Spine Disorders Practice Questions

Q: An unconscious patient is brought to the Emergency Department with suspected cervical cord injury. Which of the following clinical signs is not suggestive of cervical spinal cord injury?

Increased Rectal sphincter Tone. ***Increased Rectal sphincter Tone*** - **Increased rectal sphincter tone** suggests **intact lower motor neuron function** and is not a clinical sign of cervical spinal cord injury. [2] - In a spinal cord injury, especially in the acute phase of **spinal shock**, there is typically **decreased or absent rectal tone** due to flaccid paralysis below the level of injury. [4] *Flaccidity* - **Flaccidity**, or hypotonia, is a common finding in the acute phase of **spinal shock** following a cervical spinal cord injury. [1] - It results from the temporary loss of spinal reflex activity below the level of injury, leading to **muscle weakness** and reduced tone. [4] *Priapism* - **Priapism** (persistent erection) is an important indicator of **cervical or high thoracic spinal cord injury**. - It occurs due to **disruption of autonomic pathways** that regulate penile detumescence, leading to unopposed parasympathetic activity. *Diaphragmatic Breathing* - **Diaphragmatic breathing** (belly breathing) can be a sign of **high cervical spinal cord injury** [3] because the intercostal muscles, responsible for chest wall expansion, are paralyzed. - The **phrenic nerve**, which innervates the diaphragm, originates from C3-C5, so if the injury is below C5, diaphragmatic breathing may be maintained even if other respiratory muscles are lost.

Q: A 38-year-old woman presents with a history of backache. X-ray and MRI of the spine reveal collapse of the D12 vertebra with normal intervertebral disc space. The LEAST likely diagnosis is:

Osteoporosis. ***Osteoporosis*** - While osteoporosis can cause **vertebral collapse**, it typically results in a **wedging deformity** or uniform compression, usually without significantly affecting the intervertebral disc space [1]. - The patient's age (38 years old), while not precluding osteoporosis, makes it less likely to be the primary cause of a severe D12 collapse with normal disc space compared to other destructive processes. *Tuberculosis* - **Tuberculous spondylitis (Pott's disease)** commonly affects the vertebral body, often leading to its collapse (gibbus deformity) and subsequent **destruction of the intervertebral disc space** in later stages due to infection spread [2]. - The initial presentation with vertebral collapse and normal disc space followed by disc involvement is characteristic of tuberculous infection, making it a likely consideration. *Metastasis* - **Vertebral metastases** frequently cause osteolytic lesions that weaken the vertebral body, leading to collapse while often **sparing the intervertebral discs** initially due to their avascular nature [3]. - This presentation directly matches the description of D12 collapse with a normal disc space. *Multiple myeloma* - **Multiple myeloma** is a plasma cell malignancy that commonly causes **osteolytic lesions** in the spine, resulting in vertebral body collapse without significant involvement of the intervertebral discs. - This is a highly characteristic presentation for multiple myeloma, making it a strong differential for the given clinical and radiological findings.

Q: False among the following

Clay Shoveler's fracture involves C6 vertebrae. ***Clay Shoveler's fracture involves C6 vertebrae*** - A **Clay Shoveler's fracture** typically involves the **spinous processes of C6, C7 or T1**, meaning C6 is often involved. - This fracture is usually stable and results from forced neck flexion or direct trauma, often affecting lower cervical or upper thoracic vertebrae. *Teardrop fracture involves C5-C6 vertebrae* - **Teardrop fractures** are severe and unstable fractures of the cervical spine, often occurring at **C2 or C5-C7 (not exclusively C5-C6)**. - They are named for the characteristic triangular fragment of bone detached from the anterior aspect of the vertebral body and can be either flexion or extension type, with flexion teardrop fractures being particularly unstable due to posterior ligamentous disruption. *Hangman fracture involves Axis* - A **Hangman's fracture** is a fracture of the **C2 (Axis) pedicles**, typically due to hyperextension and distraction. - While it involves C2, the statement implies it solely involves the "Axis" which is broad, but specifically it's the pedicles of C2. *Jefferson's fracture involves Atlas* - A **Jefferson's fracture** is a burst fracture of the **C1 (Atlas) ring**, typically caused by an axial load on the head. - This fracture involves the Atlas, as stated, and is often unstable due to disruption of the transverse atlantal ligament in severe cases.

