Intervertebral Disc Disease — MCQs

10 questions

Which of the following is not a typical symptom of a lumbar disc herniation?

All of the following contribute to the intervertebral disc EXCEPT:

A patient while lifting a heavy weight presents with sudden onset pain in the lower back radiating along the postero-lateral thigh and lateral leg to the big toe with numbness. The most likely diagnosis is:

A patient presented with Saddle anaesthesia with bladder and bowel involvement and muscle power is normal. The diagnosis is:

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 right-sided disc herniation at the L5-S1 level typically may cause:

Investigation of choice for lumbar prolapsed disc -

Tuberculosis of the spine commonly affects all of the following parts of the vertebra except:

Identify the condition shown in the image:

Q10

Which of the following statements about Pott's spine is false?

Intervertebral Disc Disease Indian Medical PG Practice Questions and MCQs

Question 1: Which of the following is not a typical symptom of a lumbar disc herniation?

A. Positive straight leg raise test
B. Saddle anesthesia (Correct Answer)
C. Radicular leg pain
D. Weakness in foot dorsiflexion

Explanation: ***Saddle anesthesia*** - While a severe complication, **saddle anesthesia** is indicative of **cauda equina syndrome**, a medical emergency, and not a typical, isolated symptom of a simple lumbar disc herniation. - It suggests **compression of multiple nerve roots** in the lumbosacral region, beyond what is usually seen with a single disc herniation. *Positive straight leg raise test* - This is a common and reliable physical exam finding in patients with **lumbar disc herniation**, indicating nerve root irritation. - It elicits radiating pain down the leg when the affected leg is raised between 30 and 70 degrees. *Radicular leg pain* - **Radicular pain**, often described as sharp, shooting pain down the leg, is the hallmark symptom of a lumbar disc herniation as it signifies **nerve root compression**. - The pain typically follows a **dermatomal pattern**, corresponding to the specific nerve root involved. *Weakness in foot dorsiflexion* - Weakness in **foot dorsiflexion** (commonly affecting the **L4 or L5 nerve roots**) is a frequently observed neurological deficit in lumber disc herniation. - This can be assessed through manual muscle testing and is a sign of **motor nerve root compression**.

Question 2: All of the following contribute to the intervertebral disc EXCEPT:

A. Fibrocartilage
B. Elastic cartilage (Correct Answer)
C. Annulus fibrosus
D. Nucleus pulposus

Explanation: ***Elastic cartilage*** - **Elastic cartilage** is characterized by the presence of **elastic fibers**, providing flexibility to structures like the ear and epiglottis. - It is **not found** within the intervertebral disc, which requires specific properties for weight-bearing and shock absorption. *Fibrocartilage* - **Fibrocartilage** is a primary component of the **annulus fibrosus** and plays a crucial role in providing tensile strength and resisting compressive forces [1]. - Its presence is essential for the structural integrity and function of the intervertebral disc. *Annulus fibrosus* - The **annulus fibrosus** is the **tough, outer fibrous ring** of the intervertebral disc, composed of concentric layers of fibrocartilage. - It encircles the nucleus pulposus, containing it and providing stability to the disc. *Nucleus pulposus* - The **nucleus pulposus** is the **gel-like core** of the intervertebral disc, rich in proteoglycans and water. - It acts as a shock absorber and allows for flexibility between vertebrae.

Question 3: A patient while lifting a heavy weight presents with sudden onset pain in the lower back radiating along the postero-lateral thigh and lateral leg to the big toe with numbness. The most likely diagnosis is:

