Adult Neurosurgery PDF Past Papers

3 Adult Neurosurgery 1. A. Perform a lumbar puncture, and send spinal Which tumor is associated with hydrocephalus fluid cultures. and sudde...

3 Adult Neurosurgery 1. A. Perform a lumbar puncture, and send spinal Which tumor is associated with hydrocephalus fluid cultures. and sudden death? B. Obtain a CT scan of the spine. A. Colloid cyst C. Obtain blood cultures. B. Glioblastoma multiforme D. Obtain a bone scan. C. Lymphoma E. Schedule follow-up with a repeat MRI in 4 to 6 D. Pilocytic astrocytoma weeks. 2. 5. Complex regional pain syndrome type 2 (formerly How is mechanical back pain associated with known as causalgia) is defined by what symptoms? activity? A. Burning pain, autonomic dysfunction, and tro- A. Improves with activity phic changes following obvious nerve damage B. Worsens with activity B. Increased perspiration in excess of what is re- C. Relieved by standing quired for regulation of body temperature D. Worsens with axial unloading C. Burning pain, autonomic dysfunction, and tro- phic changes without obvious nerve damage 6. D. An initial lack of sensation and tingling on one Where should the dissection take place during a side of the body followed later by severe, transpsoas approach to the lumbar spine in order chronic dysesthesias or allodynia to minimize the risk of nerve injury? E. Recurrent hospitalizations with dramatic, un- A. Anterior to the psoas major true, and extremely improbable tales of past B. Posterior to the psoas major experiences C. Through the bulk of the psoas major D. Along the medial aspect of the psoas major 3. E. Along the lateral aspect of the psoas major What factors contribute to the intracranial hemor- rhage (ICH) score for a patient with a hemorrhagic 7. stroke? A 17-year-old girl presents to the neuro-ophthal- A. Patient age, Glasgow Coma Scale (GCS) score, mology clinic with complaints of episodic diplopia acuity of ICH that has been present for the past week. The epi- B. ICH volume, GCS score, acuity of ICH sodes occur about every hour and last around 1 C. Intraventricular hemorrhage (IVH), position of minute each time. The patient has a history of a ICH, patient age transsphenoidal resection of a craniopharyngioma D. Position of ICH, patient age, baseline Karnofsky 3 years ago followed by radiation. Postoperative Scale score ophthalmologic exams including visual fields have E. Patient age, IVH, hemiplegia been unremarkable. An MRI from 1 month ago demonstrated no evidence of recurrent disease. 4. The patient is examined during one of these epi- A patient with a history of intravenous drug use is sodes and is found to have an exotropia of her right seen in clinic with new-onset severe back pain. An eye that resolves spontaneously. She is prescribed MRI is obtained that demonstrates bony erosion carbamazepine, and her symptoms improve. What and collapse of the L2/L3 disk. What is the next is her most likely diagnosis? step in the management of this patient? A. Craniopharyngioma recurrence B. Myasthenia gravis C. Ocular neuromyotonia D. Seizures 20 Birinyi et al., The Comprehensive Neurosurgery Board Preparation Book: Illustrated Questions and Answers (ISBN 978-1-62623-280-8), copyright © 2017 Thieme Medical Publishers All rights reserved. Usage subject to terms and conditions of license.  3 Adult Neurosurgery 8. D. Diplopia A man presents to clinic with results from an elec- E. Hypothalamic dysfunction tromyographic (EMG) study showing fibrillations and reduced motor unit potentials in his gluteus 13. medius and extensor digitorum longus. He has no A patient undergoing a craniotomy for resection of abnormal EMG findings in his biceps femoris (short a vestibular schwannoma has a reasonable chance head). Weakness of foot eversion and numbness of losing serviceable hearing following surgery if on the dorsum of the foot are noted on his exam. the preoperative speech discrimination is below What nerve(s) is/are being affected? what percentage? A. L4 nerve root only A. 50% B. L5 nerve root only B. 65% C. S1 nerve root only C. 75% D. Common peroneal nerve proximal to the fibu- D. 85% lar head only E. 95% E. L5 nerve root and common peroneal nerve at the fibular head 14. A woman with a known pituitary macroadenoma 9. presents to the emergency room with a sudden, A malignant peripheral nerve sheath tumor is dis- intense headache and a new-onset ophthalmo- covered in a patient’s left upper extremity. Where plegia with her chronic visual field cuts. She en- should screening first be focused to detect distant dorses photophobia. After imaging confirms the metastases? most likely diagnosis, what is the next step in her A. Brain management? B. Other extremities A. Sumatriptan administration C. Axial skeleton B. Follow-up with repeat imaging in 6 weeks D. Lungs C. Repeat pituitary lab work as an outpatient E. Lymph nodes D. Observation E. Preparation for transsphenoidal decompres- 10. sion immediately What type of spinal arteriovenous malformation typically is associated with low blood flow? 15. A. Dural A woman is referred to you for treatment of a cere- B. Juvenile bellopontine angle tumor. She has obvious weak- C. Extramedullary/intradural ness of the right side of her face. She does have D. Glomus some motion but has no motor contraction over her forehead, she cannot close her eye completely, 11. and she has noticeable asymmetry of her mouth Multiple sclerosis is a contraindication to what when attempting to smile. What is her House- procedural treatment for trigeminal neuralgia? Brackmann classification grade? A. Microvascular decompression A. 2 B. Percutaneous radiofrequency rhizotomy B. 3 C. Percutaneous glycerol injection into the Meckel C. 4 cave D. 5 D. Percutaneous balloon microcompression E. 6 E. Stereotactic radiosurgery 16. 12. What form of nicotine potentially will not decrease What is the major complication of a stereotactic spinal fusion rates? mesencephalotomy for medically intractable right A. Cigarette smoking upper extremity pain? B. Chewing tobacco A. Ipsilateral weakness C. Nicotine gum B. Anesthesia dolorosa D. Nicotine patches C. Memory deficits E. No form of nicotine avoids the risk of de- creased spinal fusion rates. 21 Birinyi et al., The Comprehensive Neurosurgery Board Preparation Book: Illustrated Questions and Answers (ISBN 978-1-62623-280-8), copyright © 2017 Thieme Medical Publishers All rights reserved. Usage subject to terms and conditions of license.  