Spine Disorders Practice Questions

Q: A 60-year-old man with treated TB 1 year ago presents with low back pain. MRI spine shows a lesion. What is the most appropriate next investigation?

Mantoux test. ***Mantoux test*** - In a patient with a history of treated tuberculosis presenting with a new spinal lesion, reactivation or reinfection must be considered, and the **Mantoux test** (or Tuberculin Skin Test) helps assess the patient's immune response to Mycobacterium tuberculosis. - While the Mantoux test helps guide the clinical suspicion, a **positive test** in a previously treated patient requires careful clinical correlation to distinguish between old immunity and active disease. *CECT spine* - A **CECT spine** generally provides less soft-tissue resolution compared to an MRI, which has already been performed in this case. - Further imaging with contrast is usually focused on the extent of the disease or planning for intervention rather than the primary next diagnostic step in this context. *CT chest* - While **CT chest** may show old healed TB foci or reactivation, it is not the next most appropriate step to characterize the specific spinal lesion presenting as back pain. - It is a secondary investigation to rule out pulmonary involvement but does not directly diagnose the spinal pathology. *Biopsy* - Although **histopathology** via biopsy is the gold standard for a definitive diagnosis of Pott's spine or suspected malignancy, it is an invasive procedure generally reserved for cases where prior non-invasive testing or clinical suspicion remains unresolved. - In the initial diagnostic workup for a suspected tuberculous spinal lesion, less invasive investigations are prioritized before proceeding to surgical intervention.

Q: Which of the following is NOT a clinical feature of Tuberculosis of the Spine?

Weight gain. **Explanation:** Tuberculosis (TB) of the spine, also known as **Pott’s Disease**, is a chronic granulomatous infection caused by *Mycobacterium tuberculosis*. Understanding its systemic and local manifestations is crucial for NEET-PG. **Why "Weight Gain" is the correct answer:** Tuberculosis is a **chronic catabolic state**. The body’s immune response to the infection increases the basal metabolic rate, leading to significant **weight loss** and anorexia (loss of appetite). Therefore, weight gain is clinically inconsistent with a diagnosis of active spinal TB. **Analysis of other options:** * **Loss of lordosis (Option A):** This is a classic early sign. The infection typically affects the anterior part of the vertebral body, leading to bone destruction and collapse. This causes the normal inward curve (lordosis) of the cervical or lumbar spine to straighten or reverse, eventually leading to a **kyphotic deformity (Gibbus)**. * **Night sweats (Option B) & Evening rise of temperature (Option D):** These are hallmark **constitutional symptoms** of TB. They are mediated by cytokines like TNF-alpha and Interleukins released during the chronic inflammatory process. **High-Yield Clinical Pearls for NEET-PG:** 1. **Most common site:** Lower thoracic and upper lumbar vertebrae (Thoracolumbar junction). 2. **Earliest sign:** Loss of joint space (disc space narrowing) on X-ray, though the disc is initially spared as it is avascular. 3. **Paradiscal type:** The most common pattern of involvement where the infection starts in the metaphysis and spreads under the anterior longitudinal ligament. 4. **Cold Abscess:** A collection of pus without the typical signs of inflammation (heat/redness), often presenting as a psoas abscess in lumbar TB.

Q: Flowing wax appearance on anterior and posterior borders of vertebrae with normal intervertebral disc space, occurring due to ligament calcification, is seen in which condition?

Diffuse idiopathic skeletal hypertrophy. **Explanation:** The correct answer is **Diffuse Idiopathic Skeletal Hypertrophy (DISH)**, also known as Forestier’s disease. **1. Why DISH is correct:** DISH is a non-inflammatory systemic condition characterized by the ossification of ligaments and entheses. The hallmark radiological feature is the **"flowing wax"** or **"melted candle wax"** appearance, caused by the ossification of the **Anterior Longitudinal Ligament (ALL)**. * **Key Diagnostic Criteria:** * Involvement of at least four contiguous vertebral bodies. * **Preservation of intervertebral disc height** (unlike degenerative disc disease). * **Absence of sacroiliac (SI) joint involvement** (distinguishes it from Ankylosing Spondylitis). **2. Why other options are incorrect:** * **Ankylosing Spondylitis (AS):** Characterized by thin, vertical **syndesmophytes** (Bamboo spine) and mandatory **SI joint involvement** (sacroiliitis). It involves the destruction of disc spaces and is an inflammatory condition (HLA-B27 positive). * **Psoriatic Spondyloarthropathy:** Features asymmetric, coarse, and bulky non-marginal syndesmophytes. It usually presents with skin lesions and "pencil-in-cup" deformities in peripheral joints. * **Rheumatoid Arthritis:** Primarily affects the cervical spine (atlantoaxial subluxation). It does not cause flowing calcification of the thoracolumbar ligaments and typically spares the rest of the spine. **3. High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in elderly males (>50 years). * **Metabolic Association:** Strongly associated with **Diabetes Mellitus** and obesity. * **Clinical Presentation:** Often asymptomatic or presents with stiffness; large cervical osteophytes may rarely cause **dysphagia**. * **Radiology Tip:** If you see "Bamboo spine," think AS; if you see "Flowing wax" with normal discs and normal SI joints, think DISH.

