Spine Disorders Practice Questions

Q: What is the most common malignancy that metastasizes to the spine in females?

Breast. **Explanation:** The spine is the most common site for skeletal metastasis due to its high vascularity and the presence of the **Batson venous plexus** (a valveless system allowing retrograde spread of tumor cells). **Why Breast is Correct:** In females, **Breast cancer** is the most common primary malignancy that metastasizes to the spine. It typically presents as **osteolytic** lesions (though it can be mixed or osteoblastic). The spread often occurs via the hematogenous route or direct extension. Statistically, approximately 70% of patients with advanced breast cancer will develop bone metastases, with the thoracic spine being the most frequently involved segment. **Analysis of Incorrect Options:** * **Thyroid:** While thyroid cancer frequently metastasizes to bone (often presenting as highly vascular, expansile lytic lesions), it is significantly less common than breast cancer in the general female population. * **Prostate:** This is the most common primary tumor causing spinal metastasis in **males**. It characteristically produces **osteoblastic** (sclerotic) lesions. * **Lung:** This is the second most common cause in both genders. Lung cancer is known for rapid progression and is the most common source of "drop metastases" to the spinal canal. **NEET-PG High-Yield Pearls:** * **Overall Most Common:** Breast (Females), Prostate (Males), Lung (Both combined/Second most common). * **Most Common Site:** Thoracic spine > Lumbar > Cervical. * **Pediatric Age Group:** Neuroblastoma is the most common primary to metastasize to the spine. * **Radiology Sign:** The **"Winking Owl Sign"** on AP X-ray indicates destruction of the pedicle (an early sign of spinal metastasis). * **Batson’s Plexus:** The key anatomical structure facilitating spread from pelvic organs to the spine without passing through the lungs.

Q: What is the commonest cause of the given condition in a young person?

Trauma. ***Trauma*** - **Trauma** is the most common cause of **spinal cord injury** and **acute paraplegia** in young people, particularly from motor vehicle accidents, falls, and sports injuries. - Young individuals are more prone to **high-energy trauma** which can cause **vertebral fractures**, **spinal cord compression**, and subsequent **kyphotic deformity**. *Tuberculosis* - **TB spine (Pott's disease)** is the commonest **pathological cause** of kyphosis/gibbous deformity but less frequent than trauma overall in young people. - More common in **developing countries** and **immunocompromised patients**, causing **vertebral body destruction** and **cold abscesses**. *Syphilis* - **Tertiary syphilis** can cause **Charcot spine** through **tabes dorsalis**, leading to **neuropathic arthropathy** of the spine. - This is a **rare cause** in modern medicine due to effective treatment of early syphilis and occurs in **older patients** with untreated disease. *Gonococcal* - **Gonococcal arthritis** rarely involves the **spine** and typically affects **peripheral joints** like knees, ankles, and wrists. - When spinal involvement occurs, it usually affects **sacroiliac joints** rather than causing **vertebral destruction** or **kyphotic deformity**.

Q: What is the commonest presenting symptom of Pott's spine?

Back pain. **Explanation:** **Pott’s Spine (Tuberculous Spondylitis)** is the most common form of extra-pulmonary tuberculosis involving the musculoskeletal system. 1. **Why Back Pain is Correct:** **Back pain** is the earliest and most common presenting symptom (seen in >90% of cases). It is typically chronic, localized to the site of involvement, and characteristically increases with activity or weight-bearing. The pain is often described as a "dull ache" and is frequently associated with nocturnal worsening (night cries) due to the relaxation of protective muscle spasms during sleep. 2. **Analysis of Incorrect Options:** * **Cold Abscess:** While a hallmark of Pott’s spine, it usually develops later as the infection tracks along tissue planes (e.g., psoas abscess). It is a sign of disease progression rather than the initial presenting symptom. * **Decreased Spinal Movements:** This occurs due to protective muscle spasms and pain. While common on clinical examination, patients usually seek medical attention for the *pain* itself rather than the stiffness. * **Collapse of Spine:** This is a late structural complication resulting in kyphosis (Gibbus deformity). It indicates advanced destruction of the vertebral bodies. **Clinical Pearls for NEET-PG:** * **Most common site:** Lower Thoracic and Upper Lumbar vertebrae (Thoracolumbar junction). * **Earliest Radiological Sign:** Rarefaction/blurring of the vertebral endplates and narrowing of the disc space. * **Paradiscal type:** The most common pattern of involvement, where the infection starts in the metaphysis and destroys the intervening disc. * **Neurological Deficit:** Pott’s paraplegia is the most dreaded complication; however, pain remains the primary reason for initial presentation.

