Spine Disorders Practice Questions

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: Which intervertebral disc level is most commonly involved in spinal disc prolapse?

T3-T4. **Explanation:** The question asks for the most common site of spinal disc prolapse across the entire vertebral column. While lumbar disc herniations are clinically more frequent, the **L4-L5** level is statistically the most common site for disc prolapse in the human spine. **Wait! Let's re-evaluate the provided key:** There appears to be a discrepancy in the provided key (T3-T4). In standard orthopaedic teaching (Apley’s, Campbell’s), the most common sites are: 1. **Lumbar (Most Common):** L4-L5 followed by L5-S1. 2. **Cervical:** C5-C6 and C6-C7. 3. **Thoracic (Least Common):** T11-T12. **Analysis of Options:** * **L4-L5 (Correct Answer in standard texts):** This is the most common site of disc prolapse overall due to maximum mobility and mechanical stress at this level. * **L5-S1:** The second most common site. It typically involves the S1 nerve root. * **C6-C7:** The most common site for *cervical* disc prolapse, often affecting the C7 nerve root. * **T3-T4 (Incorrect):** Thoracic disc prolapse is extremely rare (less than 1% of all cases) because the rib cage stabilizes the thoracic spine, limiting the mechanical stress required for herniation. **High-Yield NEET-PG Pearls:** * **Most common level overall:** L4-L5. * **Most common cervical level:** C6-C7 (affects C7 root). * **Schmorl’s Nodes:** Prolapse of the nucleus pulposus into the vertebral body. * **Posterolateral Prolapse:** The most common direction due to the relative weakness of the Posterior Longitudinal Ligament (PLL). * **Rule of Nerve Roots:** In the lumbar spine, a posterolateral disc prolapse usually compresses the **traversing** (lower) nerve root (e.g., L4-L5 disc affects the L5 root).

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: What is the last joint typically involved in ankylosing spondylitis?

Temporomandibular joint. **Explanation:** Ankylosing Spondylitis (AS) is a chronic inflammatory seronegative spondyloarthropathy that primarily affects the axial skeleton. The disease follows a characteristic **ascending pattern**, starting from the base of the spine and progressing cranially. **1. Why Temporomandibular Joint (TMJ) is the correct answer:** The TMJ is involved in only about 10% of patients and typically occurs in the very late stages of the disease. Because AS progresses from the sacroiliac joints upward through the lumbar, thoracic, and cervical spine, the TMJ—being the most superiorly located joint involved in the disease process—is usually the last to be affected. **2. Analysis of Incorrect Options:** * **Sacroiliac Joint (A):** This is the **first** joint to be involved. Bilateral, symmetrical sacroiliitis is the hallmark and often the presenting radiographic feature of AS. * **Costovertebral Joint (C):** These are involved as the disease ascends to the thoracic spine. Involvement leads to reduced chest expansion, a key clinical diagnostic criterion. * **Vertebral Apophyseal Facet Joint (D):** These are involved early to mid-course as the disease moves up the spinal column, leading to the characteristic "Bamboo Spine" appearance due to syndesmophyte formation and facet joint fusion. **Clinical Pearls for NEET-PG:** * **HLA-B27:** Strongly associated (>90% of cases). * **Schober’s Test:** Used to assess restricted lumbar flexion. * **Radiology:** Look for "Bamboo spine" (syndesmophytes), "Dagger sign" (ossification of supraspinous/interspinous ligaments), and "Romanus lesions" (shiny corners of vertebrae). * **Extra-articular manifestation:** Acute anterior uveitis is the most common. * **First-line Treatment:** NSAIDs and physical therapy.

Q: What is the most common cause of endplate destruction with reduction of the intervertebral disc space on X-ray?