I Questions 17. 22. What is the recommended torque used on a halo Halo bracing is least effective for what type of cer- pin on an adult skull? vical fractures? A. 4 in-lbs A. Odontoid fractures B. 8 in-lbs B. Levine type 2 pars fractures C. 12 in-lbs C. Midcervical spine fractures D. 20 in-lbs D. C1 fractures with a type 3 odontoid fracture E. 30 in-lbs E. Teardrop fractures 18. 23. Injury to the subthalamic nucleus during a func- What artery often is associated with hemifacial tional lesioning procedure classically produces spasm? what type of movement disorder? A. Posterior inferior cerebellar artery A. Myoclonus B. Anterior inferior cerebellar artery B. Hemiballism C. Superior cerebellar artery C. Pill-rolling tremor D. Posterior cerebellar artery D. Fixed posture of limbs E. Vertebral artery E. Chorea 24. 19. For nonemergent neurosurgical procedures, it is Deep brain stimulation in the setting of Parkinson recommended that a patient’s INR be less than or disease is expected to result in brief minimal im- equal to what value? provement to what characteristic of the disease? A. 1.0 A. Dyskinesia B. 1.2 B. Balance C. 1.4 C. Tremors D. 1.6 D. Rigidity E. Cognitive impairment 25. With pituitary tumors, what optic chiasm position 20. is most associated with optic nerve compression? What electromyography/nerve conduction study A. Prefixed chiasm finding supports a diagnosis of lumbar radiculo­ B. Postfixed chiasm pathy from a herniated disk? C. Chiasm superior to the sella turcica A. Paraspinal muscle fibrillations D. Neutral position chiasm B. Abnormal sensory nerve action potentials (SNAPs) 26. C. Increased motor fiber recruitment with voli- Over 95% of vestibular schwannomas present with tional activity progressive unilateral or asymmetric sensorineu- D. Absence of spontaneous sensory nerve activity ral, high-frequency hearing loss. In general, what is considered the definition of serviceable hearing? 21. A. Pure tone audiogram of 40 dB or less; speech A patient presents with a blunt cerebrovascular discrimination score of at least 40% ­injury after a motor vehicle collision. The patient B. Pure tone audiogram of 60 dB or less; speech has no intracranial hemorrhage. CT angiogram discrimination score of at least 60% ­reveals an internal carotid artery luminal irregu- C. Pure tone audiogram of 60 dB or less; speech larity with < 25% stenosis. What is the next step in discrimination score of at least 40% the management of this patient? D. Pure tone audiogram of 40 dB or less; speech A. No acute intervention; repeat imaging in 4 to discrimination score of at least 60% 6 weeks. E. American Academy of Otolaryngology–Head B. Initiate a heparin drip if there are no and Neck Surgery (AAO-HNS) class C or D contraindications. C. Perform endovascular stenting. D. Perform a ligation/occlusion of carotid artery. E. Initiate antiplatelet therapy if there are no contraindications. 22 Birinyi et al., The Comprehensive Neurosurgery Board Preparation Book: Illustrated Questions and Answers (ISBN 978-1-62623-280-8), copyright © 2017 Thieme Medical Publishers All rights reserved. Usage subject to terms and conditions of license.  3 Adult Neurosurgery 27. A. Type 2 odontoid fracture A 50-year-old woman presents with an acute onset B. Combined 5-mm overhang of the lateral masses of severe headache, bitemporal hemianopsia, and of C1 on C2 cranial nerve III palsy. She is alert and conversant. C. Acute fracture What is the most appropriate next step in this pa- D. Reducible fracture tient’s management? E. Barrel chest A. Rapid administration of corticosteroids B. Cerebral angiography 32. C. Administration of nimodipine A patient presents in the emergency room with a D. Obtaining an erythrocyte sedimentation rate, cervical spine fracture and the following radio- C-reactive protein concentration, and blood graphic findings: a triangular bone fragment frac- cultures tured off the anterior inferior vertebral body, E. Intracranial pressure monitoring retrolisthesis of the caudal vertebrae, and disrup- tion of the facet joints and the disk space. What 28. type of fracture is suspected? A 19-year-old man presents following a motor A. Avulsion fracture ­vehicle collision complaining of lower extremity B. Clay-shoveler fracture weakness. He is found to have a thoracic spine C. Jefferson fracture Chance fracture. He has full strength in his upper D. Teardrop fracture extremities. He has sensation in his lower extrem- E. Locked facets ities and perineum, and his motor strength in his lower extremities ranges from 4–/5 to 4/5. What 33. is his American Spinal Injury Association (ASIA) A patient presents after a significant fall from a impairment scale score? ladder with an L2 burst fracture that has a 70% loss A. A of height, 50% canal stenosis due to retropulsion, B. B and 15 degrees of angulation. How would you re- C. C duce this fracture with ligamentotaxis? D. D A. Removing ligaments such as the ligamentum E. E flavum that would allow for easier manipula- tion of the fracture 29. B. Distracting pedicle screws to reduce indirectly What incomplete spinal cord injury syndrome is the retropulsed segment by putting tension on associated with a poor prognosis for recovery and the posterior longitudinal ligament dissociated sensory loss? C. Compressing pedicle screws to reduce the ret- A. Central cord syndrome ropulsed fragment by releasing tension on the B. Anterior cord syndrome posterior longitudinal ligament C. Brown-Séquard syndrome D. Placing a strut or cage to reduce the loss of D. Posterior cord syndrome height of the vertebral body E. Cauda equina syndrome E. Positioning the patient to utilize the anterior longitudinal ligament to reduce the kyphotic 30. angulation associated with the fracture When placing a C2 pedicle screw, what is the tra- jectory of the screw? 34. In what zone is a sacral fracture that occurs in the A. Superior and medial region of the sacral foramina? B. Superior and lateral C. Inferior and medial A. Zone 1 D. Inferior and lateral B. Zone 2 E. Parallel to the spinous process C. Zone 3 (vertical) D. Zone 4 (transverse) 31. E. Zone 5 What is a relative contraindication for the place- ment of an anterior odontoid screw that may make surgery technically very difficult? 