Spine Disorders Practice Questions

Q: A 40-year-old construction worker presents with pain in the arm on lifting weights. The following test and X-ray of neck was performed. Which is correct about this patient?

Elevated arm stress test: Cervical rib. ***Elevated arm stress test: Cervical rib*** - The image shows a patient performing the **Elevated Arm Stress Test (EAST)**, or Roos Test, which places tension on the neurovascular structures in the thoracic outlet. The X-ray image reveals the presence of a **cervical rib** (indicated by the arrow), a common cause of **thoracic outlet syndrome (TOS)**. - The patient's symptom of **pain in the arm on lifting weights** is consistent with **neurovascular compression** due to a cervical rib, which is often exacerbated by arm elevation. *Adson test: Cervical rib* - The **Adson test** involves palpating the radial pulse while the patient extends, externally rotates the arm, and turns their head toward the ipsilateral arm and inhales. This maneuver compresses the **subclavian artery** by the anterior and middle scalene muscles, not the position shown. - While a cervical rib can cause a positive Adson test, the maneuver depicted in the image is not the Adson test. *Falconer test: Spinal canal stenosis* - The **Falconer test** is not a standard or widely recognized orthopedic special test. - **Spinal canal stenosis** typically presents with different symptoms, such as **neurogenic claudication** or myelopathy, and is assessed with specific neurological examination techniques and imaging (MRI), not the maneuver shown. *Allen test: Fracture of first rib* - The **Allen test** is used to assess **patency of the radial and ulnar arteries** in the hand, and involves compressing both arteries and observing capillary refill. It is not performed as shown in the picture. - A **fracture of the first rib** might cause pain, but the Allen test is not used to diagnose a rib fracture.

Q: Consider the following clinical features : 1. Low back pain 2. Saddle anaesthesia 3. Motor weakness in the lower extremities 4. Variable rectal and urinary symptoms Which of the above features may be present in a patient with Cauda Equina syndrome ?

1, 2, 3 and 4. ***1, 2, 3 and 4*** - **Cauda equina syndrome** is a serious neurological condition involving compression of the cauda equina nerve roots, typically manifesting with **low back pain**, **saddle anesthesia**, and **motor weakness** in the lower extremities [1]. - The compression of the nerve roots can also lead to varying degrees of **rectal and urinary dysfunction**, including incontinence or retention, depending on which nerve roots are affected [2]. *1, 2 and 3 only* - While **low back pain**, **saddle anesthesia**, and **motor weakness** are prominent features of cauda equina syndrome, this option incorrectly excludes the crucial symptom of **rectal and urinary dysfunction**. - **Bladder and bowel dysfunction**, along with sexual dysfunction, are hallmark symptoms resulting from the involvement of sacral nerve roots in cauda equina compression [2]. *1 and 2 only* - This option correctly identifies **low back pain** and **saddle anesthesia** as features but omits two critical components of cauda equina syndrome: **motor weakness** and **rectal/urinary symptoms** [1]. - Without considering **motor weakness** and **sphincter dysfunction**, the diagnostic picture of cauda equina syndrome is incomplete, potentially delaying necessary surgical intervention [3]. *3 and 4 only* - This option incorrectly suggests that **motor weakness** and **rectal/urinary symptoms** are the only relevant features, excluding the highly characteristic **low back pain** and **saddle anesthesia**. - **Low back pain** is almost universally present and **saddle anesthesia** is a key indicator of sacral nerve root involvement, crucial for distinguishing cauda equina syndrome from other neurological conditions [1].

Q: Hangman's fracture is

traumatic spondylolisthesis of axis vertebra (C2). ***traumatic spondylolisthesis of axis vertebra (C2)*** - A Hangman's fracture is a specific type of **traumatic spondylolisthesis** involving the **C2 (axis) vertebra**. - It results from bilateral fractures of the **pars interarticularis** of C2, often due to hyperextension and distractive forces. *traumatic spondylolisthesis of atlas vertebra (C1)* - A fracture of the atlas (C1) is typically called a **Jefferson fracture**, not a Hangman's fracture. - A Jefferson fracture usually involves ruptures of facets or arches, often caused by **axial loading**. *traumatic spondylolisthesis of lumbar vertebra (L1)* - **Spondylolisthesis** can occur in the lumbar spine, but it most commonly affects L5-S1 or L4-L5, and is usually a **fatigue fracture** not a traumatic spondylolisthesis. - Fractures in the lumbar region have different causes and clinical implications than cervical fractures, and are not termed a Hangman's fracture. *traumatic spondylolisthesis of thoracic vertebra (T1)* - While traumatic spine fractures can occur in the **thoracic spine**, spondylolisthesis is much less common due to the rib cage's stabilizing effect. - Fractures in this region are distinctly different from the characteristic C2 pars interarticularis fracture of a Hangman's fracture.

Q: Identify the condition shown in the image:

Spondylolysis. ***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.

