Spine Disorders — MCQs

A 17-year-old boy presents with chronic low back pain and stiffness for the past 8 months. He denies any gastrointestinal or genital infections. His temperature is 98.6 F. Laboratory investigations show normal ESR and negative RA factor. X-ray films of the vertebral column show flattening of the lumbar curve and subchondral bone erosion involving the sacroiliac joints. What is the most likely diagnosis?

Q114Easy

What is the most common site of ossification of the posterior longitudinal ligament (OPLL)?

Q115Medium

Which of the following is NOT a clinical sign of Pott's spine?

Q116Medium

Which of the following is NOT true about ankylosing spondylitis?

Q117Medium

Which statement is true regarding Hangman's fracture?

Q118Easy

What is the first sign of tuberculosis of the spine?

Q119Medium

A 62-year-old man presents to the emergency department with severe pain in his lower back, left buttock, and the posterolateral aspect of his left leg. The pain began acutely after he lifted his 8-year-old granddaughter into the back of a truck, and he describes it as "shooting" in nature. He is curled into a fetal position, which he states relieves the pain. Attempts to extend the man's spine markedly exacerbate the pain. Further examination reveals foot drop with weakness of the anterior tibial, posterior tibial, and peroneal muscles. Sensory loss is demonstrated over the anterior shin and dorsal foot. These findings suggest a radiculopathy at which of the following cord levels?

Q120Easy

All of the following may cause metastatic tumors causing spinal cord compression except?

Spine Disorders Indian Medical PG Practice Questions and MCQs

Question 111: A 23-year-old woman presents with back pain. Radiographic examination reveals a condition affecting her vertebral column. Her history includes polio and muscular dystrophy. Which of the following vertebral column conditions is most likely present in this patient?

A. Lordosis
B. Kyphosis
C. Scoliosis (Correct Answer)
D. Spina bifida

Explanation: **Explanation:** The correct answer is **Scoliosis**. Scoliosis is defined as a lateral curvature of the spine (greater than 10 degrees). While the most common type is Adolescent Idiopathic Scoliosis (AIS), this patient’s history of **Polio** and **Muscular Dystrophy** points toward **Neuromuscular Scoliosis**. In these conditions, muscle weakness or imbalance (asymmetric paralysis in polio or progressive degeneration in dystrophy) leads to an inability of the paraspinal muscles to support the vertebral column, resulting in a "C-shaped" or "S-shaped" lateral deformity. **Analysis of Incorrect Options:** * **Lordosis:** This is an excessive inward (anterior) curvature of the lumbar or cervical spine. While it can occur secondary to hip flexion contractures (common in polio), it is not the primary structural deformity associated with generalized neuromuscular weakness. * **Kyphosis:** This refers to an increased posterior curvature (hunchback) of the thoracic spine. It is typically seen in conditions like Scheuermann’s disease or vertebral fractures, rather than as a primary result of muscular dystrophy. * **Spina Bifida:** This is a congenital neural tube defect characterized by the incomplete closure of the vertebral arches. It is a developmental anomaly present at birth, not an acquired deformity resulting from neuromuscular diseases like polio. **High-Yield Clinical Pearls for NEET-PG:** * **Cobb’s Angle:** The gold standard for measuring the severity of scoliosis on an X-ray. * **Risser Sign:** Used to grade skeletal maturity by assessing the ossification of the iliac apophysis; it helps predict the risk of curve progression. * **Adam’s Forward Bend Test:** The most common clinical screening tool for scoliosis; a positive test shows a "rib hump" due to vertebral rotation. * **Neuromuscular Scoliosis** often presents with a long, sweeping C-shaped curve and is more likely to progress even after skeletal maturity compared to idiopathic types.

Question 112: The Hong Kong operation is performed for which condition?

A. Tuberculosis of the spine (Correct Answer)
B. Tuberculosis of the hip
C. Tuberculosis of the knee
D. Chronic osteomyelitis