23 Birinyi et al., The Comprehensive Neurosurgery Board Preparation Book: Illustrated Questions and Answers (ISBN 978-1-62623-280-8), copyright © 2017 Thieme Medical Publishers All rights reserved. Usage subject to terms and conditions of license.  I Questions 35. 39. Fisher grade 3 is differentiated from Fisher grade 2 Following resection of a low-grade oligodendrogli- for aneurysmal subarachnoid hemorrhage by what oma, what is the next step in adjuvant therapy? characteristic? A. Intravenous chemotherapy A. Greater than 1 mm of blood B. Focused radiation B. Presence of hydrocephalus C. Whole brain radiation C. Intracerebral or intraventricular clot D. Intrathecal chemotherapy D. Presence of vasospasm E. Greater than 1 cm of blood 40. What is the complication rate for shunting a 36. ­patient with normal pressure hydrocephalus? A 37-year-old man presents with a sudden onset A. 5 to 10% of the “worst headache of my life.” The CT shows B. 10 to 25% intraventricular hemorrhage that you suspect re- C. 25 to 40% sulted from hemorrhage entering through the lam- D. 40 to 55% ina terminalis. You are suspicious of an aneurysm at what location? 41. A. Middle cerebral artery bifurcation A woman is referred to your office for symptoms B. Posterior communicating artery consistent with carpal tunnel syndrome. She has C. Internal carotid artery terminus had a nerve conduction study showing that the D. Anterior communicating artery proximal median nerve latency is shorter than the E. Basilar artery tip distal median nerve latency. What is the explana- tion for this finding? 37. A. Poor quality/erroneous nerve conduction study A patient presents with subacute bacterial endo- B. Lesion of the proximal median nerve carditis. Evaluation and workup includes a CT an- C. Presence of a Martin-Gruber anastomosis giogram followed by a cerebral angiogram that D. Marinacci syndrome demonstrates two small aneurysms on distal left E. Diabetic neuropathy middle cerebral artery branches. What treatment modality is indicated? 42. A. Endovascular coiling A 17-year-old boy is brought to the emergency B. Surgical clipping room following a motor vehicle collision with mul- C. Antibiotics and serial imaging tiple fatalities. He is alert, awake, and oriented. He D. Observation denies neck pain, has no midline tenderness, and does not have any other injuries. The neurologic 38. exam is unremarkable. He has not used alcohol or Following the standard of care, what role does drugs. What is the minimum radiographic study brachytherapy play as an adjunctive treatment for needed to clear the cervical spine? high-grade gliomas? A. Radiographs are not indicated A. Brachytherapy is a viable alternative to whole B. Upright lateral and AP X-rays brain radiation. C. Flexion-extension X-rays B. Brachytherapy is superior to stereotactic D. Lateral and AP X-rays with CT imaging of areas radiosurgery. that are suspicious or not easily seen on plain C. Brachytherapy has no role as an adjuvant to films whole brain radiation. E. Thin-cut axial CT scan from the occiput to T1 D. Brachytherapy can be useful in addition to with sagittal and coronal reconstructions whole brain radiation. E. Brachytherapy can substitute for whole brain radiation. 24 Birinyi et al., The Comprehensive Neurosurgery Board Preparation Book: Illustrated Questions and Answers (ISBN 978-1-62623-280-8), copyright © 2017 Thieme Medical Publishers All rights reserved. Usage subject to terms and conditions of license.  3 Adult Neurosurgery 43. 46. A 63-year-old diabetic man with a remote history A teenager suffering from a defect in his L5 pars of vertebral osteomyelitis presents to the hospital interarticularis as a result of an insufficiency frac- with low back pain and pain down the anterior ture of the pars can be characterized as having part of the thigh for the past 3 weeks. Neuro- what type of spondylolisthesis? logic exam is unremarkable. MRI suggests a psoas A. Dysplastic and epidural abscess without severe compres- B. Isthmic sion. What is the next appropriate step in this pa- C. Degenerative tient’s management? D. Traumatic A. Discharge home on oral antibiotics with E. Pathological ­follow-up with an infectious disease specialist. B. Admit to the floor, place on antibiotics, and 47. consult interventional radiology for culture You perform a stereotactic-guided biopsy of a tha- and biopsy of the epidural abscess. lamic lesion. You notice bleeding from the cannula. C. Consult interventional radiology for culture What is the next step? and biopsy of the epidural space prior to start- A. Perform an emergent craniotomy and ing antibiotics. exploration. D. Admit to the floor, obtain blood cultures, and B. Immediately abort the procedure, and obtain consult interventional radiology for biopsy of a CT. the psoas abscess prior to administering anti- C. Abort the procedure, wake the patient, and biotics (if the biopsy can be done in a timely obtain a neurologic exam. manner). D. Elevate the head of the bed, decrease the blood E. Perform a decompressive laminectomy with pressure, and irrigate the cannula. evacuation of the abscess. E. Insert a Fogarty catheter into the cannula, ­inflate the balloon, and obtain a CT. 44. An 82-year-old woman presents to the neurosur- 48. gery clinic with typical trigeminal neuralgia. She What is the most common location of mycotic has substantial medical comorbidities and would aneurysms? like to avoid surgery. The patient opts for stereo- A. Distal middle cerebral artery branches tactic radiosurgery. What factor would predict a B. Proximal anterior cerebral artery favorable outcome? C. Distal anterior cerebral artery A. Absence of atypical pain D. Basilar tip B. Using a radiation dose less than 60 Gy E. Posterior inferior cerebellar artery C. Prior successful surgical microvascular decompression 49. D. Decreased sensation in the affected nerve A 35-year-old woman presents with spontaneous prior to treatment neck pain. A noncontrast head CT demonstrates E. Trigeminal neuralgia related to multiple subarachnoid hemorrhage, and an angiogram sclerosis ­reveals a lesion suspicious for an intradural ver­ tebral artery dissection. What is the appropriate 45. treatment for this finding? What is the most effective surgical option for the A. Observation if asymptomatic treatment of glossopharyngeal neuralgia in the B. Immediate heparinization followed by oral absence of vascular compression? anticoagulation A. Cranial nerve IX rhizotomy alone C. Immediate surgery or endovascular treatment B. Cranial nerve X rhizotomy alone D. Delayed surgery to allow for swelling C. Cranial nerve IX rhizotomy with sectioning resolution the upper one third of cranial nerve X E. Nonoperative treatment followed by a delayed D. Extracranial nerve ablation of cranial nerve IX angiogram in 5 to 7 days to assess healing E. Cranial nerve XI rhizotomy alone 25 Birinyi et al., The Comprehensive Neurosurgery Board Preparation Book: Illustrated Questions and Answers (ISBN 978-1-62623-280-8), copyright © 2017 Thieme Medical Publishers All rights reserved. Usage subject to terms and conditions of license.  