Q: Which of the following is NOT true regarding Scheuermann's osteochondritis?

Autosomal recessive inheritance. **Scheuermann’s Disease** (Juvenile Kyphosis) is a developmental disorder of the spine characterized by a structural increase in thoracic or thoracolumbar kyphosis. ### **Explanation of Options** * **Option B (Correct Answer):** The inheritance pattern of Scheuermann's disease is **Autosomal Dominant** with variable expressivity, not autosomal recessive. This makes Option B the false statement. * **Option A:** **Dorsal kyphosis** is the hallmark clinical feature. Unlike postural kyphosis, this is a "fixed" deformity (rigid) that becomes more apparent on the forward bending test (Adam’s test). * **Option C:** The condition typically presents in **adolescents** (13–16 years). While some studies suggest a near-equal gender distribution, classic teaching and many clinical series indicate a slight **predominance in boys**. * **Option D:** Pathologically, there is **irregular ossification of the vertebral endplates** and disc space narrowing. This leads to the classic radiographic finding of **Schmorl’s nodes** (herniation of the nucleus pulposus into the vertebral body). ### **NEET-PG High-Yield Pearls** * **Sorensen’s Radiographic Criteria:** Diagnosis requires at least **3 adjacent vertebrae** wedged by **5° or more** each. * **Clinical Sign:** Compensatory cervical and lumbar hyperlordosis is often present. * **Radiological Signs:** 1. **Schmorl’s nodes** (protrusion of disc into the vertebral body). 2. **Limbus vertebrae** (bone fragment at the anterior-superior edge of the vertebral body). 3. **Wedging** of vertebral bodies. * **Management:** Conservative (exercises/bracing) for curves 70–75° or progressive neurological deficits.

Q: What is the commonest extradural spinal tumor?

Metastasis. **Explanation:** The spinal column is the most common site for skeletal metastasis, and **Metastasis** is the overall commonest extradural spinal tumor. These tumors typically reach the vertebrae via the hematogenous route (often through Batson’s venous plexus). The most frequent primary sources are cancers of the breast, prostate, lung, and kidney. **Analysis of Options:** * **D. Metastasis (Correct):** Approximately 95% of spinal tumors are extradural, and the vast majority of these are metastatic. They typically involve the vertebral body and can lead to pathological fractures or cord compression. * **A. Neurofibroma:** This is the most common **intradural-extramedullary** tumor. While it can occasionally have an extradural component (forming a "dumbbell" shape), it is not as common as metastatic disease. * **C. Meningioma:** This is the second most common **intradural-extramedullary** tumor, typically found in the thoracic spine of middle-aged women. * **B. Glioma:** These (specifically ependymomas and astrocytomas) are **intramedullary** tumors, meaning they arise within the substance of the spinal cord itself. **High-Yield Clinical Pearls for NEET-PG:** * **Classification by Location:** * **Extradural (95%):** Metastasis (Most common), Chordoma, Multiple Myeloma. * **Intradural-Extramedullary:** Neurofibroma (Most common), Meningioma. * **Intramedullary:** Ependymoma (Most common in adults), Astrocytoma (Most common in children). * **Winking Owl Sign:** On a spinal X-ray, the disappearance of a pedicle due to metastatic destruction is a classic radiological sign. * **MRI** is the gold standard investigation for suspected spinal cord compression.

Q: Whiplash injury of the spine is primarily due to which of the following mechanisms?

Hyperextension. **Explanation:** **1. Why Hyperextension is Correct:** Whiplash injury, also known as a cervical acceleration-deceleration (CAD) injury, most commonly occurs during rear-end motor vehicle collisions. When a vehicle is struck from behind, the occupant's body is accelerated forward, but the head lags behind due to inertia. This results in a sudden, forceful **hyperextension** of the cervical spine. This motion stretches the anterior longitudinal ligament and compresses the posterior elements (facet joints and intervertebral discs), leading to the characteristic pain and stiffness. While a secondary "rebound" flexion occurs, the primary pathological insult is the initial hyperextension. **2. Why Other Options are Incorrect:** * **Hyperflexion:** While flexion occurs as a secondary recoil in whiplash, it is not the primary mechanism. Pure hyperflexion injuries are more commonly associated with "clay-shoveler’s fractures" or wedge fractures of the vertebral bodies. * **Rotation:** Rotational forces usually lead to unilateral facet dislocations or rotatory subluxation (e.g., Grisel’s syndrome). While rotation can complicate a whiplash injury, it is not the defining mechanism. * **Sideward Traction:** This mechanism is associated with brachial plexus injuries (like Erb’s palsy) rather than spinal whiplash. **3. NEET-PG Clinical Pearls:** * **Quebec Classification:** Used to grade the severity of Whiplash-Associated Disorders (WAD). * **Radiology:** X-rays are often normal, but the most common finding is the **loss of normal cervical lordosis** due to paravertebral muscle spasms. * **WAD Grade II:** Includes musculoskeletal signs (decreased range of motion and point tenderness). * **Management:** Early mobilization and NSAIDs are preferred over prolonged immobilization with a hard collar.

