Spine Disorders Practice Questions

Q: A 50-year-old male with a history of chronic low back pain presents with new-onset bowel and bladder incontinence. What is the next best step in management?

Urgent MRI of the spine. ***Urgent MRI of the spine*** - The new onset of **bowel and bladder incontinence** in a patient with chronic low back pain is highly suggestive of **cauda equina syndrome**. This is a surgical emergency. - An **urgent MRI** is crucial to confirm the diagnosis and identify the level of compression, guiding immediate surgical decompression to prevent permanent neurological deficits. *Conservative management with NSAIDs* - This approach is appropriate for routine, uncomplicated low back pain, but it is entirely inadequate for a **neurological emergency** like potential cauda equina syndrome. - Delaying definitive diagnosis and treatment in such cases can lead to irreversible neurological damage, including chronic incontinence and paralysis. *Bed rest* - While bed rest might be recommended for acute exacerbations of certain types of back pain, it is not a primary treatment for neurologic emergencies and will not resolve the underlying compression causing **cauda equina syndrome**. - Prolonged bed rest can also lead to complications like deconditioning and venous thromboembolism, and it would waste critical time for diagnosis and intervention. *Physical therapy* - Physical therapy is a cornerstone of management for chronic low back pain and for rehabilitation after an acute event once stability is achieved. - However, in cases of suspected **cauda equina syndrome**, physical therapy is contraindicated as an initial step because it does not address the acute spinal cord or nerve root compression and may worsen the condition or delay necessary surgical intervention.

Q: What is the characteristic postural deformity observed in advanced ankylosing spondylitis?

Kyphosis. **Kyphosis** - In advanced **ankylosing spondylitis**, progressive inflammation and fusion of the vertebrae, especially in the thoracic spine, lead to a characteristic **forward curvature** of the upper back. - This results in a **stooped posture**, often described as a **\"bamboo spine\"** due to ossification of spinal ligaments, making kyphosis the typical deformity. *Increased lumbar lordosis* - While some individuals might initially compensate with increased lumbar lordosis, the overall progression of ankylosing spondylitis typically leads to a **flattening of the lumbar curve** and subsequent development of kyphosis in the thoracic spine. - The characteristic deformity in advanced disease is not an increased lumbar lordosis but rather a **loss of lumbar lordosis** and development of thoracic kyphosis. *Scoliosis* - **Scoliosis** involves a **lateral curvature** of the spine and is not a typical characteristic deformity of advanced ankylosing spondylitis. - Although some individuals might have an associated mild scoliosis, it is not the primary or defining postural change in this condition. *Spinal hyperextension* - **Spinal hyperextension** refers to an excessive backward bending of the spine, which is the opposite of the forward-stooped posture seen in advanced ankylosing spondylitis. - The hallmark of advanced ankylosing spondylitis is limited spinal mobility and a **flexion deformity**, not hyperextension.

Q: During an examination of the back, a palpable step-off in the lower lumbar region suggests a disruption of which structure?

Vertebral body disruption. ***Vertebral body disruption*** - A palpable **step-off** in the lumbar region often indicates **spondylolisthesis**, where one **vertebra** slips forward over the one below it. This slippage is fundamentally a **disruption of the vertebral body's** alignment. - This condition commonly results from a defect or fracture in the **pars interarticularis** or from degenerative changes, leading to the displacement of the **vertebral body**. *Intervertebral disc disruption* - **Intervertebral disc** disruption, such as a herniation, typically causes pain and neurological symptoms but does not directly result in a **palpable step-off** of the vertebral column. - While disc issues can contribute to spinal instability, the disc itself does not create the physical misaligned feeling of a **step-off**. *Ligamentum flavum injury* - Injury to the **ligamentum flavum** (e.g., hypertrophy, rupture) can lead to **spinal stenosis** or instability. - However, it does not typically manifest as a **palpable step-off** on physical examination, as it primarily affects the confines of the **spinal canal**. *Facet joint injury* - **Facet joint injury** or degeneration can cause localized back pain and reduce spinal mobility. - While it contributes to overall spinal stability, isolated **facet joint injury** alone is unlikely to cause a noticeable **palpable step-off**, which is a more significant structural displacement.

Q: A 40-year-old athlete experiences sudden back pain while lifting heavy weights. An MRI reveals a herniated lumbar disc. What is the best initial management?