I Questions 50. 54. A 32-year-old man presents with slurred speech After elective clipping of an unruptured anterior and a hypoglossal palsy. He reported that he was communicating artery aneurysm, the patient wakes involved in a motor vehicle collision 3 weeks prior up with dysarthria and contralateral paresis of his for which he did not pursue medical evaluation. He face and arm. What vessel likely is incorporated reports that he has had neck pain since the acci- into the aneurysm clip? dent. What is the suspected diagnosis? A. Anterior choroidal artery A. Atlanto-occipital dislocation B. Recurrent artery of Heubner B. Vertebral artery dissection with stroke C. Middle cerebral artery C. Odontoid fracture D. Distal anterior cerebral artery D. Clival fracture E. Condyle fracture 55. The most common primary, intra-axial posterior 51. fossa tumor in adults is associated with what A 43-year-old woman presents to the neurosur- condition? gery clinic complaining of hand clumsiness. A A. Smoking neurologic exam reveals wasting and weakness of B. Tumor suppressor gene inactivation on chro- the abductor pollicis brevis and hand intrinsics. mosome 9q34 There is sensory loss over the medial forearm, but C. Tumor suppressor gene inactivation on chro- sensation in the hand is normal. According to the mosome 7q21 above findings, what is the next appropriate test D. Tumor suppressor gene inactivation on chro- for diagnosis? mosome 3p25 A. MRI of the brain B. Cerebrospinal fluid studies 56. C. Chest radiograph A 21-year-old man presents with a brachial plexus D. MRI of the cervical spine avulsion type injury. What is the recommended E. Cervical spine radiographs with oblique and treatment option? apical lordotic views A. Periodic electromyography/nerve conduction studies starting 3 to 12 weeks following the 52. injury with consideration of surgical neu­ What tumor often arises from the “roof” of the rotization at 3 to 6 months if there is no fourth ventricle? improvement A. Ependymoma B. Periodic electromyography/nerve conduction B. Juvenile pilocytic astrocytoma studies starting 3 to 12 weeks following the C. Brainstem glioma injury with consideration of surgical neu­ D. Choroid plexus papilloma rolysis at 3 to 6 months if there is no E. Medulloblastoma improvement C. Periodic electromyography/nerve conduction 53. studies starting 3 to 12 weeks following the A 38-year-old man presents with seizures, and injury with consideration of a spinal cord workup reveals an arteriovenous malformation stimulator if pain remains after 3 to 6 months that is 6.4 cm in size, involves the posterior fronto- D. Exploration and surgical repair within 3 days parietal and occipital lobes, and drains into the E. Exploration at 2 to 3 weeks galenic system. What is the preferred treatment option for this lesion? 57. A. Embolization alone What type of basal skull fracture is associated with B. Stereotactic radiosurgery alone an increased risk of mortality? C. Surgical resection A. Longitudinal temporal bone fracture D. Observation B. Transverse temporal bone fracture E. Embolization and stereotactic radiosurgery C. Fracture through the planum sphenoidale D. Clival fracture 26 Birinyi et al., The Comprehensive Neurosurgery Board Preparation Book: Illustrated Questions and Answers (ISBN 978-1-62623-280-8), copyright © 2017 Thieme Medical Publishers All rights reserved. Usage subject to terms and conditions of license.  3 Adult Neurosurgery 58. 62. During decompression of an ulnar nerve, the sur- What characteristics (location and size) of a cere- geon wishes to ensure that the nerve is decom- bral abscess are a surgical indication? pressed distally. The ulnar nerve can be found A. Subcortical location; 2.5 cm in diameter entering the forearm in relation to what structure? B. Brainstem location; 1.0 cm in diameter A. Deep to the pronator teres C. Small lesion in the early cerebritis stage; 0.5 B. Deep to the flexor carpi radialis cm in diameter C. Deep to the flexor digitorum profundus D. Periventricular location; 2.0 cm in diameter D. Lateral to the ulnar artery E. Between the two heads of the flexor carpi 63. ulnaris A patient presents with subarachnoid hemorrhage due to a ruptured aneurysm. What is the approxi- 59. mate risk of re-rupture over the next 14 days if the During a carotid endarterectomy, what is the cor- aneurysm is not treated? rect order of vessel occlusion? A. 1 to 2% A. External, common, and then internal carotid B. 5 to 10% artery C. 15 to 20% B. Internal, common, and then external carotid D. 50% artery E. 75% C. Common, internal, and then external carotid artery 64. D. Internal, external, and then common carotid What is the most definitive treatment for atonic artery seizures? E. External, internal, and then common carotid A. Ethosuximide artery B. Adrenocorticotropic hormone C. Multiple subpial transections 60. D. Hemispherectomy A 63-year-old woman presents with ruptured E. Corpus callosotomy ­anterior communicating artery aneurysm and an intracranial hemorrhage in the gyrus rectus. What 65. is her Fisher grade? What is the most effective thalamic target during A. 0 deep brain stimulation to control tremor associated B. 1 with Parkinson disease? C. 2 A. Medial nucleus D. 3 B. Ventralis intermedius nucleus E. 4 C. Nucleus accumbens D. Anterior nucleus 61. E. Pedunculopontine nucleus What approach characterizes a far lateral craniotomy? A. Suboccipital craniotomy including opening of the foramen magnum and drilling of the ­occipital condyle B. Suboccipital craniotomy with exposure of the transverse and sigmoid sinus C. Suboccipital craniotomy with pre- and post­ sigmoid exposure D. Subtemporal craniotomy with removal of the petrous apex E. Retrosigmoid craniotomy with removal of the lamina of C1 and C2 27 Birinyi et al., The Comprehensive Neurosurgery Board Preparation Book: Illustrated Questions and Answers (ISBN 978-1-62623-280-8), copyright © 2017 Thieme Medical Publishers All rights reserved. Usage subject to terms and conditions of license.  