentous complex, and incomplete cord
injury) (see Fig. 2.7). Conservative treatment is only indi-
cated in stable burst fracture without neurological deficit. We
can also assume from the ASIA impairment scale that the
patient’s Osinski reflex is intact. The best surgical option to
maximize structural stability is decompression through ver-
tebral corpectomy with the placement of an interbody cage,
followed by posterior instrumentation [40].
Question 68
With regard to ossification of the posterior longitudinal
ligament (OPLL) and degenerative cervical myelopathy, a
posterior approach is preferred in which of the following
indications?
A. K-line (+) OPLL with canal-occupying ratio < 50 to
60%
B. K-line (−) OPLL regardless of the canal-occupying
ratio
C. K-line (+) OPLL with canal-occupying ratio > 60%
D. Preexisting cervical kyphosis
E. None of the above
Response (A) Posterior approach is preferred for K-line (+)
OPLL with canal-occupying ratio < 50–60% and for
multi-level degenerative cervical myelopathy. The anterior
approach is preferred for K-line (−) OPLL, K-line (+) with
canal occupying ratio > 60% and degenerative cervical
myelopathy with preexisting cervical kyphosis. However,
the anterior approach is associated with increased rates of
complications and thereby needs to be weighed carefully
during the decision-making process [41].
Question 69
After lifting a heavy load, a 46-year-old construction worker
presents with an immediate onset of right leg burning pain.
The pain exacerbates by coughing, sneezing, and sitting.
Physical examination shows severe weakness in hip abduc-
tion, knee flexion, and foot dorsiflexion on the right. Which
direction is the structure implicated in this patient’s pre-
sentation most likely displaced?
48 A. Khan et al.
A. Central posterior
B. Lateral
C. Posterolateral
D. Anterior
E. Inferio-medial
Response (C) Protrusions of nucleus pulpous through
annulus fibrosis are most likely to occur posterolaterally at the
level of L4-L5 or L5-S1. The presence of a thicker posterior
longitudinal ligament in the center prevents the disc from
herniating directly posteriorly, and the annulus fibrosis is
thinner on the posterolateral aspect, making it vulnerable for
herniation. Pain from lumbar disc herniation arises from the
protruding material exerting pressure on the nerve root(s).
Question 70
A 39-year-old woman presents to the emergency department
with postural abnormality. She was admitted to the hospital
three weeks ago for a non-traumatic pontine and midbrain
intracranial hemorrhage. On examination, the patient had
significant head nodding, bilateral flexion of the upper
extremities, and bilateral extension of the lower extremities.
Which extrapyramidal tract is most likely to facilitate this
patient’s postural abnorm ality?
A. Reticulospinal tracts
B. Rubrospinal tract
C. Corticobulbar tract
D. Olivospinal tract
E. Tectospinal tract
Response (B)This patient’s presentation is consistent with
decorticate rigidity. The rubrospinal tract, which originates
from the red nucleus, travels adjacent to the lateral corti-
cospinal tract and ends in the upper cervical segments of the
spinal cord. When there is an injury distal to the red nucleus,
the rubrospinal tract becomes overactivated, leading to an
unimpeded flexion reflex of the upper limbs. The vestibu-
lospinal tract is also left disinhibited, thereby induce biased
extension of the lower limbs [42].
Question 71
A 13-year-old boy presents to the clinic complaining of
progressive low back pain for the last month. He plays ice
hockey in school and trains at least four times a week. The
pain is located at the lumbar region, non-radiating, and
exacerbates by extension or twisting of the spine. What is the
most likely diagnosis?
A. Pars interarticularis fracture
B. Lumbar disc herniation
C. Sprain/strain injuries
D. Vertebra fracture
Response (A)Spondylolysis is a common identifiable cause
of low back pain in young athletes participating in sports,
Fig. 2.7 Table demonstrating the
Thoracolumbar injury
classification and severity score
[40]
2 Surgical Anatomy and Techniques to the Spine 49
particularly those involving repetitive hyperextension and
axial loading of the spine. Gymnastics, weight-lifters, divers,
rowers, and tennis players have higher rates of this injury.