Q: According to the Denis classification, which of the following is NOT included in the middle column?

Posterior elements of the spine. The **Denis Three-Column Classification** is a fundamental concept in spinal trauma used to assess stability. According to Denis, the spine is divided into three functional columns: 1. **Anterior Column:** Consists of the anterior longitudinal ligament (ALL), the anterior half of the vertebral body, and the anterior half of the annulus fibrosus. 2. **Middle Column:** Consists of the **Posterior Longitudinal Ligament (PLL)**, the **posterior half of the vertebral body**, and the **posterior half of the annulus fibrosus/disc**. 3. **Posterior Column:** Consists of the **posterior elements**, including the pedicles, facets, lamina, spinous processes, and the posterior ligamentous complex (supraspinous and interspinous ligaments). ### Why the Correct Answer is Right: **Option B (Posterior elements of the spine)** is the correct answer because, by definition, these structures belong to the **Posterior Column**. In the Denis model, the middle column acts as a "buffer" between the anterior and posterior columns; its disruption is the hallmark of an unstable injury (e.g., a burst fracture). ### Why the Other Options are Wrong: * **Option A (PLL):** This is the posterior-most boundary of the middle column. * **Options C & D (Posterior part of the disc and body):** These comprise the bony and fibrocartilaginous components of the middle column. ### High-Yield Clinical Pearls for NEET-PG: * **Stability Rule:** An injury involving **two or more columns** is generally considered **unstable**. * **Burst Fracture:** Characterized by the failure of both the anterior and **middle columns** under axial loading. * **Compression Fracture:** Typically involves only the anterior column (stable). * **Chance Fracture:** A "seatbelt injury" involving failure of all three columns due to distraction. * **Key Distinction:** The middle column is the most critical for determining mechanical stability and potential for neurological deficit.

Q: A male patient presents with weakness in the extensor hallucis longus (EHL). Which of the following is the most likely spinal level involved?

L4-L5 disc herniation. ### Explanation **1. Why L4-L5 disc herniation is correct:** In the lumbar spine, a posterolateral disc herniation (the most common type) typically affects the **traversing nerve root** (the root exiting one level below). Therefore, an **L4-L5 disc herniation** compresses the **L5 nerve root**. The **Extensor Hallucis Longus (EHL)**, responsible for great toe extension, is the classic "key muscle" supplied by the **L5 nerve root**. Weakness in EHL is a hallmark clinical sign of L5 radiculopathy. **2. Analysis of Incorrect Options:** * **L5-S1 disc herniation:** This typically compresses the **S1 nerve root**. Clinical features include a diminished or absent ankle jerk (Achilles reflex) and weakness in plantar flexion (Gastrocnemius/Soleus). * **S2-S3 disc herniation:** This level is rare for herniations and would involve sacral roots affecting bowel/bladder function or perianal sensation, rather than specific toe extensors. * **L2-L3 disc herniation:** This compresses the **L3 nerve root**. It presents with weakness in hip flexion (Iliopsoas) or knee extension (Quadriceps) and a diminished knee jerk (Patellar reflex). **3. High-Yield Clinical Pearls for NEET-PG:** * **L4 Root (L3-L4 disc):** Weakness in Tibialis Anterior (foot inversion/dorsiflexion); diminished **Knee Jerk**. * **L5 Root (L4-L5 disc):** Weakness in **EHL** and Extensor Digitorum Brevis; sensory loss on the first dorsal web space. * **S1 Root (L5-S1 disc):** Weakness in Peroneus Longus/Brevis (eversion); diminished **Ankle Jerk**. * **Rule of Thumb:** For lumbar herniations, the nerve root involved is the lower number of the two vertebrae (e.g., L4-L5 = L5 root). For cervical herniations, it is the same (e.g., C5-C6 = C6 root).

Q: A 44-year-old man presented with acute onset of low backache radiating to the right lower limb. Examination revealed SLRR?