A. L4 - L5 Disc prolapsed (Correct Answer)
B. L3 - IA Disc prolapsed
C. L5 fracture
D. L5 - SI Disc prolapse

Explanation: ***L4 - L5 Disc prolapsed*** - A disc prolapse at the **L4-L5 level** typically compresses the **L5 nerve root**. - This compression leads to pain radiating along the **postero-lateral thigh** and **lateral leg**, reaching the **big toe**, often accompanied by numbness in the same distribution due to **L5 dermatome** involvement. *L3 - IA Disc prolapsed* - A prolapse at the **L3-L4 level** would compress the **L4 nerve root**, causing pain in the **anterior thigh** and medial leg, with potential numbness over the **medial calf** and ankle. - This presentation does not match the described symptoms of pain radiating to the big toe and lateral leg. *L5 fracture* - An **L5 fracture** would primarily manifest as localized lower back pain, often exacerbated by movement, and might not necessarily cause radiating pain or numbness in a dermatomal pattern to the big toe unless there's associated nerve root compression. - The sudden onset with radiating pain in a specific distribution points more towards nerve impingement from a disc prolapse rather than a fracture. *L5 - SI Disc prolapse* - A disc prolapse at the **L5-S1 level** compresses the **S1 nerve root**. - This typically results in pain radiating down the **posterior thigh**, **calf**, and to the **little toe** and lateral foot, along with numbness in the **S1 dermatome**, which is different from the big toe and lateral leg involvement described.

Question 4: A patient presented with Saddle anaesthesia with bladder and bowel involvement and muscle power is normal. The diagnosis is:

A. L4-L5 disc prolapsed
B. L3-L4 root involvement
C. Conus medullaris lesion (Correct Answer)
D. Cauda equina syndrome

Explanation: ***Conus medullaris lesion*** - A **conus medullaris lesion** typically presents with **saddle anesthesia**, early and severe **bladder and bowel dysfunction**, and often **symmetrical neurological deficits** [1], [3]. - **Motor weakness in the legs** is usually minimal or absent, which aligns with the patient's normal muscle power in this case. *L4-L5 disc prolapsed* - A **L4-L5 disc prolapse** primarily causes **radicular pain** and weakness in the distribution of the L5 nerve root (e.g., foot drop, weakness of ankle dorsiflexion) [2]. - While it can cause some sensory changes, **saddle anesthesia** and severe bladder/bowel dysfunction are not typical features. *L3-L4 root involvement* - **L3-L4 root involvement**, often from a disc herniation, would typically present with **quadriceps weakness**, absent patellar reflex, and sensory loss over the medial thigh [2]. - It would not cause **saddle anesthesia** or significant bladder/bowel dysfunction as a primary symptom. *Cauda equina syndrome* - **Cauda equina syndrome** presents with **saddle anesthesia** and **bladder/bowel dysfunction**, but it is generally characterized by **significant motor weakness** in the lower extremities (e.g., severe leg weakness, foot drop), which is absent here. - The onset of bladder and bowel symptoms in cauda equina syndrome is often more gradual and less severe initially compared to conus medullaris lesions.

Question 5: 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 6: A right-sided disc herniation at the L5-S1 level typically may cause:

A. Low back pain and right-sided sciatica (Correct Answer)
B. Normal ankle jerk reflex.
C. Weakness of dorsiflexion of the right foot.
D. Diminished sensation over the medial aspect of the foot.

Explanation: ***Low back pain and right-sided sciatica*** - A right-sided disc herniation at the L5-S1 level typically compresses the **S1 nerve root** on the right side. - This compression leads to **sciatica**, which presents as radiating pain along the S1 dermatome (back of the leg and sole of the foot), often accompanied by localized **low back pain**. *Weakness of dorsiflexion of the right foot* - **Dorsiflexion weakness** is primarily associated with compression of the **L4 or L5 nerve roots**, not S1. - The muscles responsible for dorsiflexion (e.g., tibialis anterior) are predominantly innervated by L4 and L5. *Normal ankle jerk reflex* - The **ankle jerk reflex** is mediated by the **S1 nerve root**. - Therefore, compression of the S1 nerve root would typically lead to a **diminished or absent ankle jerk reflex**, not a normal one. *Diminished sensation over the medial aspect of the foot* - **Diminished sensation** over the **medial aspect of the foot** corresponds to the **L4 dermatome**. - A herniation at L5-S1 primarily affects the S1 dermatome, which involves the **lateral aspect of the foot** and sole.

