Spine Disorders Practice Questions

Q: In Spondylolisthesis, which of the following is NOT a useful investigation?

Anteroposterior X-ray. **Explanation:** **Spondylolisthesis** is defined as the forward slippage of one vertebra over the one below it (most commonly L5 over S1). To diagnose and grade this condition, the clinician must visualize the sagittal alignment of the vertebral column. 1. **Why Anteroposterior (AP) X-ray is the correct answer (NOT useful):** An AP view provides a frontal look at the spine. While it may show secondary signs in severe cases (like the "inverted Napoleon hat sign"), it cannot demonstrate the **forward displacement** of the vertebral body. Since the slippage occurs in the sagittal plane, an AP view is insufficient for diagnosis, grading, or assessing the stability of the slip. 2. **Why the other options are wrong (Useful investigations):** * **Lateral View X-ray:** This is the **investigation of choice** and the most useful initial tool. it allows for the measurement of the degree of slip (Meyerding Grading) and visualization of the defect in the pars interarticularis. * **CT Scan:** Excellent for detailed bony anatomy. It is the best modality to visualize the **pars defect** (spondylolysis) and associated bony changes. * **MRI Scan:** The gold standard for evaluating **neural structures**. It is essential to assess the degree of canal stenosis, foraminal narrowing, and nerve root compression. **High-Yield Clinical Pearls for NEET-PG:** * **Meyerding Grading:** Based on the percentage of slip (Grade I: <25%, Grade II: 25-50%, Grade III: 50-75%, Grade IV: 75-100%, Grade V: Spondyloptosis). * **Oblique X-rays:** Used to see the **"Scotty Dog"** sign; a break in the dog's neck represents a pars interarticularis defect. * **Inverted Napoleon Hat Sign:** Seen on **AP X-rays** only in severe cases (Grade IV or V) where the L5 vertebra tilts downward and overlaps the sacrum. * **Most common site:** L5-S1 (Isthmic type); L4-L5 (Degenerative type).

Q: Adson's test is positive in which condition?

Thoracic Outlet Syndrome. **Explanation:** **Adson’s Test** is a clinical provocative maneuver used to diagnose **Thoracic Outlet Syndrome (TOS)**, specifically the compression of the subclavian artery by a cervical rib or tight scalene muscles. **Why Option A is Correct:** In Thoracic Outlet Syndrome, the neurovascular bundle (brachial plexus and subclavian vessels) is compressed as it passes through the cervico-axillary canal. During Adson's test, the patient’s arm is abducted, the neck is extended, and the head is rotated toward the affected side while taking a deep breath. A **positive test** is indicated by a **marked decrease or disappearance of the radial pulse**, suggesting arterial compression in the interscalene triangle. **Why Other Options are Incorrect:** * **B. Horner’s Syndrome:** This is caused by a lesion in the sympathetic trunk (ptosis, miosis, anhidrosis) and is not assessed by vascular provocative tests. * **C. Carpal Tunnel Syndrome:** This involves compression of the median nerve at the wrist. It is diagnosed using **Phalen’s test** or **Tinel’s sign** at the flexor retinaculum. * **D. Axillary artery thrombosis:** While this affects the pulse, it is a fixed vascular occlusion. Adson's test specifically identifies *positional* compression at the thoracic outlet. **High-Yield Clinical Pearls for NEET-PG:** * **Other TOS Tests:** **Roos Test** (Elevated Arm Stress Test/“East Test”) is considered the most reliable clinical screening test for TOS. * **Cervical Rib:** The most common anatomical cause of neurovascular TOS. * **Halsted’s Maneuver:** Similar to Adson’s but involves downward traction of the arm and neck rotation to the *opposite* side. * **Wright’s Hyperabduction Test:** Used to identify compression in the subcoracoid (pectoralis minor) space.

Q: A person might become quadriplegic if the injury to the spine is at which level?