Physical therapy. ***Physical therapy*** - **Physical therapy** is a cornerstone of initial management for most herniated lumbar discs, aiming to reduce pain, improve mobility, and strengthen supporting muscles. - It involves exercises, stretching, and education on proper body mechanics to prevent recurrence. *Surgical discectomy* - **Surgical discectomy** is generally reserved for patients with persistent, severe pain that has not responded to conservative treatments, or those with progressive neurological deficits like foot drop. - It is not considered the **best initial management** given that most herniated discs resolve with conservative care. *Corticosteroid injections* - **Corticosteroid injections** can provide temporary pain relief by reducing inflammation around the nerve root. - However, they are typically used as an adjunct to physical therapy or when initial conservative measures are insufficient, not as the primary initial management. *Bed rest for 2 weeks* - **Prolonged bed rest** is generally discouraged for disc herniations as it can lead to muscle deconditioning, increased stiffness, and actually prolong recovery. - **Limited rest** for a day or two may be appropriate for acute pain, but active rehabilitation through physical therapy is preferred for long-term recovery.

Q: Craniocervical junction abnormalities are seen in all of the following except:

Ankylosing spondylitis. ***Ankylosing spondylitis*** - While ankylosing spondylitis primarily affects the **axial skeleton**, prominent craniocervical junction abnormalities are **less common** compared to other conditions listed. - The disease typically involves progressive **fusion of the sacroiliac joints** and spine, and while cervical involvement can occur, it usually doesn't lead to the severe instability or malformations seen in the other options at the craniocervical junction. *Rheumatoid arthritis* - **Rheumatoid arthritis** can lead to significant **craniocervical junction abnormalities**, including **atlantoaxial subluxation**. - This occurs due to inflammation and destruction of ligaments and joints in the upper cervical spine, particularly the **odontoid process**. *Odontoid dysgenesis* - **Odontoid dysgenesis** refers to congenital abnormalities in the development of the **odontoid process** (dens) of the axis (C2). - This can result in an unstable craniocervical junction and increased risk of **spinal cord compression**. *Basilar invagination* - **Basilar invagination** is a condition where the **odontoid process** protrudes abnormally high into the foramen magnum. - This can be congenital or acquired, and it significantly impacts the **craniocervical junction**, potentially causing brainstem or cerebellar compression.

Q: What is a common symptom of lumbar canal stenosis?

Neurogenic claudication. ***Neurogenic claudication*** - This is the hallmark symptom of lumbar canal stenosis, characterized by **leg pain, numbness, or weakness** that is induced by walking or standing and relieved by sitting or leaning forward. - The narrow spinal canal compresses nerve roots, leading to these symptoms, often described as a **"shopping cart sign"** where patients lean over to alleviate pain. *Lower back pain* - While lumbar canal stenosis can cause lower back pain, it is a very **non-specific symptom** and not the primary defining characteristic of the condition. - Many conditions, including muscle strains or disc herniations, can cause lower back pain, making it an insufficient standalone indicator. *Numbness in the legs* - Numbness in the legs can occur as part of **neurogenic claudication** in lumbar canal stenosis, but it is typically accompanied by pain and/or weakness and follows a pattern related to activity. - Numbness alone can also be a symptom of various other neurological conditions or peripheral neuropathies, making it too broad a descriptor. *Weakness in the legs* - Leg weakness can be a component of **neurogenic claudication** in lumbar canal stenosis, often appearing after walking or standing for some time. - However, isolated leg weakness without other classic claudication features can also indicate conditions like stroke, multiple sclerosis, or nerve damage from other causes.

Q: Schober's sign is for :

Flexion of lumbar spine. ***Flexion of lumbar spine*** - **Schober's test** measures the degree of **lumbar spine flexion**, indicating the mobility of the lower back. - A limited increase in the marked distance during lumbar flexion suggests reduced spinal mobility, often seen in conditions like **ankylosing spondylitis**. *Chest expansion* - While important in assessing conditions affecting the spine like ankylosing spondylitis, chest expansion is typically measured using a **tape measure** around the chest, not Schober's sign. - Reduced chest expansion indicates **costovertebral** and **costosternal joint involvement**. *Pain with motion of hip* - Hip joint pathology is assessed through specific range of motion tests and palpation, independent of Schober's test. - Pain during hip motion could indicate conditions like **osteoarthritis** or **hip impingement**. *Neck pain and stiffness* - Neck pain and stiffness are assessed through cervical spine range of motion tests, such as flexion, extension, and rotation. - Schober's test specifically evaluates lumbar spine mobility, not the cervical spine.

Q: Hangman's fracture is the fracture involving which cervical vertebra?

C2. ***C2*** - A **Hangman's fracture** specifically refers to a fracture of the **pars interarticularis of the second cervical vertebra (C2)**, also known as the axis. - This type of fracture is typically caused by extreme **hyperextension** and distraction injuries, historically associated with judicial hanging. *C1* - The first cervical vertebra, C1 (atlas), is involved in a **Jefferson fracture**, which is a burst fracture resulting from an axial load. - A Jefferson fracture involves fractures of the anterior and posterior arches of C1, distinguishing it from a Hangman's fracture. *C3* - Fractures of C3 are less common than C1 or C2 and are typically associated with higher energy trauma causing a **flexion-distraction injury**. - These fractures can involve the vertebral body or posterior elements but are not specifically termed a Hangman's fracture. *C4* - Fractures of the fourth cervical vertebra (C4) can occur due to various mechanisms, including flexion, extension, or compression. - While significant, C4 fractures do not carry the specific designation of a Hangman's fracture, which is reserved for C2.