There is no sciatica or leg pain for a disc herniation diag-
nosis. Spinal sprain/strain injures may be a possibility, but
the symptoms should subside with pain medications and rest
within a few weeks. The patient also did not experience
acute trauma, making vertebra fracture less likely.
Question 72
A 63-year-old male underwent decompressive laminectomy
for lumbar stenosis and neurogenic claudication. The patient
complains of persistent pain at the surgical site postopera-
tively, especially when walking. He has no fever and no
wound drainage. His C-reactive protein level and erythro-
cyte sedimentation rate are within normal limits. What is the
next step in management?
A. MRI scan
B. Increase opioid dosage
C. Digital Motion X-ray
D. Antibiotics
Response (C) Joint instability is a common complication
for laminectomy of the spine bec ause off disruption of many
of the bony stabiliz ing structures durin g the procedure.
Patients experiencing postoperative spinal instability often
present with characteristic localized pain, especially during
ambulation. Digital motion X-ray (DMX) can provide clear
images being able to see the bones in motion. The proba-
bility of discitis in this patient is also very low, as his ery-
throcyte sedimentation rate and C-reactive protein levels are
normal as well as there is no constitutional symptoms [43].
Question 73
Generally, the indications for anterior lumbar interbody
fusion (ALIF) and lateral lumbar interbody fusion (LLIF) at
the L4-5 level are similar. However, which of the following
complications seen in ALIF is normally avoided in LLIF
when performing the surgery at the L4-L5 level?
A. Vascular injury
B. Interbody subsidence
C. Neurologic injury
D. Retrograde ejaculation
E. Incisional hernia
Response (D) Complication rates appear similar to ALIF
(26.6%) and LLIF (25%). However, their complication
profiles differ slightly. LLIF gains access to the lumbar spine
via a lateral approach that passes through the retroperitoneal
fat and psoas major. It thus avoids the peritoneal contents,
sympathetic chain, and great vessels, which are all potential
injury sites in ALIF. The risk of injury to the superior
hypogastric plexus, which leads to retrograde ejaculation in
men, is reported to be less than 3% in ALIF and has not been
reported yet in LLIF.
Question 74
Which of the following ligaments attach to a spinous
process?
A. Anterior longitudinal ligament
B. Posterior longitudinal ligament
C. Nuchal ligament
D. Ligamentum flavum
Response (C) The inferior part of the nuchal ligament
attaches to the C7 spinous process. None of the remaining
answers A, B, D attach to any spinous processes.
Question 75
Which of the following correctly lists the embryological
progression of somatogenesis?
A. Paraxial mesoderm ! Somite ! Ventromedial
Sclerotomes ! Dorsolateral dermomyotomes
B. Somite ! Ventromedial Sclerotomes !Paraxial
mesoderm ! Dorsolateral dermomyotomes
C. Dorsolateral dermomyotomes ! Ventromedial Sclero-
tomes !Paraxial mesoderm ! Somite
D. Somite ! Paraxial mesoderm ! Dorsolateral der-
momyotomes ! Ventromedial Sclerotomes
Response (A) This is the proper progression of somato-
genesis for the bony development of the vertebral body.
Question 76
Which gene is specifically responsible for the shape of the
vertebral body?
50 A. Khan et al.
A. ATM
B. FXN
C. HOX
D. ATP7B
Response (C) the Hox and SHH gene controls the shape of
the vertebral body. ATM gene is associated with
ataxia-telangiectasia. FXN is associated with Friedreich
ataxia. ATP7B is associated with Wilson disease [ 44 ].
Question 77
There are ______ primary ossification centers and ______
secondary ossifications for the bony development of the
vertebrae.
A. Two, Four
B. Four, Two
C. Three, Four
D. Three, Five
Response (D) C3 through L5 have one primary ossification
center for the vertebral body and two primary ossification
centers that each contribute to one-half of each vertebral
arch. There is one secondary ossification center for superior
and inferior endplates, one at each end of the transverse
processes, and one for the spinous process [45].
Question 78
Which pair of spinal curves is not present during the fetal
period?