Explanation: **Explanation:** The **Hong Kong operation** is a landmark surgical procedure specifically designed for the management of **Tuberculosis of the spine (Pott’s disease)**. **Why Option A is correct:** Developed by Hodgson and Stock in 1956, the Hong Kong operation involves a **radical anterior debridement** of the necrotic bone and tuberculous debris, followed by an **anterior interbody fusion** using an autologous bone graft (usually from the rib or iliac crest). The rationale is that since TB spine primarily affects the anterior column (vertebral bodies), an anterior approach allows direct access to the lesion, ensures complete clearance of the cold abscess, and provides better stability through grafting, leading to faster healing and prevention of kyphosis. **Why other options are incorrect:** * **Options B & C:** While Tuberculosis of the hip and knee are common extra-axial sites, they are managed via joint-specific procedures like Girdlestone arthroplasty (for hip) or arthrodesis/synovectomy. The term "Hong Kong operation" is strictly reserved for spinal intervention. * **Option D:** Chronic osteomyelitis of long bones typically requires sequestrectomy and saucerization, not the specific radical anterior approach and fusion defined by the Hong Kong technique. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard:** The Hong Kong operation remains the classic surgical reference for Pott’s spine with neurological deficit or progressive kyphosis. * **Approach:** It is an **Anterior Approach** (Transthoracic, Retroperitoneal, or Transperitoneal depending on the level). * **Indication:** Indicated when there is a poor response to AKT, persistent neurological deficit, or severe spinal instability. * **Most common site of TB Spine:** Lower Thoracic and Upper Lumbar vertebrae.

Question 113: A 17-year-old boy presents with chronic low back pain and stiffness for the past 8 months. He denies any gastrointestinal or genital infections. His temperature is 98.6 F. Laboratory investigations show normal ESR and negative RA factor. X-ray films of the vertebral column show flattening of the lumbar curve and subchondral bone erosion involving the sacroiliac joints. What is the most likely diagnosis?

A. Ankylosing spondylitis (Correct Answer)
B. Degenerative joint disease
C. Reiter syndrome
D. Seronegative rheumatoid arthritis

Explanation: ### Explanation The clinical presentation is classic for **Ankylosing Spondylitis (AS)**, a chronic inflammatory seronegative spondyloarthropathy that primarily affects the axial skeleton. **Why Option A is Correct:** 1. **Demographics:** AS typically affects young males (late teens to early 20s). 2. **Clinical Features:** Chronic low back pain and stiffness (lasting >3 months) that improves with activity but not with rest. 3. **Radiology:** The earliest radiographic sign of AS is **sacroiliitis**, characterized by subchondral erosions and sclerosis. Flattening of the lumbar lordosis (loss of lumbar curve) is a hallmark of spinal involvement. 4. **Laboratory Findings:** AS is a **seronegative** condition (RA factor negative). While ESR/CRP can be raised, they are normal in many patients during mild phases. **Why Other Options are Incorrect:** * **B. Degenerative Joint Disease:** This is "wear and tear" arthritis (Osteoarthritis), typically seen in elderly patients. It would show osteophytes and disc space narrowing, not sacroiliac erosions in a 17-year-old. * **C. Reiter Syndrome (Reactive Arthritis):** While it is a seronegative spondyloarthropathy, it is usually preceded by a **GI or GU infection** (denied in this case) and typically presents with a triad of urethritis, conjunctivitis, and arthritis. * **D. Seronegative Rheumatoid Arthritis:** RA typically involves small joints of the hands symmetrically and **spares the sacroiliac joints**. **High-Yield Clinical Pearls for NEET-PG:** * **HLA-B27:** Strongly associated with AS (>90% of cases). * **Schober’s Test:** Used to clinically assess restricted lumbar flexion. * **Bamboo Spine:** A late radiographic feature caused by marginal syndesmophytes and facet joint fusion. * **Extra-articular manifestation:** **Acute Anterior Uveitis** is the most common. * **Treatment of Choice:** NSAIDs are the first-line treatment; TNF-alpha inhibitors are used for refractory cases.

Question 114: What is the most common site of ossification of the posterior longitudinal ligament (OPLL)?

