Spine Disorders

Spine Disorders Indian Medical PG Question 1: A 50-year-old male presents with chronic low back pain that has failed physical therapy and conservative measures. MRI shows disc herniation at L5-S1 with radiculopathy. What is the next step in management?

• A. Epidural steroid injection (Correct Answer)
• B. Surgical decompression
• C. Acupuncture
• D. NSAIDs

Spine Disorders Explanation: ***Epidural steroid injection*** - This is often the appropriate **next step** for radiculopathy from disc herniation that has failed conservative management, as it can reduce **inflammation** and pain at the nerve root. - It helps manage pain and allows patients to engage more effectively in **physical therapy**. *Surgical decompression* - This is typically considered after **less invasive methods** like epidural steroid injections have failed, especially if there are progressive neurological deficits or intractable pain. - While it can relieve nerve compression, it carries higher risks than injections and is not the immediate next step after failure of basic conservative measures. *Acupuncture* - While acupuncture can be used as an **adjunctive therapy** for chronic pain, it is not primary management for symptomatic disc herniation with radiculopathy that has failed physical therapy. - There is limited evidence to support its effectiveness in resolving nerve compression or significant radicular symptoms. *NSAIDs* - **NSAIDs** are part of the initial conservative management for low back pain and disc herniation. - Since the question states that **conservative measures have failed**, continuing or restarting NSAIDs alone would likely be ineffective and is not the next step.

Spine Disorders Indian Medical PG Question 2: What is normally seen in lumbar spine?

• A. Lordosis (Correct Answer)
• B. Recurvatum
• C. Scoliosis
• D. Kyphosis

Spine Disorders Explanation: ***Lordosis*** - **Lordosis** describes the normal inward curvature of the lumbar and cervical spine. - This curvature helps maintain the body's balance and absorb axial stress. *Recurvatum* - **Recurvatum** refers to hyperextension, commonly seen in the knee joint (genu recurvatum), not a normal curvature of the spine. - It describes a posterior bending or bowing, opposite to the normal spinal curves. *Scoliosis* - **Scoliosis** is an abnormal lateral (sideways) curvature of the spine, which is not a normal physiological finding. - It can be either C-shaped or S-shaped and is often associated with vertebral rotation. *Kyphosis* - **Kyphosis** is the normal outward curvature found in the thoracic and sacral regions of the spine. - An excessive outward curvature, often seen as a "hunchback," is an abnormal condition called hyperkyphosis.

Spine Disorders Indian Medical PG Question 3: A lesion in the cauda equina will likely present with what type of signs?

• A. Lower motor signs (Correct Answer)
• B. Spastic paralysis
• C. Hyperreflexia
• D. Upper motor signs

Spine Disorders Explanation: Lower motor signs - The **cauda equina** consists of nerve roots that have **exited the spinal cord** proper, making them part of the **peripheral nervous system**. [2] - Damage to these peripheral nerves results in **lower motor neuron deficits** such as **flaccid paralysis**, **areflexia**, and **muscle atrophy**. [1] *Spastic paralysis* - **Spastic paralysis** is characteristic of **upper motor neuron lesions**, not lesions affecting the peripheral nerves of the cauda equina. - This condition involves increased muscle tone and hyperreflexia due to the disinhibition of spinal reflexes. *Hyperreflexia* - **Hyperreflexia** is typically a sign of an **upper motor neuron lesion**, indicating damage to the neural pathways above the level of the spinal reflex arc. [2] - Lesions of the cauda equina, being lower motor neuron lesions, usually present with **hyporeflexia** or **areflexia**. *Upper motor signs* - **Upper motor neuron signs** (e.g., spasticity, hyperreflexia, positive Babinski sign) arise from damage to the motor pathways within the **brain** or **spinal cord**. - The cauda equina, comprising nerve roots **distal to the spinal cord termination** (conus medullaris), is part of the peripheral nervous system, and its lesions produce lower motor neuron signs. [1]

Spine Disorders Indian Medical PG Question 4: A 50-year-old male with a history of chronic low back pain presents with new-onset bowel and bladder incontinence. What is the next best step in management?