A. Thoracic, Lumbar
B. Lumbar, Sacral
C. Thoracic, Cervical
D. Cervical, Lumbar
Response (D) The cervical lordosis curve forms after time
as the infant works on learning to hold their head up. The
lumbar lordosis curve forms later as the infant learn how to
walk. The thoracic and sacral curves are present in the fetus.
Question 79
Lateral masses are composed of which of the following?
A. Superior and inferior articulating processes
B. Bilateral lamina
C. Superior and inferior transverse processes
D. Ipsilateral and contralateral lamina
Response (A) The lateral mass does not begin until the
lateral junction of the lamina and the pedicle. The transverse
processes have no contributions to the lateral mass. The
lateral masses are made from the superior and inferior
articulating surfaces that form the facet joint [46].
Question 80
What is the theoretical benefit of approaching the anterior
cervical spine from the left side?
A. Lower risk of bradycardia
B. Lower risk of recurrent laryngeal nerve injury (RLN)
C. Lower risk of postoperative facial droop
D. Elevated risk of thoracic duct injury during a right-sided
approach
E. Lower risk of phrenic nerve injury
Response (B) Based on a purely anatomical basis, there is
thought to be a lower risk of damage to the recurrent
laryngeal nerve when using a left-sided approach to the
anterior cervical spine. This is due to a more anterolateral
course of the nerve outside the tracheoesophageal groove.
However, studies have not demonstrated a significant dif-
ference in RLN injury in the left-sided approach compared to
the right-sided approach.
References
1. Rucco V, Basadonna PT, Gasparini D. Anatomy of the iliolumbar
ligament: a review of its anatomy and a magnetic resonance study.
Am J Phys Med Rehabil. 1996;75(6):451–5. https://doi.org/10.
1097/00002060-199611000-00010. PMID: 8985109
2. Malek E, Faddoul DG, Baydoun H, Omeis I, Makki A. Rev-
ersible acute anterior longitudinal ligament calcification with
retropharyngeal inflammation. J ClinRheumatol. 2021;27(4):
e123–5. https://doi.org/10.1097/RHU.0000000000000878. PMID:
30142115.
3. Ohara Y. Ossification of the ligaments in the cervical spine,
including ossification of the anterior longitudinal ligament,
ossification of the posterior longitudinal ligament, and ossifica-
tion of the ligamentum flavum. NeurosurgClin N Am. 2018;29
(1):63–8. https://doi.org/10.1016/j.nec.2017.09.018. PMID:
29173437.
4. Gala FB, Aswani Y. Imaging in spinal posterior epidural space
lesions: a pictorial essay. Indian J Radiol Imaging. 2016;26
(3):299–315. https://doi.org/10.4103/0971-3026.190406.
5. Wu ZH, Zheng Y, Yin QS, Ma XY, Yin YH. Anterior pedicle
screw fixation of C2: an anatomic analysis of axis morphology and
simulated surgical fixation. Eur Spine J. 2014;23(2):356–61.
https://doi.org/10.1007/s00586-013-3042-8.
6. Scali F, Marsili ES, Pontell ME. Anatomical connection between
the rectus capitis posterior major and the dura mater, Spine.
2011;36(25):E1612–4
2 Surgical Anatomy and Techniques to the Spine 51
7. Mysorekar VR, Nandedkar AN. Surface area of the
atlanto-occipital articulations. Acta Anat (Basel). 1986;126
(4):223–5. https://doi.org/10.1159/000146221. PMID: 3766103.
8. Er U, Fraser F, Lanzino G. The anterior spinal artery origin: a
microanatomical study; Spinal Cord. 2008;46(1):45–9. https://doi.
org/10.1038/sj.sc.3102060
9. Dominik T, Bendik S, Przemysław AP, Wan CH, Roberto C,
Jerzy AW, Shane Tubbs R, Krzysztof AT, Brandon MH. Artery of
Adamkiewicz: a meta-analysis of anatomical characteristics. Neuro-
radiology. 2019;61(8): 869–80. Published online 2019 Apr 27. https://
doi.org/10.1007/s00234-019-02207-y. PMCID: PMC6620248
10. Shuaifeng Y, Yunfan Z, Kai W, Yingchao H, Kai Z, Fan H, Jun T.
Three-dimensional morphological characteristics of lower lumbar
intervertebral foramen with age. Biomed Res Int.