Q: Regarding Hangman's fracture, which of the following statements are correct? 1) Fracture of either pedicles or lamina of C2 cervical vertebra 2) Bilateral in nature

Both are true. ***Both are true*** - A **Hangman's fracture** is specifically a fracture through the **pedicles** (or pars interarticularis) of the **C2 vertebra**, which can also involve the lamina. - This fracture is inherently **bilateral** across both pedicles, classifying it as a spondylolisthesis of C2 on C3. *Both are false* - This option is incorrect because both presented statements are accurate descriptions of a Hangman's fracture. - The definition and typical presentation of this fracture align with both points. *1 is true, 2 is false* - This is incorrect because the fracture of the C2 pedicles/lamina is indeed the hallmark (statement 1), but the bilateral nature across the pedicles is also a defining characteristic, making statement 2 true as well. - A Hangman's fracture is a **traumatic spondylolisthesis** of C2 on C3 due to bilateral pedicle fractures. *2 is true, 1 is false* - This is incorrect because statement 1 accurately defines the location of the fracture at the **C2 pedicles/lamina**. - While it is **bilateral**, the primary anatomical location in C2 is foundational to the diagnosis.

Q: Most common site of disc prolapse in lumbar spine is

L5-S1. ***L5-S1*** - The **L5-S1 intervertebral disc** is the most common site for disc prolapse in the lumbar spine. - This is due to the significant **biomechanical stresses** at the lumbosacral junction, including axial loading and rotational forces, which make it susceptible to herniation. *L4-5* - While **L4-5** is a common site for disc prolapse, it is less frequent than L5-S1. - Disc herniation at L4-5 typically affects the **L5 nerve root**. *L3-4* - Disc prolapse at **L3-4** is relatively uncommon compared to the lower lumbar segments. - A herniation at this level would typically impinge on the **L4 nerve root**. *L2-3* - **L2-3** disc prolapse is a rare occurrence in the lumbar spine. - Symptoms would involve the **L3 nerve root**, affecting motor function of the quadriceps and sensation in the medial thigh.

Q: What is an absolute indication for surgery in disc prolapse?

Cauda equina syndrome. ***Cauda equina syndrome*** - **Cauda equina syndrome** is a neurological emergency characterized by compression of the cauda equina nerves, leading to symptoms like **saddle anesthesia**, bowel/bladder dysfunction, and severe neurological deficits, necessitating immediate surgical decompression. - Delay in surgery for **cauda equina syndrome** can result in permanent neurological damage, making it an *absolute indication* for surgical intervention within **48 hours**. *Recurrent episodes of sciatica* - While recurrent **sciatica** can be debilitating and may eventually warrant surgery, it is typically managed conservatively initially and is not considered an *absolute emergency* for surgery. - Surgical intervention in recurrent **sciatica** is usually considered when conservative treatments fail over 6-12 weeks, but it is a *relative indication*, not an immediate requirement. *Progressive motor weakness despite conservative management* - **Progressive motor weakness** is a serious concern and represents a *relative indication* for surgery, especially if documented over serial examinations. - Unlike **cauda equina syndrome**, which requires immediate surgery, progressive weakness allows for a brief period of conservative management and surgical planning, though surgery should not be unduly delayed if weakness continues to progress. *Pain not relieved by complete rest* - **Pain not relieved by rest** is a common symptom of disc prolapse and can be an indication for surgery after failed conservative management, but it is not an *absolute emergency* like **cauda equina syndrome**. - This type of pain often indicates discogenic pain or nerve root compression but can often be managed with medications, physical therapy, or injections before surgical consideration.