Q: A 35-year-old male presents to the emergency department following a high-speed motor vehicle accident. He complains of severe lower back pain but denies any loss of consciousness or abdominal pain. A lateral X-ray of the lumbar spine is obtained, as shown in the image. The image reveals a horizontal fracture through the vertebral body, extending through the posterior elements. Based on the clinical presentation and imaging findings, what is the most likely diagnosis?

Chance fracture. ***Chance fracture*** - A **chance fracture** is characterized by a **horizontal fracture** through the entire vertebral body and posterior elements, including the neural arch, typically caused by a **flexion-distraction mechanism** in accidents like those involving seatbelts (lap belt only), consistent with the high-speed motor vehicle accident scenario. - The image distinctly shows a fracture line traversing the vertebral body and extending into the posterior elements, which is the hallmark of this type of injury. *Burst fracture* - A **burst fracture** involves a comminuted fracture of the vertebral body with **retropulsion of bone fragments** into the spinal canal due to axial loading, which is not clearly depicted here. - While it can result from high-impact trauma, the characteristic horizontal disruption of both anterior and posterior segments points away from a solely compressive mechanism. *Compression fracture* - A **compression fracture** primarily involves the **anterior wedging** or collapse of the vertebral body, resulting from only axial compression forces without significant involvement of the posterior elements. - The presented image shows a fracture extending through the posterior elements, which is not typical for a simple compression fracture. *Spondylolisthesis* - **Spondylolisthesis** is the **anterior slippage of one vertebral body over another**, often due to pars interarticularis defects (spondylolysis) or degenerative changes. - This condition involves vertebral displacement, not a fresh fracture line across the body and posterior elements as seen in the image.

Q: The most common pattern of involvement in Pott's spine is

Paradiscal. ***Paradiscal*** - In **Pott's spine (tuberculous spondylitis)**, the infection typically starts in the anterior inferior aspect of the vertebral body and spreads to the adjacent disc space, making the **paradiscal** area the most common site of involvement. - This pattern is due to the rich **paradiscal vascular supply**, which facilitates the hematogenous spread of *Mycobacterium tuberculosis* to these regions. *Central* - **Central involvement** refers to the lesion being primarily located within the center of the vertebral body, which is less common in Pott's spine as the bacteria typically target the highly vascularized anterior and inferior margins. - While central lesions can occur, they are not the predominant pattern seen in initial stages of tuberculous spondylitis. *Posterior* - **Posterior involvement** usually refers to involvement of the posterior vertebral elements such as the neural arch, laminae, or spinous processes. - This type of involvement is **rare** in Pott's spine and is generally seen in very advanced or disseminated disease. *Anterior* - While the infection often begins in the anterior part of the vertebral body, the term **anterior** alone is less specific than "paradiscal" and doesn't fully capture the predominant involvement of the adjacent disc space. - The disease's characteristic spread across the disc space to an adjacent vertebra is a key feature of the paradiscal pattern, leading to **kyphosis** and vertebral collapse.

Q: Most common type of lesion in Pott's spine:

Paradiscal. ***Paradiscal*** - **Paradiscal lesions** are the most characteristic and common type of lesion in Pott's spine (approximately 50% of cases), preferentially affecting the anterior vertebral body adjacent to the intervertebral disc [1]. - This location is rich in **vascularity**, allowing Mycobacterium tuberculosis to spread more easily and cause significant destruction of the vertebral bodies and discs [1]. - Typically results in **angular kyphosis (gibbus deformity)** due to anterior vertebral collapse. *Posterior* - **Posterior lesions** affect the posterior elements of the vertebrae including the pedicles, laminae, and spinous processes. - This is the **rarest type** of tuberculous spinal involvement. - May present with neurological deficits due to posterior encroachment on the spinal canal. *Central* - A **central lesion** in Pott's spine involves primarily the vertebral body itself, without specific early involvement of the disc space or adjacent vertebrae. - This type is less common than paradiscal lesions and typically leads to **vertebra plana** (flat vertebra) or uniform **compression fracture** rather than angular kyphosis. *Anterior* - **Anterior lesions** affect the front part of the vertebral body and can lead to a wedge-shaped collapse. - While the anterior column is frequently involved, the term "anterior" is less specific than "paradiscal" in describing the most common initial location that characteristically spreads to the intervertebral disc space. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1197-1198.

Q: A lady had a trauma to the neck. X-ray is attached. What is the diagnosis?

Hangman's fracture. ***Hangman's fracture*** - A **Hangman's fracture** is a fracture of the **pars interarticularis of the C2 vertebra (axis)**, typically resulting from hyperextension and distractive forces, often seen in car accidents or judicial hangings. - The X-ray would show **bilateral pedicle fractures of C2**, with or without anterior displacement of C2 on C3. *Sciwora* - **SCIWORA** stands for **Spinal Cord Injury Without Radiographic Abnormality**, and it is primarily diagnosed when clinical signs of spinal cord injury are present but X-rays and CT scans show no bony abnormalities. - This patient's X-ray would show visible bony injury, ruling out SCIWORA. *Jefferson's fracture* - A **Jefferson's fracture** is a **burst fracture of the C1 vertebra (atlas)**, typically caused by axial loading with a compressive force, and involves fractures of the anterior and/or posterior arches of C1. - While it's also a cervical spine fracture, it specifically involves C1, not C2 as seen in a Hangman's fracture. *Clay shoveler fracture* - A **Clay shoveler's fracture** is an avulsion fracture of a **spinous process** in the lower cervical or upper thoracic spine, most commonly C6, C7, or T1. - It typically results from abrupt neck flexion and muscle pulling, and is a stable fracture that does not affect the C2 pars interarticularis.