2018;2018:8157061. Published online 2018 Nov 11. https://doi.
org/10.1155/2018/8157061. PMCID: PMC6252236
11. Katsunari A. Vascular anatomy of the cauda equina and its
implication on the vascular lesions in the caudal spinal structure.
Neurol Med Chir (Tokyo) 2016;56(6):310–6. Published online
2016 Mar 28. https://doi.org/10.2176/nmc.ra.2016-0006
12. Jae-Chil C, Hyung-Ki P, Soon-Kwan C. Posterior cervical
inclinatory foraminotomy for spondylotic radiculopathy prelimi-
nary. J Korean Neurosurg Soc. 2011;49(5):308–13. Published
online 2011 May 31. https://doi.org/10.3340/jkns.2011.49.5.308.
PMCID: PMC3115157
13. Christensen FB, Bünger CE. Retrograde ejaculation after retroperi-
toneal lower lumbar interbody fusion. Int Orthop. 1997;21(3):176–
80. https://doi.org/10.1007/s002640050145.
14. Enyo Y, Yamada H, Kim JH, Yoshida M, Hutton WC. Microen-
doscopic lateral decompression for lumbar foraminal stenosis.
J Spinal Disord Tech. 2014;27:257–62. https://doi.org/10.1097/
BSD.0b013e31828cff6e.
15. Tubbs RS, Demerdash A, Rizk E, Chapman JR, Oskouian RJ. Com-
plications of transoral and transnasal odontoidectomy: a compre-
hensive review. Childs NervSyst. 2016;32:55–9.
16. Sabiston CP, Wing PC, Schweigel JF, Van Peteghem PK, Yu WI.
Closed reduction of dislocations of the lower cervical spine.
J Trauma. 1988;28(6):832–5.
17. Ozgur BM, Aryan HE, Pimenta L, Taylor WR. Extreme Lateral
Interbody Fusion (XLIF): a novel surgical technique for anterior
lumbar interbody fusion. Spine J. 2006;6(4):435–43.
18. Davis TT, Hynes RA, Fung DA, Spann SW, MacMillan M,
Kwon B, Liu J, Acosta F, Drochner TE. Retroperitoneal oblique
corridor to the L2–S1 intervertebral discs in the lateral position: an
anatomic study. J Neurosurg: Spine. 2014;21(5):785–93.
19. Fountas KN, Kapsalaki EZ, Nikolakakos LG, Smisson HF,
Johnston KW, Grigorian AA, Lee GP, Robinson JS Jr. Anterior
cervical discectomy and fusion associated complications. Spine.
2007;32(21):2310–7.
20. Yüksel KZ, Yüksel M, Gonzalez LF, Baek S, Heiserman JE,
Sonntag VK, Crawford NR. Occipitocervical vertical distraction
injuries: anatomical biomechanical, and 3-tesla magnetic reso-
nance imaging investigation. Spine. 2008;33(19):2066–73.
21. Leijnse JN, D’Herde K. Revisiting the segmental organization of
the human spinal cord. J Anat. 2016;229(3):384–93.
22. Siu TLT, Lin K. Direct tubular lumbar microdiscectomy for far
lateral disc herniation: a modified approach. Orthop Surg. 2016;8
(3):301–8. https://doi.org/10.1111/os.12263. PMID: 27627712.
23. Hwang K, Kim JY, Lim JH. Anatomy of the platysma muscle.
J Craniofac Surg. 2017;28(2):539–42. https://doi.org/10.1097/
SCS.0000000000003318.
24. Yang BP, Ondra SL, Chen LA, Jung HS, Koski TR, Salehi SA.
Clinical and radiographic outcomes of thoracic and lumbar pedicle
subtraction osteotomy for fixed sagittal imbalance. J Neurosurg
Spine. 2006;5(1):9–17. https://doi.org/10.3171/spi.2006.5.1.
25. Yang BP, Ondra SL, Chen LA, Jung HS, Koski TR, Salehi SA.
Clinical and radiographic outcomes of thoracic and lumbar pedicle
subtraction osteotomy for fixed sagittal imbalance. J Neurosurg
Spine. 2006;5(1):9–17. https://doi.org/10.3171/spi.2006.5.1.9.