Q: All of the following are true about fracture of the atlas vertebra, except -

Quadriplegia is seen in 80% cases. ***Quadriplegia is seen in 80% cases*** - This statement is incorrect; **neurological deficits** such as quadriplegia are **uncommon** in atlas fractures (Jefferson fractures) because the fracture fragments tend to spread outwards, decompressing the spinal cord. - While significant trauma can lead to neurological injury, the classic Jefferson fracture mechanism often spares the spinal cord from direct compression. *Atlantooccipital fusion may sometimes be needed* - **Atlanto-occipital fusion** (craniovertebral fusion) is a surgical option reserved for **unstable atlas fractures** or those associated with significant ligamentous injury. - It aims to provide **stability** to the craniocervical junction, preventing further neurological damage, especially if non-operative measures fail. *Jefferson fracture is the most common type* - The **Jefferson fracture** is indeed the **most common type of atlas fracture**, characterized by a burst fracture of the C1 ring. - It typically results from an **axial load** to the head, such as a diving accident, leading to fractures of both anterior and posterior arches. *CT scans should be done for diagnosis* - **CT scans** are the **gold standard** for diagnosing atlas fractures due to their superior ability to visualize bone and detect subtle fractures of the C1 ring. - They provide detailed three-dimensional images that are crucial for assessing the **fracture pattern**, displacement, and involvement of adjacent structures.

Q: Teardrop fracture of lower cervical spine implies -

Flexion compression failure of body. ***Flexion compression failure of body*** - A **teardrop fracture** of the lower cervical spine is typically caused by a **flexion-compression mechanism**, leading to a fracture of the anteroinferior vertebral body. - This results in a small, triangular fragment (the "teardrop") separated from the main vertebral body, often associated with **cervical instability** and potential neurological deficits. *Wedge compression fracture* - A **wedge compression fracture** primarily involves anterior vertebral body collapse due to **axial loading** and flexion, but without the distinct separation of an anteroinferior fragment characteristic of a teardrop. - While it involves compression, it lacks the specific force vector and resulting fragment morphology seen in a teardrop fracture. *Axial compression fractures* - **Axial compression fractures** (e.g., burst fractures) typically result from a force directly along the spinal axis, causing the vertebral body to **explode outwards** and potentially into the spinal canal. - These fractures show widening of the interpedicular distance and posterior element involvement, which are not primary features of a simple teardrop fracture. *Flexion-rotation injury with failure of anterior body* - A **flexion-rotation injury** often leads to more complex patterns, such as **facet dislocation** or unilateral/bilateral interfacetal dislocation. - While it can involve anterior vertebral body failure, the primary mechanism of a classical teardrop fracture is **pure flexion-compression**, not significant rotation.

Q: Unstable spine injury occurs in

Flexion-rotation injury. ***Flexion-rotation injury*** - This type of injury is particularly unstable because it involves forces that disrupt both the **anterior and posterior columns** of the spine, leading to significant ligamentous and bony damage. - The combined flexion and rotation can shear or fracture vertebral bodies and dislocate facets, compromising the **spinal canal** and leading to neurological deficits. *Flexion injury* - Pure flexion injuries, such as **wedge fractures**, primarily affect the anterior column and are often stable, especially if the posterior elements remain intact. - While powerful flexion can cause significant damage, the rotational component is key to the inherent **instability** associated with spinal column disruption. *Compression injury* - Compression injuries typically result in **burst fractures** or wedge fractures, which are often considered stable if the posterior ligamentous complex is intact and there is no significant vertebral body retropulsion into the spinal canal. - The primary force is axial, which can cause comminution but does not necessarily disrupt the **three-column integrity** in a way that directly leads to gross instability as comprehensively as a flexion-rotation injury. *Extensor injury* - Extension injuries, often occurring in whiplash or hyperextension, can cause fractures of the posterior elements (e.g., **spinous processes**, laminae) or disc herniation. - While potentially damaging, especially to the spinal cord, they do not typically create the same degree of structural **instability** across all three spinal columns as a flexion-rotation injury.