I Questions 66. 69. How is the C7 plumb line measured? This diagram attempts to define which parameter? A. Originates at the posterior vertebral body of C7 and is measured from the anterior verte- bral body of S1 B. Originates at the mid-vertebral body of C7 and is measured from the mid-vertebral body of S1 C. Originates at the mid-vertebral body of C7 and is measured from the posterior superior cor- ner of S1 D. Originates at the anterior vertebral body of C7 and is measured from the mid-vertebral body of S1 E. Originates at the anterior vertebral body of C7 and is measured from the anterior vertebral body of S1 67. A patient with L4/L5 degenerative spondylolisthe- sis presents with radiculopathy. The L4 vertebral body is approximately 60% anterolisthesed. What A. Sacral slope grade is this spondylolisthesis according to the B. Pelvic tilt Meyerding grading scale? C. Pelvic incidence D. Sagittal vertical axis A. Grade 1 E. T1 tilt B. Grade 2 C. Grade 3 70. D. Grade 4 In the repair of peripheral nerve lesions with large E. Grade 5 gaps, the standard graft material is: 68. A. Autologous anterior interosseus nerve A middle-aged woman presents to the emergency B. Autologous sural nerve room with complaints of a sudden onset of the C. Silicone “worst headache of my life.” She complains of D. Cadaveric nerve photophobia and nuchal rigidity. The head CT was E. Autologous vein negative for subarachnoid hemorrhage, and the CT angiogram did not reveal an aneurysm. What 71. would be the most reasonable next step in this During a percutaneous trigeminal radiofrequency ­patient’s management? rhizotomy for a patient with trigeminal neuralgia, after inserting the electrode into the oral mucosa, A. Discharge the patient home with pain the initial trajectory is: medications. B. Admit the patient with aneurysm precautions, A. Toward a point on a line intersecting the ex- and repeat the CT angiogram in 5 to 7 days. ternal auditory meatus and medial aspect of C. Obtain a lumbar puncture. the pupil D. Repeat the head CT in 4 to 6 hours. B. Toward a point on a line intersecting 3 cm E. Obtain a brain MRI. ­anterior to the external auditory meatus and medial aspect of the pupil C. Toward a point on a line intersecting the exter- nal auditory meatus and contralateral medial aspect of the pupil D. Toward a point on a line intersecting the clivus and posterior clinoid E. Toward a point > 8 mm beyond the clival line 28 Birinyi et al., The Comprehensive Neurosurgery Board Preparation Book: Illustrated Questions and Answers (ISBN 978-1-62623-280-8), copyright © 2017 Thieme Medical Publishers All rights reserved. Usage subject to terms and conditions of license.  3 Adult Neurosurgery 72. A. At the internal carotid artery bifurcation With regard to vertebral artery injury and C2 B. At the origin of the posterior inferior cere­ neuralgia, what is the difference (if any) between bellar artery utilizing a C1 lateral mass–C2 pedicle/pars screw C. At the middle cerebral artery most proximal construct for C1 to C2 fixation versus placement of bifurcation transarticular screws? D. At the junction of the anterior cerebral artery A. Less chance of vertebral artery injury and C2 A1 segment and anterior communicating artery neuralgia with transarticular screw fixation E. At the junction of the basilar and superior cer- compared with the C1 lateral mass–C2 pedicle/ ebellar arteries pars screw approach B. Less chance of vertebral artery injury and 75. more C2 neuralgia with transarticular screw The most common deficit associated with a corpus fixation compared with the C1 lateral mass– callosotomy is: C2 pedicle/pars screw approach A. Intracerebral hemorrhage C. More chance of vertebral artery injury and C2 B. Hyperthermia neuralgia with transarticular screw fixation C. Memory problems compared with the C1 lateral mass–C2 pedicle/ D. Speech irregularities pars screw approach E. Visual problems D. More chance of vertebral artery injury and less C2 neuralgia with transarticular screw fixa- 76. tion compared with the C1 lateral mass–C2 A 52-year-old man presents to the emergency room pedicle/pars screw approach after a fall from his porch. The neurologic exam E. Same chance of vertebral artery injury with shows weakness more pronounced in the upper both approaches with more C2 neuralgia with extremities compared with the lower extremities, the C1 lateral mass–C2 pedicle/pars approach with distal weakness greater than proximal weak- ness. Imaging suggests severe cervical stenosis with 73. an associated cord signal change. After 24 hours, A 29-year-old woman underwent a cervical lymph the patient’s neurologic exam is worse. What is the node biopsy for persistent lymphadenopathy. Post- appropriate next step in the treatment of this operatively, she complained of an inability to a ­ bduct patient? her arm. What condition is suspected? A. High-dose steroid administration A. Hysteria B. Bracing and physical therapy B. Carotid injury and stroke C. Surgical decompression with or without C. Injury to the C5 nerve root fixation D. Injury to the spinal accessory nerve D. Dynamic radiographs to rule out instability E. Injury to the long thoracic nerve E. Neurology service consultation 74. 77. A 61-year-old woman presents with an acute, A man incurs an injury to the musculocutaneous ­severe headache with nausea and vomiting. CT of nerve during a car accident. Three months follow- the brain revealed cisternal subarachnoid hemor- ing the accident, the electrophysiological studies rhage. Cerebral angiography revealed an aneurysm of the patient’s biceps show fibrillations and motor not amenable to coiling. The patient was taken for unit potentials. What is this patient’s Sunderland an open craniotomy and clipping of the aneurysm. peripheral nerve injury classification? After surgery, the patient was noted to have an A. First degree ­oculomotor nerve palsy. Where was the patient’s B. Second or third degree aneurysm most likely located? C. Fourth degree D. Fifth degree 29 Birinyi et al., The Comprehensive Neurosurgery Board Preparation Book: Illustrated Questions and Answers (ISBN 978-1-62623-280-8), copyright © 2017 Thieme Medical Publishers All rights reserved. Usage subject to terms and conditions of license.  