26. Bunmaprasert T, Chaibhuddanugul N, Keeratiruangrong J, Raphit-
phan R, Sugandhavesa N, Liawrungrueang W. Corrective
osteotomy of global sagittal imbalance in the neglected
fracture-dislocation thoracic spine. Trauma Case
Rep. 2021;32:100409. https://doi.org/10.1016/j.tcr.2021.100409.
eCollection 2021 Apr
27. Vannucci F, Araújo JA. Thoracic sympathectomy for hyperhidro-
sis: from surgical indications to clinical results. J Thorac Dis.
2017;9(Suppl 3):S178–92. https://doi.org/10.21037/jtd.2017.04.04
28. Siribumrungwong K, Sinchai C, Tangtrakulwanich B, Chaiya-
mongkol W. Reliability and accuracy of palpable anterior neck
landmarks for the identification of cervical spinal levels. Asian
Spine J. 2018;12(1):80–4. https://doi.org/10.4184/asj.2018.12.1.80.
29. Uribe JS, Arredondo N, Dakwar E, et al. Defining the safe working
zones using the minimally invasive lateral retroperitoneal transp-
soas approach: an anatomical study. J Neurosurg Spine.
2010;13:260–6
30. Jagannathan J, Sansur CA, Oslouian RJ, et al. Radiographic
restoration of lumbar alignment after transforaminal lumbar
interbody fusion. Neurosurgery. 2009;64:955–64
31. Kurokawa R, Kim P. Cervical Laminoplasty: The History and the
Future. Neurol Med Chir (Tokyo). 2015;55(7):529-39. https://doi.
org/10.2176/nmc.ra.2014-0387
32. Sharma SB, Kim JS. A review of minimally invasive surgical
techniques for the management of thoracic disc herniations.
Neurospine. 2019;16(1):24–33. https://doi.org/10.14245/ns.
1938014.007.
33. Ishii K, Isogai N, Shiono Y, et al. Contraindication of minimally
invasive lateral interbody fusion for percutaneous reduction of
degenerative spondylolisthesis: a new radiographic indicator of
bony lateral recess stenosis using i line. Asian Spine J. 8 2021;15
(4):455–63.https://doi.org/10.31616/asj.2020.0083
34. Hong D, Andrén-Sandberg A. Punctate midline myelotomy: a
minimally invasive procedure for the treatment of pain in
inextirpable abdominal and pelvic cancer. J Pain Symptom
Manage. 2007;33(1):99–109. https://doi.org/10.1016/j.
jpainsymman.2006.06.012. PMID: 17196911.
35. Mobbs RJ, Phan K, Malham G, Seex K, Rao PJ. Lumbar interbody
fusion: techniques, indications and comparison of interbody fusion
options including PLIF, TLIF, MI-TLIF, OLIF/ATP. LLIF and
ALIF J Spine Surg. 2015;1(1):2–18. https://doi.org/10.3978/j.issn.
2414-469X.2015.10.05.
36. Murphy H, Schroeder GD, Shi WJ, Kepler CK, Kurd MF,
Fleischman AN, Kandziora F, Chapman JR, Benneker LM,
Vaccaro AR. Management of Hangman's Fractures: A Systematic
Review. J Orthop Trauma. 2017;31 Suppl 4:S90-S95. https://doi.
org/10.1097/BOT.0000000000000952uns
37. Trontelj MA, Trontelj JV. Reflex arc of the first component of the
human blink refl
ex: a single motoneurone study. J NeurolNeuro-
surg Psychiatry. 1978;41(6):538–47. https://doi.org/10.1136/jnnp.
41.6.538.
38. Al-Hourani K, Al-Aref R, Mesfin A. Upper cervical epidural
abscess in clinical practice: diagnosis and management. Global
Spine J. 2016;6(4):383–93. https://doi.org/10.1055/s-0035-
1565260.
