Degenerative Spinal Conditions — MCQs

10 questions

Bamboo spine with sacroilitis -

A 45-year-old patient presents with chronic lower back pain. X-ray shows anterior displacement of a vertebral body. What is the likely diagnosis?

A 60-year-old woman with a history of chronic back pain presents with acute-onset sharp pain radiating down the right leg. She also reports numbness and tingling in the foot. What is the best next step in management?

In an accident involving potential cervical spine damage, the first line of management is:

Investigation of choice for lumbar prolapsed disc -

A patient presents with a suspected cervical spine injury following an accident. What is the first step in management?

A 69-year-old man has an abnormally increased curvature of the thoracic vertebral column. Which of the following conditions is the most likely diagnosis?

A 23-year-old male patient presented with a history of back pain, which is more in the morning and relieved by bathing in warm water. What is the likely additional finding present in this patient?

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?

Q10

False about fracture of vertebrae

Degenerative Spinal Conditions Indian Medical PG Practice Questions and MCQs

Question 1: Bamboo spine with sacroilitis -

A. Psoriatic arthritis
B. Ankylosing spondylitis (Correct Answer)
C. OA
D. RA

Explanation: ***Ankylosing spondylitis*** - **Bamboo spine** is a classic radiographic finding in advanced **ankylosing spondylitis**, resulting from ossification of the anulus fibrosus and spinal ligaments [1]. - **Sacroiliitis**, inflammation of the sacroiliac joints, is another hallmark feature and often the earliest radiographic sign of the disease [1], [3]. *Psoriatic arthritis* - While psoriatic arthritis can involve the spine and cause sacroiliitis, it typically presents with **asymmetric involvement** [2] and is less commonly associated with the widespread, progressive ossification characteristic of true "bamboo spine" [4]. - It often also involves **skin psoriasis** and **nail changes**, which are not indicated as the primary finding here [4]. *OA* - **Osteoarthritis (OA)** is a degenerative joint disease characterized by cartilage loss and osteophyte formation, often seen in weight-bearing joints and the spine [2]. - While OA can affect spinal joints and cause stiffness, it does **not cause inflammatory sacroiliitis** or the specific syndesmophyte formation that leads to "bamboo spine." *RA* - **Rheumatoid arthritis (RA)** primarily affects peripheral joints, particularly small joints of the hands and feet, and typically spares the sacroiliac joints and the thoracolumbar spine [2]. - Spinal involvement in RA is usually limited to the **cervical spine**, leading to atlantoaxial subluxation, and does not cause "bamboo spine" or widespread sacroiliitis.

Question 2: A 45-year-old patient presents with chronic lower back pain. X-ray shows anterior displacement of a vertebral body. What is the likely diagnosis?

A. Spondylosis
B. Compression fracture
C. Osteoporosis
D. Spondylolisthesis (Correct Answer)

Explanation: ***Spondylolisthesis*** - This condition involves the **anterior displacement** (slipping forward) of one vertebral body over the one below it, which perfectly matches the X-ray finding. - It often causes **chronic lower back pain**, especially in active individuals or those with degenerative changes. *Spondylosis* - Refers to **degenerative changes** in the spine, including **osteophytes** and **disc space narrowing**, but typically does not involve anterior vertebral displacement. - While it can cause chronic back pain, the specific X-ray finding points away from isolated spondylosis. *Compression fracture* - Involves a **collapse of the vertebral body**, usually due to trauma or osteoporosis, leading to a **decreased vertebral height**. - It does not present as an anterior displacement of an entire vertebral body. *Osteoporosis* - This is a condition of **decreased bone density**, making bones fragile and prone to fractures (e.g., compression fractures), but it does not directly cause anterior vertebral displacement. - While osteoporosis can be an underlying factor for some spinal conditions, it is not the direct diagnosis for the described X-ray finding.

Question 3: A 60-year-old woman with a history of chronic back pain presents with acute-onset sharp pain radiating down the right leg. She also reports numbness and tingling in the foot. What is the best next step in management?

A. Bed rest
B. MRI of the spine (Correct Answer)
C. X-ray of the spine
D. Physical therapy

Explanation: ### MRI of the spine - The patient's symptoms of acute-onset sharp pain radiating down the right leg with numbness and tingling strongly suggest **radiculopathy**, likely due to **nerve root compression** from a herniated disc, stenosis, or other pathology [1]. - An **MRI of the spine** is the **most sensitive and specific imaging modality** to visualize soft tissue structures like intervertebral discs, nerve roots, and the spinal cord, allowing for accurate diagnosis and guiding further management. *Bed rest* - While historically recommended, **prolonged bed rest** is generally discouraged for acute low back pain and radiculopathy as it can lead to deconditioning and delayed recovery [2]. - **Modified activity** and early mobilization are often preferred over strict bed rest, even for severe pain [2]. *X-ray of the spine* - An **X-ray of the spine** can identify bony abnormalities like fractures, severe degenerative changes, or spondylolisthesis, but it **cannot visualize soft tissue structures** that are typically responsible for radicular symptoms, such as herniated discs or nerve root compression. - Therefore, it is not the best initial imaging choice for pinpointing the cause of the patient's neurological symptoms. *Physical therapy* - **Physical therapy** is an important component of long-term management for back pain and radiculopathy, focusing on exercises, stretching, and education to improve function and reduce pain. - However, in the setting of **acute, severe radicular symptoms** with numbness and tingling, it is crucial to first establish a definitive diagnosis through imaging to rule out more serious compression and guide appropriate therapeutic interventions.