• A. Conservative management with NSAIDs
• B. Bed rest
• C. Urgent MRI of the spine (Correct Answer)
• D. Physical therapy

Spine Disorders Explanation: ***Urgent MRI of the spine*** - The new onset of **bowel and bladder incontinence** in a patient with chronic low back pain is highly suggestive of **cauda equina syndrome**. This is a surgical emergency. - An **urgent MRI** is crucial to confirm the diagnosis and identify the level of compression, guiding immediate surgical decompression to prevent permanent neurological deficits. *Conservative management with NSAIDs* - This approach is appropriate for routine, uncomplicated low back pain, but it is entirely inadequate for a **neurological emergency** like potential cauda equina syndrome. - Delaying definitive diagnosis and treatment in such cases can lead to irreversible neurological damage, including chronic incontinence and paralysis. *Bed rest* - While bed rest might be recommended for acute exacerbations of certain types of back pain, it is not a primary treatment for neurologic emergencies and will not resolve the underlying compression causing **cauda equina syndrome**. - Prolonged bed rest can also lead to complications like deconditioning and venous thromboembolism, and it would waste critical time for diagnosis and intervention. *Physical therapy* - Physical therapy is a cornerstone of management for chronic low back pain and for rehabilitation after an acute event once stability is achieved. - However, in cases of suspected **cauda equina syndrome**, physical therapy is contraindicated as an initial step because it does not address the acute spinal cord or nerve root compression and may worsen the condition or delay necessary surgical intervention.

Spine Disorders Indian Medical PG Question 5: What type of neurological signs would you expect to see in a patient with a cauda equina lesion?

• A. Upper motor neuron signs
• B. Lower motor signs (Correct Answer)
• C. Flaccid paralysis
• D. Areflexia

Spine Disorders Explanation: ***Lower motor signs*** - A **cauda equina lesion** affects the spinal nerves after they exit the conus medullaris, which are part of the **peripheral nervous system**. [1] - As such, damage to these peripheral nerves results in **lower motor neuron (LMN) signs**, including weakness, hypotonia, and atrophy. [1] *Upper motor neuron signs* - **Upper motor neuron lesions** occur within the central nervous system (brain or spinal cord above the conus medullaris). [1] - These lesions are characterized by spasticity, hyperreflexia, and a positive **Babinski sign**. *Flaccid paralysis* - While flaccid paralysis can be seen in cauda equina syndrome due to loss of muscle tone, it is a *symptom* that falls under the broader category of **lower motor neuron signs**. - This option is too general and does not encompass all the neurological signs associated with LMN lesions. *Areflexia* - **Areflexia**, or the absence of reflexes, is another specific symptom commonly seen in cauda equina lesions because the reflex arc is interrupted at the peripheral nerve level. - However, like flaccid paralysis, it is a *component* of lower motor neuron signs rather than the overarching type of neurological signs to expect.

Spine Disorders Indian Medical PG Question 6: A patient presents with a suspected cervical spine injury following an accident. What is the first step in management?

• A. perform imaging studies
• B. administer oxygen
• C. stabilize the cervical spine (Correct Answer)
• D. log roll the patient

Spine Disorders Explanation: ***stabilize the cervical spine*** - In any suspected cervical spine injury, the **first and most critical step is to stabilize the cervical spine** to prevent further neurological damage. This is achieved through manual inline stabilization, followed by a **rigid cervical collar** and placement on a backboard. - This immediate stabilization is paramount before any other assessments or interventions that could potentially worsen the injury. *perform imaging studies* - While imaging studies (e.g., X-ray, CT scan) are crucial for diagnosing the extent of cervical spine injury, they should only be performed **after the spine has been adequately stabilized**. - Performing imaging prior to stabilization risks **further displacement** of vertebrae and spinal cord injury. *administer oxygen* - Administering oxygen is an important step in **maintaining adequate oxygenation** and is part of initial resuscitation, but it does not take priority over cervical spine stabilization in a trauma setting. - **Airway, Breathing, Circulation (ABC)** management should always incorporate cervical spine protection. *log roll the patient* - **Log rolling** is a technique used to move a patient with a suspected spinal injury, but it must be performed **only after the cervical spine is stabilized** and with sufficient personnel to ensure coordinated movement. - Log rolling is not the first step in management; rather, it is a technique for patient assessment and transfer once initial stabilization is achieved.