Tuberculosis. **Explanation:** The hallmark of **Infective Spondylodiscitis**, most commonly caused by **Tuberculosis (Pott’s Spine)**, is the destruction of the intervertebral disc space. In TB spine, the infection typically starts in the paradiscal area of the vertebral body. Because the disc receives its nutrition via diffusion through the vertebral endplates, the infection easily crosses the disc space to involve the adjacent vertebra. Proteolytic enzymes (in pyogenic) or the slow destruction of endplates (in TB) lead to **narrowing of the disc space** and subsequent **endplate erosion**. **Analysis of Incorrect Options:** * **Metastasis (D) & Lymphoma (A):** These are malignancies. Malignant cells typically spread via the Batson’s venous plexus to the vertebral body. Crucially, tumor cells do not cross the fibrocartilage of the intervertebral disc. Therefore, in malignancy, the **disc space is characteristically preserved**, which is a key radiological differentiator from infection. * **Eosinophilic Granuloma (C):** This typically causes "Vertebra Plana" (Calvé disease), where there is a uniform collapse of a single vertebral body (pancake vertebra) while the disc spaces above and below remain completely normal. **NEET-PG High-Yield Pearls:** * **Earliest sign of TB Spine on X-ray:** Rarefaction/blurring of the paradiscal vertebral margins. * **Most common site for TB Spine:** Thoracolumbar junction (D12-L1). * **Cold Abscess:** A hallmark of TB spine; it lacks the typical signs of inflammation (heat/redness). * **Rule of Thumb:** If the disc space is **reduced**, think **Infection** (TB/Pyogenic). If the disc space is **preserved**, think **Malignancy** (Metastasis/Myeloma).

Q: Oligoarthritis with ascending joint involvement is seen in which of the following conditions?

Seronegative arthritis. **Explanation:** The correct answer is **Seronegative arthritis** (specifically **Ankylosing Spondylitis**, which is the prototype of this group). **1. Why Seronegative Arthritis is correct:** Seronegative Spondyloarthropathies (SpA) are characterized by the absence of Rheumatoid Factor (RF). A hallmark clinical feature of Ankylosing Spondylitis is **asymmetrical oligoarthritis** (affecting <5 joints) that typically follows an **ascending pattern**. It usually begins in the sacroiliac joints (sacroiliitis), moves to the lumbar spine, and progresses cranially to the thoracic and cervical regions. This "bottom-up" progression leads to the classic "Bamboo spine" appearance on X-ray. **2. Why other options are incorrect:** * **Juvenile Osteoarthritis:** Osteoarthritis is a degenerative "wear and tear" disease, not primarily inflammatory. While it can affect multiple joints, it does not follow a specific ascending spinal pattern. * **Systemic Lupus Erythematosus (SLE):** SLE typically presents with a symmetrical, migrating, non-erosive polyarthritis (affecting small joints of the hand), rather than an ascending spinal oligoarthritis. * **Septic Arthritis:** This is usually **monoarticular** (affecting a single large joint like the knee) and is caused by an acute bacterial infection. It does not present with a chronic ascending pattern. **Clinical Pearls for NEET-PG:** * **Mnemonic for Seronegative SpA (PEAR):** **P**soriatic arthritis, **E**nteropathic arthritis, **A**nkylosing spondylitis, **R**eactive arthritis. * **HLA-B27 Association:** Strongly linked with Ankylosing Spondylitis (>90% cases). * **Key Radiological Sign:** "Dagger sign" (ossification of supraspinous/interspinous ligaments) and "Romanus lesions" (shiny corners of vertebrae). * **Schober’s Test:** Used to clinically assess the restriction of lumbar spine flexion.

Question 1

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 2

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 3

Which intervertebral disc level is most commonly involved in spinal disc prolapse?

Accepted Answer

T3-T4

Answer

L4-L5

Answer

L5-S1

Answer

C6-C7

Question 4

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 5

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 6

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 7

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 8

What is the last joint typically involved in ankylosing spondylitis?

Accepted Answer

Temporomandibular joint

Answer

Sacroiliac joint

Answer

Costovertebral joint

Answer

Vertebral apophyseal facet joint

Question 9

What is the most common cause of endplate destruction with reduction of the intervertebral disc space on X-ray?

Accepted Answer

Tuberculosis

Answer

Lymphoma

Answer

Eosinophilic granuloma

Answer

Metastasis

Question 10

Oligoarthritis with ascending joint involvement is seen in which of the following conditions?

Accepted Answer

Seronegative arthritis

Answer

Juvenile osteoarthritis

Answer

Systemic lupus erythematosus (SLE)

Answer

Septic arthritis

Spine Disorders — MCQs

Spine Disorders — MCQs

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