I Questions 78. Use the following answers for questions 82, 83, and A punctate midline myelotomy can be valuable 84: for patients with intractable pain associated with A. Dorsal root entry zone lesioning malignancy in the abdominal or pelvic regions. A B. C1-C2 cordotomy myelotomy for these purposes commonly is per- C. Spinal cord stimulation formed at what spinal level? D. Selective dorsal rhizotomy A. L2 E. Midline myelotomy B. T2 C. T8 82. D. T10 What pain procedure is best for pelvic visceral can- E. T12 cer pain? 79. 83. Anterior choroidal artery aneurysms usually have What pain procedure is best for intractable severe what orientation compared to the parent vessel? upper extremity cancer pain? A. Oriented superiorly/superolaterally B. Oriented medially 84. C. Oriented inferiorly/inferomedially What pain procedure is best for diplegic spasticity? D. Oriented anteriorly E. Oriented posteriorly 85. When accessing the third ventricle through a tran- 80. scallosal, transchoroidal surgical approach, what How much of the superior sagittal sinus can be layers, in order, are passed through as the roof of sacrificed without a high risk of inducing venous the third ventricle is traversed? infarctions? A. Fornix, vascular layer, superior layer of the tela A. Anterior two thirds choroidea, inferior layer of the tela choroidea, B. No more than one third of any portion choroid of the third ventricle C. Anterior one third B. Superior layer of the tela choroidea, fornix, D. Entire sinus as long as the cortical bridging vascular layer, choroid plexus of the third ven- veins are left intact tricle, inferior layer of the tela choroidea E. None of the sinus but all of the cortical bridg- C. Superior layer of the tela choroidea, fornix, ing veins can be sacrificed without risk of vascular layer, inferior layer of the tela cho- ­venous infarctions. roidea, choroid plexus of the third ventricle D. Choroid plexus of the third ventricle, superior 81. layer of the tela choroidea, vascular layer, for- A man presents with an infarct of the artery of nix, inferior layer of the tela choroidea Percheron. What are his expected deficits? E. Fornix, superior layer of the tela choroidea, vascular layer, inferior layer of the tela cho- A. Obtundation, coma, variable degrees of hemi- roidea, choroid plexus of the third ventricle plegia or hemisensory loss, a vertical gaze palsy, and memory impairment B. Hemiparesis, hemisensory loss, and a homon- ymous hemianopsia C. Hemiparesis of the upper extremity and face, dysarthria, and hemichorea D. A cranial nerve III palsy, Parinaud syndrome, abulia, and somnolence E. Ipsilateral sensory loss in the face and contra- lateral sensory loss in the body without pyra- midal findings or a change in sensorium 30 Birinyi et al., The Comprehensive Neurosurgery Board Preparation Book: Illustrated Questions and Answers (ISBN 978-1-62623-280-8), copyright © 2017 Thieme Medical Publishers All rights reserved. Usage subject to terms and conditions of license.  3 Adult Neurosurgery 86. A. Retractor placement A 40-year-old man presented to the emergency B. Carotid dissection room with complaints of left-hand numbness. Fur- C. Recurrent laryngeal nerve injury ther workup revealed the lesion on MRI that is D. Vertebral artery injury shown in this image. He was taken to surgery for resection. Postoperatively, the patient awoke with 88. a dense left hemiparesis. Supplementary motor In the event of trauma, what finding on a skull area (SMA) syndrome was suspected. What is the radiograph best indicates the possible need for ­ expected prognosis of SMA syndrome? emergent surgical intervention? A. Fluid level in the sphenoid sinus B. Pneumocele C. Double density sign D. Fluid level in the frontal sinus E. Linear temporal fracture 89. According to the Asymptomatic Carotid Artery ­Stenosis (ACAS) trial, what are the recommenda- tions regarding performing a carotid endarterec- tomy (CEA)? A. There is a moderate benefit to performing an immediate CEA compared with medical man- agement in patients under 75 years of age with asymptomatic carotid stenosis > 60%. B. Patients with symptomatic moderate (50 to 69%) and severe (≥ 70%) carotid stenosis should be considered for a CEA. C. Carotid stenting and CEA are associated with similar rates of death and disabling strokes, with an increased stroke incidence associated A. Permanent left hemiparesis/hemiplegia with stenting and an increased myocardial in- B. Temporary decreased spontaneous and volun- farction incidence associated with CEA. tary movements of the left upper and lower D. Patients with carotid stenosis > 80% or symp- extremities with spontaneous recovery tomatic lesions > 50% and who are at high risk C. Permanent decreased spontaneous and volun- for surgery have equal outcomes when treated tary movements of the left upper and lower by stenting compared with a CEA. extremities with aphasia without spontaneous E. In patients with good health and asymptom- recovery atic carotid stenosis > 60%, a CEA is beneficial D. Temporary left lower extremity paresis with if the surgeon maintains perioperative mor- loss of muscle tone with spontaneous recovery bidity/mortality rates less than 3%. E. Temporary left upper and lower extremity ­paresis and hemisensory loss with spontaneous 90. recovery During a subtemporal approach, the greater super- ficial petrosal nerve often is divided. What deficit 87. is expected upon sectioning this nerve? A 63-year-old man wakes from anesthesia follow- A. Decreased salivation ing an anterior cervical diskectomy and fusion B. Miosis (ACDF). Postoperatively, he complains of unilateral C. Decreased tearing blurry vision, and ptosis is noted on the same side. D. Mydriasis What is the most common cause of Horner syn- E. Hyperacusis drome following an ACDF? 31 Birinyi et al., The Comprehensive Neurosurgery Board Preparation Book: Illustrated Questions and Answers (ISBN 978-1-62623-280-8), copyright © 2017 Thieme Medical Publishers All rights reserved. Usage subject to terms and conditions of license.  I Questions 91. 