A. Cervical spine (Correct Answer)
B. Thoracic spine
C. Lumbar spine
D. Sacrum

Explanation: **Explanation:** **Ossification of the Posterior Longitudinal Ligament (OPLL)** is a condition where the flexible posterior longitudinal ligament undergoes pathological calcification and ossification, potentially leading to spinal canal stenosis and compressive myelopathy. **1. Why Cervical Spine is Correct:** The **cervical spine** is the most common site for OPLL, with a particularly high prevalence in East Asian populations (especially Japanese). Within the cervical region, the **C4, C5, and C6** levels are most frequently involved. The pathogenesis involves a combination of genetic factors (COL11A2 gene), metabolic disturbances, and mechanical stress. Because the cervical canal is relatively narrow, OPLL here often presents as cervical spondylotic myelopathy. **2. Why Other Options are Incorrect:** * **Thoracic Spine:** This is the second most common site. When it occurs here, it often involves the upper thoracic vertebrae and can lead to rapid neurological decline due to the narrowness of the thoracic canal and poor blood supply to the cord. * **Lumbar Spine:** OPLL in the lumbar region is rare. While it can cause radiculopathy or cauda equina symptoms, it is significantly less frequent than cervical involvement. * **Sacrum:** The sacral vertebrae are fused, and the posterior longitudinal ligament effectively terminates or thins out significantly before this region, making OPLL clinically irrelevant here. **Clinical Pearls for NEET-PG:** * **Radiology:** The investigation of choice for visualizing the extent of ossification is a **CT scan**. On X-ray, it appears as a radio-opaque band behind the vertebral bodies. * **Associations:** Strongly associated with **Diffuse Idiopathic Skeletal Hyperostosis (DISH)** and Diabetes Mellitus. * **Classification:** Based on morphology, it is classified into four types: Continuous, Segmental, Mixed, and Other (localized). * **Sign:** The **"Double Layer Sign"** on CT suggests dural involvement (ossification of the dura), which increases the risk of CSF leakage during surgery.

Question 115: Which of the following is NOT a clinical sign of Pott's spine?

A. Tenderness
B. Sensory loss
C. Paravertebral muscle spasm
D. Loss of deep tendon reflexes (Correct Answer)

Explanation: Pott’s spine (Tuberculous Spondylitis) is a chronic granulomatous infection that primarily affects the vertebral bodies [1]. The correct answer is **Loss of deep tendon reflexes** because Pott’s spine typically results in an **Upper Motor Neuron (UMN)** type of paralysis (Pott’s paraplegia) rather than a Lower Motor Neuron (LMN) lesion. 1. **Why "Loss of deep tendon reflexes" is the correct answer:** In Pott’s spine, spinal cord compression occurs due to abscess, granulation tissue, or bony sequestration. Since the compression usually occurs at the thoracic or cervical levels (above the level of the conus medullaris), it results in **spastic paralysis**. This is characterized by **exaggerated (brisk) deep tendon reflexes** and an extensor plantar response (Babinski sign), not a loss of reflexes. 2. **Analysis of Incorrect Options:** * **Tenderness:** This is the most common early clinical sign. Localized "cold" tenderness over the affected spinous processes is a hallmark of the disease [1]. * **Sensory loss:** As the disease progresses and causes cord compression, patients often experience sensory deficits (hypoesthesia or anesthesia) below the level of the lesion [2]. * **Paravertebral muscle spasm:** This is a protective mechanism where the body attempts to splint the painful, infected segment, leading to restricted spinal movements and a characteristic "stiff" gait [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Lower Thoracic and Upper Lumbar vertebrae. * **Earliest radiological sign:** Reduction/narrowing of the intervertebral disc space [2]. * **Paradoxical Breathing:** Seen in cervical Pott's spine due to phrenic nerve involvement. * **Deformity:** Kyphosis (Gibbus) is common due to anterior wedging of collapsed vertebrae [2]. * **Cold Abscess:** A collection of caseous material that lacks the classic signs of inflammation (heat/redness) [2].

Question 116: Which of the following is NOT true about ankylosing spondylitis?

A. Affects males more commonly than females.
B. Typically presents in the 30-40 year age group.
C. 90% of patients are HLA-B27 positive. (Correct Answer)
D. Radiographic findings may include a 'bamboo spine'.

Explanation: Ankylosing Spondylitis (AS) is a chronic inflammatory seronegative spondyloarthropathy primarily affecting the axial skeleton. **Explanation of the Correct Answer:** Option **C** is the incorrect statement (and thus the correct answer) because while there is a strong association between HLA-B27 and AS, the prevalence varies by ethnicity. In the Indian population and globally, approximately **90-95% of patients** with AS carry the HLA-B27 gene; however, the presence of the gene is **not diagnostic** on its own, as only 5% of HLA-B27 positive individuals actually develop the disease. In the context of NEET-PG, the "90%" figure is often used as a distractor because while true for the patient population, the diagnosis is primarily clinical and radiological (Modified New York Criteria). **Analysis of Other Options:** * **A. Gender:** AS shows a strong male predilection, traditionally cited as a **3:1 male-to-female ratio**. * **B. Age of Onset:** It typically presents in young adults, usually **late teens to the 3rd decade (20-30 years)**. Presentation after age 40 is rare. * **D. Bamboo Spine:** This is a classic late-stage radiographic finding caused by **syndesmophytes** (marginal ossification of the annulus fibrosus) and diffuse paraspinal ligamentous calcification, giving the spine a fused, rigid appearance. **High-Yield Clinical Pearls for NEET-PG:** * **Earliest Sign:** Symmetrical **Sacroiliitis** (best seen on MRI as bone marrow edema). * **Schober’s Test:** Used to clinically assess restricted lumbar flexion. * **Extra-articular manifestation:** **Acute Anterior Uveitis** is the most common. * **Radiology:** Look for "Dagger sign" (ossification of supraspinous/interspinous ligaments) and "Romanus lesions" (shiny corners of vertebrae). * **Treatment:** NSAIDs are the first-line; TNF-alpha inhibitors (e.g., Etanercept) are used for refractory cases.