Q: What is the most common cause of vertebra plana?

Eosinophilic granuloma. **Explanation:** **Vertebra plana** (also known as Calvé disease) refers to the complete symmetrical collapse of a vertebral body, resulting in a thin, wafer-like or "pancake" appearance, while the adjacent intervertebral discs remain preserved. **1. Why Eosinophilic Granuloma (EG) is correct:** Eosinophilic granuloma, a localized form of **Langerhans Cell Histiocytosis (LCH)**, is the most common cause of vertebra plana, particularly in children (ages 2–10). The pathological process involves the infiltration of the vertebral body by histiocytes, leading to osteolysis and rapid collapse. A classic radiographic feature is that despite the severe collapse, the bone density often remains normal, and the height can partially recover over time. **2. Why other options are incorrect:** * **Leukemia:** While it can cause generalized osteopenia and vertebral compression fractures in children, it rarely leads to the classic, isolated "wafer-thin" vertebra plana seen in EG. * **Tuberculosis (TB):** TB of the spine (Pott’s disease) typically involves the **intervertebral disc** (discitis) and adjacent vertebrae. It leads to wedge-shaped collapse and angulation (Gibbus deformity) rather than the uniform, flat collapse of a single body with disc preservation. * **Metastasis:** In adults, metastases (e.g., from lung or breast) are a common cause of pathological collapse, but they usually present as asymmetric destruction or "winking owl" sign (pedicle involvement) rather than classic vertebra plana. **Clinical Pearls for NEET-PG:** * **Mnemonic:** "MELT" for causes of Vertebra Plana (**M**etastasis/Myeloma, **E**osinophilic Granuloma, **L**ymphoma/Leukemia, **T**uberculosis). * **Key Radiographic Sign:** Preservation of disc space is the hallmark of EG, distinguishing it from infection. * **Age Factor:** If a question mentions a child with a "pancake vertebra," always suspect Eosinophilic Granuloma first.

Question 1

A 60-year-old man with treated TB 1 year ago presents with low back
pain. MRI spine shows a lesion. What is the most appropriate next
investigation?

Accepted Answer

Mantoux test

Answer

CECT spine

Answer

CT chest

Answer

Biopsy

Question 2

Which of the following is NOT a clinical feature of Tuberculosis of the Spine?

Accepted Answer

Weight gain

Answer

Loss of lordosis

Answer

Night sweats

Answer

Evening rise of temperature

Question 3

Flowing wax appearance on anterior and posterior borders of vertebrae with normal intervertebral disc space, occurring due to ligament calcification, is seen in which condition?

Accepted Answer

Diffuse idiopathic skeletal hypertrophy

Answer

Ankylosing spondylitis

Answer

Psoriatic spondyloarthropathy

Answer

Rheumatoid arthritis

Question 4

Which of the following is the etiological agent for the given case below?

Accepted Answer

Congenital

Answer

Neurofibromatosis

Answer

Degenerative arthritic

Answer

Idiopathic

Question 5

Which of the following is NOT true regarding Scheuermann's osteochondritis?

Accepted Answer

Autosomal recessive inheritance

Answer

Dorsal kyphosis

Answer

Predominantly affects adolescent boys

Answer

Irregular ossification of vertebral endplates

Question 6

What is the commonest extradural spinal tumor?

Accepted Answer

Metastasis

Answer

Neurofibroma

Answer

Glioma

Answer

Meningioma

Question 7

Which of the following types of odontoid fractures is considered unstable?

Accepted Answer

Both Type II and Type III

Answer

Type II

Answer

Type III

Answer

Neither Type II nor Type III

Question 8

Whiplash injury of the spine is primarily due to which of the following mechanisms?

Accepted Answer

Hyperextension

Answer

Hyperflexion

Answer

Rotation

Answer

Sideward traction

Question 9

What is the most common cause of vertebra plana?

Accepted Answer

Eosinophilic granuloma

Answer

Leukemia

Answer

Tuberculosis (TB)

Answer

Metastasis

Question 10

A 38-year-old male presents with pain and tenderness in the dorsolumbar junction. Radiographs show destruction of the 12th dorsal vertebra with loss of disc space between D12 and L1. What is the most probable diagnosis?

Accepted Answer

Pott's spine

Answer

Trauma

Answer

Vertebral osteomyelitis

Answer

Metastasis of carcinoma lung

Spine Disorders — MCQs

Spine Disorders — MCQs

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