Question 7: 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 8: Tuberculosis of the spine commonly affects all of the following parts of the vertebra except:

A. Lamina
B. Body
C. Spinous process (Correct Answer)
D. Pedicle

Explanation: ***Spinous process*** - **Tuberculosis of the spine (Pott's disease)** typically affects the anterior columns of the vertebrae, primarily the vertebral bodies, due to their rich vascular supply. - The **spinous process** (posterior element) is rarely involved in tuberculosis because it has a relatively poor blood supply compared to the vertebral body. *Lamina* - The **lamina**, part of the vertebral arch (posterior element), is also less commonly affected by tuberculous spondylitis compared to the vertebral body. - While possible in advanced or disseminated disease, initial involvement is usually anterior. *Body* - The **vertebral body** is the most commonly affected part of the vertebra in tuberculosis of the spine. - This is due to its abundant blood supply, allowing for easy hematogenous spread of the *Mycobacterium tuberculosis* bacteria. *Pedicle* - The **pedicle** connects the vertebral body to the lamina and is considered an anterior element, albeit less frequently involved than the vertebral body itself. - Involvement of the pedicle tends to occur via direct extension from an affected vertebral body or disk space.

Question 9: Identify the condition shown in the image:

A. Renal osteodystrophy
B. Spondylolisthesis
C. Tuberculosis (TB)
D. Spondylolysis (Correct Answer)

Explanation: ***Spondylolysis*** * The image shows a **break in the pars interarticularis** of a vertebra, indicated by the arrow, which is characteristic of spondylolysis. * This condition is a **stress fracture** or defect in the pars interarticularis, a bony segment connecting the superior and inferior articular facets. *Renal osteodystrophy* * Renal osteodystrophy refers to a spectrum of **bone abnormalities** that occur in chronic kidney disease, not a specific vertebral fracture pattern. * It typically involves features such as **osteomalacia**, **osteitis fibrosa cystica**, or **osteoporosis**, which are not directly depicted as a fracture in this image. *Spondylolisthesis* * Spondylolisthesis is the **anterior slippage** of one vertebral body over another, which can be caused by bilateral spondylolysis but is not directly shown as a slip in this specific image. * The image distinctly highlights the **fracture line** itself, rather than the displacement of the vertebral body. *Tuberculosis (TB)* * Spinal tuberculosis (Pott's disease) typically presents with **destruction of vertebral bodies**, disc space narrowing, and often a **paravertebral abscess**. * The image does not show these features; instead, it demonstrates a clear **bony defect** in the pars interarticularis.

Question 10: Which of the following statements about Pott's spine is false?

A. There is disc space narrowing on x-ray
B. Back pain is an early symptom
C. Commonest at dorsolumbar junction
D. Always heals by chemotherapy (Correct Answer)

Explanation: ***Always heals by chemotherapy*** - This statement is false because while **chemotherapy** (anti-tubercular drugs) is the primary treatment for **Pott's disease** (tuberculosis of the spine), healing is not always guaranteed and can sometimes require **surgical intervention** in cases of severe neurological deficit or instability. - The success of treatment depends on early diagnosis, patient compliance, and the severity of the disease, and not all cases resolve completely without residual issues. *Commonest at dorsolumbar junction* - **Pott's spine**, or **vertebral tuberculosis**, most frequently affects the **thoracic** and **lumbar regions**, particularly the **dorsolumbar junction** (T9-L1). - This predilection is attributed to the rich vascular supply and increased mechanical stress in this area. *Back pain is an early symptom* - **Back pain** is often one of the **earliest and most common symptoms** of Pott's spine, due to inflammation and destruction of vertebral bodies. - The pain is typically **localized**, progressive, and may worsen with movement. *There is disc space narrowing on x-ray* - **X-rays** of Pott's spine often show **disc space narrowing** along with vertebral destruction and collapse, differentiating it from pyogenic osteomyelitis where disc spaces might be initially preserved. - This narrowing is a consequence of the tuberculous infection spreading from the vertebral body to the adjacent **intervertebral disc**.

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