95. What is/are the contraindication(s) for traction What is the most common location for dural with a cervical spine injury? arterio­venous fistulae to drain? A. Atlanto-occipital dislocation and a type 2A A. Superior sagittal sinus hangman fracture B. Junction of the transverse and sigmoid sinus B. C4/C5 locked facets and a type 2A hangman C. Cavernous sinus fracture D. Inferior petrosal sinus C. Atlantoaxial rotatory subluxation and a type E. Junction of the sigmoid sinus and jugular vein 2A hangman fracture D. Atlanto-occipital dislocation and atlantoaxial 96. rotatory subluxation With subthalamic nucleus deep brain stimulation, E. C4/C5 locked facets and atlantoaxial rotatory the adverse effect of flushing and sweating follow- subluxation ing surgery indicates current spread to what direc- tion relative to the intended target? 92. A. Anterior After what age does the chance of a spontaneous B. Posterior subarachnoid hemorrhage become more likely to C. Lateral be due to an aneurysm than due to an arterio­ D. Medial venous malformation? E. Anterolateral A. 18 years old B. 30 years old 97. C. 45 years old What is a contraindication to performing an ante- D. 55 years old rior lumbar interbody fusion? E. 68 years old A. Unilateral pars defect B. Bilateral pars defect 93. C. Grade 3 or 4 spondylolisthesis A 67-year-old woman presents to the emergency D. Severe loss of disk space height room following a motor vehicle collision with a E. Grade 1 isthmic spondylolisthesis large right-sided subdural hematoma and uncal herniation seen on CT. The Glasgow Coma Scale 98. score is 5. She has a dilated and nonreactive right A 65-year-old woman presents with headache. She pupil. She has flexor posturing on the left side and describes scalp tenderness in the temporal region, is hemiplegic on the right side. What is the most with her jaw being stiff when she chews. She also likely explanation for her right-sided hemiplegia? describes chronic fatigue, muscle aches, and weight A. Uncal compression of the right midbrain loss. Headache treatment is started, and she is B. Compression of the left midbrain scheduled for surgery. With what complication can C. Diffuse axonal injury involving the right inter- a delay in the treatment of her suspected diagnosis nal capsule be associated? D. Spinal cord injury A. Blindness E. Left-side Duret hemorrhages in the pons B. Re-rupture C. Contiguous intracranial spread 94. D. Herniation What is the most effective means of sterilization for E. Corneal abrasions operating room procedures involving Creutzfeldt-­ Jakob disease? A. Boiling B. Immersion in 1 N NaOH for 15 minutes C. Ultraviolet radiation D. Immersion in sodium hypochlorite E. Steam autoclaving for 1 hour at 132°C 32 Birinyi et al., The Comprehensive Neurosurgery Board Preparation Book: Illustrated Questions and Answers (ISBN 978-1-62623-280-8), copyright © 2017 Thieme Medical Publishers All rights reserved. Usage subject to terms and conditions of license.  3 Adult Neurosurgery 99. 102. A 22-year-old man presents after a motorcycle Isthmic spondylolisthesis is found in what group of accident complaining of neck pain and lower patients? ­extremity paraplegia. He has a cervical burst frac- A. HLA-B27 histocompatability complex positive ture. His exam demonstrates 0/5 strength in the individuals lower extremities. He has 4/5 strength in the bi- B. Truck drivers ceps and wrist extensors bilaterally. He has 0/5 C. Rheumatoid arthritis patients strength in the triceps, grip, and hand intrinsics. D. Gymnasts, football linemen, and weight lifters What is the American Spinal Injury Association E. Black people, diabetics, and women over 40 (ASIA) motor score? years old A. 8 B. 16 103. C. 42 This image shows what type of intracranial lesion? D. 58 E. 92 100. What is the benign lesion seen in this intraopera- tive image with a gross pearly white appearance? A. Arachnoid cyst B. Epidermoid cyst C. Dermoid cyst D. Neurenteric cyst 104. A 70-year-old woman presents with large, enhanc- ing frontoparietal mass suspicious for a glioblas- toma. She is unable to work but is able to live at A. Epidermoid cyst home and care for some of her personal needs. She B. Dermoid cyst requires considerable assistance and frequent med- C. Lipoma ical care. What is the estimated Karnofsky Scale D. Adamantinomatous craniopharyngioma score? A. 10 101. B. 30 A patient presents with complaints of a herniated C. 50 disk that correlates with imaging. MRI demon- D. 70 strates a far lateral disk herniation at L4/L5. What E. 90 nerve root should be affected? A. L4 traversing nerve root 105. B. L4 exiting nerve root Ankylosing spondylitis is associated with what C. L5 traversing nerve root human leukocyte antigen? D. L5 exiting nerve root A. HLA-DQA1 B. HLA-DRB1 C. HLA-B27 D. HLA-DR2 E. HLA-B47 33 Birinyi et al., The Comprehensive Neurosurgery Board Preparation Book: Illustrated Questions and Answers (ISBN 978-1-62623-280-8), copyright © 2017 Thieme Medical Publishers All rights reserved. Usage subject to terms and conditions of license.  I Questions 106. 109. Current spread in what direction during sub­ What recess is indicated by the arrow in this image? thalamic nucleus deep brain stimulation will cause double vision and pupillary constriction? A. Anterior B. Posterior C. Lateral D. Medial E. Inferomedial 107. During a carotid endarterectomy, the internal ­carotid artery (ICA) is identified coursing posterior to the external carotid artery (ECA). What land- mark is used to differentiate the external from the internal carotid artery during surgery? A. Lingual artery arising from the ECA B. Superior thyroid artery arising from the ECA C. Ascending pharyngeal artery arising from the ECA D. Facial vein coursing over the ECA A. Opticocarotid cistern E. Ascending pharyngeal artery arising from the B. Carotico-oculomotor cistern ICA C. Interpeduncular cistern D. Lamina terminalis 108. E. Cerebellopontine angle Prior to cross-sectional imaging, a named point was used to identify the fourth ventricle and deter- 110. mine if any midline shift was present. Where is In the adult patient, subdural effusions are associ- this point located? ated with what entity? A. Where the septal and thalamostriate veins A. Chronic subdural hematomas converge B. Tuberculosis B. At the arterial branch from the inferior extent C. Syphilis (caudal loop) of the tonsillomedullary segment D. Haemophilus influenzae meningitis of the posterior inferior cerebellar artery E. Skull fractures C. Where the posterior choroidal artery enters the velum interpositum 111. D. At the arterial branch from the superior extent A patient is referred to the neurosurgical clinic for (cranial loop) of the telovelotonsillar segment a dural arteriovenous fistula (dAVF). An angiogram of the posterior inferior cerebellar artery shows anterograde drainage into a venous sinus E. Where the anterior choroidal artery enters the with retrograde flow into subarachnoid veins. What choroidal fissure of the lateral ventricle is the Borden classification for this dAVF? A. 1 B. 2 C. 3 D. 4 E. 5 34 Birinyi et al., The Comprehensive Neurosurgery Board Preparation Book: Illustrated Questions and Answers (ISBN 978-1-62623-280-8), copyright © 2017 Thieme Medical Publishers All rights reserved. Usage subject to terms and conditions of license.  