C3. **Explanation:** The level of spinal cord injury (SCI) determines the extent of motor and sensory loss. **Quadriplegia (Tetraplegia)** refers to the loss of function in all four limbs and the torso, resulting from injuries to the **cervical segments (C1 to C8)** of the spinal cord. **Why C3 is the correct answer:** An injury at the **C3 level** results in complete quadriplegia. More importantly, it is life-threatening because the **phrenic nerve**, which innervates the diaphragm, originates from the **C3, C4, and C5** nerve roots. An injury at or above C3 leads to respiratory paralysis, requiring immediate mechanical ventilation for survival. **Analysis of Incorrect Options:** * **C5:** While an injury here still causes quadriplegia, the patient retains some shoulder function (deltoid) and elbow flexion (biceps). The diaphragm usually remains functional as the C3 and C4 roots are intact. * **C7:** An injury at C7 allows for elbow extension (triceps) and some finger extension. The patient is still a quadriplegic but has significantly more upper limb utility than a C3 injury. * **T1:** The thoracic spine begins at T1. Injuries from **T1 downwards result in Paraplegia** (loss of function in the lower half of the body), as the nerve supply to the upper extremities (Brachial Plexus: C5-T1) remains largely intact. **High-Yield Clinical Pearls for NEET-PG:** * **Diaphragm Innervation:** "C3, 4, 5 keep the diaphragm alive." * **Autonomic Dysreflexia:** Most common in injuries at or above **T6**. * **Neurogenic Shock:** Characterized by the triad of hypotension, **bradycardia**, and peripheral vasodilation; typically seen in injuries above T6. * **Spinal Shock:** A physiological loss of all reflex activity below the level of injury; the end of spinal shock is marked by the return of the **Bulbocavernosus reflex**.

Q: An eight-year-old boy presents with back pain and mild fever. His plain X-ray of the dorsolumbar spine reveals a solitary collapsed dorsal vertebra with preserved disc spaces. There was no associated soft tissue shadow. What is the most likely diagnosis?

Histiocytosis. **Explanation:** The clinical presentation of a solitary collapsed vertebra with **preserved disc spaces** in a child is a classic radiological sign known as **Vertebra Plana** (Calvé disease). **1. Why Histiocytosis is Correct:** Langerhans Cell Histiocytosis (LCH) is the most common cause of vertebra plana in children. The pathology involves eosinophilic granulomatous infiltration that destroys the vertebral body, causing it to collapse into a thin, dense plate (the "coin-on-edge" appearance). Crucially, the **intervertebral discs are resistant** to these lesions, remaining radiologically intact and of normal height. **2. Why the other options are incorrect:** * **Tuberculosis (Pott’s Spine):** This is the most common cause of spinal pathology in India, but it characteristically **destroys the disc space** (paradiscal type) and is almost always associated with a pre-vertebral or paravertebral **soft tissue shadow** (cold abscess). * **Ewing’s Sarcoma:** While it can cause vertebral collapse, it typically presents with a significant soft tissue mass and more aggressive bone destruction rather than a symmetrical "flat" vertebra. * **Metastasis:** Rare in an 8-year-old. When it occurs (e.g., Neuroblastoma), it usually involves multiple levels and pedicle destruction (winking owl sign), rather than isolated vertebra plana. **Clinical Pearls for NEET-PG:** * **Vertebra Plana Differential:** Remember the mnemonic **COMPRESS** (C-Calvé/LCH, O-Osteomyelitis, M-Metastasis/Malignancy, P-Pott’s, R-Rickets, E-Ewing’s, S-Scurvy, S-Steroids). * **LCH Management:** Most cases of spinal LCH are self-limiting; the vertebral height often partially recovers as the child grows. * **Disc Space Rule:** If the disc space is **lost**, think Infection (TB/Pyogenic). If the disc space is **preserved**, think Tumor or LCH.

Q: In Klippel-Feil syndrome, the patient has all of the following clinical features except?