Spine Disorders Indian Medical PG Question 7: A 33-year-old man is brought to the emergency department after being involved in a major motor vehicle accident. He is unable to move his legs and complains of severe pain in his mid to lower back. On physical examination, he is found to have exquisite tenderness over some of the bony prominence of his lower back, but no gross physical deformity can be appreciated. On neurologic examination, flaccid paralysis of both lower extremities and complete anesthesia to all sensory modalities below approximately the L3 dermatome are noted. Catheterization of his bladder yields approximately 700 mL of urine. Plain radiographs of the spine reveal compression fracture in the body of L3 with greater than 50% of loss in its height. A computed tomography (CT) scan through this area reveals a burst fracture of the body of L3. There are large fragments of bone driven dorsally with an 80% canal compromise. What is the cause of weakness?

• A. Compression of the cauda equina (Correct Answer)
• B. Compression of the conus medullaris
• C. Rupture of the anterior spinal ligament
• D. Compression of the spinal cord at the level of L3

Spine Disorders Explanation: ***Compression of the cauda equina*** - The patient's presentation with flaccid paralysis of both lower extremities and complete anesthesia below L3, along with a **burst fracture of L3** and significant **canal compromise**, is consistent with **cauda equina syndrome**. The spinal cord typically ends at the L1-L2 vertebral level, so an injury at L3 would affect the cauda equina nerve roots. - The **cauda equina** consists of lumbar and sacral nerve roots that innervate the lower extremities and bladder, explaining the incontinence (700 mL of urine retention) and neurological deficits observed. *Compression of the conus medullaris* - The **conus medullaris** is the tapered end of the spinal cord, located around the T12-L2 vertebral levels. While an injury at this level can cause similar neurological deficits, the L3 fracture is below this point. - Compression of the conus medullaris often presents with a more **symmetrical and sudden onset** of symptoms, and the specific vertebral level of injury makes cauda equina more likely here. *Rupture of the anterior spinal ligament* - A rupture of the **anterior spinal ligament** alone would primarily lead to **spinal instability** and potentially pain, but it does not directly explain flaccid paralysis and anesthesia below L3. - While ligamentous injury often accompanies fractures, the neurological deficits are due to **compression of neural structures**, not the ligament itself. *Compression of the spinal cord at the level of L3* - The **spinal cord typically terminates** at the L1-L2 vertebral level in adults, forming the conus medullaris, and then continues as the cauda equina. - Therefore, compression at the L3 level would not directly involve the spinal cord itself but rather the **nerve roots of the cauda equina**.

Spine Disorders Indian Medical PG Question 8: Open reduction (OR) is not required in which fracture?

• A. Fracture of the patella
• B. Fracture of the outer one-third of the radius (Correct Answer)
• C. Displaced fracture of the olecranon
• D. Fracture of the condyle of the humerus

Spine Disorders Explanation: ***Fracture of the outer one-third of the radius*** - Fractures of the **outer one-third of the radius** (distal radius fractures) often can be managed with **closed reduction and casting** if stable and adequately reduced. - While some unstable distal radius fractures require OR, many stable patterns, especially those with minimal displacement or good alignment after closed manipulation, do not. *Fracture of the patella* - Many patellar fractures lead to significant **extensor mechanism disruption**, necessitating OR with **tension band wiring** or screw fixation to restore quadriceps function. - Displaced patellar fractures, especially transverse ones, require surgical fixation to prevent extensor lag and **nonunion**. *Displaced fracture of the olecranon* - Displaced olecranon fractures disrupt the **triceps mechanism** and compromise elbow stability, almost always requiring **open reduction and internal fixation (ORIF)**, typically with tension band wiring. - Without surgical repair, a displaced olecranon fracture can lead to significant loss of extension strength and **nonunion**. *Fracture of the condyle of the humerus* - Fractures of the humeral condyle, particularly in children, often require OR due to the risk of **avascular necrosis** (especially lateral condyle) and the need for **precise anatomical reduction** to prevent joint incongruity and cubitus varus/valgus deformities. - Intra-articular and displaced condylar fractures almost invariably require surgical intervention to ensure harmonious joint function and prevent long-term complications like **stiffness and deformity**.