3 Adult Neurosurgery 112. A. Arcade of Struthers What structure impedes the caudal exposure of the B. Cubital tunnel thoracic spine during a transthoracic approach? C. Medial epicondyle A. Vena cava D. Medial intramuscular septum B. Aorta E. Deep flexor aponeurosis C. Diaphragm D. Liver 118. E. Twelfth rib Although not always conclusive, what imaging ­sequence is most helpful in differentiating a cere- 113. bral abscess from a tumor? After a proximal shunt revision surgery, a patient A. CT with contrast is unable to void and requires straight catheteriza- B. MR T1 with contrast tion. What is the most appropriate next step in C. MR FLAIR treating this patient’s condition? D. Diffusion-weighted imaging A. Obtain a urology consultation for possible E. MR angiography bladder injury. B. Administer bethanechol. 119. C. Administer diazepam What components constitute the system for indo- D. Administer oxybutynin. cyanine green video angiography? E. Administer morphine. A. Incandescent tungsten-halogen light source projecting light through the collector lens and 114. into the substage condenser Occlusion of a dAVF is most effective with what B. Mercury vapor arc lamp with a mono­ minimally invasive method? chromatic light source expanded in the near- A. Transvenous coil embolization ultraviolet B. Transarterial embolization with Onyx glue C. Argon ion emission at 488 to 514 nm used in C. Minimally invasive keyhole endoscopic micro- confocal source emission surgical clip ligation of feeding arteries D. Near-infrared light source with an optical fil- D. Stereotactic radiosurgery ter to block ambient and excitation light E. Electronic flash 5500 K illumination to capture 115. specimens with high-speed daylight trans­ During an endonasal transsphenoidal approach, parency film what structure limits the working space and ma- neuverability of the instruments? 120. A bilateral thalamotomy is contraindicated due to A. Inferior turbinate the possibility of what side effects? B. Middle turbinate C. Superior turbinate A. Hemiparesis and homonymous hemianopsia D. Anterior nasal septum B. Dysarthria and cognitive impairment C. Myosis and anhydrosis 116. D. Quadriparesis and respiratory depression Patients flying soon after major intracranial surgery E. Hemiparesis and bladder dysfunction may be theoretically at risk for what complication? 121. A. Blindness What are the Surgical Care Improvement Project B. Wound infection (SCIP) prophylactic antibiotic guidelines? C. Pneumonia D. Tension pneumocephalus A. All surgical patients must receive cefazolin E. Spontaneous hemorrhage prior to the skin incision. B. Prophylactic antibiotics must be received 117. within 1 hour prior to the surgical incision. What is the most common site of ulnar nerve com- C. Prophylactic antibiotics should be continued pression around the elbow? for 24 hours after the surgery end time. D. Prophylactic antibiotics should be continued for at least 48 hours after the surgery end time. 35 Birinyi et al., The Comprehensive Neurosurgery Board Preparation Book: Illustrated Questions and Answers (ISBN 978-1-62623-280-8), copyright © 2017 Thieme Medical Publishers All rights reserved. Usage subject to terms and conditions of license.  I Questions 122. 126. What procedure is best at relieving the symptoms What bone product is primarily an osteoinductive associated with a traumatic brachial plexus nerve agent? root avulsion? A. Demineralized bone matrix A. Cordotomy B. Bone morphogenic protein B. Midline myelotomy C. Cadaveric fibular strut C. Dorsal root entry zone lesioning D. Tricalcium phosphate D. Cingulotomy E. Hydroxyapatite E. Rhizotomy 127. 123. What size must an aneurysm be to be considered Superior hypophyseal artery aneurysms usually giant? have what orientation compared to the parent A. 0.7 cm vessel? B. 1.0 cm A. Oriented superolaterally C. 1.5 cm B. Oriented posterolaterally D. 2.5 cm C. Oriented inferolaterally E. 4.0 cm D. Oriented inferomedially E. Oriented posteromedially 128. Ophthalmic artery aneurysms usually have what 124. orientation and origin compared with the parent How does melanoma in the central nervous sys- vessel? tem respond to radiation? A. Oriented medially and arising from the poste- A. Melanoma is entirely radiation insensitive and rior wall should not be treated by radiation. B. Oriented superiorly and arising from the ante- B. Melanoma is mostly radiation insensitive, but rior wall radiation may be somewhat effective. C. Oriented anteriorly and arising from the pos- C. Melanoma is mostly radiation sensitive, and terior wall radiation typically may be effective. D. Oriented superiorly and arising from the D. Melanoma is entirely radiation sensitive and ­superior wall should be treated primarily by radiation. E. Oriented anteriorly and arising from the ante- rior wall 125. A 58-year-old woman underwent an uneventful 129. single-level anterior cervical diskectomy and f­ usion Anterior communicating artery (ACOM) aneurysms (ACDF). Six months later, she presented with a low- usually have what orientation and origin com- grade fever, dysphagia, anorexia, and neck pain. pared with the parent vessel? The symptoms had been ongoing for a month. MRI A. Directed laterally and arising from the branch showed osteomyelitis at the surgical site. What is point of the dominant A1 segment and the the most appropriate diagnostic test to find the ACOM source of infection? B. Directed laterally and arising from the non- A. Panorex imaging to look for dental abscesses dominant A2 segment B. Echocardiogram C. Directed laterally and arising from the domi- C. Blood cultures nant A2 segment D. Upper gastrointestinal imaging D. Directed contralaterally and arising from the E. Nuclear bone scan branch point of the nondominant A1 segment and the ACOM