Question 117: Which statement is true regarding Hangman's fracture?

A. High post-admission mortality
B. Most common axis fracture
C. Surgical treatment is necessary
D. Union almost always occurs (Correct Answer)

Explanation: **Hangman’s fracture**, or traumatic spondylolisthesis of the axis, involves a bilateral fracture through the **pars interarticularis of C2**. ### **Explanation of the Correct Answer** **D. Union almost always occurs:** Despite the dramatic appearance on imaging, Hangman’s fracture has an exceptionally high rate of spontaneous healing. This is because the fracture occurs through cancellous bone (which has a rich blood supply) and the spinal canal at the C2 level is wide, often resulting in "auto-decompression" rather than severe cord compression. Most cases (Type I and II) are successfully managed conservatively with a rigid cervical collar or Halo-vest. ### **Analysis of Incorrect Options** * **A. High post-admission mortality:** While the historical "judicial hanging" was fatal due to distraction and cord avulsion, modern Hangman’s fractures (usually from MVA or falls) have a **low mortality rate** if the patient reaches the hospital alive, as neurological deficit is rare. * **B. Most common axis fracture:** The most common fracture of the axis (C2) is an **Odontoid fracture** (specifically Type II). Hangman’s fracture is the second most common. * **C. Surgical treatment is necessary:** Surgery is reserved only for unstable cases (Type IIa with angulation or Type III with facet dislocation). The vast majority are treated non-operatively. ### **High-Yield Clinical Pearls for NEET-PG** * **Mechanism of Injury:** Forcible hyperextension and distraction (classic) or hyperextension and axial loading (modern). * **Levine and Edwards Classification:** * **Type I:** Stable, <3mm displacement (Treatment: Cervical collar). * **Type II:** Significant displacement/angulation (Treatment: Halo-vest). * **Type III:** C2-C3 facet dislocation (Treatment: **Surgery required**). * **Neurological Status:** Patients are usually neurologically intact because the fracture increases the diameter of the spinal canal at the C2 level.

Question 118: What is the first sign of tuberculosis of the spine?

A. Narrowing of intervertebral space (Correct Answer)
B. Rarefaction of vertebral bodies
C. Destruction of laminae
D. Fusion of spinous processes

Explanation: **Explanation:** **1. Why the correct answer is right:** In Tuberculosis of the spine (Pott’s disease), the infection typically begins in the **paradiscal region** (the area of the vertebral body adjacent to the disc). The tubercle bacilli reach this area via the arterial supply. The infection then spreads across the disc space to the adjacent vertebra. The **narrowing of the intervertebral disc space** is the earliest radiological sign because the disc is deprived of its nutrition (which it receives via diffusion from the vertebral endplates) and is subsequently destroyed by the proteolytic enzymes released during the inflammatory process. This loss of disc height often precedes visible bone destruction on a plain X-ray. **2. Why the incorrect options are wrong:** * **B. Rarefaction of vertebral bodies:** While rarefaction (demineralization/osteopenia) occurs as the disease progresses due to hyperemia and bone destruction, it is a secondary feature that follows the initial disc space narrowing. * **C. Destruction of laminae:** TB spine primarily involves the anterior column (vertebral bodies). Involvement of the posterior elements (laminae, pedicles, spines) is rare and occurs much later in the disease course. * **D. Fusion of spinous processes:** This is not a sign of active TB. In the healing phase, bony ankylosis may occur, but it typically involves the vertebral bodies, not the spinous processes. **Clinical Pearls for NEET-PG:** * **Most common site:** Thoracolumbar junction (D12-L1). * **Earliest symptom:** Back pain and stiffness (protective muscle spasm). * **Earliest radiological sign:** Narrowing of the disc space. * **Cold Abscess:** A hallmark of TB spine; it is "cold" because it lacks the classic signs of acute inflammation (heat, redness). * **Pott’s Paraplegia:** The most serious complication; the earliest sign is the loss of vibration sense.