Q: Test used for prolapsed lumbar intervertebral disc is?

Lasegue test. ***Lasegue test*** - The **Lasegue test**, also known as the **straight leg raise test**, is a primary diagnostic test for **lumbar disc herniation** causing **sciatic nerve root compression**. - It elicits radiating pain down the leg when the affected leg is passively raised, due to stretching the **sciatic nerve**. *Active straight leg raising test* - This test is primarily used to assess for **sacroiliac joint dysfunction** or **lumbar instability**, not disc prolapse. - The patient actively lifts their leg, and the examiner assesses for pain or instability in the pelvic region. *Thomas test* - The **Thomas test** is used to determine the presence of a **hip flexion contracture**. - It involves assessing the ability of the hip to extend fully when the contralateral hip is flexed to the chest. *Apley's grinding test* - **Apley's grinding test** is a specific maneuver used to detect **meniscal injuries** in the knee joint. - It involves compressing and rotating the tibia on the femur while the patient is prone.

Q: What should be the most likely diagnosis of this 65-year-old lady who presents with backache?

Spondylolisthesis. ***Spondylolisthesis*** - The lateral X-ray image reveals an **anterior displacement of one vertebral body over the one below it**, which is characteristic of spondylolisthesis. - In a 65-year-old lady, degenerative spondylolisthesis due to **arthritic changes and instability** is a common cause of backache. *Osteoporotic fracture* - An osteoporotic fracture would typically show a **compression deformity** or a wedge-shaped vertebral body, which is not clearly depicted here. - While osteoporosis is common in this age group, the primary finding on this image is vertebral slippage, not fracture. *Spondylolysis* - Spondylolysis is a **defect in the pars interarticularis** (a thin segment of bone connecting the superior and inferior articular facets) and is best seen on oblique views or CT. - Although spondylolysis can *lead to* spondylolisthesis, the immediate and most striking finding on this lateral view is the slippage itself. *Discitis* - Discitis, an **inflammation or infection of the intervertebral disc and adjacent vertebrae**, would typically show **loss of disc height** and **endplate irregularities or erosions**. - These features are not the predominant finding on this image, which clearly demonstrates vertebral body displacement.

Question 1

A 50-year-old male with a history of chronic low back pain presents with new-onset bowel and bladder incontinence. What is the next best step in management?

Accepted Answer

Urgent MRI of the spine

Answer

Conservative management with NSAIDs

Answer

Bed rest

Answer

Physical therapy

Question 2

What is the characteristic postural deformity observed in advanced ankylosing spondylitis?

Accepted Answer

Kyphosis

Answer

Scoliosis

Answer

Increased lumbar lordosis

Answer

Spinal hyperextension

Question 3

During an examination of the back, a palpable step-off in the lower lumbar region suggests a disruption of which structure?

Accepted Answer

Vertebral body disruption

Answer

Intervertebral disc disruption

Answer

Ligamentum flavum injury

Answer

Facet joint injury

Question 4

A 40-year-old athlete experiences sudden back pain while lifting heavy weights. An MRI reveals a herniated lumbar disc. What is the best initial management?

Accepted Answer

Physical therapy

Answer

Surgical discectomy

Answer

Corticosteroid injections

Answer

Bed rest for 2 weeks

Question 5

Craniocervical junction abnormalities are seen in all of the following except:

Accepted Answer

Ankylosing spondylitis

Answer

Odontoid dysgenesis

Answer

Basilar invagination

Answer

Rheumatoid arthritis

Question 6

What is a common symptom of lumbar canal stenosis?

Accepted Answer

Neurogenic claudication

Answer

Lower back pain

Answer

Numbness in the legs

Answer

Weakness in the legs

Question 7

Schober's sign is for :

Accepted Answer

Flexion of lumbar spine

Answer

Chest expansion

Answer

Pain with motion of hip

Answer

Neck pain and stiffness

Question 8

Hangman's fracture is the fracture involving which cervical vertebra?

Accepted Answer

C2

Answer

C1

Answer

C3

Answer

C4

Question 9

Test used for prolapsed lumbar intervertebral disc is?

Accepted Answer

Lasegue test

Answer

Active straight leg raising test

Answer

Thomas test

Answer

Apley's grinding test

Question 10

What should be the most likely diagnosis of this 65-year-old lady who presents with backache?

Accepted Answer

Spondylolisthesis

Answer

Osteoporotic fracture

Answer

Spondylolysis

Answer

Discitis

Spine Disorders — MCQs

Spine Disorders — MCQs

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