Spine Disorders Indian Medical PG Question 9: False about fracture of vertebrae

• A. Fracture dislocation is common in flexion rotation injury
• B. Chance fracture occurs due to flexion distraction injury
• C. Wedge compression causes flexion injury
• D. Anterior longitudinal ligament runs along the posterior surface of vertebral bodies (Correct Answer)

Spine Disorders Explanation: ***Anterior longitudinal ligament runs along the posterior surface of vertebral bodies*** - The **anterior longitudinal ligament (ALL)** runs along the **anterior aspect** of the vertebral bodies, preventing hyperextension. - The **posterior longitudinal ligament (PLL)** runs along the posterior surface of the vertebral bodies, within the vertebral canal. *Fracture dislocation is common in flexion rotation injury* - **Flexion-rotation injuries** are highly unstable and frequently lead to **fracture-dislocations** of the vertebral column. - The combined forces cause significant disruption of both bony and ligamentous structures, increasing the likelihood of displacement. *Chance fracture occurs due to flexion distraction injury* - A **Chance fracture** (or seatbelt fracture) is caused by a **flexion-distraction injury**, typically seen in individuals wearing lap belts during deceleration. - This mechanism results in a horizontal splitting of the vertebral body and posterior elements. *Wedge compression causes flexion injury* - A **wedge compression fracture** is the most common type of vertebral fracture and results from a **flexion injury** (hyperflexion). - The anterior portion of the vertebral body collapses, creating a wedge shape, while the posterior column remains intact.

Spine Disorders Indian Medical PG Question 10: The most common pattern of involvement in Pott's spine is

• A. Central
• B. Posterior
• C. Paradiscal (Correct Answer)
• D. Anterior

Spine Disorders Explanation: ***Paradiscal*** - In **Pott's spine (tuberculous spondylitis)**, the infection typically starts in the anterior inferior aspect of the vertebral body and spreads to the adjacent disc space, making the **paradiscal** area the most common site of involvement. - This pattern is due to the rich **paradiscal vascular supply**, which facilitates the hematogenous spread of *Mycobacterium tuberculosis* to these regions. *Central* - **Central involvement** refers to the lesion being primarily located within the center of the vertebral body, which is less common in Pott's spine as the bacteria typically target the highly vascularized anterior and inferior margins. - While central lesions can occur, they are not the predominant pattern seen in initial stages of tuberculous spondylitis. *Posterior* - **Posterior involvement** usually refers to involvement of the posterior vertebral elements such as the neural arch, laminae, or spinous processes. - This type of involvement is **rare** in Pott's spine and is generally seen in very advanced or disseminated disease. *Anterior* - While the infection often begins in the anterior part of the vertebral body, the term **anterior** alone is less specific than "paradiscal" and doesn't fully capture the predominant involvement of the adjacent disc space. - The disease's characteristic spread across the disc space to an adjacent vertebra is a key feature of the paradiscal pattern, leading to **kyphosis** and vertebral collapse.

Spine Disorders Flashcard 1 of 10

Question: _____ classification is used for classifying spondylolisthesis based on the cause

Answer: Wiltse-Newman

Spine Disorders Flashcard 2 of 10

Question: According to the Denis classification, _____ column is the anterior part of the vertebra and disc, and the anterior longitudinal ligament

Answer: anterior

Spine Disorders Flashcard 3 of 10

Question: _____ is used to describe degenerative findings in the adjacent vertebral endplates due to age-related skeletal changes or osteophyte formation.

Answer: Spondylosis

Spine Disorders Flashcard 4 of 10

Question: Spinal stenosis is most commonly due to _____ of the spine, whereupon the ligamentum flavum hypertrophies and compresses nerve roots

Answer: osteoarthritis

Spine Disorders Flashcard 5 of 10

Question: _____ classification and the subaxial cervical spine injury classification (SLIC) is used for subaxial (C3-C7) cervical injuries

Answer: Ferguson and Allen

Spine Disorders Flashcard 6 of 10

Question: Number of bony prominences felt in gibbus is _____, and presents as a sharp posterior angulation

Answer: two to three

Spine Disorders Flashcard 7 of 10

Question: _____ is a rigid cervical brace which may be used as a treatment for cervical spine injury or for cervical pain due to rheumatoid arthritis

Answer: Sternal Occipital Mandibular Immobilizer (SOMI)

Spine Disorders Flashcard 8 of 10

Question: Which test is specific for diagnosing disc prolapse? _____

Answer: Bowstring sign/Popliteal compression test

Spine Disorders Flashcard 9 of 10

Question: _____ test is used for diagnosing inter-vertebral disc prolapse

Answer: Bragard

Spine Disorders Flashcard 10 of 10

Question: Odontoid fractures are classified by _____ classification into 3 types

Answer: Anderson and D’Alonzo