Bilateral shortness of sternocleidomastoid muscles. **Explanation:** Klippel-Feil Syndrome (KFS) is a congenital skeletal condition characterized by the **failure of segmentation of cervical vertebrae**, leading to the fusion of two or more cervical segments. **Why Option C is the correct answer:** Bilateral shortness of the sternocleidomastoid (SCM) muscles is **not** a feature of Klippel-Feil syndrome. Shortening of the SCM is the hallmark of **Congenital Muscular Torticollis** (Wry neck). In KFS, the physical limitations and deformities are due to underlying **bony vertebral fusion**, not primary muscular contractures. **Analysis of other options:** * **A & D (Low hairline and Gross limitation of neck movements):** These are two components of the classic clinical triad of KFS. The fusion of vertebrae directly restricts the range of motion (especially lateral rotation and flexion) and anatomically results in a low-seated posterior hairline. * **B (Bilateral neck webbing):** Due to the extremely short neck and the underlying bony abnormalities, the skin folds from the mastoid to the acromion appear prominent, creating a "pterygium colli" or webbed neck appearance. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** 1. Low posterior hairline, 2. Short neck ("Breviscollis"), 3. Restricted neck motion. (Present in only ~50% of cases). * **Associated Anomalies:** The most common associated condition is **Sprengel’s deformity** (undescended scapula). Others include renal agenesis, sensorineural hearing loss, and congenital heart disease (VSD). * **Radiology:** Lateral X-ray of the cervical spine is the gold standard for diagnosis, showing fused vertebral bodies ("Wasp-waist" sign). * **Genetics:** Often associated with mutations in GDF6 or MEOX1 genes.

Q: A patient is diagnosed with disc prolapse. Examination reveals paralysis of extensor hallucis longus. Which nerve root is affected?

L5. **Explanation:** The clinical presentation of **Extensor Hallucis Longus (EHL)** paralysis is a classic sign of **L5 nerve root** involvement. In the context of lumbar disc prolapse, the nerve root affected is typically the one traversing the disc space (e.g., an L4-L5 posterolateral disc prolapse compresses the L5 nerve root). **1. Why L5 is Correct:** The L5 nerve root provides the primary motor innervation to the **Extensor Hallucis Longus** (responsible for big toe extension) and the **Extensor Digitorum Brevis**. It also supplies the Gluteus Medius (hip abduction) and Tibialis Anterior (dorsiflexion, though shared with L4). Sensory loss in an L5 lesion typically occurs over the **first dorsal web space** and the lateral aspect of the leg. **2. Why Other Options are Incorrect:** * **L3:** Primarily involves the Iliopsoas and Quadriceps. Clinical signs include weak hip flexion/knee extension and a diminished patellar reflex. * **L4:** Primarily supplies the **Tibialis Anterior**. A lesion leads to weak ankle dorsiflexion and a **diminished Patellar (Knee-jerk) reflex**. * **S1:** Primarily supplies the **Peroneus Longus/Brevis** (eversion) and **Gastrocnemius/Soleus** (plantarflexion). A lesion leads to weakness in tip-toe walking and a **diminished Achilles (Ankle-jerk) reflex**. **Clinical Pearls for NEET-PG:** * **Root vs. Action:** L4 = Foot Inversion/Dorsiflexion; L5 = Big Toe Extension; S1 = Foot Eversion/Plantarflexion. * **Reflexes:** L4 (Knee), S1 (Ankle). Note: **L5 has no reliable deep tendon reflex.** * **Most Common Level:** L4-L5 and L5-S1 are the most frequent sites for lumbar disc herniation. * **Rule of Thumb:** In a posterolateral disc herniation, the **lower** (traversing) root is compressed (e.g., L4-L5 herniation affects L5).

Q: An X-ray shows reduction of the intervertebral disc space and a fusiform shadow along the vertebra. What is the most likely diagnosis?