39. Mallory GW, Halasz SR, Clarke MJ. Advances in the treatment of
cervical rheumatoid: Less surgery and less morbidity. World J
Orthop. 2014;5(3):292–303. Published 2014 Jul 18. https://doi.
org/10.5312/wjo.v5.i3.292
40. Lee JY, Vaccaro AR, Lim MR, et al. Thoracolumbar injury
classification and severity score: a new paradigm for the treatment
52 A. Khan et al.
of thoracolumbar spine trauma. J Orthop Sci. 2005;10(6):671–5.
https://doi.org/10.1007/s00776-005-0956-y.
41. Kwok SSS, Cheung JPY. Surgical decision-making for ossification
of the posterior longitudinal ligament versus other types of
degenerative cervical myelopathy: anterior versus posterior
approaches. BMC MusculoskeletDisord. 2020;21:823. https://doi.
org/10.1186/s12891-020-03830-0.
42. Riddle CN, Edgley SA, Baker SN. Direct and indirect connections
with upper limb motoneurons from the primate reticulospinal tract.
J Neurosci. 2009;29(15):4993–9. https://doi.org/10.1523/
JNEUROSCI.3720-08.2009.
43. Bisschop A, van Royen BJ, Mullender MG, et al. Which factors
prognosticate spinal instability following lumbar laminectomy?
Eur Spine J. 2012;21(12):2640–8. https://doi.org/10.1007/s00586-
012-2250-y.
44. Mallo M, Wellik DM, Deschamps J. Hox genes and regional
patterning of the vertebrate body plan. Dev Biol. 2010;344(1):
7–15.
45. Baumgart M, Wiśniewski M, Grzonkowska M, et al. Digital image
analysis of ossification centers in the axial dens and body in the
human fetus. Surg Radiol Anat. 2016;38(10):1195–203.
46. Pait TG, McAllister PV, Kaufman HH. Quadrant anatomy of the
articular pillars (lateral cervical mass) of the cervical spine.
J Neurosurg. 1995;82(6):1011–4. https://doi.org/10.3171/jns.1995.
82.6.1011.
2 Surgical Anatomy and Techniques to the Spine 53
3
Instrumentation
Asham Khan, Moleca M. Ghannam, Ryan M. Hess, Slah Khan,
Alexander O. Aguirre, Cathleen C. Kuo, Ali Y. Elkady, Ahmed H. Omar,
Mohammad Elbaroody, and Mohamed A. R. Soliman
Question 1
What complication is seen with lateral breach of a lateral
mass screw in the fixation of C2?
A. Spinal cord durotomy
B. Vertebral artery injury
C. Disruption of the atlantoaxial joint
D. Screw loosening
Response (B) The vertebral artery is located just laterally
to the lateral mass of the C2 vertebral body. The other
options are associated with a superior or medial breach of the
lateral mass screw [1].
Question 2
Which of the following is the benefit of using cross-links in
spinal instrumentation?
A. Increase in torsional (rotation) stiffness.
B. Increase resistance to lateral bend.
C. Increase in axial stiffness.
D. Increase resistance to flexion/extension.
E. Increase fusion rate.
Response (A) Adding cross-links to spinal instrumenta-
tions can increase torsional (rotational) stiffness, which is
especially crucial for long constructs. There are no signifi-
cant changes in implants’ axial, flexural/extensional, and
lateral stiffness with the addition of either the cross-links or
segmental medical screws [2].
Question 3
Which of the following is
not a known risk factor for
proximal junctional kyphosis after a spinal fusion?
A. Large preoperative sagittal parameters.
B. Greater curvature correction.
C. Anterior–posterior spinal fusion.
D. Male sex.
Response (D) Large preoperative sagittal parameters, greater
curvature correction, and anterior–posterior spinal fusion are
all known risk factors that increase the risk of a proximal
junctional kyphosis occurring after a spinal fusion [3].