Q: Which of the following is a poor prognostic factor in Pott's paraplegia?

Long-standing paraplegia. ***Long-standing paraplegia*** - **Long-standing paraplegia** indicates prolonged spinal cord compression, leading to irreversible neurological damage due to fibrosis, myelomalacia, and permanent structural changes. - This is associated with poor recovery outcomes even after surgical decompression. - **Sudden/rapid progression** is also a poor prognostic factor, but long-standing duration has consistently worse outcomes in literature. *Motor paralysis alone* - **Motor paralysis without sensory or sphincter involvement** suggests incomplete cord compression affecting primarily the motor tracts. - This is considered a **good prognostic factor** as it indicates less severe and more localized cord damage. - Recovery potential is significantly higher when sensory and autonomic functions are preserved. *Paraplegia in children* - Children have **better neurological recovery potential** compared to adults due to higher neuroplasticity and better capacity for neural regeneration. - Early intervention in pediatric Pott's paraplegia often results in **favorable outcomes**. - This is considered a **good prognostic factor**. *Gradual onset of paraplegia* - **Gradual onset** allows time for medical intervention before irreversible cord damage occurs. - It also allows for compensatory mechanisms and collateral circulation to develop. - This is a **good prognostic factor** compared to acute/sudden onset which indicates rapid cord compression.

Question 1

An unconscious patient is brought to the Emergency Department with suspected cervical cord injury. Which of the following clinical signs is not suggestive of cervical spinal cord injury?

Accepted Answer

Increased Rectal sphincter Tone

Answer

Flaccidity

Answer

Priapism

Answer

Diaphragmatic Breathing

Question 2

A 38-year-old woman presents with a history of backache. X-ray and MRI of the spine reveal collapse of the D12 vertebra with normal intervertebral disc space. The LEAST likely diagnosis is:

Accepted Answer

Osteoporosis

Answer

Tuberculosis

Answer

Metastasis

Answer

Multiple myeloma

Question 3

False among the following

Accepted Answer

Clay Shoveler's fracture involves C6 vertebrae

Answer

Teardrop fracture involves C5-C6 vertebrae

Answer

Hangman fracture involves Axis

Answer

Jefferson's fracture involves Atlas

Question 4

Regarding Hangman's fracture, which of the following statements are correct? 1) Fracture of either pedicles or lamina of C2 cervical vertebra 2) Bilateral in nature

Accepted Answer

Both are true

Answer

Both are false

Answer

2 is true, 1 is false

Answer

1 is true, 2 is false

Question 5

Most common site of disc prolapse in lumbar spine is

Accepted Answer

L5-S1

Answer

L4-5

Answer

L3-4

Answer

L2-3

Question 6

What is an absolute indication for surgery in disc prolapse?

Accepted Answer

Cauda equina syndrome

Answer

Recurrent episodes of sciatica

Answer

Pain not relieved by complete rest

Answer

Progressive motor weakness despite conservative management

Question 7

All of the following are true about fracture of the atlas vertebra, except -

Accepted Answer

Quadriplegia is seen in 80% cases

Answer

Atlantooccipital fusion may sometimes be needed

Answer

Jefferson fracture is the most common type

Answer

CT scans should be done for diagnosis

Question 8

Teardrop fracture of lower cervical spine implies -

Accepted Answer

Flexion compression failure of body

Answer

Wedge compression fracture

Answer

Axial compression fractures

Answer

Flexion-rotation injury with failure of anterior body

Question 9

Unstable spine injury occurs in

Accepted Answer

Flexion-rotation injury

Answer

Flexion injury

Answer

Compression injury

Answer

Extensor injury

Question 10

Which of the following is a poor prognostic factor in Pott's paraplegia?

Accepted Answer

Long-standing paraplegia

Answer

Paraplegia in children

Answer

Gradual onset of paraplegia

Answer

Motor paralysis alone

Spine Disorders — MCQs

Spine Disorders — MCQs

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