Tuberculosis of the spine. **Explanation:** The clinical presentation described—**reduction of intervertebral disc space** combined with a **fusiform shadow**—is a classic radiological hallmark of **Tuberculosis of the spine (Pott’s disease)**. 1. **Why it is correct:** In spinal TB, the infection typically begins in the paradiscal area. Proteolytic enzymes are absent in TB (unlike pyogenic infections), but the destruction of the subchondral bone leads to the collapse of the disc into the vertebral bodies, causing **disc space narrowing**. The "fusiform shadow" represents a **paravertebral abscess** (cold abscess) formed by the collection of pus, debris, and caseous material under the anterior longitudinal ligament. 2. **Why other options are incorrect:** * **Psoas abscess:** While often caused by spinal TB, a psoas abscess typically presents as a teardrop-shaped shadow tracking along the psoas muscle margin toward the groin, rather than a localized fusiform shadow along the thoracic/lumbar vertebrae. * **Hemorrhage in posterior mediastinum:** This would present as a widened mediastinum on X-ray, usually following trauma or aortic pathology, and would not cause destruction of the intervertebral disc space. * **Osteoporosis:** This leads to increased radiolucency, "codfish vertebrae" (biconcave), or wedge fractures, but the **intervertebral disc space is characteristically preserved** or even appears widened. **High-Yield Clinical Pearls for NEET-PG:** * **Earliest sign of Spinal TB on X-ray:** Reduction/narrowing of the intervertebral disc space. * **Most common site:** Lower thoracic and upper lumbar vertebrae. * **Gibbus Deformity:** A sharp angular kyphosis resulting from the collapse of anterior vertebral bodies. * **Paradiscal type:** The most common pattern of involvement in adults. * **Imaging of choice:** MRI is the most sensitive modality to detect early marrow edema and soft tissue extensions.

Question 1

In Spondylolisthesis, which of the following is NOT a useful investigation?

Accepted Answer

Anteroposterior X-ray

Answer

Lateral view X-ray

Answer

CT scan

Answer

MRI scan

Question 2

What is the early feature of Pott's paraplegia?

Accepted Answer

Ankle clonus

Answer

Flexor spasm

Answer

Increased tendon jerk

Answer

Sensory loss

Question 3

Which of the following is NOT true about spinal injuries?

Accepted Answer

The cervical spine is more prone to fracture than dislocation

Answer

Forms 6% of all trauma cases

Answer

Neurodeficit is present in 50% of all cases

Answer

Traumatic injuries most commonly affect the cervical spine

Question 4

A 40-year-old male presented with a two-week history of worsening lower back pain, which began while gardening. He experiences back stiffness, difficulty sitting for prolonged periods, and relief with walking. Coughing or sneezing exacerbates the pain, causing it to radiate down his right leg. Physical examination revealed paraspinal muscle spasm and tenderness in the right lumbar region. The straight leg raise test was positive at 50 degrees on the right and negative on the left. Examination of the right foot showed weakness in dorsiflexion and hypesthesia over the first web space, with the remainder of the neurological examination being normal. What is the most likely cause of his symptoms?

Accepted Answer

Prolapsed intervertebral disc at L4-L5 level

Answer

Prolapsed intervertebral disc at L5-S1 level

Answer

Spinal cord astrocytoma

Answer

Epidural hematoma

Question 5

Adson's test is positive in which condition?

Accepted Answer

Thoracic Outlet Syndrome

Answer

Horner's Syndrome

Answer

Carpal Tunnel Syndrome

Answer

Axillary artery thrombosis

Question 6

A person might become quadriplegic if the injury to the spine is at which level?

Accepted Answer

C3

Answer

C5

Answer

C7

Answer

T1

Question 7

An eight-year-old boy presents with back pain and mild fever. His plain X-ray of the dorsolumbar spine reveals a solitary collapsed dorsal vertebra with preserved disc spaces. There was no associated soft tissue shadow. What is the most likely diagnosis?

Accepted Answer

Histiocytosis

Answer

Ewing's sarcoma

Answer

Tuberculosis

Answer

Metastasis

Question 8

In Klippel-Feil syndrome, the patient has all of the following clinical features except?

Accepted Answer

Bilateral shortness of sternocleidomastoid muscles

Answer

Low hairline

Answer

Bilateral neck webbing

Answer

Gross limitations of neck movements

Question 9

A patient is diagnosed with disc prolapse. Examination reveals paralysis of extensor hallucis longus. Which nerve root is affected?

Accepted Answer

L5

Answer

L3

Answer

L4

Answer

S1

Question 10

An X-ray shows reduction of the intervertebral disc space and a fusiform shadow along the vertebra. What is the most likely diagnosis?

Accepted Answer

Tuberculosis of the spine

Answer

Psoas abscess

Answer

Hemorrhage in posterior mediastinum

Answer

Osteoporosis

Spine Disorders — MCQs

Spine Disorders — MCQs

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