AAOS Adult Spine Self-Assessment Examination Answer Book | Latest 2025/2026 Edition | American Academy of Orthopaedic Surgeons

w Adult Spine 201
Self-Assessment Examination 201
2015




AAOS
Yowr Sorefor Lifelong Orthopaedic learig

,1 - Figures 1 and 2 are CT scans obtained from a 68-year-old man who has had progressive neck pain and stiffness,
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worsening gait imbalance, upper extremity weakness, early muscle fatigue, difficulty with fine motor control, and
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difficulty with activities of daily living over the past few years. On physical examination, he has a wide based stiff
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legged gait, generalized upper extremity weakness, dense sensory loss in the upper and lower extremities, and
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markedly brisk reflexes. What is the most appropriate treatment for this patient?
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Figure 1 R Figure 2 R




A. Observation
B. Cervical epidural injections R R


C. Multilevel anterior cervical decompression and fusion R R R R R


D. Posterior cervical laminoplasties from C3-6 R R R R




Correct answer: D R R




This patient has progressive myelopathy secondary to ossification of the posterior longitudinal ligament. Diagnostic
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Rimaging reveals multilevel cervical cord compression from C4-6. The patient has maintained reasonable cervical
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Rlordosis. A posterior procedure such as multilevel laminoplasty decompresses the spine, is motion preserving, and has
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Ra low complication rate. Observation and cervical epidural injections are not viable options in patients with
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Rprogressive myelopathy. Anterior cervical decompression, including corpectomy, is an option; however, anterior
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Rprocedures have an increased risk of complications such as dural tear or cerebrospinal fluid leak. The axial CT image
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Rshows a "double layer"
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sign, which is consistent with dural ossification and increases the risk of dural injury with anterior decompression.
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2 - When compared with posterior decompression and fusion, the addition of an interbody fusion for the treatment
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of degenerative spondylolisthesis and stenosis has been shown to
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A. result in increased patient functional outcome scores.
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B. reduce the incidence of symptomatic pseudarthrosis.
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, C. increase the length of hospital stay. R R R R R


D. increase hospital costs. R R




Correct answer: D R R




The use of an interbody graft has been shown to increase hospital costs. Gottschalk and associates found no
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change in Oswestry Disability Index (ODI) or 36-Item Short-Form Health Survey (SF-36) scores when
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comparing patients fused using either posterior fusion or transforaminal interbody fusion. They also found
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no change in fusion rates at 3 years after surgery. Carreon and associates showed some that using a posterior
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place interbody transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF)
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did result in improved ODI and SF-6D scores but did not result in any change in EuroQol five dimensions
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questionnaire (EQ-5D) scores. Using the EQ-5D data, they estimated that the use of an interbody graft
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becomes cost prohibitive if the charges exceed $1,570 above the cost of a posterior fusion. The use of an
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interbody cage has not been shown to increase hospital stay.
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3 - Figures 1 and 2 are MRI images obtained from a 22-year-old man who fell from a 2-story building. On examination,
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he has diminished rectal tone and urinary retention. If surgical stabilization is elected, what is the most
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biomechanically stable option?
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Figure 1 R Figure 2 R




A. Sacral plating R


B. Iliosacral screws R


C. Iliosacral screws and lumbopelvic fixation R R R R


D. External fixation R

, Correct answer: CR R




The patient has a U-shaped sacral fracture or spondylopelvic dissociation. Treatment options for these fractures range
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from percutaneous placement of iliosacral screws to lumbopelvic fixation (lumbar pedicle screws and iliac screws).
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Lumbopelvic fixation can be supplemented by iliosacral screws, which has been termed triangular osteosynthesis.
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Biomechanical studies have shown that iliosacral screws with lumbopelvic fixation—or triangular osteosynthesis—is
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the most stable construct when compared with iliosacral screws alone. The advantage of lumbopelvic fixation is that
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concurrent sacral laminectomy can be performed, which is recommend in this patient because of his neurologic
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symptoms. External fixation or sacral plating play minimal roles in U-shaped sacral fractures.
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4 - Clinical Situation
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Figure 1 shows a CT from the cervical spine of an 85-year-old woman who fell from a standing height 1
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week earlier. She is independent and ambulatory and resides in an assisted living facility. She reports
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persistent neck pain but denies arm pain or weakness. She is neurologically intact.
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Fractures in this region of C2 have a high risk of
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Figure 1


A. spinal cord injury. R R


B. union.
C. nonunion.
D. stroke.