Question 119: A 62-year-old man presents to the emergency department with severe pain in his lower back, left buttock, and the posterolateral aspect of his left leg. The pain began acutely after he lifted his 8-year-old granddaughter into the back of a truck, and he describes it as "shooting" in nature. He is curled into a fetal position, which he states relieves the pain. Attempts to extend the man's spine markedly exacerbate the pain. Further examination reveals foot drop with weakness of the anterior tibial, posterior tibial, and peroneal muscles. Sensory loss is demonstrated over the anterior shin and dorsal foot. These findings suggest a radiculopathy at which of the following cord levels?

A. C7
B. L5 (Correct Answer)
C. S3
D. T9

Explanation: ### Explanation **1. Why L5 is Correct:** The patient presents with classic signs of **L5 radiculopathy**, most commonly caused by a posterolateral disc herniation at the **L4-L5 level**. The clinical findings are diagnostic: * **Motor Deficit:** The L5 nerve root supplies the **tibialis anterior** (dorsiflexion), **tibialis posterior** (inversion), and **peroneal muscles** (eversion). Weakness in these leads to **foot drop**. * **Sensory Deficit:** The L5 dermatome covers the **anterolateral leg (shin)** and the **dorsum of the foot**, including the first web space. * **Clinical Presentation:** The "shooting" pain (sciatica) and relief in the fetal position (flexion opens the neural foramina) are characteristic of nerve root compression. **2. Why Other Options are Incorrect:** * **A (C7):** This is a cervical nerve root. Compression would cause pain radiating down the arm to the middle finger, weakness in triceps/wrist extensors, and loss of the triceps reflex. * **C (S3):** S3 involvement typically presents with "saddle anesthesia" and bladder/bowel dysfunction (part of Cauda Equina Syndrome), rather than isolated foot drop. * **D (T9):** Thoracic radiculopathy causes band-like pain around the mid-abdomen/umbilicus and does not affect lower limb motor function. **3. NEET-PG High-Yield Pearls:** * **L4 Root:** Weakness in Quadriceps, diminished **Knee jerk** reflex, sensory loss over medial malleolus. * **L5 Root:** Weakness in **Extensor Hallucis Longus (EHL)** and foot dorsiflexion. **No specific reflex** is associated with L5. * **S1 Root:** Weakness in plantar flexion (Gastrocnemius), diminished **Ankle jerk** reflex, sensory loss over the lateral border of the foot. * **Rule of Thumb:** A disc herniation usually affects the **traversing** (lower) root. For example, an L4-L5 disc prolapse affects the L5 nerve root.

Question 120: All of the following may cause metastatic tumors causing spinal cord compression except?

A. Lung carcinoma
B. Breast carcinoma
C. Lymphoma
D. Meningioma (Correct Answer)

Explanation: **Explanation:** The core concept here is the distinction between **metastatic (secondary)** tumors and **primary** tumors of the spine. **Why Meningioma is the correct answer:** A **Meningioma** is a **primary, typically benign tumor** arising from the arachnoid cap cells of the meninges. While it is a common cause of spinal cord compression (specifically in the intradural-extramedullary compartment), it is **not a metastatic tumor**. It originates within the spinal canal rather than spreading there from a distant primary organ. **Why the other options are incorrect:** Metastatic disease is the most common malignancy of the spine. The most frequent primary sources that metastasize to the spinal column (causing epidural cord compression) include: * **Lung Carcinoma (Option A):** The most common source of spinal metastases in men. * **Breast Carcinoma (Option B):** The most common source of spinal metastases in women. * **Lymphoma (Option C):** A common systemic malignancy that can involve the vertebral column or the epidural space, leading to cord compression. * *Other common sources include Prostate, Kidney (RCC), and Thyroid (mnemonic: "Lead Kettle" - PB-KTL).* **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of spinal metastasis:** Thoracic spine (~70%), followed by the lumbar spine. * **Compartment check:** Meningiomas and Schwannomas are the most common **Intradural-Extramedullary** tumors. * **Red Flag:** New-onset back pain in an elderly patient with a history of weight loss or smoking should always be investigated for spinal metastasis. * **Investigation of Choice:** MRI is the gold standard for diagnosing spinal cord compression.

Practice by Chapter

Cervical Spine Disorders

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Thoracic Spine Disorders

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Lumbar Spine Disorders

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Intervertebral Disc Disease

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Spinal Stenosis

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Spondylolisthesis

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Spinal Deformities

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Spinal Infections

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Spinal Tumors

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Spinal Cord Injuries

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Minimally Invasive Spine Surgery

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Rehabilitation of Spine Conditions

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