Prolapsed intervertebral disc L4-5. ### Explanation **Correct Option: A (Prolapsed Intervertebral Disc L4-5)** The clinical presentation of acute-onset low backache radiating to a lower limb (sciatica) combined with a positive **Straight Leg Raising Test (SLRT)** is the classic hallmark of a **Prolapsed Intervertebral Disc (PIVD)**. * **Mechanism:** SLRT is a neurodynamic test that stretches the L4, L5, and S1 nerve roots. A positive result (pain reproduced between 30°–70°) indicates nerve root compression or tension, most commonly due to a disc herniation at the **L4-L5** or **L5-S1** levels. * **Why L4-5?** Statistically, 95% of lumbar disc herniations occur at the L4-L5 or L5-S1 levels. **Why Incorrect Options are Wrong:** * **B & D (Spondylolysis/Spondylolisthesis):** These involve a defect or slip of the vertebrae (pars interarticularis). While they can cause back pain, they typically present with chronic "mechanical" pain and "hamstring tightness" rather than acute radiculopathy with a positive SLRT. * **C (Lumbar Canal Stenosis):** This is characterized by **neurogenic claudication** (pain on walking, relieved by leaning forward/sitting). SLRT is usually negative in stenosis as the compression is chronic and circumferential rather than acute and focal. **Clinical Pearls for NEET-PG:** * **Lasegue’s Sign:** Another name for the SLRT. * **Fajersztajn Test (Crossed SLRT):** Lifting the unaffected leg causes pain in the affected limb. This is **highly specific** for disc herniation. * **Level of Disc vs. Nerve Root:** In the lumbar spine, a posterolateral disc protrusion usually compresses the **traversing nerve root** (e.g., L4-L5 disc affects the L5 root). * **Gold Standard Investigation:** MRI Spine. * **Most common level of PIVD:** L4-L5 > L5-S1.

Q: Which brace is used in the management of scoliosis?

Milwaukee Brace. **Explanation:** **Scoliosis** is a lateral curvature of the spine, and its management depends on the Cobb’s angle. Bracing is indicated for skeletally immature children (Risser sign 0-3) with a curve between **20° and 40°**. * **Milwaukee Brace (Correct Answer):** This is a **Cervico-Thoraco-Lumbo-Sacral Orthosis (CTLSO)**. It is the gold standard for high thoracic curves (apex above T8). It consists of a pelvic mold, three metal uprights, and a neck ring. It works on the principle of longitudinal traction and lateral pressure. **Discussion of Incorrect Options:** * **LS (Lumbo-Sacral) Belt:** Used primarily for symptomatic relief in degenerative conditions like Lumbar Spondylosis or acute low back strain. It provides abdominal compression but lacks the rigidity to correct spinal deformities. * **Taylor’s Brace:** A **Thoraco-Lumbo-Sacral Orthosis (TLSO)** used to limit flexion and extension. It is traditionally used for **Pott’s disease (Spinal TB)** or stable vertebral fractures of the lower thoracic and upper lumbar spine. * **Four Post Collar:** A cervical orthosis used to stabilize the **cervical spine** (C1-C7). It provides moderate restriction of motion and is used after cervical spine injuries or surgeries. **High-Yield Clinical Pearls for NEET-PG:** * **Boston Brace:** A low-profile TLSO (underarm brace) used for scoliosis where the apex is below T8. * **Charleston Bending Brace:** A nocturnal (night-time) brace used for scoliosis. * **Indication for Surgery:** If the Cobb’s angle is **>40°**, surgical intervention (e.g., Spinal fusion with pedicle screws) is generally required. * **Risser Sign:** Used to grade skeletal maturity based on the ossification of the iliac apophysis.

Q: What is vertebroplasty?

Stabilization of vertebral compression fracture. **Explanation:** Vertebroplasty is a minimally invasive image-guided procedure used primarily to treat painful **vertebral compression fractures (VCFs)**, most commonly caused by osteoporosis or malignancy (e.g., multiple myeloma, bony metastasis). **Why Option A is Correct:** The procedure involves the percutaneous injection of medical-grade bone cement—typically **Polymethylmethacrylate (PMMA)**—directly into the fractured vertebral body. The cement hardens quickly, providing internal stabilization of the fracture and immediate mechanical support, which significantly reduces pain and prevents further collapse. **Why Other Options are Incorrect:** * **Options B & C:** These describe a **Corpectomy** (removal/replacement of the vertebral body), which is a major reconstructive surgery used for severe trauma or tumors, often involving cages or bone grafts. Vertebroplasty does not replace the bone; it reinforces it. * **Option D:** This describes **Spinal Fusion** (Arthrodesis), where two or more vertebrae are permanently joined using hardware (rods/screws) and bone grafts to eliminate motion between them. **NEET-PG High-Yield Pearls:** * **Kyphoplasty vs. Vertebroplasty:** Kyphoplasty involves inflating a balloon first to restore vertebral height before injecting cement, whereas vertebroplasty is a direct injection. * **Indications:** Painful osteoporotic VCFs refractory to conservative management (analgesics, bracing). * **Common Complication:** Cement leakage is the most frequent complication. While usually asymptomatic, it can lead to pulmonary embolism or nerve root compression. * **Contraindications:** Active systemic infection, uncorrected coagulopathy, or a fracture that has already healed.