Q: Condition in which there is anterior or posterior displacement of a vertebra in relation to the vertebrae below:

Spondylolisthesis. ***Spondylolisthesis*** - This term specifically refers to the **slippage** (anterior or posterior displacement) of one vertebra relative to an adjacent one. - It often results from conditions like **spondylolysis** (a defect in the pars interarticularis) or degenerative changes. *Spondylitis* - This condition involves **inflammation of the vertebrae**, often seen in diseases like ankylosing spondylitis. - While it can cause pain and stiffness, it does not primarily describe the displacement of one vertebra over another. *Spondylolysis* - This refers to a **defect or stress fracture in the pars interarticularis** of a vertebra. - It is a common *cause* of spondylolisthesis, but not the slippage itself. *Spondylosis* - This is a general term for **degenerative changes** in the spine, including osteoarthritis of the spinal joints and disc degeneration. - It describes age-related wear and tear, not the direct displacement of a vertebra.

Question 1

A 40-year-old construction worker presents with pain in the arm on lifting weights. The following test and X-ray of neck was performed. Which is correct about this patient?

Accepted Answer

Elevated arm stress test: Cervical rib

Answer

Adson test: Cervical rib

Answer

Falconer test: Spinal canal stenosis

Answer

Allen test: Fracture of first rib

Question 2

Consider the following clinical features :

1. Low back pain
2. Saddle anaesthesia
3. Motor weakness in the lower extremities
4. Variable rectal and urinary symptoms Which of the above features may be present in a patient with Cauda Equina syndrome ?

Accepted Answer

1, 2, 3 and 4

Answer

1, 2 and 3 only

Answer

1 and 2 only

Answer

3 and 4 only

Question 3

Hangman's fracture is

Accepted Answer

traumatic spondylolisthesis of axis vertebra (C2)

Answer

traumatic spondylolisthesis of atlas vertebra (C1)

Answer

traumatic spondylolisthesis of lumbar vertebra (L1)

Answer

traumatic spondylolisthesis of thoracic vertebra (T1)

Question 4

Identify the condition shown in the image:

Accepted Answer

Spondylolysis

Answer

Renal osteodystrophy

Answer

Spondylolisthesis

Answer

Tuberculosis (TB)

Question 5

A 35-year-old male presents to the emergency department following a high-speed motor vehicle accident. He complains of severe lower back pain but denies any loss of consciousness or abdominal pain. A lateral X-ray of the lumbar spine is obtained, as shown in the image. The image reveals a horizontal fracture through the vertebral body, extending through the posterior elements. Based on the clinical presentation and imaging findings, what is the most likely diagnosis?

Accepted Answer

Chance fracture

Answer

Burst fracture

Answer

Compression fracture

Answer

Spondylolisthesis

Question 6

The most common pattern of involvement in Pott's spine is

Accepted Answer

Paradiscal

Answer

Central

Answer

Posterior

Answer

Question 7

Most common type of lesion in Pott's spine:

Accepted Answer

Paradiscal

Answer

Posterior

Answer

Central

Answer

Question 8

A lady had a trauma to the neck. X-ray is attached. What is the diagnosis?

Accepted Answer

Hangman's fracture

Answer

Sciwora

Answer

Jefferson's fracture

Answer

Clay shoveler fracture

Question 9

Condition in which there is anterior or posterior displacement of a vertebra in relation to the vertebrae below:

Accepted Answer

Spondylolisthesis

Answer

Spondylitis

Answer

Spondylolysis

Answer

Spondylosis

Question 10

A 47-year-old man awakens with low back pain after a weekend of gardening. He recalls no specific incident of trauma and has never had back pain before. There is no radiation of the pain and no disturbance of normal bowel or bladder function. The ROM of the low back is painful and restricted in all planes, and there is paraspinal tenderness from L2 to L5 on the right. Scoliosis and kyphosis are absent. Findings on straight-leg-raising test are negative, reflexes are active and equal, and the patient can walk on his heels and toes. Findings on x-rays of the lumbar spine are normal. Which is the best treatment?

Accepted Answer

Bed rest for 48 hours, anti-inflammatory agents, heat to the low back, and nonnarcotic analgesics

Answer

Immediate magnetic resonance image (MRI) for the lumbar spine

Answer

Bed rest for 7-10 days, heat to the lower back, anti-inflammatory agents, muscle relaxants, and analgesics

Answer

Hospitalization for pelvic traction, physical therapy, anti-inflammatory agents, intramuscularly analgesics, and muscle relaxants

Spine Disorders — MCQs

Spine Disorders — MCQs

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