Question 4: In an accident involving potential cervical spine damage, the first line of management is:

A. x-ray
B. turn head to side
C. maintain airway (Correct Answer)
D. stabilize the cervical spine

Explanation: ***Correct: Maintain airway*** - In trauma management, the **ATLS protocol** follows the **A-B-C-D-E** approach where **Airway is the first priority** - In suspected cervical spine injury, airway management is performed **with concurrent cervical spine protection** (using jaw thrust maneuver instead of head tilt-chin lift) - A compromised airway leads to death within minutes, making it the **immediate first-line intervention** - **Cervical spine stabilization is performed simultaneously** during airway assessment and management, not as a separate preceding step - The correct approach: **"Airway with cervical spine protection"** - both are done together, but airway assessment/management takes priority *Incorrect: Stabilize the cervical spine* - While **cervical spine stabilization** is critical and must be maintained throughout trauma management, it is **not performed before airway assessment** - Manual inline stabilization and cervical collar application are done **during** airway management, not before it - ATLS teaches that C-spine protection is **integrated into** airway management, not a separate first step *Incorrect: X-ray* - **X-ray** is a diagnostic tool performed after initial stabilization and resuscitation - Imaging is part of the **secondary survey**, not primary trauma management - Never delay life-saving interventions for diagnostic studies *Incorrect: Turn head to side* - **Turning the head** is absolutely contraindicated in suspected cervical spine injury - Any movement can convert an unstable fracture into a **complete spinal cord injury** - If airway management is needed, use **jaw thrust** or **chin lift without head tilt**

Question 5: Investigation of choice for lumbar prolapsed disc -

A. CT Scan
B. Myelogram
C. X-ray
D. MRI (Correct Answer)

Explanation: ***MRI*** - An **MRI** provides the best visualization of **soft tissues**, including the intervertebral discs, spinal cord, and nerve roots, making it the **gold standard** for diagnosing lumbar prolapsed disc. - It can accurately show the **degree of disc herniation**, its impact on neural structures, and associated edema, which are crucial for treatment planning. *CT Scan* - While a **CT scan** provides good bony detail and can show disc herniation, its ability to visualize soft tissues is inferior to MRI for this specific condition. - It involves **ionizing radiation** and may miss subtle nerve root compression or spinal cord abnormalities apparent on MRI. *Myelogram* - A **myelogram** involves injecting contrast dye into the spinal canal and then performing X-rays or CT scans to outline the spinal cord and nerve roots. - Though effective in showing **nerve compression**, it is an **invasive procedure** with potential complications and has largely been replaced by MRI as a first-line diagnostic investigation. *X-ray* - **X-rays** primarily visualize **bony structures** and are useful for detecting fractures, spinal alignment issues, or severe degenerative changes. - They **cannot directly visualize intervertebral discs** or nerve compression, making them unsuitable for diagnosing a prolapsed disc.

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

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.

Question 7: A 69-year-old man has an abnormally increased curvature of the thoracic vertebral column. Which of the following conditions is the most likely diagnosis?

A. Meningocele
B. Kyphosis (Correct Answer)
C. Meningomyelocele
D. Lordosis

Explanation: ***Kyphosis*** - **Kyphosis** is defined as an exaggerated posterior curvature of the **thoracic spine**, often seen in older adults due to **osteoporosis** or degenerative disc disease. - The patient's age and description of an "abnormally increased curvature of the thoracic vertebral column" directly correspond to the definition of **kyphosis**. *Meningocele* - A **meningocele** is a type of **spina bifida** where the meninges protrude through an opening in the spine, forming a sac. - This condition involves a **neural tube defect** and typically presents at birth, not as an acquired condition in a 69-year-old. *Meningomyelocele* - A **meningomyelocele** is a more severe form of **spina bifida** where the spinal cord and meninges protrude through an opening in the spine. - Like meningocele, it is a congenital birth defect and does not present as an abnormally increased spinal curvature in an elderly individual. *Lordosis* - **Lordosis** is an exaggerated anterior curvature, most commonly affecting the **lumbar spine**. - It results in an inward swayback appearance, which is the opposite of an increased posterior curvature of the thoracic spine.

Question 8: A 23-year-old male patient presented with a history of back pain, which is more in the morning and relieved by bathing in warm water. What is the likely additional finding present in this patient?

A. Marrow fibrosis
B. Decreased chest wall expansion (Correct Answer)
C. Pleural nodules
D. Distal phalangeal joint involvement

Explanation: Decreased chest wall expansion - The patient's symptoms of morning back pain relieved by activity and warm baths are classic for ankylosing spondylitis. This condition commonly leads to fusion of the costovertebral joints, limiting chest wall expansion [1]. - Reduced chest wall expansion is a specific finding in ankylosing spondylitis, reflecting the ankylosis of the axial skeleton and enthesitis at various sites, including rib attachments [1]. Marrow fibrosis - Myelofibrosis is a bone marrow disorder characterized by fibrosis, typically leading to symptoms like fatigue, splenomegaly, and cytopenias, and is not directly associated with ankylosing spondylitis. - While inflammatory conditions can rarely cause reactive changes in bone marrow, widespread fibrosis is not a hallmark or common feature of ankylosing spondylitis. Pleural nodules - Pleural nodules are more characteristic of conditions like rheumatoid arthritis (rheumatoid nodules) or various lung malignancies/infections. - Although lung involvement, such as apical pulmonary fibrosis, can occur in ankylosing spondylitis, discrete pleural nodules are not common. Distal phalangeal joint involvement - Involvement of the distal interphalangeal (DIP) joints is a hallmark feature of psoriatic arthritis [2]. - Ankylosing spondylitis primarily affects the axial skeleton (spine and sacroiliac joints) and large peripheral joints, with DIP joint involvement being very rare [2].

Question 9: 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

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**.

Question 10: 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)

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.

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