Q: The Nexus criteria is used for the assessment of which type of injury?

Traumatic cervical spine injury. The **NEXUS (National Emergency X-Radiography Utilization Study)** criteria is a clinical decision tool used to safely rule out **cervical spine (C-spine) injury** in stable trauma patients without the need for radiographic imaging. ### 1. Why Option A is Correct The primary goal of NEXUS is to identify patients at low risk for cervical spine fractures or dislocations. If a patient meets **all five** of the following criteria, the C-spine can be clinically cleared without an X-ray or CT scan: 1. **N**o focal neurological deficit. 2. **E**thanol (or other) intoxication is absent. 3. **X** (eXtreme) - No painful distracting injuries (e.g., a femur fracture that masks neck pain). 4. **U**nderlying midline cervical tenderness is absent. 5. **S**ensorium is normal (Alert and oriented; GCS 15). ### 2. Why Other Options are Incorrect * **Option B (Ankle):** Assessment of traumatic ankle injuries uses the **Ottawa Ankle Rules** to determine the need for X-rays. * **Option C (Knee):** Traumatic knee injuries are evaluated using the **Ottawa Knee Rules** or the **Pittsburgh Decision Rules**. * **Option D (Hip):** There is no specific "Nexus-like" clinical decision rule for hip trauma; diagnosis relies on clinical deformity (shortening/rotation) and standard pelvic radiographs. ### 3. Clinical Pearls for NEET-PG * **Canadian C-Spine Rule (CCR):** This is another high-yield tool for C-spine clearance. It is generally considered more sensitive and specific than NEXUS but is more complex to apply. * **Sensitivity:** NEXUS has a sensitivity of nearly **99%** for detecting clinically significant C-spine injuries. * **Imaging Choice:** If a patient fails NEXUS criteria, a **CT scan** is now the gold standard initial investigation for C-spine trauma in most trauma centers, replacing the traditional 3-view X-ray series.

Question 1

What is the most common malignancy that metastasizes to the spine in females?

Accepted Answer

Breast

Answer

Thyroid

Answer

Prostate

Answer

Lung

Question 2

What is the commonest cause of the given condition in a young person?

Accepted Answer

Trauma

Answer

Tuberculosis

Answer

Syphilis

Answer

Gonococcal

Question 3

What is the commonest presenting symptom of Pott's spine?

Accepted Answer

Back pain

Answer

Cold abscess

Answer

Decreased spinal movements

Answer

Collapse of spine

Question 4

According to the Denis classification, which of the following is NOT included in the middle column?

Accepted Answer

Posterior elements of the spine

Answer

Posterior longitudinal ligament

Answer

Posterior part of the vertebral disc

Answer

Posterior part of the vertebral body

Question 5

A male patient presents with weakness in the extensor hallucis longus (EHL). Which of the following is the most likely spinal level involved?

Accepted Answer

L4-L5 disc herniation

Answer

L5-S1 disc herniation

Answer

S2-S3 disc herniation

Answer

L2-L3 disc herniation

Question 6

A 44-year-old man presented with acute onset of low backache radiating to the right lower limb. Examination revealed SLRR?

Accepted Answer

Prolapsed intervertebral disc L4-5

Answer

Spondylolysis L5-S1

Answer

Lumbar canal stenosis

Answer

Spondylolisthesis L4-5

Question 7

Which brace is used in the management of scoliosis?

Accepted Answer

Milwaukee Brace

Answer

LS Belt

Answer

Taylor's Brace

Answer

Four post collar

Question 8

What is vertebroplasty?

Accepted Answer

Stabilization of vertebral compression fracture

Answer

Replacement of vertebral body only

Answer

Replacement of vertebral body with intervertebral disc

Answer

Fusion of the adjacent vertebrae

Question 9

Dislocation without fracture is most commonly seen in which part of the spine?

Accepted Answer

Cervical spine

Answer

Sacral spine

Answer

Lumbar spine

Answer

Thoracic spine

Question 10

The Nexus criteria is used for the assessment of which type of injury?

Accepted Answer

Traumatic cervical spine injury

Answer

Traumatic ankle injury

Answer

Traumatic knee injury

Answer

Traumatic hip injury

Spine Disorders — MCQs

Spine Disorders — MCQs

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