Question 4
In those with SI joint injury undergoing either open or
percutaneous placement of sacroiliac screws as part of a
A. Khan M. M. Ghannam R. M. Hess S. Khan
A. O. Aguirre C. C. Kuo M. A. R. Soliman (&)
Department of Neurosurgery, University at Buffalo,
Buffalo, NY, USA
e-mail: msolim8@uwo.ca
A. Khan
e-mail: akhan@ubns.com
M. M. Ghannam
e-mail: mghannam@ubns.com
R. M. Hess
e-mail: rhess@ubns.com
S. Khan
e-mail: slahkhan@buffalo.edu
A. O. Aguirre
e-mail: aa284@buffalo.edu
C. C. Kuo
e-mail: ckuo9@buffalo.edu
A. Y. Elkady A. H. Omar M. Elbaroody M. A. R. Soliman
Department of Neurosurgery, Cairo University, Cairo, Egypt
e-mail: ayousri54@gmail.com
A. H. Omar
e-mail: a.hussein.omar1990@gmail.com
M. Elbaroody
e-mail: mohammad.elbaroody@kasralainy.edu.eg
© 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_3
55
longer lumbosacral construct, what is required to ensure the
safety of the patient and good clinical outcome?
A. Fracture reduction.
B. Dissection of surrounding soft tissue.
C. Removal of any invasive vasculature.
D. Retraction of the pudendal nerve.
Response (A) A fracture reduction is mandatory when
placing an iliosacral screw as this is key in the final align-
ment for long term fusion. Complications related to SI screw
placement are usually caused by inadequate appreciation of
the pelvic anatomy due to osseous injury, anatomical vari-
ability, and displacement. Several neurova scular structures
are in the vicinity of the posterior ilium and sacrum and can
be damaged during this procedure but it is not necessary for
these to be exposed, removed, or retracted. The L5, S1, or S2
nerve roots and the common iliac vessels are in close rela-
tionship to the sacrum. If a guide wire or drill is aberrantly
placed into the greater sciatic notch, damage to the sciatic
nerve, superior and inferior gluteal neurovascular bundles,
pudendal nerve, and internal pudendal artery/vein could
occur. In addition, branches of the superior gluteal neu-
rovascular bundle are at risk during the procedure while
passing through the abductor musculature [4].
Question 5
Which of the following is true regarding CT myelography?
A. It is an indirect spinal imaging method.
B. It carries extremely high specificity.
C. Can diagnose the pathology of compressive lesions.
D. It is a non-invasive procedure.
Response (A) This procedure carries low specificity, can-
not diagnose the pathology of compressive lesions and is an
invasive procedure. Therefore, A is the only correct answer.
It is an indirect, rather than direct, assessment of extradural
compression as diagnosis can be inferred based on changes
in the contour of the contrast-filled thecal sac and nerve root
sleeves [ 5].
Question 6
Management of adult spinal deformities often involves long
thoracolumbar fusions. What is the major advantage of
selecting sacrum over L5 as the caudal extent of fusion?
A. Improved correction and maintenance of sagittal
balance.
B. Decreased risk of pseudarthrosis.
C. Improvement in pain and disability.
D. Decreased major medical complication rates.
E. Improved curve correction in the coronal plane.
Response (A) Fusion to the sacrum achieves a better cor-
rection of sagittal imbalance than fusion to L5. Proponents
of ending fusions at L5, on the other hand, often cite three
main reasons: decreased complication rate (pseudoarthrosis
and implant-related complications), maintenance of lum-
bosacral motion, and avoiding possible anterior surgery at
L5-S1. There is no difference in medical complication rate,
coronal plane curve correction, and postoperative pain and
disability between these two approaches, as assessed by
VAS (visual analogue score) score and ODI (Oswestry
disability index), respectively [6].
Question 7
Which of the following is not a risk from ionizing radiation
exposure?
A. Temporary or permeant sterility.
B. Glaucoma.
C. Depression of hematopoiesis.
D. Heart disease.
Response (B) All the risks are impacted by ionizing radi-
ation, although in the eyes, this manifests as cataracts, not
glaucoma. The remaining options are all true.
Question 8
If an autologous bone stem cell harvest were to occur during
a spine surgery, what nerve would be at risk by the instru-
mentation trajectory?
A. Lateral femoral cutaneous nerve.
B. Ilio-hypogastric nerve.
C. Ilioinguinal nerve.
D. All of the above.
Response (D) All of the following nerves would be at risk
from the instrumentation during this stem cell harvest [7].
Question 9
If a lateral lumbar interbody fusion was completed while the
patient was in the right lateral decubitus position and the
56 A. Khan et al.